Gender Dyshoria and Health

1. Gender Dyshoria and Health Dr Mary Samuhel Gender Dysphoria Clinic Monash Medical Centre Gender Competency Training for Medical Educators28th of April 2003

2. Health Issues in the Transgender Community • Definitional difficulties • Historical context • Health Concerns • Recommendations for health care professionals • Future Directions

3. Definitions -Victorian Gay, Lesbian, Bisexual, Transgender and Intersex Health Action Plan • Gender identity- A person’s sense of identity defined in relation to the categories male and female. In the action plan the term is primarily used to describe people whose gender identity does not match their biological sex. However, it is important to note that not everybody identifies exclusively with one sex or the other. Some people may identify as male in one setting and female in another. This suggests a gender continuum, rather than simply an opposition between one gender (male) and another (female).

4. Definitions continued • Large variation in preference amongst transgender groups Boston study concludes • “Older adult group dislike for term transgender..... Younger groups preferred term transgender over transsexual.. may reflect differences in both social and physical attributes amongst individuals, or may indeed reflect changing cultural norms around language over time. Starting point to study the use of meanings of language.

5. The Ancients • The surgical methods and effects of castration were first known to Ancient cultures through their experience of domestication of animals. It became known that castration of human male’s testes at a young enough age would prevent his masculinisation. Slaves were castrated and became known as “eunuchs”.

6. The Ancient Greeks and Romans • In these cultures men were completely emasculated by the removal of the testes, penis and scrotum. In addition the external pubic area was often sculptured to look feminine. After undergoing these procedures men went through religious ceremonies and then took their place as “women” in society.

7. Transsexuals in India and Bangladesh • Young transsexuals in India and Bangladesh join the Hijra caste. To become hijra these teens undergo full emasculation surgeries under primitive conditions only with opium as an anaesthetic. • "Hijra - The Third Gender in India"

8. Other cultures • Native American folklore includes reference to cross dressing and cross gender behaviour. The explorers called such individuals berdache. The tradition still exists in various parts of the world including: Central and southern Asia, Amazon regions, Australia, Tahiti (where they are called the mahu) and India.

9. Modern accounts of transsexuality • Krafft-Ebling publishes “Psychopathia Sexualis” in 1894. He was an Austrian psychiatrist whose work under “Metamorphis Sexualis Paranoica” or “Psychic Hermaphrodism” gives the clinical picture of transsexualism. He saw this condition as he did homosexuality as a delusion and a mental illness

10. Havelock Ellis • In his second Volume of “Studies in the Psychology of Sex” in 1920, Ellis coins the name “Eonism” and “Sex-aesthetic inversion” • Magnus Hirschfeld expands on Ellis’s work, coins the term transsexual in 1923 and opened the “Institute for Sexual Science” from 1919 until it was closed by the Nazis in 1933.

11. Sex reassignment surgery • The first complete male to female SRS was reported in 1931, it was performed based on Hirschfeld’s recommendations by two co-workers in the institute, Dr Levy-Lenz and Dr Felix Abraham. Hirschfeld viewed transsexuality as a form of intersex.

12. WWII developments • Clinics in Denmark and Norway resume some of the work begun in Berlin • WWII advancements in flap surgery promoted knowledge in SRS as did the advent of hormone therapy with estrogens being discovered and utilised.

13. Public awareness of transsexuals New York Daily “Ex-GI becomes Blonde Beauty” Christine Jorgensen the first American to undergo SRS in Copenhagen, 1952-1954

14. Scientific investigations • Cauldwell 1949 Psychopathia Transsexualis • 1953 Dr Harry Benjamin authored articles and begun treating transsexuals with hormone therapy in 1949. He wrote his seminal work the - Transsexual Phenomenon in 1966 • SRS grew dramatically- Burou late 1950’s pioneered a new form of SRS

15. Surgery in the USA • Wealthy FTM Reid Erickson formed the Erickson Education Foundation to promote the study of transsexualism. 1965 John Hopkins Gender Clinic in the next couple of years clinics opened at Stanford, Northwestern and the University of Minnesosta. Biber opened the first private clinic in 1969 an alternative to gender clinic with less strict criteria.

16. Other countries also developed Gender clinics • 1967 the Charing Cross Hospital in England and other programs in Germany and Paris. • Australia - In the 1960’s Professor Ball came to Australia from England where he did a doctoral thesis on gender dysphoria he coordinated the transsexual clinic at Parkville and at the Royal Melbourne hospital which diagnosed and operated on a number of patients.

17. 1975 Dr Bower establishes the GDC at the Queen Elizabeth Hospital • In 1975 Dr Bower approached Prof Carl Wood and A/Prof Walters at the Queen Victoria Hospital to start a clinic • The first operation was performed in 1976 • The team wrote a textbook in 1986 • In the late 1980’s Professor Walters goes to Newcastle, Dr Kennedy becames coordinator and the clinic transfers to Monash medical Centre.

18. Treatments • Counselling, superficial and in-depth psychotherapy, psychoanalytic treatment even exorcism were used in the management but with few exceptions were unsuccessful. • Behaviour modification, hormone therapy (enhancing the biological gender) and even ECT all were tried and abandoned.

