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Transgender and Gender Identity Issues (higher central academic course)

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Title: Transgender and Gender Identity Issues (higher central academic course)


1
Transgender and Gender Identity Issues (higher
central academic course)
  • Sam Winter and Jackie,
  • Kwai Chung Hospital, 8th Jan 2010

2
This session
  • Sex, gender, sexuality and transgender people
  • key terms and background information.
  • Jackies story growing up
  • Cultural, social and legal issues for transgender
    people.
  • Jackies experiences and opinions
  • Mental health work with transgender people
  • diagnosis and treatment issues
  • Jackies experiences, opinions and
    recommendations
  • Q and A

3
Sex, gender and sexuality
4
  • When we are born each of us is labelled boy or
    girl
  • As we grow up, most of us learn to think of
    ourselves as either male or female, and adopt the
    appearance, behaviour, interests and traits
    associated with being male or female in our
    culture
  • Most of us develop patterns of attraction
    (physical, romantic, erotic) males to females,
    females to males.

5
  • When we are born each of us is labelled boy or
    girl SEX
  • As we grow up, most of us learn to think of
    ourselves as either male or female, and adopt the
    appearance, behaviour, interests, and traits
    associated with being male or female in our
    culture
  • Most of us develop patterns of attraction
    (physical, romantic, erotic) males to females,
    females to males.

6
  • When we are born each of us is labelled boy or
    girl SEX
  • As we grow up, most of us learn to think of
    ourselves as either male or female, and adopt the
    appearance, behaviour, interests, and traits
    associated with being male or female in our
    culture GENDER
  • Most of us develop patterns of attraction
    (physical, romantic, erotic) males to females,
    females to males.

7
  • When we are born each of us is labelled boy or
    girl SEX
  • As we grow up, most of us learn to think of
    ourselves as either male or female, and adopt the
    appearance, behaviour, interests and traits
    associated with being male or female in our
    culture GENDER
  • We develop patterns of attraction (physical,
    romantic, erotic) males to females, females to
    males. SEXUALITY


8
  • When we are born each of us is labelled boy or
    girl SEX
  • As we grow up, most of us learn to think of
    ourselves as either male or female, and adopt the
    appearance, behaviour, interests and traits
    associated with being male or female in our
    culture GENDER
  • Most of us develop patterns of attraction
    (physical, romantic, erotic) males to females,
    females to males. SEXUALITY


9
1. Sexuality about sexual attraction
(libido), sexual preference, sexual behaviour,
sexual identity
  • Two traditional categories heterosexual
    (straight) v homosexual (gay / lesbian)
  • Homosexuals have been viewed as deviant, immoral,
    criminal, mentally ill.
  • Shift in opinion different not disordered.
  • Two extremes of a continuum Bisexuality very
    common, at least over a life span.

10
1. Sexuality about sexual attraction
(libido), sexual preference, sexual behaviour,
sexual identity
  • Two traditional categories heterosexual
    (straight) v homosexual (gay / lesbian)
  • Homosexuals have been viewed as deviant, immoral,
    criminal, mentally ill.
  • Shift in opinion different not disordered.
  • Two extremes of a continuum Bisexuality very
    common, at least over a life span.

11
2. Sex our biological status as male / female.
Four aspects
  • Chromosomes
  • ( XY v XX )
  • Gonads (sex glands)
  • (testes (testicles) v ovaries)
  • Hormones
  • (androgens (e.g.. testosterone) v oestrogen,
    progesterone)
  • Genitals (sex organs)
  • (penis, scrotal sac v clitoris, vagina / womb)


12
2. Sex our biological status as male / female.
Four aspects
  • Chromosomes
  • ( XY v XX )
  • Gonads (sex glands)
  • (testes (testicles) v ovaries)
  • Hormones
  • (androgens (e.g.. testosterone) v oestrogen,
    progesterone)
  • Genitals (sex organs)
  • (penis, scrotal sac v clitoris, vagina / womb)


13
A fifth aspect of biological sex?
  • Brain Sex

14
A fifth aspect of biological sex?
  • Brain Sex

15
3. Gender
  • about gender identity how you see yourself (male
    or female) and want to live
  • about gender stereotypes (gender norms) your own
    and your cultures beliefs about what behaviour,
    interests, traits, appearance males and females
    typically (and/or ideally?) display
  • about gender performance (gender expression)
    your own behaviour, interests, traits and
    appearance (consistent with those gender
    stereotypes and your own gender identity)

