Transcript File - CEP 756: Sexual Issues

Tory Clark
 Special Thanks to the Fenway Institute in Boston, MA
for their contributions to this slide presentation.
www.fenwayhealth.org
 Mary Minten LMFT, DAACS, LCADC Marriage and
Family Therapist, Diplomate of American Academy of
Clinical Sexologists, Alcohol and Drug Counselor
 Transgender Allies Group
What is this person’s:
Sex?
Gender?
Gender identity?
Gender expression?
Sexual orientation?
Assumptions about how people are likely to behave based on
their maleness or femaleness
“Gender and gender role refers to society's idea of
how boys or girls or men and women are expected
to behave and should be treated. It can be said
that one is a sex and one does gender; that sex
typically, but not always, represents what is
between one's legs while gender represents what
is between one's ears.”
~ Dr. Milton Diamond
Gender Identity: How one psychologically
perceives oneself as either male or female
Gender Role: A collection of attitudes and
behaviors that a specific culture considers
normal and appropriate for people of a
particular sex (social script)
1) How would you raise Noah?
2) How would you handle your other family members
regarding Noah’s feminine expression?
3) Would you allow Noah to express his femininity at
school? Why or why not?
4) If the school would not allow Noah to express his
femininity, what would you do?
5) Noah is now approaching puberty and has not
changed one bit. Would you allow Noah to go on
puberty delaying medications?
A person whose gender identity is not in agreement
with her/his biological sex. Many diverse identities and
expressions – no one way to be trans.
Transgender woman or Trans woman – Male-to-female
(MTF), assigned male at birth, lives
female/feminine/affirmed woman, transfeminine
spectrum
Transgender Man or Trans man–Female-to-male (FTM),
assigned female at birth, lives as
male/masculine/affirmed man, transmasculine
spectrum
How people define their transgender identity
varies by individual and changes over time.
Terminology related to transgender is evolving,
and some terms may be less popular or accepted
by the community at different points in time. For
example, some gender variant people do not like
being called transgender. It is always best to ask
clients how they define or would describe
themselves.
Many (but not all) seek some degree of medical or
surgical intervention to align their minds and bodies
Transition: The emotional and/or physical process of
actively moving away from the gender you were
assigned at birth and toward whatever makes you feel
more comfortable.
This looks different for EVERY individual.
This process may or may not involve a new name, new
clothes, new pronouns. Hormone Replacement Therapy
(HRT), surgery, etc.
Reversible and allows an adolescent to have more time to
decide
2013 study followed 127 adolescents- no negative bone density
or metabolic effects
“Hormonal interventions to block the pubertal development of children with
gender dysphoria are effective and sufficiently safe to alleviate the stress of
gender dysphoria,” said the study’s lead author, Henriette Delemarre-van de
Waal, MD, PhD, a professor of pediatric endocrinology at Leiden University
Medical Center, Leiden, The Netherlands.
“These patients often harm themselves if they are not treated
because they are clearly in the wrong body….the younger
generation of endocrinologists who have grown up with gendervariant people see this as a disregard for a human right.” -Dr.
Norman Spack
(greek-emotional distress): a marked incongruence between one’s
experienced/expressed gender and assigned gender.
2008 AMA position paper affirms the medical necessity
of surgical and hormonal interventions (Avery, 2008)
APA Council of Representatives supports full equality
and ‘the legal and social recognition of transgender
individuals consistent with their gender identity and
expression’ (Glicksman, 2013, p. 1).
Depression
Prejudice & discrimination
Difficulty finding housing
Difficulty obtaining health care
Loss of family / significant other
Loss of employment
Substance abuse
Self mutilation
Suicide
Between January 1, 2008 and October 31, 2013, 1,374
transgender people in 60 countries worldwide were murdered
(68 in the U.S.). (Transrespect versus Transphobia Worldwide,
2013).
The National Center for Transgender Equality and the National
Gay and Lesbian Task Force (2011) surveyed 6,450 transgender
and gender non-conforming people and found that 41% have
attempted suicide (25 times higher than the general population)
The American Journal of Public Health (2013) reported that of
the 1,093 transgender individuals surveyed, 44.1% struggle with
clinical depression, 33.2% with anxiety
57% experience rejection from their family (Grant et al., 2011).
Table 6. Fears and concerns about accessing health care. Reprinted from “When Healthcare Isn’t Caring:
LambdaLegal’s Survey on Discrimination Again LGBT People and People Living with HIV” by LambdaLegal, 2010, p.
12, LambdaLegal: New York. Available at www.lambdalegal.org/health-care-report .
Being transgender is not a disorder; however,
living in a culture that does not yet really
understand, support, or outright rejects
transgender people can lead to mental health
issues. Note, however, that not all transgender
individuals struggle with their gender identity.
No reliable data on the number of tans people
1 in 1000 to 1 in 2000 (Joan Roughgarden)
This # pertains to postoperative trans
Closer to 1 in 500?
Approximately 800 – 1,000 SRS/yr in the U.S.
