Transsexualism 08.09.11

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The DSM-IV and ICD-10 have defined hundreds of mental disorders which vary in onset, duration, pathogenesis, functional disability, and treatability. The designation of gender identity disorders (GID) as mental disorders is not a license for stigmatization, or for the deprivation of patients' civil rights. The use of a formal diagnosis is often important in offering relief, providing health insurance coverage, and guiding research to provide more effective care.

DSM-5 Development Group indicate that GID can still be given to children who reject the assigned gender but who do not experience any anatomical dysphoria. To qualify as a mental disorder, a behavioral pattern must result in a significant adaptive disadvantage to the person or cause personal mental suffering. However, the removal of distress/impairment criterion can lead to over-diagnosis of children who do not meet criteria. Instead, it is argued that criterion should be kept based on distress resulting from living in the present gender as apposed to anguish stemming from societal prejudice and discrimination. It would be more appropriate and respectful if the diagnosis is written in language reflecting contemporary views of gender rather than views that are based on gender-specific games or clothing.

Goals: Psychotherapy often provides education about a range of options not previously seriously considered by the patient. It emphasizes the need to set realistic life goals for work and relationships, and it seeks to define and alleviate the patient's conflicts that may have undermined a stable lifestyle.

The Therapeutic Relationship: The establishment of a reliable trusting relationship with the patient is the first step toward successful work as a mental health professional. This is usually accomplished by competent nonjudgmental exploration of the gender issues with the patient during the initial diagnostic evaluation. Other issues may be better dealt with later, after the person feels that the clinician is interested in and understands their gender identity concerns. Ideally, the clinician's work is with the whole of the person's complexity. The goals of therapy are to help the person to live more comfortably within a gender identity and to deal effectively with non-gender issues. The clinician often attempts to facilitate the capacity to work and to establish or maintain supportive relationships.

Language is very important to indicate that a community is making an effort to be trans-friendly. It often makes the difference in whether a transgender person will approach a community and/or clinician and whether they will choose to stay.

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  • Biological Sex: one’s anatomical and reproductive structures, determined by karyotype, gonads, external genitalia ,and secondary sex differentiation at pubertyGender: “cultural rules, ideologies, and expected bx for individuals of diverse phenotypes and psychosocial characteristics”Identity: one’s subjective sense of congruence with an attributed genderRole: public display of gender identity conveying societal schemes of how boys and girls should behaveTransgender: umbrella term referring to ppl who move away from gender reassigned to them at birth, violating societal conceptualizations of what it means to be man or womanTranssexual: ppl whose gender identity does not correspond to their physical body, sometimes transform their body and often assume gender roles that are congruent with their experienced gender identity, best describes adults who may meet criteria for GIDSexuality and Sexual Orientation: how and with whom ppl act on their affectionate, intimate, and erotic desiresWestern cultural beliefs dictate that there are only 2 biological sexes corresponding to 2 genders: males are expected to have masculine gender identification/roles and to be attracted to women, whereas females are expected to have feminine gender identification/roles and to be attracted to men. These 2 models are considered the “norm”. Other considerations are possible: a biologically born female may identify with the gender identity of a male, as an adult, this person may self-identify as transgender or transsexual and live as a man, who like any person can be of any sexual orientation. Or a biologically born male can identify as a male, be attracted to other males, and identify as gay.
  • Along the nature vs. nurture continuum: both innate and acquired aspects of the human experience are inextricably involved in development of gender identity.Gender identity formation is seen from integrative perspective as a complex biological and psychological process, which is unique for each person and which involves a variety of genetic, hormonal and environmental factors, acting separately or in combination with each other (Gender Identity Research and Education Society, 2006, pg. 38).