16
3. Gender
  • about gender identity how you see yourself (male
    or female) and want to live
  • about gender stereotypes (gender norms) your own
    and your cultures beliefs about what behaviour,
    interests, traits, appearance males and females
    typically (and/or ideally?) display
  • about gender performance (gender expression)
    your own behaviour, interests, traits and
    appearance (consistent with those gender
    stereotypes and your own gender identity)

17
3. Gender
  • About how you develop
  • not what you are like in your mothers womb
  • About psychology
  • (though there may be roots in biology)
  • About what is between your ears
  • (not between your legs,,,,or inside your body!)


18
Transgender people
19
Transgender people (transpeople)
  • Transgender people grow up identifying and
    wanting to express as members of another gender
    (i.e. different to the one associated with their
    birth-assigned sex)
  • Gender expression
  • Behaviour
  • Interests
  • Traits
  • Appearance
  • Gender variance
  • Gender identity
  • as a member of the other gender, or, in some
    cultures, as a third sex (or a blend of
    genders).
  • Gender identity variance (GIV)

20
Transgender people (transpeople)
  • Transgender people grow up identifying and
    wanting to express as members of another gender
    (i.e. different to the one associated with their
    birth-assigned sex)
  • Gender expression
  • Behaviour
  • Interests
  • Traits
  • Appearance
  • Gender variance
  • Gender identity
  • as a member of the other gender, or, in some
    cultures, as a third sex (or a blend of
    genders).
  • Gender identity variance (GIV)

21
(No Transcript)
22
Transgender people more information
  • Transwomen (assigned male at birth, but
    identifying as female)
  • (transgender women, MtF transpeople, women
    of transgender experience)
  • Transmen (assigned female at birth, but
    identifying as male)
  • (transgender men, FtM transpeople, men of
    transgender experience )
  • May make the gender transition (towards
    presenting socially in accordance with their
    identity)
  • May undergo sex / gender reassignment surgery (
    sex / gender confirmation surgery)
  • Transsexual people


23
Transgender people more information
  • Transwomen (assigned male at birth, but
    identifying as female)
  • (transgender women, MtF transpeople, women
    of transgender experience)
  • Transmen (assigned female at birth, but
    identifying as male)
  • (transgender men, FtM transpeople, men of
    transgender experience )
  • May make the gender transition (towards
    presenting socially in accordance with their
    identity)
  • May undergo sex / gender reassignment surgery (
    sex / gender confirmation surgery)
  • Transsexual people


24
Transgender people more information
  • Often believed to be low prevalence.
  • DSM-IV-TR cites figures for adults approx
    130,000 males / 1100,000 females
  • From clinic studies (i.e. transsexual people).
  • From old studies (in UK number approaching
    clinics doubling every 5 years)
  • But what about those who do not approach clinic?
  • e.g. non-op transgender people?
  • e.g. those who are GIV but choose not to
    transition?

25
Transgender people more information (Hong Kong)
  • Centralised Gender Clinic 1985-2006, making
    possible an incidence study
  • 34 transsexuals referred for assessment for SRS
    over 11 years (1.1.1991-31/12/2001).
  • 15 females (birth-assigned), 13 males
    (birth-assigned)
  • 6 did not satisfy diagnostic criteria.
  • People dont know about service?
  • People referred for other treatment?
  • People going elsewhere? for hormones? for
    surgery?
  • A rise in referrals inevitable.

John Ko A Descriptive Study of Sexual
Dysfunction and Gender Identity Clinic in the
University of Hong Kong Psychiatric Unit.
Extracts from a HKCP dissertation, posted on the
TransgenderASIA website.
26
Transgender people who they are not
  • Not the same as transvestites (cross-dressers)
  • who they feel they are,,,,,,,,
  • not simply how they like to dress.
  • Its about gender identity

27
Transgender people who they are not
  • Not a subset of homosexuals
  • who they feel they are ,,,,,,
  • not who they are attracted to.
  • (its about gender identity,,, not the same as
    sexuality).
  • Many adult transpeople are heterosexual
  • boys who grew up to be women who like men
  • girls who grew up to be men who like women
  • Some are homosexual
  • boys who grew up to be women who like women
  • girls who grew up to be men who like men

28
.Do gender identity variant children always grow
into transgender adults?
  • Most GIV children appear to become adults who
    are not transgender adults
  • A GIV boy may grow up happy to be a man.
  • A homosexual man? (46)
  • A heterosexual man? (23)
  • But some do become transgender people as adults
    (5)
  • and there are a lot more we dont know about
    (26)
  • And many transgender adults recall being GIV
    children.

