Transcript Transgender and Gender Identity Issues

Transgender and Gender Identity Issues
(higher central academic course)
Sam Winter and Jackie,
Kwai Chung Hospital, 8th Jan 2010
This session
Sex, gender, sexuality and transgender people:
key terms and background information.
Jackie’s story: growing up
Cultural, social and legal issues for transgender people.
Jackie’s experiences and opinions
Mental health work with transgender people:
‘diagnosis’ and ‘treatment’ issues
Jackie’s experiences, opinions and recommendations
Q and A
Sex, gender and sexuality
• 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.
*
• 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.
*
• 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.
*
• 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
*
• 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
*
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.
*
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.
*
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)
*
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)
*
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 culture’s 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);
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 culture’s 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);
3. Gender:
• About how you develop
– not what you are like in your mother’s womb
• About psychology
– (though there may be roots in biology)
• About ‘what is between your ears’
– (not between your legs,,,,or inside your body!)
*
Transgender people
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)
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)
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
*
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
*
Transgender people: more information
• Often believed to be low prevalence.
– DSM-IV-TR cites figures for adults: approx 1:30,000 males / 1:100,000
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?
*
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 don’t 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.
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.
• It’s about gender identity
*
Transgender people: who they are not
• Not a subset of homosexuals
• who they feel they are ,,,,,,
• not who they are attracted to.
• (it’s 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
*
….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 don’t 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.
*
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).
Transgender people: some key points to remember
It’s not just about gender expression, it’s 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
*
*
Jackie’s story: growing up
Transgender people:
cultural, social and legal issues
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)
Transgender people:
cultural, social and legal issues
•Large population
Large population:
CLINIC STUDIES
Iran:
1:2200 –
1:3300
(transpeople)
Taiwan:
1:1030
(transpeople)
Singapore:
1:2900 (transwomen)
1:8300 (transmen)
Large population:
COMMUNITY ESTIMATES
India:
Thailand:
1:600
(transwomen) 1:300
(transwomen)
Malaysia
1:75 to1:150
(transwomen)
Transgender people:
cultural, social and legal issues
•Large population
•Deep cultural roots and old social roles
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)
.
Transgender people:
cultural, social and legal issues
•Large population
•Deep cultural roots and old social roles
•Local identities and genders
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,
Fa’afafine
Fakaleiti
Pinapinaine
Apwint, Acault
Kathoey
Pumia,
Pumae,
Phet thee sam,
Sao praphet song,
Phuying kham phet
Maknyah
Waria,
Banci,
Bencong,
Calabai,
Kedie,
Wandu
Bakla,
Transpinay
Bayot,
Bayog,
Asog,
Bantut,
Binabae
Transgender people:
cultural, social and legal issues
•Large population
•Deep cultural roots and old social roles
•Local identities and genders
•Modern stigma and prejudice
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 God’s 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’?
*
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
Seven societies: a range of prejudice
Transacceptance
United Kingdom
Philippines
Thailand
Hong Kong, Singapore
Malaysia – United States
Transprejudice
Stigma and prejudice
Trans-stigma and trans-prejudice clear in all 7 societies.
Some sample figures:
Rejecting transwomen’s right to marry a man:
63% Malaysians
53% Filipinos
Rejecting transwomen’s right to work with children
33% Malaysians
14% Filipinos
13% Thais
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)
Discrimination and marginalisation
• Family and school
– dropping out and leaving home
Discrimination and marginalisation
• Family and school
– dropping out and leaving home
• Wider society
– employment, housing, health services, access to public spaces
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
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,
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
Discrimination and marginalisation
• Family and school
Legal recognition of gender status:
– Dropping out and leaving homeas reflected in the right to marry:
• Wider society
only 7 countries in Asia?
– employment and housing
– drift towards ‘ghetto’ employment
• Government
– documentation: ID cards,
– documentation: legal gender status
Discrimination and marginalisation
• Family and school
Legal recognition of gender status:
– Dropping out and leaving homeas reflected in the right to marry:
• Wider society
only 7 countries in Asia?
– employment and housing
– drift towards ‘ghetto’ employment
• Government
– documentation: ID cards,
– documentation: legal gender status
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
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)
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)
Risk: PHYSICAL HEALTH
HIV prevalence among transgender people: some 1996-2007 studies
Pakistan various:
2006-7: 2%
(Larkana 14%)
Mandalay:
1996: 33% (?)
Chiangmai
2005: 18%
2007: 17%
Bangkok
2005: 12%
Lahore:
2005: 1%
Cambodia various:
2005: 10%
(Phnom Penh 17%)
Karachi
2005: 1.5%
Dhaka
2004-5: 0%
Chennai:
2001: 60%
Phuket
2005: 12%
Jakarta:
2002: 22%
20009: 34%?
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)
The General Picture:
A chain,
from STIGMA to RISK
Stigma,
Prejudice
Discrimination,
Social/economic/legal marginalisation + exclusion
Vulnerability and increased
risks to mental / physical
health
?
?
?