Map of gender diverse cultures
HBO Middle Sexes
Biological Process
(Nature)
Social-Learning
(Nurture)
1. Chromosomal sex differences
1. Social and cultural models
and influences during early
development
2. Development of gonads
3. Production of hormones
4. Development of internal &
external reproductive
structures
5. Sex differentiation of the brain
Interaction model – both
nature & nurture
In contrast to the biological material, social-learning theory says
that gender identity results primarily from social and cultural
influences during early development
Boys and girls are treated differently from the moment of birth or
before
By 18 months, most children have developed a firm sense of
gender identity, and usually insist in behaving in a way consistent
with that gender identity
Long-term case studies by John Money of intersex individuals with
atypical gender development were interpreted as supporting the
importance of gender of assignment and rearing
Reimer twins - As Nature Made Him: The Boy Who Was Raised As
A Girl by John Colapinto
Follow-up of Money’s cases by Diamond, however, suggested that
biological factors during development do affect gender identity
“If we as physicians or scientists want to know about a person’s
sexual identity we have to ask them.” (Dreifus, 2005)
There are two major types of variations in
development:
1)Sex Chromosome Variations – patterns other than XX or XY more than 70 variations.
2)Prenatal Hormone Variations – presence or absence of the usual
prenatal hormones changes the development of the internal and/or
external genitals, and probably the brain as well
Endocrine disrupters
Diethylstilbestrol (DES) – Acts as a potent synthetic
estrogen, no longer used in the US
Dioxin – mimics the effects of estrogen at low levels
Bispenol A (BPA) – estrogenic effects
A term applied to people who possess biological
attributes of both sexes.
Hermaphrodite (outdated term): have both ovarian and
testicular tissue. Genitals are a mixture of male & female
– incidence of true hermaphroditism is about 1 in a
million
Intersex: 1 in 1500 to 1 in 2000 births
Genital surgery sometimes performed on infants
Ideally, rather than surgery, should be up to the individual
when they are old enough to make an informed decision
http://www.thevisualmd.com/visualizations/result/healthy_nerv
e_supply_of_clitoris_and_labia
 Words that are offensive to transgender people
 She-male
 He-she
 It
 Trannie or tranny
 “Real” woman or “real” man
Unhelpful questions or comments
 “When did you decide to be a man/woman?”
 “You look so real. I never would have known.”
 “Have you had/do you want THE surgery?”
 “How do you have sex?”
 “What is your real name?”
 “You’re so attractive, why would you want to…?”
 "Meet my friend _____; he's a transgender!"
Employment discrimination and housing discrimination based on gender
identity & expression now against the law in Nevada
Nevada hate crime laws now include gender identity and expression
language
Referral list for therapists, doctors, salons, shopping, electrolysis, and more
has grown from one-page document Mary Minten created in 2006, to a
multiple page booklet now printed and hosted online at NNHOPES and UNR
NNHOPES - Now offers transgender care - medical, mental health,
prescriptions and more. Transgender concerns are part of staff training and
standards of care are utilized.
UNR - Now has a working policy for transgender athletes, assisted by Dr.
Carol Scott
Two screenings of the documentary Trans in 2012 sponsored by early TAG
members, AASECT, Unitarian Universalist Church, select UNR departments,
and others. Another screening sponsored by Carson City’s PLFAG chapter in
2013
Trainings done by clinicians, advocates, and transgender people throughout
medical, law enforcement, therapy, and other fields.
And more.... being done for awareness and education
Signs and health related materials
Display photos/ads reflecting gender diversity
LGBTQ Newspapers, magazines, etc.
Single occupancy or gender neutral bathroom
Call people by preferred name/pronoun; If you slip
up, apologize! Individuals often appreciate sincerity
and good intentions.
Post non-discrimination policy
Include ‘gender identity and expression’ in the language
Ensure safety in lobby and parking areas
Intake forms
Assigned sex at birth
Current gender identity
Create and follow a protocol for noting preferred names, pronouns,
mail, voice message instructions
Have clear lines of referral for questions
Appoint a staff person responsible for providing guidance, assisting with
procedures, offering referrals, fielding complaints
Ongoing training and retraining of staff
Annual transgender competency trainings and boundary trainings (e.g., know
what/what not to ask about)
Train new staff on protocols within one month of hire
Accountability for transphobic responses
Advanced training for staff involved in direct care with expectations of
continuing education on transgender issues
Throughout the client’s transition it is
important to have open communication with
them regarding things like: name, pronoun,
disclosure, interventions and the treatment
pathway
AFFIRMATION builds resilience, hope,
trust and confidence with the authentic
self.
Do all transgender people need counseling to
come to an understanding and acceptance of
their gender identity?
Not requisite for understanding or accepting
gender identity
Making it mandatory reinforces the idea that trans
are unable to make healthy, educated choices
Therapy is expensive & some fear going
My patient says he is transgender but he often shows
up at my office using his female birth name and looking
like a girl. Is it possible that he is not really
transgender?
Trans identity is not necessarily related to their public
presentation
Risks of being harassed for not “passing”
Mentally ready
Fear of losing job, family