  • Alexis ArquetteChaz BonoIsis KingThomas Beatie
  • 3 main pathways to atypical gender identity development:Anomalous prenatal hormonal influences – increased incidence of left-handedness among transsexuals, and finger ratio measurement of transsexual men resembling that of biological womenAnatomic brain differences – examinations of brains of MTF transsexuals, show typically female-sized portion of central subdivision of bed nucleus of striaterminalis, a brain area vital in sexual bxGenetic influences – heritability of GID among twins, highest concordance rates found among monozygotic twins
  • Upon finding biological sex of child, parents make arrangements by purchasing gender-specific clothes, toys, nursery items, thus assigning gender identity to child who has not yet been born. After birth, boys and girls elicit specific parental responses: boys are stronger, girls are finer featured and delicate. Traditional gender bx’s are reinforced with inclusion and praise, whereas “unacceptable” gender bx’s are stigmatized.Intrapsychic conflict stemming from environmental instability: gender-noncomforming identification results in bisexual mother, absent father, symbiosis between mother and son, and a special beauty in boy. Femininity was reinforced by family members and rejected by peers, intensified negative self-feelings and further propelled boy’s wish to become a girl (Green’s reinforcement theory, 1974)Child’s temperament and problematic family environment: anxious children and sensitive to parental dynamics (family discord, conflict about matters of masculinity/femininity, possible psychopathology), rendered parent’s preoccupied and inattentive to child’s gender-variant bx (Zucker and Bradley, 2004)Socialization on gender development include:Psychoanalytic theories – early childhood experiences and identifications with parentsLearning theories – underscore role of reinforcement, punishment, imitation, modeling in gender developmentSocial constructivism – social construction of gender against backdrop of time, place, and social experience of peopleCognitive theories – focus on children’s knowledge about gender and gender-related bx’s
  • Children: in boys, assertion that his penis or testes are disgusting or will disappear, aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, does not want to grow breasts or menstruate, marked aversion toward normative feminine clothingAdolescents/Adults: preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to stimulate the other sex) or belief that he or she was born the wrong sex
  • DSM-5 Development Sexual and Gender Identity Disorders Work Group (APA, 2010):Gender incongruence seen as less stigmatizing and more representative of symptomatology.Gender dysphoria: psychological discomfort with one’s biological sexAcknowledgement of problems in population stem from increased experiences of stigmaDSM-5 Development Group indicate that GID can still be given to children who reject the assigned gender but who do not experience any anatomical dysphoria. Removal of distress/impairment criterion can lead to over-diagnosis of children who do not meet criteria, instead criterion should be kept based on distress resulting from living in the present gender as apposed to anguish stemming from societal prejudice and discrimination. Diagnosis should be written in language reflecting contemporary views of gender rather than views that are based on gender-specific games or clothing.
  • To qualify as a mental disorder, a behavioral pattern must result in a significant adaptive disadvantage to the person or cause personal mental suffering. The DSM-IV and ICD-10 have defined hundreds of mental disorders which vary in onset, duration, pathogenesis, functional disability, and treatability. The designation of gender identity disorders as mental disorders is not a license for stigmatization, or for the deprivation of gender patients' civil rights. The use of a formal diagnosis is often important in offering relief, providing health insurance coverage, and guiding research to provide more effective future treatments.
  • Diagnostic Assessment – includes history related to experience of gender discomfort, general medical examination, investigations and psychiatric assessmentMental health professionals who recommend hormonal and surgical therapy share the legal and ethical responsibility for that decision with the physician who undertakes the treatment. Hormonal treatment can often alleviate anxiety and depression in people without the use of additional psychotropic medications. Some individuals, however, need psychotropic medication prior to, or concurrent with, taking hormones or having surgery. The mental health professional is expected to make this assessment, and see that the appropriate psychotropic medications are offered to the patient. The presence of psychiatric co-morbidities (increase the likelihood of an even higher prevalence: unrecognized gender problems are occasionally diagnosed when patients are seen with anxiety, depression, bipolar disorder, conduct disorder, substance abuse, dissociative identity disorders, borderline personality disorder, other sexual disorders and intersexed conditions)does not necessarily preclude hormonal or surgical treatment, but some diagnoses pose difficult treatment dilemmas and may delay or preclude the use of either treatment.
