Sam Winter and Jackie, Kwai Chung Hospital, 8th Jan 2010 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) *

A fifth aspect of biological sex? Brain Sex

A fifth aspect of biological sex? Brain Sex

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 About psychology 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 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)

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: 1:600 (transwomen) Thailand: 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) . Gender Identity Variance: Universal, Timeless. A part of human experience.

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 Bakla, Transpinay Bayot, Bayog, Asog, Bantut, Binabae Apwint, Acault Waria, Banci, Bencong, Calabai, Kedie, Wandu Maknyah Kathoey Pumia, Pumae, Phet thee sam, Sao praphet song, Phuying kham phet

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’? *

International Journal of Sexual Health, 21, pp96-118 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 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?

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?

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 Mandalay: 1996: 33% (?) Chiangmai 2005: 18% 2007: 17% 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)

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 ? Western Medicine Culture? Religion? Western Medicine 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 Across the study, those who BELIEVE transwomen ARE MENTALLY ILL EXPRESS MORE STIGMA AND PREJUDICE towards them also United Kingdom Philippines So ideas about ‘MENTAL ILLNESS’ PROMPT OR SUPPORT STIGMA and PREJUDICE. Thailand Hong Kong, Singapore An argument for REMOVAL of ‘Gender Identity Disorder’ AND ‘Transsexualism’ FROM THE MEDICAL MANUALS?? 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). Gender affirmative treatment !

Diagnostic assessment Psychotherapy Hormone therapy The WPATH Standards of Care, 6th edition Five elements of clinical work Diagnostic assessment Psychotherapy Hormone therapy Real life experience Surgical therapy. Not an absolute requirement for triadic therapy. But may be involved in all three elements ‘Triadic’ therapy Patient may not need all 3 elements Elements may be concurrent 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 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 patient’s 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.

The WPATH Standards of Care, 6th edition 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 patient’s 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

The WPATH Standards of Care, 6th edition 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 patient’s 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

The WPATH Standards of Care, 6th edition 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 patient’s 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. Don’t make assumptions about what your patient needs! Each of the following may be vital, helpful to the patient’s 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;

The WPATH Standards of Care, 6th edition 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 patient’s 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.

The WPATH Standards of Care, 6th edition 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 patient’s 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.

The WPATH Standards of Care, 6th edition 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 patient’s 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, patient’s history of compliance with SOC, nature of the gender team, and author’s place in it (if any), invitation for the recipient to make a confirmatory phone call

The WPATH Standards of Care, 6th edition 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 patient’s 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.

The WPATH Standards of Care, 6th edition 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 patient’s 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

The WPATH Standards of Care, 6th edition 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 patient’s 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

Jackie’s experiences, opinions and recommendations

Website resources: Books Journals 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)