Figures from Zucker, K. (1985). Cross-gender
Identified Children. In Steiner,B. (Ed.) Gender
Dysphoria. New York Plenum.
29
Is transgender a modern and western phenomenon?
  • Universal phenomenon
  • throughout history and across cultures.
  • evidence for a biological factor (brain sex?)
  • Transgender people can now change appearance with
    hormones and surgery
  • sex / gender reassignment surgery (SRS / GRS).

30
Transgender people some key points to remember
  • Its not just about gender expression, its about
    gender identity.
  • About psychology, not biology (but there may be
    biological causes).
  • A mismatch between mind and body.
  • desire to live as, be, a member of another
    gender.
  • Universal and timeless aspect of human diversity
  • Not the same as transvestism or homosexuality.
  • GIV often starts in childhood, sometimes persists
    into adulthood.
  • Some transpeople want to undergo sex reassignment
    surgery

31
Jackies story growing up
32
Transgender people cultural, social and legal
issues
A focus on Asia-Pacific
This next section based on a presentation at a
meeting (Bangkok, 13-16 Dec 2009) to set up the
Asia and Pacific Transgender Network (APTN)
33
Transgender people cultural, social and legal
issues
  • Large population

34
Large population CLINIC STUDIES
Iran 12200 13300 (transpeople)
Taiwan 11030 (transpeople)
Singapore 12900 (transwomen) 18300 (transmen)
35
Large population COMMUNITY ESTIMATES
India 1600 (transwomen)
Thailand 1300 (transwomen)
Malaysia 175 to1150 (transwomen)
36
Transgender people cultural, social and legal
issues
  • Large population
  • Deep cultural roots and old social roles

37
Deep cultural roots a place in society for
transpeople
  • Japan
  • China, Korea,
  • Myanmar, Laos, Thailand,
  • Indonesia, Oman, Pakistan, Bangladesh,
  • Afghanistan
  • India
  • Philippines
  • Siberia
  • Pacific
  • (Okinawa, Hawai'i,
  • Samoa, Tonga, Tuva etc)

Gender Identity Variance Universal, Timeless. A
part of human experience.
38
Transgender people cultural, social and legal
issues
  • Large population
  • Deep cultural roots and old social roles
  • Local identities and genders

39
Some local identities and genders (modern or
traditional, affirming or offensive)
Yirka-la-ul-va-irgin, Ne-uchica
Khanith, Xanith
Hijra, Kothi, Meti, Aravani, Khusra, Zanana
Mahu, Faafafine Fakaleiti Pinapinaine
Bakla, Transpinay Bayot, Bayog, Asog, Bantut, Bina
bae
Apwint, Acault
Waria, Banci, Bencong, Calabai, Kedie, Wandu
Maknyah
Kathoey Pumia, Pumae, Phet thee sam, Sao praphet
song, Phuying kham phet
40
Transgender people cultural, social and legal
issues
  • Large population
  • Deep cultural roots and old social roles
  • Local identities and genders
  • Modern stigma and prejudice

41
Modern stigma and prejudice.
  • Challenging rigid (Western?) ideas about sex and
    gender
  • two sexes (biology), two genders (psychology)
  • within any person the two must match.
  • In those cultures transpeople seen as
  • deviant (an unfortunate defect),
  • immoral (disobeying Gods will),
  • deceitful (homosexuals employing a strategy to
    get partners),
  • mentally ill (Gender Identity Disorder).
  • Responses of
  • incomprehension, shock, embarrassment, fear,
    disgust, hatred.
  • family, friends, neighbours, employers, broader
    society.
  • transphobia ( transprejudice)
  • fear, hatred or disgust in reaction to
    transgender people (and their GIV)
  • GIV boys less easily accepted than GIV
    girls?

