(Natal) Sex: The classification of individuals as female or male on the basis of their reproductive organs and functions. Gender: Behavioral, cultural, or psychological traits that a society associates with male and female sex. Transgender: Individuals who cross or transcend culturally defined categories of gender. The gender identity/expression differs (to varying degrees) from their natal sex. Transsexual: Individuals who seek to change or who have changed their primary and/or secondary sex characteristics through medical interventions (hormones and/or surgery), typically accompanied by a permanent change in gender role.
Gender nonconformity: Extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex (Institute of Medicine, 2011). Gender dysphoria: Discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (Knudson, De Cuypere, & Bockting, 2010).
“The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon [that] should not be judged as inherently pathological or negative.” (WPATH Board of Directors, May 2010).
Affirm the veteran’s gender identity Explore different options for expression of that identity Help the veteran make decisions about medical treatment options.
World Professional Association for Transgender Health promotes interdisciplinary evidence based care, education, research, advocacy, public policy, and respect in transgender health. Coordination of care is recommended HT can be initiated with a referral from a qualified MH professional or a health professional trained in behavioral health.
Provider must be competent in: Assessment of gender dysphoria Assessment of eligibility & preparation for HT Must provide documentation (chart or referral letter) of history, progress, eligibility. Health professionals who recommend HT share the ethical and legal responsibility for that decision with the physician who provides the service.
At least a Master’s in clinical behavioral science Degree should be by accredited institution Documented credentials from licensing board Competence in using DSM and/or ICD Ability to recognize and diagnose MH concerns, and distinguish them from gender dysphoria Documented supervision in psychotherapy/counseling Knowledge about gender nonconforming identities and assessment/tx of gender dysphoria Continuing ed in assessment and tx of gender dysphoria (WPATH Guidelines)
VA Mandate (June 2011): “Medically otherwise eligible intersex and transgender veterans, including hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long- term care following sex reassignment surgery. SRS cannot be performed or funded by VHA.”
62 y/o veteran presented stating he sometimes lives as a woman Initially diagnosed with DID Extensive trauma history: severe childhood abuse, childhood sexual assault, Army service in Vietnam on Cambodian border Multiple suicide attempts (6+), ETOH Depend Referred to MHC (Bipolar & PTSD)
Presented to Dr. Goldman in acute distress Ability to dress/live as a woman was negated Transported to JC ER; admitted to JB inpatient Sensitivity in notes: She is listed as “John” in the computer, but she prefers to be addressed as “Jane.” She is transgendered. She will need to be treated as a woman throughout her stay.
Five inpatient hospitalizations in 2011. Presents to ER or calls hotline when in acute distress. Outpt care with Drs. Goldman & Agnihotri Completed SARRTP, enrolled in PRRC Consistently involved in MH care Requested referral for Hormone Therapy Dr. Goldman placed consult to Endo
Veteran requested Hormone Therapy VA staff endocrinologist refused treatment COS approved fee-based consult to private endocrinologist Conflict of interest for Dr. Goldman to provide letter of support to private endocrinologist.
Permission sought to complete this eval First clinician to do this at this VA Research and consultation Joined VHALGBT & APA Division 44 Listservs Phone conferences with national experts WPATH Guidelines
3 meetings 2 (75’) extended diagnostic interview sessions 1 (50’) feedback session Consulted with a family member Sensitively informed clerical staff Consulted with colleagues extensively - Requested feedback on my documentation Shout out to Drs. Heiland & Goldman!
Highly disturbed self-image Difficulty with mood regulation, sobriety Self-perception of masculinity is distressing Feels “disgusted” by her masculinity Refers to her penis as “it” Identifies self-stimulation as a trigger to drink Only looks at full self in mirror if clothed
“Assess eligibility, prepare and refer the patient for HT, particularly in the absence of significant co-existing mental health concerns” Informed Consent: Does she have the capacity to understand the medical implications of hormone therapy on her physical condition? Consultation with clinical pharmacist Veteran was insightful about her health & congruent health behaviors
FtM: Deepened voice, clitoral enlargement, growth in facial and body hair, cessation of menses, breast atrophy, increased libido, redistribution of body fat, increased muscle mass, roughening of skin MtF: Breast growth, decreased libido and erections, decreased testicular size, redistribution of body fat, softened skin, decreased body hair, slowed balding patterns Most physical changes occur over two years
Effect Expected Onset Expected Effect Skin oiliness/acne 1-6 months 1-2 years Facial hair growth 3-6 months 3-5 years Scalp hair loss >12 monthsvariable ^ muscle strength 6-12 months 2-5 years Body fat redistrib 3-6 months 2-5 years Cessation of menses 2-6 months n/a Clitoral enlargement 3-6 months 1-2 years Vaginal atrophy 3-6 months 1-2 years Deepened voice 3-12 months 1-2 years
Effect Expected Onset Expected Effect Body fat redistrib 3-6 months 2-5 years Decr muscle strength3-6 months 1-2 years Softer skin3-6 months unknown Decreased libido 1-3 months 1-2 years Decreased erections1-3 months 3-6 months EDvariable variable Breast growth 3-6 months 2-3 years Decr testicular mass 3-6 months 2-3 years Decr sperm prodvariable variable Thinning facial hair6-12 months > 3 years
Persistent, well-documented gender dysphoria Capacity to make fully informed consent for treatment Age of majority Any significant medical or mental health concerns must be reasonably well controlled WPATH SOC, 7 th Version, p. 34
“chicken and egg” problem HT risks < Gender Dysphoria risks Letter of support was drafted Followed WPATH SOC guidelines for letter
Patient’s general identifying characteristics Results of client’s psychosocial assessment, including any dx Duration of referring provider’s relationship with client, including type of evaluation and therapy to date Note that criteria for hormone therapy have been met. Brief description of the clinical rationale for supporting the client’s request for HT. Statement that informed consent has been obtained. Statement that the referring provider is available for coordination of care (and via telephone to establish this). (WPATH SOC, 7 th Version, p. 26)
Current state of the field: Gatekeeper Model Does the veteran need to demonstrate “Persistent, well-documented gender dysphoria”? Does the clinician need to demonstrate “Clinical rational for supporting the client’s request”? Move toward: Informed Consent Model Pt has information to make an informed choice Pt has cognitive ability to make informed choice
Media focuses on SRS, but HT makes largest difference in lives of trans people. The patient’s autonomy is underscored Assumes that transgender is not a MI Decreases patient’s jumping through hoops DSM diagnosis, extensive counseling, “real-life experiences” (6-24 mos.) Decreases use of Black Market hormones