The document provides an overview of the history and current standards of care for treating transgender individuals. It discusses the evolution of diagnostic criteria and treatment protocols over time, from early experimentation in the 1900s to current guidelines. The current standards outlined in the Harry Benjamin Standards of Care include requirements for mental health professionals to accurately diagnose individuals, provide psychotherapy, and make formal treatment recommendations. It also outlines the current diagnostic criteria for gender identity disorder under the DSM-IV and protocols for psychotherapy, hormone therapy, and gender-affirming surgery.

1. Trauma in the
Transgender Community:
Revisiting Best Practice
By Morganne Ray
SWSS 380 Transformative Social Work Approaches to
Violence in Multiple Communities
University of Vermont
November 11, 2010

2. Transgender 101
Sex – assignment (generally made at birth) based on external and internal reproductive organs,
hormones, secondary sex characteristics, chromosomes, etc.
Gender – an individual’s internal sense of being masculine and/or feminine and their expression of that
identity
Transgender – an umbrella term for people whose gender expression and gender identity fall outside
constructed gender norms.
Transsexual – generally used to identify transgender individuals who are seeking to physically transition
Cisgender – refers to individuals whose gender identity and expression correspond with the gender they
were assigned at birth.
MtF and FtM – abbreviations for Male-to-Female and Female-to-Male, most often referring to
transsexual individuals
Sexual Reassignment Surgery – also known as SRS, GRS or “bottom surgery”, required by many states in
order to have legal documentation changed
Gender Dysphoria – clinical language for the experience of one’s gender identity not matching one’s
assigned sex
Cis-sexim – also known as “genderism”, The system of oppression which promotes beliefs and behaviors
that privilege gender normativity and cisgender identities over other forms of gender identity and
expression.
Transphobia – The irrational fear and oppression of gender variant or transgender people and/or the
inability to understand/deal with/cope with gender ambiguity and gender variance.

3. acault, agender, ambigender, ambiguous, androgyne, androgynous, anomalous, bent,
berdache, between-
genders, bigender, bioboy, biogirl, birl, boi, both, boy, boychick, boydyke, brother, bul
l dyke, burl, butch, butchdyke, byke, crossdresser, daddy, diesel dyke, drag hag, drag
king, drag prince, drag princess, drag
queen, dyke, effeminate, either, enaree, epicene, faerie, fag, fairy, fellagirlie, feminist,
femme, fluid, fourth gender, freak, FTX, gender bender, gender free, gender
gifted, gender neutral, gender noncomforming, gender normative, gender
outlaw, gender refusenik, gender transcender, gender
variant, genderbent, gendered, genderfuck, genderqueer, genderstraight, gink, girl, gir
lfag, goy, grrl, gurl, guy, guydyke, gynandroid, gyrl, hard, hermaphrodyke, high
femme, hijra, homovestite, intergender, khal, lady, ladyboy, lesbro, low
femme, MTX, mahu, man, man-
chick, me, merm, mesbian, metamorph, midgender, mixed-
gendered, monogender, mukhannathun, multigender, mutarajjulat, neither, nelly, neu
ter neutral, neutrois, new man, new woman, no-gender, none of the above, none of
your business, nongender, omnigender, other, other-
gendered, pangender, pansy, person, plumber
femme, polygender, poof, pregender, prettyboy, queen, queer, questioning, sekrata, s
elf-defined, shapeshifter, shemale, single-gender, sir, sissy, sister, soft butch, static
gendered, stone butch, stone femme, switch, tg butch, third
gender, tomboy, tomgirl, tranny, trannyboy, trannygirl, transboy, transdyke, transsexu