42
Stigma and Prejudice
A seven country study of prejudice 841
university students. A questionnaire on
attitudes towards transwomen
  • Transpeople, transprejudice and pathologisation
    a seven-country factor analytic study.
  • Winter,S., Chalungsooth,P., Teh,Y.K.,
    Rojanalert,N., Maneerat, K., Wong, Y.W.,
    Beaumont,A., Ho,M.W., Gomez,F., Macapagal,R.A.
  • International Journal of Sexual Health, 21,
    pp96-118

43
Seven societies a range of prejudice
Transacceptance
United Kingdom
Philippines
Thailand
Hong Kong, Singapore
Malaysia United States
Transprejudice
44
Stigma and prejudice
  • Trans-stigma and trans-prejudice clear in all 7
    societies.
  • Some sample figures
  • Rejecting transwomens right to marry a man
  • 63 Malaysians
  • 53 Filipinos
  • Rejecting transwomens right to work with
    children
  • 33 Malaysians
  • 14 Filipinos
  • 13 Thais

45
Transgender people cultural, social and legal
issues
  • Large population
  • Deep cultural roots and old social roles
  • Local identities and genders
  • Modern stigma and prejudice
  • ?Discrimination and marginalisation
  • (social, economic and legal)

46
Discrimination and marginalisation
  • Family and school
  • dropping out and leaving home

47
Discrimination and marginalisation
  • Family and school
  • dropping out and leaving home
  • Wider society
  • employment, housing, health services, access to
    public spaces

48
Discrimination and marginalisation
  • Family and school
  • dropping out and leaving home
  • Wider society
  • employment, housing, health services, , access to
    public spaces
  • drift towards ghetto employment

49
Discrimination and marginalisation
  • Family and school
  • dropping out and leaving home
  • Wider society
  • employment, housing, health services, access to
    public spaces
  • drift towards ghetto employment
  • Government
  • documentation ID cards,

50
Discrimination and marginalisation
  • Family and school
  • dropping out and leaving home
  • Wider society
  • employment, housing, health services, access to
    public spaces
  • drift towards ghetto employment
  • Government
  • documentation ID cards,
  • documentation legal gender status

51
Discrimination and marginalisation
  • Family and school
  • Dropping out and leaving home
  • Wider society
  • employment and housing
  • drift towards ghetto employment
  • Government
  • documentation ID cards,
  • documentation legal gender status

Legal recognition of gender status as reflected
in the right to marry only 7 countries in Asia?
52
Discrimination and marginalisation
  • Family and school
  • Dropping out and leaving home
  • Wider society
  • employment and housing
  • drift towards ghetto employment
  • Government
  • documentation ID cards,
  • documentation legal gender status

Legal recognition of gender status as reflected
in the right to marry only 7 countries in Asia?
53
Discrimination and marginalisation
  • Family and school
  • dropping out and leaving home
  • Wider society
  • employment, housing, health services, access to
    public spaces
  • drift towards ghetto employment
  • Government
  • documentation ID cards,
  • documentation legal gender status
  • lack of protection against discrimination
  • despite widespread ratification or accession to
  • ICCPR (International Covenant on Civil and
    Political Rights)
  • ICESCR (International Covenant on Economic,
    Social and Cultural Rights)
  • UNCRC (United Nations Convention on the Rights of
    the Child)
  • police harassment, violence

54
Transgender people cultural, social and legal
issues
  • Large population
  • Deep cultural roots and old social roles
  • Local identities and genders
  • Modern stigma and prejudice
  • Discrimination and marginalisation
  • (social, economic and legal)
  • ? Vulnerability - risky situations and risky
    behaviours
  • (risks to mental and physical health)

55
Risk MENTAL HEALTH ( transgender women
reporting ever attempting suicide)
Thailand 22 (Winter and Vink, unpublished
report)
Malaysia 14 (Teh, 2002)
Philippines 16 (Winter and Vink, unpublished
report)
56
Risk PHYSICAL HEALTH
HIV prevalence among transgender people some
1996-2007 studies
Chiangmai 2005 18 2007 17
Mandalay 1996 33 (?)
Pakistan various 2006-7 2 (Larkana 14)
Bangkok 2005 12
Lahore 2005 1
Cambodia various 2005 10 (Phnom Penh 17)
Karachi 2005 1.5
Dhaka 2004-5 0
Jakarta 2002 22 20009 34?
Chennai 2001 60
Phuket 2005 12
Source HIV and associated risk behaviours among
men who have sex with men in the Asia and
Pacific region implications for policy and
programming. UNAIDS/APCOM 2008 (working draft)
57
The General Picture A chain, from STIGMA to
RISK
Stigma, Prejudice
58
The General Picture A chain, from STIGMA to
RISK
Western Medicine
Stigma, Prejudice
Discrimination, Social/economic/legal
marginalisation exclusion
59
Seven countries study of trans-stigma and
trans-prejudice
Trans-acceptance
Across the study, those who BELIEVE transwomen
ARE MENTALLY ILL also EXPRESS MORE STIGMA AND
PREJUDICE towards them
United Kingdom
Philippines
Thailand
So ideas about MENTAL ILLNESS PROMPT OR SUPPORT
STIGMA and PREJUDICE.
Hong Kong, Singapore
An argument for REMOVAL of Gender Identity
Disorder AND Transsexualism FROM THE MEDICAL
MANUALS??
Malaysia United States
Trans-prejudice
60
Jackies experiences and opinions
61
Mental health work with transgender
people diagnosis and treatment issues
62
Mental health work with transgender
people diagnosis and treatment issues
63
Gender Identity Disorder (DSM-IV)
  • 4 diagnostic criteria (all 4 must be satisfied)

