Transgender grand rounds


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  • Working through one’s own gender issues is an important first step to increasing competence with doing psychotherapy with transgender clients.
  • Psychoanalytic theories saw transgender individuals as victims of negative childhood events; some of these theories, for example, postulated that gender identity issues might stem from physically or emotionally absent parents, while others attributed transgender wishes or behavior to the influence of an overbearing mother (Brown & Rounsley, 1996). Transsexualism in DSM (1980): officially pathologized/mental illness GID: This diagnosis was an improvement over the diagnostic category of transsexualism in that it acknowledged that not all people with transgender expressions experience distress; unfortunately, it also furthered the perspective that, in order to be treated, gender variance had to be seen as an illness. Psychomedical gatekeeping: The process of “psychomedical gatekeeping” is defined as the practice that requires transgender people to acquire authenticating letters from one, or sometimes two, mental health professionals in order to obtain gender-confirming hormones or surgery (will discuss later)
  • But things are getting better…
  • So what does all this mean for psychotherapy?
  • Mental health screen/assessment can be sufficient
  • Posttranistion adjustment: passing and/or not passing
  • Depression: due to discrimination
  • Transgender grand rounds

    1. 1. By Erica Preston, Psy.D. CHC Grand Rounds June 28, 2013 CULTURALLY COMPETENT CARE FOR TRANSGENDER INDIVIDUALS
    2. 2. None Disclosures and Conflicts of Interest
    3. 3. Objectives  1) Define “transgender” and associated terminology  2) Be familiar with common barriers to quality health care faced by transgender individuals  3) Understand the issues surrounding access to hormones and/or surgery for transgender individuals  4) Know the risks and benefits of hormones and/or surgery for transgender individuals
    4. 4. Exploring your own relationship to gender When did you first realize that you had a “gender” – in other words, that you were a “girl” or a “boy” or “female” or “male”? Consider stories about your own evolving awareness of gender.
    5. 5. Sex vs. Gender  Sex: strictly biological (e.g. man or woman)  Gender: biological, cognitive, and social aspects of a human being, including identity, experience, and the expectations of others (e.g. masculine or feminine)
    6. 6. What if sex and gender don’t match?
    7. 7. Definitions and Vocabulary  The term transg e nde r is “…an umbrella term used to describe the full range of individuals who have a conflict with or question about their gender [including] everyone from transsexuals who desire surgery, those who have no desire to have surgery, and postoperative transsexuals to male and female transvestites, drag queens, female impersonators, male impersonators, gender benders, and people who are experiencing gender confusion but don’t know exactly where they fall along the gender spectrum….” (Brown & Rounsley, 1996, pp. 18).
    8. 8. Definitions and Vocabulary (cont.)  Transm an: individuals who were born into biologically female bodies but identify as male  Transwo m an: those who were born into biologically male bodies but are female- gendered
    9. 9. History of Pathology  Conceptualization of transgender behavior: disorder and pathology  Psychoanalytic theories (Brown & Rounsley, 1996).  “Transsexualism” in DSM in 1980  In 1994, “Gender Identity Disorder” (GID) replaced “Transsexualism” as the official diagnosis for gender non-conforming individuals (American Psychiatric Association, APA, 2000).
    10. 10. Barriers to Health Care  Lack of legal protection to prevent against discrimination by providers (Kammerer, Mason, & Connors, 1999)  Inadequate finances (Nemoto et al., 2005)  Providers who are not competent or willing  Negative past experiences with providers (Feinberg, 2001)  Psychomedical gatekeeping
    11. 11. But things are changing…
    12. 12. Changing view of gender/transgenderism: Postmodern Theory  Queer theorists believe that all categories (e.g. man and woman; straight and gay) are socially constructed in order to privilege one category over another.  They are changing the way that many people are looking at sex, gender, and sexual orientation. (Bornstein, 1994)
    13. 13. Transgender Theory  Gender and sex lie on a continuum (Denny, 2004).  Nontraditional gender expression is seen as “natural form of human variability” (Denny, 2004, p. 25).  Many transgender people now identify as “gender queer” (i.e. no gender category) rather than “male” or “female” (American Psychological Association Task Force on Gender Identity and Gender Variance, 2009).
