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Transgender and Gender Identity Issues (higher central academic course). Sam Winter and Jackie, Kwai Chung Hospital, 8 th Jan 2010. This session. Sex, gender, sexuality and transgender people: key terms and background information. Jackie’s story: growing up

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transgender and gender identity issues higher central academic course

Transgender and Gender Identity Issues(higher central academic course)

Sam Winter and Jackie,

Kwai Chung Hospital, 8th Jan 2010

this session

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

slide4
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. *
slide5
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. *
slide6
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. *
slide7
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 cultureGENDER
  • We develop patterns of attraction (physical, romantic, erotic): males to females, females to males.SEXUALITY *
slide8
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
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 identity1
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
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 aspects1
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
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 gender1
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 gender2
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 transpeople
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 transpeople1
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
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 information1
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 information2
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
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
Transgender people: who they are not
  • Notthe 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 not1
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
….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
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
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 * *

transgender people cultural social and legal issues

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)

large population clinic studies
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
Large population: COMMUNITY ESTIMATES

India:

1:600

(transwomen)

Thailand:

1:300

(transwomen)

Malaysia

1:75 to1:150

(transwomen)

transgender people cultural social and legal issues2

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
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 issues3

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

Some local identities and genders (modern or traditional, affirming or offensive)

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 issues4

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
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

Stigma and Prejudice

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
Seven societies: a range of prejudice

Transacceptance

United Kingdom

Philippines

Thailand

Hong Kong, Singapore

Malaysia – United States

Transprejudice

stigma and prejudice1

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 issues5

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
Discrimination and marginalisation
  • Family and school
    • dropping out and leaving home
discrimination and marginalisation1
Discrimination and marginalisation
  • Family and school
    • dropping out and leaving home
  • Wider society
    • employment, housing, health services, access to public spaces
discrimination and marginalisation2
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 marginalisation3
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 marginalisation4
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 marginalisation5
Discrimination and marginalisation

Legal recognition of gender status:

as reflected in the right to marry:

only 7 countries in Asia?

  • 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
discrimination and marginalisation6
Discrimination and marginalisation

Legal recognition of gender status:

as reflected in the right to marry:

only 7 countries in Asia?

  • 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
discrimination and marginalisation7
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 issues6

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)

Risk: MENTAL HEALTH(% transgender women reporting ever attempting suicide)

Malaysia:

14%

(Teh, 2002)

Philippines: 16%

(Winter and Vink,

unpublished report)

slide56

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)

slide57

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

slide58

The General Picture:

A chain,

from STIGMA to RISK

?

Religion?

Western

Medicine

?

?

Stigma,

Prejudice

Culture?

Discrimination,

Social/economic/legal marginalisation + exclusion

Vulnerability and increased

risks to mental / physical

health

seven countries study of trans stigma and trans prejudice
Seven countries study of trans-stigma and trans-prejudice

Trans-acceptance

Across the study, those who

BELIEVE transwomen ARE MENTALLY ILL

also

EXPRESS MORE STIGMA AND PREJUDICE towards them

United Kingdom

Philippines

Thailand

So ideas about ‘MENTAL ILLNESS’ PROMPT OR SUPPORT STIGMA and PREJUDICE.

Hong Kong, Singapore

An argument for REMOVAL of ‘Gender Identity Disorder’ AND ‘Transsexualism’ FROM THE MEDICAL MANUALS??

Malaysia – United States

Trans-prejudice

gender identity disorder dsm iv
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
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 *
slide65

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 breastsormenstruate, 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 iv1

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 iv2
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
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 diagnosis1
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’sidentity is pathologised, not his or her dysphoria.
    • contributes to unfavourable court decisions for transpeople *
slide70
The Royal Society of Psychiatrists (UK): draft Good PracticeGuidelines for the Assessment and Treatment ofGender 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
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
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) *
the wpath standards of care 6 th edition
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 6 th edition1
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 !

the wpath standards of care 6 th edition five elements of clinical work
The WPATH Standards of Care, 6th editionFive 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 6 th edition the ten tasks of the mental health professional mhp
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 6 th edition the ten tasks of the mental health professional mhp1
The WPATH Standards of Care, 6th edition.The ten tasks of the mental health professional (MHP)

…and to communicate that diagnosis

clearly and promptly to the patient

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 6 th edition the ten tasks of the mental health professional mhp2
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 6 th edition the ten tasks of the mental health professional mhp3
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 6 th edition the ten tasks of the mental health professional mhp4
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 6 th edition the ten tasks of the mental health professional mhp5
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 6 th edition the ten tasks of the mental health professional mhp6
The WPATH Standards of Care, 6th edition.The ten tasks of the mental health professional (MHP)

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

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 6 th edition the ten tasks of the mental health professional mhp7
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 6 th edition the ten tasks of the mental health professional mhp8
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 6 th edition the ten tasks of the mental health professional mhp9
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

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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)