The General Picture:
A chain,
from STIGMA to RISK
Stigma,
Prejudice
Discrimination,
Social/economic/legal marginalisation + exclusion
Vulnerability and increased
risks to mental / physical
health
Seven countries study of trans-stigma and trans-prejudice
Trans-acceptance
United Kingdom
Philippines
Thailand
Hong Kong, Singapore
Malaysia – United States
Trans-prejudice
Jackie’s experiences and opinions
Mental health work with transgender people:
‘diagnosis’ and ‘treatment’ issues
Mental health work with transgender people:
‘diagnosis’ and ‘treatment’ issues
Gender Identity Disorder (DSM-IV)
• 4 diagnostic criteria (all 4 must be satisfied)
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
*
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.
*
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.
*
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)
*
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)
*
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 person’s 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 transperson’s
identity is pathologised, not his or her dysphoria.
• contributes to unfavourable court decisions for transpeople
*
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.
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’))
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)
*
Mental health work with transgender people:
‘diagnosis’ and ‘treatment’ issues
The WPATH Standards of Care, 6th edition
‘this international organisation’s 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).
*
The WPATH Standards of Care, 6th edition
‘this international organisation’s 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).
The WPATH Standards of Care, 6th edition
Five elements of clinical work
1. Diagnostic assessment
Not an absolute requirement for triadic
therapy.
2. Psychotherapy
But may be involved in all three elements
‘Triadic’ therapy
3. Hormone therapy
Patient may not need all 3 elements
Elements may be concurrent
4. Real life experience
5. Surgical therapy.
Maintaining employment, education etc.,
Adopting a gender-appropriate name etc
(Hopefully) being responded to as a member
of the adopted gender
The WPATH Standards of Care, 6th edition.
The ten tasks of the mental health professional (MHP)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
to accurately diagnose the gender disorder
to accurately diagnose any co-morbid psychiatric conditions and
see to their appropriate treatment
to counsel about the range of treatment options
to engage in psychotherapy
to ascertain eligibility and readiness for hormone and surgical
therapy
to make formal recommendations to medical and surgical
colleagues
to document the patient’s relevant history in a letter of
recommendation
to be a colleague on a team of professionals with an interest in
GIDs
to educate family members, employers, and institutions about GIDs
to be available for follow-up of previously seen patients.
The WPATH Standards of Care, 6th edition.
The ten tasks of the mental health professional (MHP)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
to accurately diagnose the gender disorder
…and to communicate that diagnosis
to accurately diagnose any co-morbid psychiatric
clearly andconditions
promptly to and
the patient
see to their appropriate treatment
to counsel about the range of treatment options
to engage in psychotherapy
to ascertain eligibility and readiness for hormone and surgical
therapy
to make formal recommendations to medical and surgical
colleagues
to document the patient’s relevant history in a letter of
recommendation
to be a colleague on a team of professionals with an interest in
GIDs
to educate family members, employers, and institutions about GIDs
to be available for follow-up of previously seen patients.
The WPATH Standards of Care, 6th edition.
The ten tasks of the mental health professional (MHP)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
to accurately diagnose the gender disorder
to accurately diagnose any co-morbid psychiatric conditions and
see to their appropriate treatment
Most common
mental health problems?
to counsel about the range of treatment
options
Low self-esteem, depression, social anxiety,
to engage in psychotherapy
helplessness, hopelessness
and associated
risk behaviours
to ascertain eligibility and readiness
for hormone
and surgical
therapy
to make formal recommendations to medical and surgical
colleagues
to document the patient’s relevant history in a letter of
recommendation
to be a colleague on a team of professionals with an interest in
GIDs
to educate family members, employers, and institutions about GIDs
to be available for follow-up of previously seen patients.
The WPATH Standards of Care, 6th edition.
The ten tasks of the mental health professional (MHP)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
to accurately diagnose the gender disorder
to accurately diagnose any co-morbid psychiatric conditions and
see to their appropriate treatment
to counsel about the range of treatment options
Don’t make
assumptions about what your patient needs!
to engage
in psychotherapy
Each of the following may be vital, helpful to the patient’s well-being.
to ascertain
eligibility
andmay
readiness
for to
hormone
surgical
Occasionally
any of them
be sufficient
establish and
well-being.
opportunities for cross-dressing;
therapy
hair removal, breast binding, body building, minor cosmetic surgery;
to make formal
recommendations to medical and surgical
improved grooming, wardrobe, vocal skills;
colleagues
involvement in support groups (incl. internet),
involvement
in recreational
activities
adopted gender;
to document the patient’s
relevant
history in
a letterofof
private study regarding SOC, legal issues etc;
recommendation
episodic cross-gender living;
to be a colleague on a team of professionals with an interest in
GIDs
to educate family members, employers, and institutions about GIDs
to be available for follow-up of previously seen patients.
The WPATH Standards of Care, 6th edition.