  • Psychotherapy – psychiatrist referral to help pt’s cope with stress of transition process and to set realistic goals and expectations. While some individuals manage to do this on their own, psychotherapy can be very helpful in bringing about the discovery and maturational processes that enable self-comfort.When the mental health professional's initial assessment leads to a recommendation for psychotherapy, the clinician should specify the goals of treatment, and estimate its frequency and duration. There is no required minimum number of psychotherapy sessions prior to hormone therapy, the real-life experience, or surgery.Goals:Psychotherapy often provides education about a range of options not previously seriously considered by the patient. It emphasizes the need to set realistic life goals for work and relationships, and it seeks to define and alleviate the patient's conflicts that may have undermined a stable lifestyle.The Therapeutic Relationship. The establishment of a reliable trusting relationship with the patient is the first step toward successful work as a mental health professional. This is usually accomplished by competent nonjudgmental exploration of the gender issues with the patient during the initial diagnostic evaluation. Other issues may be better dealt with later, after the person feels that the clinician is interested in and understands their gender identity concerns.Ideally, the clinician's work is with the whole of the person's complexity. The goals of therapy are to help the person to live more comfortably within a gender identity and to deal effectively with non-gender issues. The clinician often attempts to facilitate the capacity to work and to establish or maintain supportive relationships. Even when these initial goals are attained, mental health professionals should discuss the likelihood that no educational, psychotherapeutic, medical, or surgical therapy can permanently eradicate all vestiges of the person's original sex assignment and previous gendered experience.
  • The therapist should make clear that it is the patient's right to choose among many options. The patient can experiment over time with alternative approaches. Ideally, psychotherapy is a collaborative effort. The therapist must be certain that the patient understands the concepts of eligibility and readiness, because the therapist and patient must cooperate in defining the patient's problems, and in assessing progress in dealing with them. Collaboration can prevent a stalemate between a therapist who seems needlessly withholding of a recommendation, and a patient who seems too profoundly distrusting to freely share thoughts, feelings, events, and relationships. Psychotherapy is not intended to cure the gender identity disorder. Its usual goal is a long-term stable life style with realistic chances for success in relationships, education, work, and gender identity expression. Gender distress often intensifies relationship, work, and educational dilemmas.
  • Mental health professionals (MHPs) who work with individuals with gender identity disorders may be regularly called upon to carry out many of these responsibilities…
  • Real-Life Experience – period of time, usually one/two years, living in new or evolving gender role with which the person identifies, with change in name and documents, pt should continue employment, education or voluntary work, and provide evidence that other ppl are aware of their new role.An example of an eligibility requirement is: a person must live full time in the preferred gender for twelve months prior to genital surgery. To meet this criterion, the professional needs to document that the real-life experience has occurred for this duration. This is part of letter of recommendation before hormonal therapy or surgery.
  • Hormone Therapy – letter of rec is required from psychiatrist before therapy is commenced, lifelong and induces development of secondary sex characteristics of the opposite sex (some are irreversible), associated with physical and psychological side-effects, instituted only after all necessary medical tests and informed consent; pt’s should have documented real life experience of at least 3 months prior to administration of hormones, or a period of psychotherapy of duration specified by psychiatrist (no less than 3 months) after initial eval.For example, those who are receiving psychotherapy and/or cross-sex hormonal treatments should be allowed to continue this medically necessary treatment to prevent or limit emotional lability, undesired regression of hormonally-induced physical effects and the sense of desperation that may lead to depression, anxiety and suicidality.
  • Eligibility Criteria. The administration of hormones is not to be lightly undertaken because of their medical and social risks. Three criteria exist. 1. Age 18 years; 2. Demonstrable knowledge of what hormones medically can and cannot do and their social benefits and risks; 3. Either: a.) A documented real-life experience of at least three months prior to the administration of hormones; or b. A period of psychotherapy of a duration specified by the mental health professional after the initial evaluation (usually a minimum of three months).
  • Readiness Criteria. Three criteria exist: 1.The patient has had further consolidation of gender identity during the real-life experience or psychotherapy; 2.The patient has made some progress in mastering other identified problems leading to improving or continuing stable mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis and suicidality; 3.The patient is likely to take hormones in a responsible manner.