4. History of Treatment for Transgender
Individuals
1910 – Vienna scientists experimenting on changing the sex of animals (Meyerowitz, 2002)
1920 – doctors in Berlin claimed to have successfully changed the sex of human patients (Meyerowitz, 2002)
1931 – Lili Elbe, one of the first recipient of modern sexual reassignment surgery, receives the first of five surgeries
(Hoyer, 2004)
1946 – Michael Dillion, likely the first transman to transition utilizing surgery and hormones, undergoes the first of 13
surgeries (Kennedy, 2007)
1949 – Psychopathia Transexualis by D. O. Cauldwell is published in Sexology Magazine, coining the term “transexual”
(Meyerowitz, 2002)
1964 – Erickson Educational Institute was founded by Reed Erikson, a wealthy transman, to conduct research, provide
care, and educate doctors on providing for their transgender patients (Meyerowitz, 2002)
1970 – UCLA Gender Clinic finally formally recognized the existence of female to male transsexuals (Meyerowitz 2002)
1979 – Harry Benjamin International Gender Dysphoria Association (HBIGDA) was founded and the first version of the
Harry Benjamin Standards of Care are published (WPATH, 2010)
1980 – “Transsexualism” was introduced in the DSM III (Meyerowitz 2002)
1994 – “Gender Identity Disorder” is introduced in the DSM IV (Meyerowitz, 2002)
2005 – most recent version of the Harry Benjamin Standards of Care is published (WPATH, 2010)
2006 – HBIGDA changed its name to the World Profe ssional Association for Transgender Health (WPATH) (WPATH,
2010)

5. Current Standards of Care

6. Current Diagnostic Criteria
Gender Identity Disorder
A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages
of being the other sex)… In adolescents and adults, the disturbance is 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 typical feelings and reactions of the other sex.
B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex… In
adolescents and adults, the disturbance is manifested by symptoms such as 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 simulate the other sex) or belief that he or she was born the wrong
sex.
C. The disturbance is not concurrent with a physical intersex condition.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
Code based on current age:
302.6 Gender Identity Disorder in Children
302.85 Gender Identity Disorder in Adolescents or Adults
Specify if (for sexually mature individuals):
Sexually Attracted to Males
Sexually Attracted to Females
Sexually Attracted to Both
Sexually Attracted to Neither

7. Current Treatment Protocol:
Harry Benjamin Standards of Care
Harry Benjamin Standards of Care states that mental health care providers
are required:
1. To accurately diagnose the individual's gender disorder
2. 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

8. Current Treatment Protocol
Diagnostic Assessment
The Mental Health Professional’s Documentation Letter for Hormone Therapy or Surgery Should Succinctly Specify:
1. The patient's general identifying characteristics;
2. The initial and evolving gender, sexual, and other psychiatric diagnoses;
3. The duration of their professional relationship including the type of psychotherapy or evaluation that the patient
underwent;
4. The eligibility criteria that have been met and the mental health professional’s rationale for hormone therapy or surgery;
5. The degree to which the patient has followed the Standards of Care to date and the likelihood of future compliance;
6. Whether the author of the report is part of a gender team;
7. That the sender welcomes a phone call to verify the fact that the mental health professional actually wrote the letter as
described in this document.
The organization and completeness of these letters provide the hormone-prescribing physician and the surgeon an important
degree of assurance that mental health professional is knowledgeable and competent concerning gender identity disorders.
One Letter is Required for Instituting Hormone Therapy, or for Breast Surgery. One letter from a mental health professional,
including the above seven points, written to the physician who will be responsible for the patient’s medical treatment, is
sufficient for instituting hormone therapy or for a referral for breast surgery (e.g., mastectomy, chest reconstruction, or
augmentation mammoplasty).
Two Letters are Generally Required for Genital Surgery. Genital surgery for biologic males may include orchiectomy,
penectomy, clitoroplasty, labiaplasty or creation of a neovagina; for biologic females it may include hysterectomy, salpingo-
oophorectomy, vaginectomy, metoidioplasty, scrotoplasty, urethroplasty, placement of testicular prostheses, or creation of a
neophallus.