    14. 14. Behavioral Health Counseling Approach
    15. 15. Behavioral Health: Approach to Counseling
    16. 16. BH Assessment
    17. 17. BH Assessment (cont)  May result in diagnosis of Gender Dysphoria  This dx may help gain access to medical interventions (WPATH, 2011)
    18. 18. BH Goals  To achieve long term comfort in gender identity role with realistic chances for success in their relationships, education, and work (WPATH, 2011)
    19. 19. Other Tasks of the Therapist  Educate and advocate on behalf of clients within their community (schools, workplaces, other organizations) and assist clients with making changes in identity documents.  Provide information and referral for peer support. (WPATH, 2011)
    20. 20. Common Concerns of Transgender Clients  Discrimination  Guilt and shame  Coping with loss  Sexual orientation  Post-transition adjustment  Disclosure (family therapy?)  Physical safety  Safe sex  Feelings of isolation  Religion  Public Bathroom  “I need a letter.” (Carlson, 2002)
    21. 21. Referral Letter for Hormones/Surgery 1. Identifying characteristics 2. Any diagnoses 3. Duration and type of counseling 4. A statement providing the rationale for medical intervention 4. A statement about the fact that informed consent has been obtained from the patient 6. A statement that the referring health professional is available for coordination of care (WPATH, 2011)
    22. 22. Common Comorbid Psychological Disorders  Depression  Substance abuse  Anxiety  Adjustment Disorders  PTSD (Israel & Tarver, 1997)
    23. 23. Transitioning to Medical Care
    24. 24. Be Aware of The Stigma Phenomenon
    25. 25. Primary Medical Treatment Options  HRT (Hormone Replacement Therapy): the masculinizing or feminizing hormones that transgender people inject in order to develop the secondary sex characteristics of the gender with which they identify  GCS (GenderConfirming Surgery): surgery undergone by some transgender people in order that their physical sex will match their gender identity
    26. 26. Other options: Alternatives to medical intervention Examples of other options: 1. Offline and online peer support resources, groups, or community organizations that provide avenues for social support and advocacy; 2. Hair removal-electrolysis, laser Tx, or waxing; 3. Breast binding or padding, genital tucking or penile prostheses, padding of hips or buttocks; 4. Changes in name and gender marker on identity documents. (WPATH, 2011)
    27. 27. Legal Rights and Processes
    28. 28. Primary Care Protocol for Working With Transgender Patients  Developed by UCSF in 2011 by eight physicians experienced in working with transgender patients  Based on critical review of medical literature on trans healthcare and physician experience
    29. 29.
    30. 30. Assessing Readiness for Hormones in Primary Care Setting  Informed consent model: Patient only needs to be able to understand risks and benefits and be sure about desire to transition
    31. 31. Assessing Readiness (cont.)  Risks are the same as for non-transgender people  Sample consent forms: hormone-ready  Only absolute medical contra-indication for hormones is estrogen or testosterone sensitive cancer  Other conditions should not preclude treatment, only affect dosing and preparation  Guide to dosing/prep: hormones
    32. 32. Assessing Readiness for Hormones (cont)  If patient does not seem to understand risks and benefits and/or does not seem sure, can refer to BH for assessment.  Simply the presence of a pre-existing MH condition should not preclude treatment or necessitate BH referral.
    33. 33. Baseline Labs
    34. 34. Follow-Up Care
    35. 35. Medical Transition: HRT
    36. 36. HRT for Transmen  Goal of HRT for transmen: to increase testosterone level so that it is in the high range for biological men  More successful than HRT for transwomen (Gorton, Buth, & Spade, 2005).  Changes are also more irreversible for transmen than for transwomen.
    37. 37. HRT for Transmen  Methods of administration: injection, a patch, gel, and buccal  Most begin on weekly injections  Takes one to four months to start working
    38. 38. HRT for Transmen: Changes  Skin will become thicker and more oily.  Redistribution of weight  Hair will increase and thicken  Libido will likely increase  Periods decrease or vanish  Emotional changes
    39. 39. HRT for Transmen: Risks  Most serious known risk is polycythemia, or the overproduction of red blood cells (Dept of Health, 2008)  Mood changes can be extreme, especially for those with preexisting depressive sx (Israel & Tarver, 1997)  Will reduce fertility, but can store eggs for future use
    40. 40. HRT for Transwomen
    41. 41. HRT for Transwomen: Changes  Breast growth (smaller than bio woman)  Body hair growth will lessen within several years, but facial hair will never completely disappear  Skin becomes thinner and less oily  Fat redistribution  Infertility is likely, but not definite
    42. 42. HRT for Transwomen: Risks  Not many studies on Long term effects  Risks are similar to non-transgender women taking hormones  May be additional risks that we do not know about
    43. 43. Gender Confirmation Surgery
    44. 44. GCS for Transwomen  Full process: breast augmentation, vaginoplasty (or less invasive alternatives), and other feminizing procedures that are not trans-specific operations.  Breast augmentation is usually performed by inserting saline-filled implants via an incision under the breast (Bowman & Goldberg, 2006).