  • The Misuse of Hormones. Some individuals obtain hormones without prescription from friends, family members, and pharmacies in other countries. Medically unmonitored hormone use can expose the person to greater medical risk. Persons taking medically monitored hormones have been known to take additional doses of illicitly obtained hormones without their physician's knowledge. Mental health professionals and prescribing physicians should make an effort to encourage compliance with recommended dosages, in order to limit morbidity. It is ethical for physicians to discontinue treatment of patients who do not comply with prescribed treatment regimens.Patients with medical problems or otherwise at risk for cardiovascular disease may be more likely to experience serious or fatal consequences of cross-sex hormonal treatments. For example, cigarette smoking, obesity, advanced age, heart disease, hypertension, clotting abnormalities, malignancy, and some endocrine abnormalities may increase side effects and risks for hormonal treatment. Therefore, some patients may not be able to tolerate cross-sex hormones. However, hormones can provide health benefits as well as risks. Risk-benefit ratios should be considered collaboratively by the patient and prescribing physician.*Homeless youth get their illegal hormones from johns – link to http://www.nationalhomeless.org/factsheets/lgbtq.html*
  • Sex Reassignment Surgery – replaces some physical characteristics of biological sex with that of opposite sex, irreversible procedure and considered after careful evaluation. Letters from 2 separate consultant psychiatrists are required prior to initiating genital surgery. Eligibility criteria for SRS include 12 months of continual hormonal therapy for those without medical contraindications and 12 months of successful continuous full-time real-life experience, and also regular psychotherapy. In persons diagnosed with transsexualism or profound GID, sex reassignment surgery, along with hormone therapy and real-life experience, is a treatment that has proven to be effective. Such a therapeutic regimen, when prescribed or recommended by qualified practitioners, is medically indicated and medically necessary. Sex reassignment is not "experimental," "investigational," "elective," "cosmetic," or optional in any meaningful sense. It constitutes very effective and appropriate treatment for transsexualism or profound GID.In order to understand how surgery can alleviate the psychological discomfort of patients diagnosed with gender identity disorders, professionals need to listen to these patients discuss their life histories and dilemmas. The resistance against performing surgery on the ethical basis of "above all do no harm" should be respected, discussed, and met with the opportunity to learn from patients themselves about the psychological distress of having profound gender identity disorder.It is unethical to deny availability or eligibility for sex reassignment surgeries or hormone therapy solely on the basis of blood seropositivity for blood-borne infections such as HIV, or hepatitis B or C, etc.
  • The average cost for a male-to-female surgery is about $17,000. Adding in a cost of about $1000 for therapy, $1500 for hormones, and $500 for doctors visits and lab tests, the cost to transition averages about $20,000 over a two year transition period
  • 1 out of 4 MTFs reported decrease in libido (Low testosterone?)FTM – Reported more difficulty in establishing a stable relationship post-opFound that informing new partners on past has a positive effect on the relationship
  • In general, sex life improvedContingent on finally having the right body with the right genitalsSome dissatisfaction in MTF occurred when there was dysfunctional vaginasFTM reported masturbating more frequently
  • Found that FTMs that chose to have penile prosthesis implanted had their sexual expectations more realizedHowever, they reported more pain during intercourseCould be due to reconstructed neural pathwaysCould be due to the prosthesis putting pressure on places where the constructed penis is attached.
  • Language is very important. People pick up on small cues. The following changes may seem minor, but they are among the most important ways to indicate that a community is making an effort to be trans-friendly. It often makes the difference in whether a transgender person will approach a community and whether they will choose to stay.- On flyers, in newsletters, event announcements, etc.: Instead of writing "men and women welcome" or "for both men and women," try "all genders welcome" or "for all genders."- In articles, essays etc.: Rather than "both genders" or "men and women," refer to "all genders" or "people of any gender."- If events, groups or programs (event, social group, etc.) are advertised or indicated as "gay and lesbian," consider whether it really is only for gay and lesbian people or whether a transgender (or bisexual person, for that matter) would be welcomed. If the latter is true, change the language.  
  • Don't unnecessarily refer to a person's previous gender status. If this information is not known publicly, revealing it could put the person at risk of harm. Regardless of how open a person is about being transgender, referring to their previous status usually makes that person uncomfortable.Don't insist that someone must be either a man or a woman. Some people identify themselves as neither gender, as both genders, or as a third gender. This may seem confusing, but this is a legitimate choice. Some people are in a process of discovering their identity or deciding how they wish to live. People may be in various stages of a gender transition. If you need clarification on which pronoun to use, ask.Don't say things like: "But you look like a woman!" or "But I've always known you as a man" or "But you made such a good/attractive woman." Comments like these make people feel badly.Don't be afraid to say, "I don't understand, but I want to be respectful of you." Being a good ally to transgender people does not mean that you never get confused or make mistakes. It means that you are doing everything in your power to learn and to act in a respectful way, always--even when you don't quite understand.