9. Current Treatment Protocol
Psychotherapy
Activities:
Biological Males:
1. Cross-dressing: unobtrusively with undergarments; unisexually; or in a feminine fashion;
2. Changing the body through: hair removal through electrolysis or body waxing; minor plastic cosmetic surgical
procedures;
3. Increasing grooming, wardrobe, and vocal expression skills.
Biological Females:
1. Cross-dressing: unobtrusively with undergarments, unisexually, or in a masculine fashion;
2. Changing the body through breast binding, weight lifting, applying theatrical facial hair;
3. Padding underpants or wearing a penile prosthesis.
Both Genders:
1. Learning about transgender phenomena from: support groups and gender networks, communication with peers via the
Internet, studying these Standards of Care, relevant lay and professional literatures about legal rights pertaining to work,
relationships, and public cross-dressing;
2. Involvement in recreational activities of the desired gender;
3. Episodic cross-gender living.
Processes:
1. Acceptance of personal homosexual or bisexual fantasies and behaviors (orientation) as distinct from gender identity and
gender role aspirations;
2. Acceptance of the need to maintain a job, provide for the emotional needs of children, honor a spousal commitment, or
not to distress a family member as currently having a higher priority than the personal wish for constant cross-gender
expression;
3. Integration of male and female gender awareness into daily living;
4. Identification of the triggers for increased cross-gender yearnings and effectively attending to them; for instance,
developing better self-protective, self-assertive, and vocational skills to advance at work and resolve interpersonal struggles
to strengthen key relationships.

10. Current Treatment Protocol
Real-Life Experience
Parameters of the Real-Life Experience. When clinicians
assess the quality of a person's real-life experience in the
desired gender, the following abilities are reviewed:
1. To maintain full or part-time employment;
2. To function as a student;
3. To function in community-based volunteer activity;
4. To undertake some combination of items 1-3;
5. To acquire a (legal) gender-identity-appropriate first name;
6. To provide documentation that persons other than the
therapist know that the patient functions in the desired
gender role.

11. Current Treatment Protocol
Hormone Therapy
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
3. The patient is likely to take hormones in a responsible manner.

12. Current Treatment Protocol
Surgical Therapy
Eligibility Criteria. These minimum eligibility criteria for various genital surgeries equally apply
to biologic males and females seeking genital surgery. They are:
1. Legal age of majority in the patient's nation;
2. Usually 12 months of continuous hormonal therapy for those without a medical
contraindication
3. 12 months of successful continuous full time real-life experience. Periods of returning to
the original gender may indicate ambivalence about proceeding and generally should not be
used to fulfill this criterion;
4. If required by the mental health professional, regular responsible participation in
psychotherapy throughout the real-life experience at a frequency determined jointly by the
patient and the mental health professional.
5. Demonstrable knowledge of the cost, required lengths of hospitalizations, likely
complications, and post-surgical rehabilitation requirements of various surgical approaches;
6. Awareness of different competent surgeons.
Readiness Criteria. The readiness criteria include:
1. Demonstrable progress in consolidating one’s gender identity;
2. Demonstrable progress in dealing with work, family, and interpersonal issues resulting in a
significantly better state of mental health

13. Proposed Diagnostic Criteria
Gender Incongruence (in Adolescents or Adults)
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of
at least 6 months duration, as manifested by two (or more) of the following indicators:
1. a marked incongruence between one’s experienced/expresses gender and primary and/or
secondary sex characteristics (or, in young adolescents, the anticipated secondary sex
characteristics)
2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a
marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a
desire to prevent the development of the anticipated secondary sex characteristics)
3. a strong desire for the primary and/or secondary sex characteristics of the other gender
4. a strong desire to be of the other gender (or some alternative gender different from one’s
assigned gender)
5. a strong desire to be treated as the other gender (or some alternative gender different from
one’s assigned gender)
6. a strong conviction that one has the typical feelings and reactions of the other gender (or some
alternative gender different from one’s assigned gender)
Code based on type:
With a disorder of sex development
Without a disorder of sex development

14. Barriers to services?
 Stigmatization of Gender Identity Disorder as a mental
illness
 Misclassification of Sexual Reassignment Surgery as
“elective” or “experimental” thus eliminating
insurance coverage
 Absence of FDA approval for the “off label” use of
estrogen and testosterone for hormone therapy
 Lack of training within the Mental Health and Medical
professions
 Unavailability of services for individuals not seeking
medical transition