    45. 45. GCS for Transwomen  Vaginoplasty (“bottom surgery”) is a procedure that has evolved significantly over time and has become relatively low in complications (Bowman & Goldberg 2006; Spehr, 2007).  However, the results are rarely perfect in that many people require multiple surgeries to optimize aesthetic results, lubrication is usually necessary for sexual intercourse, and pregnancy is impossible (Selvaggi et al., 2005).
    46. 46. GCS for Transmen  Only a minority of transmen do “bottom surgery”  Majority will pursue testosterone therapy and, subsequently “top surgery” or breast removal/reduction.  “Bottom surgery,” or genital reconstruction, includes hysterectomy and oophorectomy, vaginectomy and urethral lengthening, the creation of a phallus, and scrotoplasty (Bowman & Goldberg, 2007).
    47. 47. GCS for Transmen  Forearm flap method has become the treatment of choice (Krueger, Yekani, Hundt, & Daverio, 2007). This technique consists of fashioning a penis from a flap of skin on the forearm (Krueger et al., 2007).  It usually takes about one year for the new phallus to reach optimal functioning (Bowman & Goldberg, 2006)  97% of transmen who undergo full phalloplasty are happy with the results (Garrafa, Christopher, & Ralph,2009).
    48. 48. Satisfaction With Outcome  Research has shown overwhelmingly that, across countries, cultures, and types of medical intervention, incidences of regret among transgender people who undergo medical transition are very low.  A study that evaluated 19 patients who received GCS between 2000 and 2004 (ranging from one to 2.5 years following surgery) found that none of the patients regretted the procedure (Lobato et al., 2006).
    49. 49. Looking Forward  “Gender Dysphoria” will replace “GID” in new DSM  Advocates pushing for even more changes to diagnostic criteria (e.g. no diagnosis based on external stressors)
    50. 50. Discussion Questions 1. Is gender a concept that is becoming outdated? Is the ultimate future of human identity to be simply an individual on a totally open continuum between male and female behavior? 2. How do you feel about the diagnosis of GID? Should it be included in the DSM?
    51. 51. Case Study: Sheila  Age 53  MTF (Male-to-Female)  Has known for about five years that she would like to transition into a female body  Schizophrenia, well-controlled  Uses cocaine recreationally  Has obesity and heart disease
    52. 52. Case Study: Shelia  1) Discuss risks and benefits of HRT IN DETAIL ( http:// )  2) If she seems capable of understanding risks and benefits, you should move forward with HRT.  4) Conduct baseline labs.  5) Decide on dosing and preparation based on any pre-existing medical issues.  6) F/u at 4 weeks, 3 months, 6 months, and every 6-12 months thereafter.  7) Possibly refer for surgical interventions
    53. 53. Case Study: Aidan  Age 25  For the past few months, has been questioning gender identity  Bipolar Disorder, symptomatic, not on medication  No SA problems  No medical issues
    54. 54. Case Study: Aidan (cont.)  1) Refer to BH provider familiar with trans issues for an assessment.  2) Move forward with HRT if and when BH provider makes recommendation.  3) Stay in contact with BH provider to coordinate care throughout the transition process.
    55. 55. Finally….  This is a complicated journey for patients  Collaboration of Medical-Behavioral health and other providers essential, as is cultural competency and sensitivity
    56. 56. Educational and Clinical Resources  Center of Excellence for Transgender Health, University of California, San Francisco, Department of Family and Community Medicine.  World Professional Association for Transgender Health (WPATH)  Gender Spectrum (trans youth focus)
    57. 57. Legal and Patient Advocate Resources  Transgender Law and Policy Institute  Transgender Law Center  National Center for Lesbian Rights  National Center for Transgender Equality  Lambda Legal
    58. 58. Transitioning