  • Do take other people's identities seriously, even though it may not conform to your own ideas about gender or sex. Remember to treat other people's identities and choices with the respect that you would want for yourself.Do respect a person's choice of name/gender/pronoun. If a person expresses that they prefer a certain name or pronoun, take care to use only the name/gender/pronoun that they prefer, and strongly encourage others to do the same. This can take time to get used to, and most people do make mistakes--don't worry. The person is almost certainly used to mistakes. The important thing is that he or she knows that you respect their preference and are trying.Do act as an ally  If you notice non-inclusive language, suggest to the appropriate person that it be corrected. If you know that someone prefers a certain pronoun, it is appropriate to gently inform or remind someone else who is not using that correct pronoun.Do remember that you may be interacting with a transgender person and not know it.Do seek out information on your own. Transgender community members will be very appreciative of your efforts to learn about the experience of transgender people.  
  • The major purpose of the Standards of Care (SOC) is toarticulate this international organization's professional consensus about the psychiatric,psychological, medical, and surgical management of gender identity disorders. Professionalsmay use this document to understand the parameters within which they may offer assistance tothose with these conditions. Persons with gender identity disorders, their families, and socialinstitutions may use the SOC to understand the current thinking of professionals. All readersshould be aware of the limitations of knowledge in this area and of the hope that some of theclinical uncertainties will be resolved in the future through scientific investigation.
  • Transsexualism 08.09.11

    1. 1. Transsexualism Amirrah&Kulky I n t r o To S e x T h e r a p y J u l y 9 , 2 0 11 1
    2. 2. Terms and Definitions • Biological Sex • Gender o Gender Identity o Gender Role o Transgender and Transsexuals • Sexuality and Sexual Orientation (Dragowski, Scharron-del Rio, &Sandigorsky, 2011) 2
    3. 3. Process Questions: How do children know what their gender is and how to behave? Why do some children insist that their gender is not the one assigned to them at birth? 3
    4. 4. Famous Transgender People 4
    5. 5. Gender Identity Development: Nature • Anomalous prenatal hormonal influences • Anatomic brain differences • Genetic influences 5 (Gender Identity Research and Education Society, 2006)
    6. 6. Gender Identity Development: Nurture • Environmental influences begin before birth • Intrapsychic conflict stemming from environmental instability • Child’s temperament and problematic family environment • Socialization on gender development include: o Psychoanalytic theories o Learning theories o Social constructivism o Cognitive theories (Dragowski, Scharron-del Rio, &Sandigorsky, 2011) 6
    7. 7. DSM-IV-TR Diagnostic Criteria Gender Identity Disorder (GID) Criterion A: A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex) 1. Repeatedly stated desire to be, or insistence that he or she is, the other sex 2. In boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing 3. Strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex 4. Intense desire to participate in the stereotypical games and pastimes of the other sex 5. Strong preference for playmates of the other sex In adolescents and adults, disturbances are manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the 7 (APA, 2000) typical feelings and reactions of the other sex.