The ten tasks of the mental health professional (MHP)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
to accurately diagnose the gender disorder
to accurately diagnose any co-morbid psychiatric conditions and
see to their appropriate treatment
to counsel about the range of treatment options
to engage in psychotherapy Competent, nonjudgmental therapy,
Supportive,
relationship,
to ascertain eligibility and readiness
for accepting
hormone
and surgical
Discuss and set clear goals,
therapy
Overarching goal to help patient live more
to make formal recommendations
to medical
surgical
comfortably
withinand
his/her
gender identity
Help in problem solving, decision-making
colleagues
Reduction of co-morbidity,
to document the patient’s relevant
in members,
a letter of
Supporthistory
for family
recommendation
Patient and family support groups.
to be a colleague on a team of professionals with an interest in
GIDs
to educate family members, employers, and institutions about GIDs
to be available for follow-up of previously seen patients.
The WPATH Standards of Care, 6th edition.
The ten tasks of the mental health professional (MHP)
1.
2.
to accurately diagnose the gender disorder
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
for interventions:
6. Eligibility
to make
formal recommendations to medical and surgical
Reversible : puberty-delaying hormones (adolescents) (SOC says Tanner Stage 2);
colleagues
Partially reversible: cross-sex hormones (SOC says lowest age should be 16 );
Irreversible:
surgery
(SOC
says lowest
age 18 history
and afterin
RLE
forof
SRS, 2 years
7.
to document
the
patient’s
relevant
a (e.g.
letter
for adolescents, 1 year for adults);
recommendation
SOC suggests other conditions for interventions:
8.
to bee.g.
a colleague
ongender
a team
of professionals
interest
in
consolidated
identity,
knowledge of with
effectsan
/ side
effects,
GIDs monitoring by a MHP etc.
9.
to educate family members, employers, and institutions about GIDs
10.
to be available for follow-up of previously seen patients.
The WPATH Standards of Care, 6th edition.
The ten tasks of the mental health professional (MHP)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
to accurately diagnose the gender disorder
SOC suggests
a letterany
from
one MHP for
starting hormone
therapy,
from two
to accurately
diagnose
co-morbid
psychiatric
conditions
and
genital
surgery. Letters
to communicate :
see to for
their
appropriate
treatment
diagnostic history, duration of professional relationship,
to counsel about the range of treatment types
options
of evaluation / psychotherapy,
to engage in psychotherapy eligibility / rationale for recommended treatment,
patient’s history of compliance with SOC,
to ascertain eligibility and
readiness
for
and surgical
nature of the gender hormone
team, and author’s
place in it (if any),
therapy
invitation for the recipient to make a confirmatory phone call
to make formal recommendations to medical and surgical
colleagues
to document the patient’s relevant history in a letter of
recommendation
to be a colleague on a team of professionals with an interest in
GIDs
to educate family members, employers, and institutions about GIDs
to be available for follow-up of previously seen patients.
The WPATH Standards of Care, 6th edition.
The ten tasks of the mental health professional (MHP)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
to accurately diagnose the gender disorder
to accurately diagnose any co-morbid psychiatric conditions and
see to their appropriate treatment
to counsel about the range of treatment options
to engage in psychotherapy
to ascertain eligibility and readiness for hormone and surgical
therapy
Mental health professional(s),
to makeAnformal
recommendations to medical and surgical
endocrinologist,
A social worker,
colleagues
A lawyer, a speech therapist, a grooming specialist, a surgeon etc
to document the patient’s relevant history in a letter of
recommendation
Team need not be led by a psychiatrist.
to be a colleague on a team of professionals with an interest in
GIDs
to educate family members, employers, and institutions about GIDs
to be available for follow-up of previously seen patients.
The WPATH Standards of Care, 6th edition.
The ten tasks of the mental health professional (MHP)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
to accurately diagnose the gender disorder
to accurately diagnose any co-morbid psychiatric conditions and
see to their appropriate treatment
to counsel about the range of treatment options
to engage in psychotherapy
to ascertain eligibility and readiness for hormone and surgical
therapy
to make formal recommendations to medical and surgical
colleagues
to document the patient’s relevant history in a letter of
recommendation
to be a colleague on a team of professionals with an interest in
A key to successful transition
GIDs
to educate family members, employers, and institutions about GIDs
to be available for follow-up of previously seen patients.
The WPATH Standards of Care, 6th edition.
The ten tasks of the mental health professional (MHP)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
to accurately diagnose the gender disorder
to accurately diagnose any co-morbid psychiatric conditions and
see to their appropriate treatment
to counsel about the range of treatment options
to engage in psychotherapy
to ascertain eligibility and readiness for hormone and surgical
therapy
to make formal recommendations to medical and surgical
colleagues
to document the patient’s relevant history in a letter of
recommendation
to
benotes
a colleague
on aimportant
team offorprofessionals
an interest
in
SOC
that it is also
patient to havewith
follow-up
opportunities
with surgeon, endocrinologist, etc. Follow-up associated with successful postGIDs
transition outcome
to educate family members, employers, and institutions about GIDs
to be available for follow-up of previously seen patients.
Jackie’s experiences, opinions and
recommendations
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)