64
Gender Identity Disorder (DSM-IV) Criterion A
Strong persistent cross-gender identification
  • Children (4 or more of following)
  • Repeated desire to be, or insistence that he/she
    is the other sex
  • Cross-dressing. Boys preference for
    cross-dressing (actual or simulated). Girls
    insistence on wearing only male clothing
  • Strong, persistent preference for cross-sex play
    roles or persistent fantasies of being other sex
  • Intense desire to play other-sex pastimes and
    games
  • Strong preference for other-sex playmates
  • Adolescents and adults symptoms such as
  • 1. Stated desire to be other sex,
  • 2. Frequent passing as other sex,
  • 3. Desire to live or be treated as other sex,
  • 4. Conviction that he/she has typical feelings /
    reactions of other sex


65
Gender Identity Disorder (DSM-IV) Criterion B
Persistent discomfort with his/her own sex or
sense of inappropriateness in gender role of that
sex
  • Children (any of the following)
  • Boys
  • Assertion that penis or testes are disgusting or
    will disappear or
  • Assertion that it would be better not to have
    penis or
  • Aversion towards rough-and-tumble play and
    rejection of male stereotypical toys
  • Girls
  • Rejection of urinating in sitting position, or
  • Assertion that she has or will grow a penis
  • Assertion that she does not want to grow breasts
    or menstruate, or
  • Marked aversion towards normative female clothing
  • Adolescents and adults symptoms such as
  • Preoccupation with removing sex characteristics
    (e.g. requests hormones, surgery or other
    procedures) or
  • Belief that he/she was born the wrong sex.

66
Gender Identity Disorder (DSM-IV)
  • Criterion C not concurrent with a physical
    intersex condition
  • Criterion D the disturbance causes clinically
    significant distress or impairment in social,
    occupational, or other important areas of
    functioning.

67
Gender Identity Disorder (DSM-IV)
  • 4 diagnostic criteria (all 4 must be satisfied)
  • Gender Identity Disorder in Childhood (302.6, ICD
    F64.2),
  • Gender Identity Disorder in Adolescence or
    Adulthood (302.85, ICD F64.0),
  • Gender Identity Disorder (Not Otherwise
    Specified) (302.6, ICD F64.1)
  • GID distinct from Transvestic Fetishism (302.3,
    ICD F65.1), though TF can occur with gender
    dysphoria
  • Extended period often necessary for diagnosis in
    children and adolescents (DSM text)


68
Criticisms of the GID diagnosis
  • GID is a tool of social (sexual) control
    reflecting restrictive ideologies of sex, gender
    and sexuality
  • in regard to boys particularly
  • making possible diagnoses for children even where
    not they have not indicated a cross-gender
    identity
  • allowing thinly veiled attempts to prevent
    homosexuality
  • GID pathologises aspects of human diversity that
    often
  • do not cause distress,
  • do not cause disability,
  • do not cause a significantly increased risk of
    suffering death, pain, disability, or an
    important loss of freedom
  • Any distress or impairment is usually the direct
    result of prejudice and intolerance of others
    (particularly significant others)