    8. 8. Criterion B: persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex Criterion C: disturbance is not concurrent with a physical intersex condition Criterion D: disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning *Specify: Sexually attracted to males, females, neither, or both (APA, 2000) 8
    9. 9. 9
    10. 10. DSM-V Revisions for GID • Rename to Gender Dysphoria • Integration of Criterion A and B into one criterion with at least 6 of 8 indicators necessary for diagnosis • Removal of distress/impairment criterion • Demonstration of “a strong desire to be of the other gender or an insistence that he or she is the other gender” as necessary for diagnosis • Replacement of the term sex with perceived gender to accommodate persons with disorders of sex development • 6-month duration requirement to distinguish between transient and more persistent conditions (APA, 10
    11. 11. Process Question: Do you think GID should be a mental disorder? 11
    12. 12. Treatment of GID 1) Diagnostic Assessment 2) Psychotherapy 3) Real-Life Experience 4) Hormone Therapy 5) Sex Reassignment Surgery (Jain &Bradbeer, 2007) 12
    13. 13. Diagnostic Assessment • History related to experience of gender discomfort • General medical examination • Psychiatric assessment o Common Co-morbidities: anxiety, depression, bipolar disorder, conduct disorder, substance abuse, dissociative identity disorders, borderline personality disorder, other sexual disorders and intersexedconditions • Assess need for psychotropic medications (Jain &Bradbeer, 2007) 13
    14. 14. Psychotherapy with Adults Goal 1: to provide education about alternative solutions, and to set realistic life goals for work and relationships while defining and alleviating person’s conflicts Goal 2: to help person live more comfortably with gender identity and to deal effectively with nongender issues (i.e.: capacity to work and to establish or maintain supportive relationships) Therapeutic Alliance: to establish reliable, trusting relationship accomplished by competent nonjudgmental exploration of gender issues (HBIGDA Standards of Care , 2001) 14
    15. 15. Process of Psychotherapy • Developmental process that can occur at every stage of gender evolution • Collaborative effort: help person understands concepts of eligibility and readiness • Not intended to cure GID • Long-term stable life style with realistic chances for success in relationships, education, work, and gender identity expression (HBIGDA Standards of Care , 2001) 15
    16. 16. Ten Tasks of the Mental Health Professional 1. 2. To accurately diagnose the individual's gender disorder To accurately diagnose any co-morbid psychiatric conditions and see to their appropriate treatment 3. To counsel the individual about the range of treatment options and their implications 4. To engage in psychotherapy 5. To ascertain eligibility and readiness for hormone and surgical therapy 6. To make formal recommendations to medical and surgical colleagues 7. To document their patient's relevant history in a letter of recommendation 8. To be a colleague on a team of professionals with an interest in the gender identity disorders 9. To educate family members, employers, and institutions about gender identity disorders 10. To be available for follow-up of previously seen gender patients (HBIGDA Standards of Care , 2001) 16
    17. 17. Real-Life Experience • Period of time (1-2 years) living in new or evolving gender role • Person must identify by change of name and documents • Person should continue employment, education or voluntary work • Provide evidence that others are aware of their new role (HBIGDA Standards of Care , 2001) 17
    18. 18. Hormone Therapy • Letter of Recommendation required from mental health professional • Medically necessary for successfully living in new gender role – lifelong process • Must meet Eligibility and Readiness criteria (HBIGDA Standards of Care , 2001) 18
    19. 19. Eligibility Criteria The administration of hormones is not to be lightly undertaken because of their medical and social risks. Three criteria exist. 1. Age 18 years 2. Demonstrable knowledge of what hormones medically can and cannot do and their social benefits and risks 3. Either: a) A documented real-life experience of at least three months prior to the administration of hormones; or b) A period of psychotherapy of a duration specified by the mental health professional after the initial evaluation (usually a minimum of three months) (HBIGDA Standards of Care , 2001) 19
    20. 20. Readiness Criteria Three criteria exist: 1) The patient has had further consolidation of gender identity during the real-life experience or psychotherapy; 2) The patient has made some progress in mastering other identified problems leading to improving or continuing stable mental health (this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis and suicidality); 3) The patient is likely to take hormones in a responsible manner. (HBIGDA Standards of Care , 2001) 20
    21. 21. Process Question: What if you are working with a client who is transitioning through hormones acquired illegally? 21
    22. 22. Sex Reassignment Surgery (SRS) • Irreversible procedure • Letters from 2 separate consultant psychiatrists (or clinical psychologists) are required • Eligibility Requirements: 12 months of continual hormonal therapy and 12 months of successful continuous full-time real-life experience, and also regular psychotherapy • Surgical components of SRS: Male-toFemale (MTF) and Female-to-Male (FTM) (HBIGDA Standards of Care , 2001) 22