19. Late 1960’s • “Worldwide medical opinion endorsed surgical sex reassignment as the only available treatment of this gender disorder” • Benjamin standards now in the 6th revision Feb, 2001 are used as clinical guidelines by many clinicians - 1979, 1980, 1981, 1990, & 1998.

20. Psychiatric classification of GID • Diagnosis of transsexualism was introduced in DSM-III in 1980 for gender dysphoric individuals who demonstrated at least two years of continuous interest in removing their sexual anatomy and transforming their bodies and social roles. Also classifications of GID of Adolescence or Adulthood Nontranssexual Tpe or GIDNOS.

21. DSM-IV • In 1994 DSM-IV replaced the diagnosis of transsexualism with gender identity disorder. • (Many in the transsexual community do not like the psychiatric classification of GID as they do not see they have a disorder).

22. Incidence rates of M-F& F-M transsexuals • Walinder , 1967 Sweden 1: 37 000 (2.8:1) • Pauly, 1968, USA, 1: 100 000 • Hoenig & Kenna, 1974, England 1: 34 000 • Ross et al, 1981, Australia, 1: 24 000 (6:1:1) • Tsoi, 1988, Singapore, 1: 9000 • Gooren et al, 1992, Netherlands, 1: 11900 • Osburg & Weitze, 1993, West Germany, 1: 36 000- 1: 42 000. Green, 2000 1 in 10 000 men.

23. Perception by patients • “When I first heard of the GDC, horror stories abounded of girls leaving in tears and cherished dreams being ridiculed by “gatekeepers” from hell. Needless to say… what I found was rather different than my fears”.

24. Perception of a staff member - Dr Hunter-Smith surgeon • There appears to be enormous misunderstanding among the medical profession as well as the general public, about the needs and desires of transsexuals. The overall impression I got when speaking with even the most highly educated people, was that all transsexuals must be nuts and that I must be equally mad to be even slightly interested in helping them.

25. Dr Hunter Smith continued • When asked for a comment by a reputable “journalist” I spent two hours outlining the MMC team and the need for the surgery, however, what appeared in the paper was “Surgeons make penis for women”. This sort of comment he states does nothing for the confidence of mainstream doctors and really works against common goals.

26. Recent influential Studies • Dean et al. Lesbian, Gay, Bisexual and Transgender Health: Findings and Concerns. Journal of Gay and Lesbian Medical Association, Vol 4, No 3, 2000.

27. Sources investigating health concerns for GLBIT • GLMA. Healthy People 2010 - Companion Document for LGBT Health. April 2001 http://www.glma.org/policy/hp2010/index.html

28. American Public Health Journal June, 2001 (Devoted to GLBT health) • Despite many differences that separate them LGBT people share remarkably similar experiences related to stigma, discrimination, rejection, and violence across cultures and locales. • Special need to focus on health concerns.

29. Increased risks in transgender communities of: • Depression • Suicide ideation • Drug and alcohol problems • Risk of sexual transmitted diseases • Delayed health care

30. Possible risks of Hormone Therapy M-F • Benign pituitary tumours • Gallbladder disease • Hypertension • Hypothyroidism • Liver Disease • Migraine headache • Tendency for blood to clot - Aneurysm, deep vein thrombosis, pulmonary embolism, • weight gain • worsening of depression if present

31. Possible risks of hormone therapy f-m • Breast cancer • Cancer of endometrium • Diabetes • High cholesterol • Hypertension • Liver Disease • (Tobaco use can worsen the possible effects)

32. Cancer risks • Need for more research no data on actual risk however need to inform: • M to Fs still need prevention urological care and prostate examinations, as well as mammograms • F to Ms may remain at risk for cervical cancer require regular Pap tests and mammograms for remaining breast tissue

33. “Lesser Health Concerns” • Non-disclosure • Allergies • Eye infections • “If the clinician is not aware of a patient’s gender identity, he or she may fail to accurately diagnose, treat, or recommend appropriate preventative measures for a range of conditions”.

34. Recommendations • Medical Boards and other groups that license or certify health care professionals should ensure that their examinations include questions on health care for the transgendered. • Academic departments of health should encourage, if not require, an internship or a rotation at a community center or health center that includes service to LGBT people. • Home care agencies should be trained to be culturally sensitive and respectful of transgendered elders. Medical Boards and other groups that license or certify health care professionals should ensure that their examinations include questions on health care for the transgendered.

35. Recommendations Cont • Health care providers of all disciplines should be provided with education and training on how to communicate with transgendered consumers and families in a culturally competent way and how to reduce barriers to effective communication. • Health insurance companies should extend coverage to include transgender issues and remove barriers to the transgendered obtaining coverage. • Workers in alcohol and drug abuse programs should be trained in understanding the needs of their transgendered clients and made aware of the relationship between gender issues and addiction.

36. American Public Health Association • Urges researches and health care workers to categorise transgender individuals as male to female, female to male or other as appropriate, and not conflate them with gay men or lesbians (unless as appropriate to an individual’s sexual orientation in their preferred gender) as well as acknowledging the variation that exists among trans individuals.

37. What the future holds • Hopefully more clinicians willing to be involved in the field • Greater research • The need for better follow up • A clinic to help treat families