69
Criticisms of the GID diagnosis
  • The view of GIV as a mental disorder
  • perpetuates offensive perspectives of the
    transwoman as a man and transman as a woman,
    undermining the persons self-identification
  • encourages ethically questionable treatments
    (conversion / reparative treatments), and
    undermines more legitimate treatments (gender
    affirming)
  • indeed, removes possibility of exit from
    diagnosis for those who, having received gender
    affirming treatment, become well-adjusted upon
    gender transition.
  • In contrast, and ironically, gender conversion /
    reparative therapies can advertise that they
    allow the opportunity to exit the diagnosis.
  • exacerbates stigma for transpeople, and leads
    to more extreme social and economic
    marginalisation, in turn leading to impaired
    health and well-being (mental and physical)
  • and has a particularly strong effect on stigma
    because the transpersons identity is
    pathologised, not his or her dysphoria.
  • contributes to unfavourable court decisions for
    transpeople

70
The Royal Society of Psychiatrists (UK) draft
Good Practice Guidelines for the Assessment and
Treatment of Gender Dysphoria (2006)
  • Section 2.1 states that transsexualism and GID
    are clinical labels for atypical gender
    development, adding that
  • The experience of this dissonance between the sex
    appearance, and the personal sense of being male
    or female, is termed gender dysphoria. The
    diagnosis should not be taken as an indication of
    mental illness. Instead, the phenomenon is most
    constructively viewed as a rare but nonetheless
    valid variation in the human condition, which is
    considered unremarkable in some cultures.
  • Again, in DGPG section 3.1.1
  • . . . the terms disorder and disease in this
    context are widely perceived by transpeople as
    offensive and stigmatizing. The use of these
    terms should therefore be avoided in clinical
    practice.

71
American Psychological Association (2006)
  • Task Force on Gender Identity, Gender Variance
    and Intersex Conditions states
  • Many transgender people do not experience their
    transgender feelings and traits to be distressing
    or disabling, which implies that being
    transgender does not constitute a mental disorder
    per se
  • (from Answers to your questions about
    transgender individuals and gender identity, on
    the APA website (?topics,?transgender))

72
Suggested ways forward ? (4 increasingly radical
suggestions)
  • Retaining the GID diagnosis but adjusting the
    criteria
  • Reformulating the diagnosis to focus on the
    dysphoria (if any), not the identity or
    behaviour
  • Reformulating GIV as a somatic pathological
    condition, i.e. siting the pathology in the body
    that fails to match the mind, rather than in a
    mind that fails to match the body
  • Reformulating GIV as a somatic non-pathological
    condition, albeit one that may benefit from
    medical intervention (i.e. like pregnancy)

73
Mental health work with transgender
people diagnosis and treatment issues
74
The WPATH Standards of Care, 6th edition
  • this international organisations professional
    consensus about the psychiatric, psychological,
    medical and surgical management of gender
    identity disorders (p3).
  • The general goal of psychotherapeutic, endocrine
    or surgical therapy for persons with gender
    identity disorders is lasting personal comfort
    with the gendered self in order to maximise
    overall psychological well-being and fulfillment
    (p3).
  • intended to provide flexible directions for the
    treatment of persons with gender identity
    disorders (p3).

75
The WPATH Standards of Care, 6th edition
  • this international organisations professional
    consensus about the psychiatric, psychological,
    medical and surgical management of gender
    identity disorders (p3).
  • The general goal of psychotherapeutic, endocrine
    or surgical therapy for persons with gender
    identity disorders is lasting personal comfort
    with the gendered self in order to maximise
    overall psychological well-being and fulfillment
    (p3).
  • intended to provide flexible directions for the
    treatment of persons with gender identity
    disorders (p3).

Gender affirmative treatment !
76
The WPATH Standards of Care, 6th edition Five
elements of clinical work
  • Diagnostic assessment
  • Psychotherapy
  • Hormone therapy
  • Real life experience
  • Surgical therapy.

Triadic therapy Patient may not need all 3
elements Elements may be concurrent
77
The WPATH Standards of Care, 6th edition. The ten
tasks of the mental health professional (MHP)
  • 1. to accurately diagnose the gender disorder
  • 2. to accurately diagnose any co-morbid
    psychiatric conditions and see to their
    appropriate treatment
  • 3. to counsel about the range of treatment
    options
  • 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 the patients relevant history
    in a letter of recommendation
  • 8. to be a colleague on a team of
    professionals with an interest in GIDs
  • 9. to educate family members, employers, and
    institutions about GIDs
  • 10. to be available for follow-up of previously
    seen patients.

