This document provides information on culturally competent care for transgender individuals. It begins by defining key terms like transgender, transman, and transwoman. It then discusses barriers to healthcare transgender people often face, like discrimination and lack of provider competence. The document outlines a behavioral health approach to counseling transgender clients, including assessment, goals, and common concerns addressed in therapy. It also reviews primary medical treatment options like hormone replacement therapy and gender confirmation surgery. Case studies are presented to demonstrate how to approach medical transitioning while considering any comorbid psychological or medical conditions. Resources for both providers and transgender individuals are provided.

1. By Erica Preston, Psy.D.
CHC Grand Rounds June 28, 2013
CULTURALLY COMPETENT CARE FOR
TRANSGENDER INDIVIDUALS

2. None
Disclosures and Conflicts of
Interest

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. 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.

6. 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)

9. What if sex and gender don’t match?

10. 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).

11. 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

12. 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).

13. 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

14. But things are changing…

15. 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)

16. 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).

19. Behavioral Health Counseling
Approach

20. Behavioral Health: Approach to
Counseling

21. BH Assessment

22. BH Assessment (cont)
 May result in diagnosis of Gender Dysphoria
 This dx may help gain access to medical
interventions
(WPATH, 2011)

23. BH Goals
 To achieve long term comfort in gender identity role with
realistic chances for success in their relationships,
education, and work
(WPATH, 2011)

24. 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)

25. 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)

26. 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)

27. Common Comorbid Psychological
Disorders
 Depression
 Substance abuse
 Anxiety
 Adjustment Disorders
 PTSD
(Israel & Tarver, 1997)

28. Transitioning to Medical Care

29. Be Aware of The Stigma
Phenomenon

30. 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

31. 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)

32. Legal Rights and Processes

33. 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

34. http://transhealth.ucsf.edu/trans?page=protocol-00-00

35. 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

36. Assessing Readiness (cont.)
 Risks are the same as for non-transgender people
 Sample consent forms:
http://transhealth.ucsf.edu/trans?page=protocol-
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:
http://transhealth.ucsf.edu/trans?page=protocol-
hormones

37. 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.

38. Baseline Labs

39. Follow-Up Care

40. Medical Transition: HRT

41. 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.

42. 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

43. 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

44. 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

45. HRT for Transwomen

46. 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

47. 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

48. Gender Confirmation Surgery

49. 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).

50. 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).

51. 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).

52. 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).

53. 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).

54. 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)

55. 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?

56. 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

57. Case Study: Shelia
 1) Discuss risks and benefits of HRT IN DETAIL (
http://
transhealth.ucsf.edu/trans?page=protocol-hormone-re
)
 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

58. 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

59. 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.

60. Finally….
 This is a complicated journey for patients
 Collaboration of Medical-Behavioral health
and other providers essential, as is cultural
competency and sensitivity

61. 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)

62. 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

63. Transitioning