15. Current Guidelines for
Culturally Competent Care

16. Competencies for Counseling with
Transgender Clients
American Counseling Association Governing Council
A. Human Growth and Development
B. Social and Cultural Foundations
C. Helping Relationships
D. Group Work
E. Professional Orientation
F. Career and Lifestyle Development Competencies
G. Appraisal
H. Research

17. Principles of Gender-Specialty
Practice
Transgender Care
by Gianna E. Israel and Donald E. Tarver II M.D.
 Familiarity with suicide and crisis prevention
 A basic ability to recognize mental health disorders requiring
appropriate referral
 An ability to promote consumer awareness of critical
gender-oriented consumer needs
 Appropriate intervention and educational skills relating to
“safer sex” and sexually transmitted disease
 An understanding of basic gender and sexual-identity
related concerns

18. Generic Transpositive Therapeutic
Model
International Journal of Transgenderism
1. Clinical orientation/treatment philosophy
2. Assessment considerations
3. Treatment considerations
4. Therapeutic relationship
5. Comprehensive case management
6. Accountability and quality assurance
7. Advocacy and alliance building
8. Knowledge base and professional development
9. Research

19. Clinical Definition of Trauma
Trauma - event in which both of the following were
present:
(1) the person experienced, witnessed, or was
confronted with an event or events that
involved actual or threatened death or serious
injury, or a threat to the physical integrity of self
or others; and
(2) the person's response to the trauma involved
intense fear, helplessness, or horror. (DSM IV-
TR)

20. Other Common Experiences
 Perceiving the lack of safety, fear of transphobic violence and decreased feelings of power
and control due to fear of being “discovered” (Dean, 2000)
 Loosing friends, family, jobs or community standing upon disclosure (Israel, 1997)
 Not having access to social support systems or positive role models (Burdge, 2007)
 Internalizing the socially constructed gender binary due to the expectations of the Standards
of Care, and thus experiencing extreme intrapsychic pressure to pick either a male or female
body or gender identity (Burdge, 2007)
 Altering their own life stories to better match the pathologic model favored by the
institution and academic physicians and psychologists providing medical care (Israel, 1997)
 Dealing with providers who offer hormones, illegal silicone injections, and surgical
procedures without informed consent, appropriate standards of care, or adequate follow-up
(Dean, 2000)
 Facing refusal to treat, inappropriate intake forms, insensitivity, involuntary disclosure and
general trasphobic atmospheres in healthcare settings (Xavier, 2000)
 Self-mutilating, accessing unlicensed doctors and utilizing street hormones due to the
inaccessibility appropriate of health care (Burdge, 2007)

21. Statistics
 54% reported they had been sexually assaulted (Kenagy, 2005)
 47% reported they had been physically assaulted (Wilchins et al., 1997)
 75% of transgender sex workers had been assaulted by a customer
(Valera et al., 2001)
 23% of transgender sex workers met the clinical definition of PTSD
(Valera et al., 2001)
 30% attempted suicide, and of those 67% reported the attempt was
related to their gender identity (Kenagy, 2005)
 47% have no health insurance (Xavier, 2000)
 26% reported being denied health care (Kenagy, 2005)
 37% experienced workplace discrimination including firing, demotions
and unjust disciplinary actions (Wilchins et al., 1997)

22. How is this trauma?
 The repetitive nature of the incidents can make the experience traumatic. One incident
alone may not be traumatizing, but multiple microaggressions can build to create an intense
traumatic impact. (Bryant-Davis & Ocampo, 2005)
 Being targeted by someone who was formerly trusted can be particularly traumatizing even
when the incident does not rate as severe from an outsider’s perspective. Part of the
violation is based on the emotional experience of being betrayed by someone who was
trusted. (Bryant-Davis & Ocampo, 2005)
 The severity of the emotional impact due to the incident is increased when public
humiliation and perhaps the lack of public intervention are involved. (Bryant-Davis &
Ocampo, 2005)
 Covert incidents are never far from one’s consciousness and require constant expenditures
of cognitive energy, hypervigilance, and coping. (Bryant-Davis & Ocampo, 2005)
 Existing models for identity-based understandings of trauma include : cumulative trauma,
postcolonial syndrome, postslavery syndrome, intergenerational trauma, and historical
trauma. (Bryant-Davis & Ocampo, 2005) However unlike trauma based on religion or race,
transpeople often lack the social support available within the family of origin around shared
identities.