78
The WPATH Standards of Care, 6th edition. The ten
tasks of the mental health professional (MHP)
  • 1. to accurately diagnose the gender disorder
  • 2. to accurately diagnose any co-morbid
    psychiatric conditions and see to their
    appropriate treatment
  • 3. to counsel about the range of treatment
    options
  • 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 the patients relevant history
    in a letter of recommendation
  • 8. to be a colleague on a team of
    professionals with an interest in GIDs
  • 9. to educate family members, employers, and
    institutions about GIDs
  • 10. to be available for follow-up of previously
    seen patients.

and to communicate that diagnosis clearly and
promptly to the patient
79
The WPATH Standards of Care, 6th edition. The ten
tasks of the mental health professional (MHP)
  • 1. to accurately diagnose the gender disorder
  • 2. to accurately diagnose any co-morbid
    psychiatric conditions and see to their
    appropriate treatment
  • 3. to counsel about the range of treatment
    options
  • 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 the patients relevant history
    in a letter of recommendation
  • 8. to be a colleague on a team of
    professionals with an interest in GIDs
  • 9. to educate family members, employers, and
    institutions about GIDs
  • 10. to be available for follow-up of previously
    seen patients.

Most common mental health problems? Low
self-esteem, depression, social anxiety,
helplessness, hopelessness and associated risk
behaviours
80
The WPATH Standards of Care, 6th edition. The ten
tasks of the mental health professional (MHP)
  • 1. to accurately diagnose the gender disorder
  • 2. to accurately diagnose any co-morbid
    psychiatric conditions and see to their
    appropriate treatment
  • 3. to counsel about the range of treatment
    options
  • 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 the patients relevant history
    in a letter of recommendation
  • 8. to be a colleague on a team of
    professionals with an interest in GIDs
  • 9. to educate family members, employers, and
    institutions about GIDs
  • 10. to be available for follow-up of previously
    seen patients.

Dont make assumptions about what your patient
needs! Each of the following may be vital,
helpful to the patients well-being. Occasionally
any of them may be sufficient to establish
well-being. opportunities for cross-dressing
hair removal, breast binding, body building,
minor cosmetic surgery improved grooming,
wardrobe, vocal skills involvement in support
groups (incl. internet), involvement in
recreational activities of adopted
gender private study regarding SOC, legal issues
etc episodic cross-gender living
81
The WPATH Standards of Care, 6th edition. The ten
tasks of the mental health professional (MHP)
  • 1. to accurately diagnose the gender disorder
  • 2. to accurately diagnose any co-morbid
    psychiatric conditions and see to their
    appropriate treatment
  • 3. to counsel about the range of treatment
    options
  • 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 the patients relevant history
    in a letter of recommendation
  • 8. to be a colleague on a team of
    professionals with an interest in GIDs
  • 9. to educate family members, employers, and
    institutions about GIDs
  • 10. to be available for follow-up of previously
    seen patients.

Competent, nonjudgmental therapy, Supportive,
accepting relationship, Discuss and set clear
goals, Overarching goal to help patient live more
comfortably within his/her gender
identity Help in problem solving,
decision-making Reduction of co-morbidity,
Support for family members, Patient and family
support groups.
82
The WPATH Standards of Care, 6th edition. The ten
tasks of the mental health professional (MHP)
  • 1. to accurately diagnose the gender disorder
  • 2. to accurately diagnose any co-morbid
    psychiatric conditions and see to their
    appropriate treatment
  • 3. to counsel about the range of treatment
    options
  • 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 the patients relevant history
    in a letter of recommendation
  • 8. to be a colleague on a team of
    professionals with an interest in GIDs
  • 9. to educate family members, employers, and
    institutions about GIDs
  • 10. to be available for follow-up of previously
    seen patients.

Eligibility for interventions Reversible
puberty-delaying hormones (adolescents) (SOC says
Tanner Stage 2) Partially reversible
cross-sex hormones (SOC says lowest age should be
16 ) Irreversible surgery (SOC says lowest
age 18 and after RLE (e.g. for SRS, 2 years
for adolescents, 1 year for adults) SOC
suggests other conditions for interventions e.g.
consolidated gender identity, knowledge of
effects / side effects, monitoring by a MHP
etc.
83
The WPATH Standards of Care, 6th edition. The ten
tasks of the mental health professional (MHP)
  • 1. to accurately diagnose the gender disorder
  • 2. to accurately diagnose any co-morbid
    psychiatric conditions and see to their
    appropriate treatment
  • 3. to counsel about the range of treatment
    options
  • 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 the patients relevant history
    in a letter of recommendation
  • 8. to be a colleague on a team of
    professionals with an interest in GIDs
  • 9. to educate family members, employers, and
    institutions about GIDs
  • 10. to be available for follow-up of previously
    seen patients.

