TRANSGENDER CARE:

THE CLINICIAN’S JOURNEY

Lori Becker, Ph.D., ABPP

DEFINITIONS (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.

DEFINITIONS 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).

LET’S GET AWAY FROM GID….

“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).

WHAT CAN I DO? Affirm the veteran’s gender identity Explore different options for expression

of that identity Help the veteran make decisions about

medical treatment options.

WPATH SOC GUIDELINES 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.

WPATH GUIDELINES Provider must be competent in:

Assessment of gender dysphoriaAssessment 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.

COMPETENCY OF MENTAL HEALTH PROFESSIONALS:

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)

VHA DIRECTIVE 2011-024 :PROVIDING HEALTH CARE FOR

TRANSGENDER & INTERSEX VETERANS 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.”

BACKGROUND 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)

BACKGROUND 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.

SUMMARY OF CARE 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

REFERRAL QUESTION: WHERE DOES BECKER COME IN?

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.

BEGINNING WORK 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

THE CLINICIAN’S JOURNEY 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!

WHAT DRIVES HER PATHOLOGY? 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

ASSESSING APPROPRIATENESS FOR HORMONE THERAPY

“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

HORMONE THERAPY: PHYSICAL EFFECTS

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

TIMELINE: MASCULINIZING HORMONES

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 yearsBody fat redistrib 3-6 months 2-5

yearsCessation of menses 2-6 months n/aClitoral enlargement 3-6 months 1-2

yearsVaginal atrophy 3-6 months 1-2

yearsDeepened voice 3-12 months 1-2 years

TIMELINE: FEMINIZING HORMONES

Effect Expected Onset Expected EffectBody fat redistrib 3-6 months 2-5 yearsDecr muscle strength 3-6 months 1-2 yearsSofter skin 3-6 months unknownDecreased libido 1-3 months 1-2 yearsDecreased erections 1-3 months 3-6

monthsED variable variableBreast growth 3-6 months 2-3 yearsDecr testicular mass 3-6 months 2-3 yearsDecr sperm prod variable variableThinning facial hair 6-12 months > 3 years

RISKS OF FEMINIZING HT(FELDMAN & SAFER, 2009; HEMBREE ET AL., 2009)

Venous thromboembolic disease Cardiovascular, cerebrovascular disease Lipids Liver/gallbladder Decreased nocturnal erections, libido,

fertility Type 2 diabetes mellitus Hypertension Prolactinemia Breast cancer (minimal/questionable risk)

SOC’S CRITERIA FOR HORMONE THERAPY

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, 7th Version, p. 34

FORMULATION: APPROPRIATE FOR HT?

“chicken and egg” problem HT risks < Gender Dysphoria risks Letter of support was drafted Followed WPATH SOC guidelines for

letter

SOC’S RECOMMENDED CONTENT OF REFERRAL 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, 7th Version, p. 26)

FORMING OUR VA’S POLICY

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 ModelPt has information to make an informed

choicePt has cognitive ability to make informed

choice

INFORMED CONSENT MODEL

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

hoopsDSM diagnosis, extensive counseling, “real-

life experiences” (6-24 mos.) Decreases use of Black Market hormones