23. Assumptions
 Cis-sexism is a pervasive, institutional and social
system of oppression which negatively affects all
individuals, particularly gender variant and
transgender people
 To experience oppression is to experience
trauma
 Individuals process traumatic experiences
differently, have access to a variety of support
networks and possess varying levels of resiliency

24. Central Philosophy
In order to provide truly competent care for transgender
clients, providers must:
 Understand transgender identities, treatment options,
and the shortcomings of current standards or care
and
 Understand the traumatic implications of cis-sexism
and transphobia, neurobiological and psychological
effects of trauma, and trauma-specific treatment
models.

25. Guiding Concepts
 Screening and Assessment
 Develop and implement trans-positive, trauma-informed screening and
assessment tools
 Accurately identify symptoms of trauma and co-morbid concerns
 Safety
 Allow client control over the space and the process
 Ensure the client has safe places to be and all basic needs are met
 Self-Care
 Facilitate learning self regulation and sensory integration practices
 Facilitate access of avenues for self expression
 Trauma-Specific Treatment
 Utilize clinical models such as EMDR or Trauma Focused Cognitive Behavioral
Therapy
 Alternative treatments such as dance, yoga, massage, art or meditation
 Self Advocacy
 Empower clients to participate in activism and community building
 Provide opportunities for client to “fight back” against the trauma

26. References
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC:
Author
American Psychiatric Association (2010). 302.85 Gender Identity Disorder in Adolescents or Adults. Dsm-5 development. Retrieved
November 4, 2010, from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=482#
Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling. (2009). Competencies for Counseling with Transgender Clients.
Alexandria: American Counseling Association Governing Council.
Burdge, B. (2007, July). Bending gender, ending gender: Theoretical foundations for social work practice with the transgender community.
Social Work, 52(3), 243-250.
Bryant-Davis, T., & Ocampo, C. (2005, July). The trauma of racism: Implications for counseling, research, and education. The Counseling
Psychologist, 33(4), 574-578.
Dean, L. et al. (2000). Lesbian,Gay,Bisexual, and Transgender Health: Findings and Concerns. Journal of the Gay and Lesbian Medical
Association. 4 (3): 101-151)
Hoyer, N. (2004). Man into Woman: The First Sex Change. London: Blue Boat Books Ltd.
Kenagy, G. P.(2005). The health and social service needs of transgender people in Philadelphia. International Journal of Transgenderism,
3(2/3), 49-56.
Kennedy, P. (2007). The First Man-Made Man: The Story of Two Sex Changes, One Love Affair, and a Twentieth-Century Medical Revolution.
New York: Bloomsbury USA.
Meyerowitz, J. (2002). How sex changed: A history of transsexuality in the United States. Cambridge, MA: Harvard University Press.
Raj, R. (2002). Towards a transpositive therapeutic model: Developing clinical sensitivity and cultural competence in the effective support
of transsexual and transgendered clients. International Journal of Transgenderism, 6(2), 1-47.
Valera, R. J., Sawyer, R. G., & Schiraldi, G. R. (2001). Perceived health needs of inner-city street prostitutes: A preliminary study. American
Journal of Health Behavior, 25, 50–59.
Wilchins R, Lombardi E, Priesing D, & Malouf, D. (1997) The First National Survey on TransViolence. Gender Public Advocacy Coalition, New
York, NY.
WPATH. (2010). World Professional Association for Transgender Health. Retrieved November 2, 2010, from www.wpath.org
Xavier, J. M. (2000). The Washington D.C. transgender needs assessment survey: Final report for phase two. District of Columbia
Government.