SOC suggests a letter from one MHP for starting
hormone therapy, from two for genital surgery.
Letters to communicate diagnostic history,
duration of professional relationship, types of
evaluation / psychotherapy, eligibility /
rationale for recommended treatment, patients
history of compliance with SOC, nature of the
gender team, and authors place in it (if
any), invitation for the recipient to make a
confirmatory phone call
84
The WPATH Standards of Care, 6th edition. The ten
tasks of the mental health professional (MHP)
  • 1. to accurately diagnose the gender disorder
  • 2. to accurately diagnose any co-morbid
    psychiatric conditions and see to their
    appropriate treatment
  • 3. to counsel about the range of treatment
    options
  • 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 the patients relevant history
    in a letter of recommendation
  • 8. to be a colleague on a team of
    professionals with an interest in GIDs
  • 9. to educate family members, employers, and
    institutions about GIDs
  • 10. to be available for follow-up of previously
    seen patients.

Mental health professional(s), An
endocrinologist, A social worker, A lawyer, a
speech therapist, a grooming specialist, a
surgeon etc Team need not be led by a
psychiatrist.
85
The WPATH Standards of Care, 6th edition. The ten
tasks of the mental health professional (MHP)
  • 1. to accurately diagnose the gender disorder
  • 2. to accurately diagnose any co-morbid
    psychiatric conditions and see to their
    appropriate treatment
  • 3. to counsel about the range of treatment
    options
  • 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 the patients relevant history
    in a letter of recommendation
  • 8. to be a colleague on a team of
    professionals with an interest in GIDs
  • 9. to educate family members, employers, and
    institutions about GIDs
  • 10. to be available for follow-up of previously
    seen patients.

A key to successful transition
86
The WPATH Standards of Care, 6th edition. The ten
tasks of the mental health professional (MHP)
  • 1. to accurately diagnose the gender disorder
  • 2. to accurately diagnose any co-morbid
    psychiatric conditions and see to their
    appropriate treatment
  • 3. to counsel about the range of treatment
    options
  • 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 the patients relevant history
    in a letter of recommendation
  • 8. to be a colleague on a team of
    professionals with an interest in GIDs
  • 9. to educate family members, employers, and
    institutions about GIDs
  • 10. to be available for follow-up of previously
    seen patients.

SOC notes that it is also important for patient
to have follow-up opportunities with surgeon,
endocrinologist, etc. Follow-up associated with
successful post-transition outcome
87
Jackies experiences, opinions and
recommendations
88
  • Website resources
  • A. World Professional Association for Transgender
    Health (WPATH). Formerly the Harry Benjamin
    International Gender Dysphoria Association
    (HBIGDA). Publishes the Standards of Care,
    downloadable or purchasable from the site.
    http//www.wpath.org. Publishes the International
    Journal of Transgenderism, not through the
    website, but through the publishers Routledge
    (Taylor and Francis Group)
  • B. The Gender Identity Research and Education
    Society (GIRES). A UK-based organisation highly
    active in providing information for the public
    and for professionals. A large amount of
    information. Many publications, often produced in
    collaboration or for the UK Government Dept of
    Health, are downloadable from its site.
    http//www.gires.org.uk
  • C. TransgenderASIA. A centre based at the
    University of Hong Kong which is focused on
    research, education and advocacy for transgender
    people across Asia. The site contains a large
    number of links and articles, and maintains an
    update bibliography concerning transpeople in
    Asia. http//web.hku.hk/sjwinter/TransgenderASIA/
  • Books
  • A. Principles of Transgender Medicine and
    Surgery. Eds. Ettner, R., Monstrey,S. and
    Eyler,E. (2007). Binghamton, NY, Haworth Press.
  • B. Transgender Emergence therapeutic guidelines
    for working with gender-variant people and their
    families. Lev.,A. (2004). New York the Haworth
    Clinical Practice Press.
  • C. Gender Madness in American Psychiatry essays
    from the struggle for dignity. Winters, K.(2008)
    Dillon, Colorado GID Reform Advocates
  • Journals
  • A. International Journal of Transgenderism
    (Routledge)
  • B. Archives of Sexual Behaviour (Springer)
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