    23. 23. People, Time, & Money • Referral process through mental health professionals and medical professionals • Average length of time before SRS: 4.5 years • Cost of Treatment (approx.) Doctors visits and lab tests: $500 Therapy: $1000 Hormones: $1500 MTF surgery: $17,000 Over 2-year transition period: $20,000 (Retrieved from http://www.tgender.net/taw/tsins.html) 23
    24. 24. Pre-Operation Health • The coming-out process among family and friends, and in the work environment • Those who choose not to get surgery, or who are waiting for surgery, may still experience social stigma or become preoccupied with the concept of “passing” (Retrieved from, http://www.videojug.com/expertanswer/transgender-what-does-it-mean/what-is-passing-for-atransgender-person#.TkBWfPC17NU.google) 24
    25. 25. Post-OperationSexual Health • 1 out of 4 Male-To-Females (MTF) reported decrease in libido o Low testosterone? • Female-To-Male (FTM) reported more difficulty in establishing a stable relationship post-op • Found that informing new partners on past has a positive effect on the relationship (de Cuypere et al., 2005) 25
    26. 26. Post-Op Sexual Health (cont’d) • Improved sex life • Contingent on finally having the right body with the right genitals • Some dissatisfaction in MTF occurred when there was dysfunctional vaginas • FTM reported masturbating more frequently (de Cuypere et al., 2005) 26
    27. 27. Post-Op Sexual Health (cont’d) • FTMs who chose to have penile prosthesis implanted had their sexual expectations more realized o Reported more pain during intercourse Could be due to reconstructed neural pathways Could be due to the prosthesis putting pressure on places where the constructed penis is attached. (de Cuypere et al., 2005) 27
    28. 28. Transition Considerations • Saving eggs or sperm prior to transition • Setting realistic goals and expectations • Teaching clients how to conduct Self-Breast Exams • Hormone therapy is life long • Instructing how to use vaginal dilators to avoid vaginal stenosis (built-up scar tissue that makes the vagina narrower) • Supportive relationships (Jain &Bradbeer, 2007) 28
    29. 29. Complications • • • • • • Infection Pain Regret Request for reversal Fistula Formation Scrotal tissue used for the neovagina may grow soft hair in the vaginal wall • Disappointment related to poor function and/or physical outcome • Suicide (Jain &Bradbeer, 2007) 29
    30. 30. General Guidelines When Asking Clinically Relevant Questions • Respect each person’s identity and experience • Instead of asking “What are you?” or “Are you a man or a woman?” try: “What is the respectful pronoun to use for you?” or “I’m interested in hearing about your gender identity if you are comfortable sharing” or “Is there anything that I/we/the community can do to make this a more comfortable place?” • Instead of asking about a person’s genitals or medical procedures, try: “How is your health?” 30 (Retrieved from http://amikaplan.net/trans.html)
    31. 31. General Guidelines (cont’d): Don’ts • Don't unnecessarily refer to a person's previous gender status • Don't insist that someone must be either a man or a woman • Don't say things like: "But you look like a woman!" or "But I've always known you as a man" or "But you made such a good/attractive woman” • Don't be afraid to say, "I don't understand, but I want to be respectful of you." 31 (Retrieved from http://amikaplan.net/trans.html)
    32. 32. General Guidelines (cont’d): Do’s • Do take other people's identities seriously, even though it may not conform to your own ideas about gender or sex • Do respect a person's choice of name/gender/pronoun • Do act as an ally • Do remember that you may be interacting with a transgender person and not know it • Do seek out information on your own 32 (Retrieved from http://amikaplan.net/trans.html)
    33. 33. 33
    34. 34. Recommended Resources • http://www.nationalhomeless.org/factsheet s/lgbtq.html • http://www.videojug.com/interview/sexchange-and-surgery-2 • http://ai.eecs.umich.edu/people/conway/T S/SRS.html#anchor50968 • http://www.katebornstein.typepad.com/ • http://amikaplan.net/trans.html • http://hbigda.org/Documents2/socv6.pdf 34
    35. 35. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2010). DSM-5 development: 302.6 Gender identity disorder in children: Proposed revision. Retrieved from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rig=192. Carroll, L., Gilroy, P. J., & Ryan, J. (2002). Counseling transgendered, transsexual, and gender-variant clients. Journal of Counseling and Development, 80(2): 131-139. Dragowski, E. A., Scharron-del Rio, M. R., &Sandigorsky, A. L. (2011). Childhood gender identity…Disorder? Developmental, cultural, and diagnostic concerns. Journal of Counseling & Development, 89: 360-366. Gender Identity Research and Education Society. (2006). Atypical gender development: A review. International Journal of Transgenderism, 9: 22-44. HBIGDA Standards of Care 6th version. (February 2001). Retrieved on July 2011, from http://hbigda.org/Documents2/socv6.pdf. Jain, A. &Bradbeer, C. (2007). Gender identity disorder: Treatment and post-transition care in transsexual adults. International Journal of STD & AIDS, 18: 147-150. 35

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