GENDER DYSPHORIA 8 th March 2012

1. GENDER DYSPHORIA 8th March 2012 Dr Helen Greener Consultant Psychiatrist Northern Region Gender Dysphoria Team

2. What are sex, gender and gender identity? • What makes us male or female? • What is gender dysphoria? • How do we manage gender dysphoria? • What are the consequences of gender change? • What treatments are available? • What should you know about the law?

3. Problematic Terms • SEX • The classification of an individual as male or female on the basis of anatomic, functional, hormonal, and chromosomal characteristics • GENDER • Biological sex • Personal, social or legal status • “Psychological type” • Can be based on body and behaviour, not on genital and/or erotic criteria

4. Binary Definition Of Gender Female Male

5. What is Gender Identity? • Self-defined and integral to personality • The inner conviction that one is male, female, neutral or ambivalent as distinguished from biological sex • Includes the person's sense of the body, dress, speech and mannerisms • One of the most basic aspects of self determination, dignity and freedom • Closely linked to gender role, which denotes a set of behavioural norms associated with a given gendered status in a given social group or system

6. Gender & Society • IN ALL SOCIETIES • There is a set of gender categories that can serve as the basis of the formation of a social identity in relation to others • Some individuals do not identify with the gender assigned to their biological sex • IN MOST SOCIETIES • A basic division between gender attributes assigned to males and females exists • IN SOME SOCIETIES • Membership of categories is open to people regardless of biological sex • “Third genders” exist • Surgical or hormonal treatment is employed to bring people's biological characteristics in line with their gender identity

7. Gender Role • Denotes a set of behaviouralnorms associated with a gendered status in a givensocial group or system • Culturally bound and fluid often depending on social and economic circumstances • There is significant variation between different cultures and eras

8. Sexual Dimorphism • Differences between the maleand female sexes in size and appearance is seen in many animals • In humans men are generally larger, stronger and hairier while women have breasts, wider hips and a higher percentage body fat • However, the physical characteristics associated with one biological sex can often be seen in the other

9. Appearance • Appearance and gender presentation rely on much more than sexual dimorphism • We manipulate our appearance in many ways, in many cultures, for many reasons and have done so for millennia • What constitutes a feminine or masculine appearance is culturally bound and fluid • Clothes, make up, hair, surgery, piercings, scarification, gestures

10. Biology can be uncertain • Intersex & Intersexuality • States where an individuals sex chromosomes, genitalia, and/or secondary sex characteristics are neither exclusively male nor female • Includes • Non typical genital appearance (1 in 2000 births) • Chromosomal problems e.g. Klinefelter’s syndrome (1 in 500 male births) • Androgen insensitivity syndrome • Ovo-testes / “True Hermaphrodite”

11. What forms gender identity? • Social factors • Genetic factors • Prenatal hormone exposure • Childhood experiences • Socialisation • Fundamentally the Nature Vs Nurture question is an open one

12. More “Problematic” Terms • Transgendered • Transsexual • Transman • Transwoman • Pangendered • Cross dresser • Drag King • Gender Nonconforming People • T-girl / T-boy • Transvestite • Agendered • Bigendered • Hermaphrodite • Intersex • Drag Queen

13. “Problems” with Gender Identity • Gender Dysphoria: unhappiness with one’s biological sex • “Concerns, uncertainties, and questions about gender identity persist during a person’s development, become so intense as to seem to be the most important aspect of a person's life, or prevent the establishment of a relatively unconflicted gender identity.” • There are varying degrees of dissatisfaction • Controversy exists regards viewing the gender identity as problematic and the associated medicalisation of trans identities

14. Associated Difficulties • Depression & anxiety • Other mental illness • Suicidality • Deliberate self harm • Alcohol and substance misuse • Educational under performance • Crime – victim (transphobic) & perpetrator • Personality disorders (?) • Intellectual disability (?) • Autistic spectrum disorders (?)

15. F64.0 Transsexualism • A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex • The transsexual identity has been present persistently for at least 2 years • The disorder is not a symptom of another mental disorder nor is it associated with chromosome abnormality

16. Other Categories... • ICD F64.8 Other gender identity disorders • ICD F64.9 Gender identity disorder, unspecified • ICD F64.1 Dual role Transvestitism • DSM-IV Gender Identity Disorder Where is the spectrum?

17. F65.1 Fetishistic transvestism • Disorder of sexual preference not gender identity • The goal is obtaining sexual excitement through creating the appearance of a person of the opposite sex • Clear association with sexual arousal • There is usually a strong desire to remove the clothing once orgasm occurs and sexual arousal declines • It can occur as an earlier phase in the development of transsexualism

18. All Change..... • ICD 10 and DSM-IV are being rewritten • De-psychopathologisation • Conflicted gender identity or nonconformist identities no longer mental disorders • Is gender difference an inherent part of the normal spectrum of human experience? • Impact on access to care and treatment?

19. ANY QUESTIONS

20. Managing gender identity disorders

21. Our Service • Assessment & Diagnosis • Psychological & Psychosexual Therapy • Speech Therapy • Cross Gender Hormones • Referral for other treatments, including surgery • Coordinating / liaison role but not care coordination • Ongoing support and assessment

22. Assessment • Early life experiences • Gender – development, experiences, feelings • Sexual development and maturation • Sexuality • Relationships • Education & employment • Medical history • Psychiatric history • Social circumstances • Spirituality and religion • Body image • Exploration of expectations, desires, needs • Mental state examination • DIAGNOSIS • Important and leads management • Technically a medical task but input from others essential

23. TreatmentSpectrum of Gender Dysphoria • The aim of treatment is • achieve lasting personal comfort with gender expression • maximize overall psychological well-being & self acceptance • Diverse group with diverse needs • Person-centred, within boundaries of limited evidence base and accepted treatment/guidance • May address underlying causes of gender distress • Unless the long term plan is full time gender change, physical treatments do not form part of treatment • Does not mean permanent gender change for all

24. Guidelines • WPATH Standards of Care • Provide professional guidance for psychiatric, psychological, medical, and surgical management • Minimum standards • Open to local interpretation and implementation • A new edition in the last 6 months • National guidelines • Aim to provide equivalent care across England • Consensus has not been reached • There is a paucity of evidence

25. The Real Life Experience (RLE) • Becoming an outdated concept • A commitment to the RLE has been considered essential for medical treatments in the past • A transperson is expected to live in their preferred gender role for a period of time before surgery • Allows time to realise the full and sometimes unexpected consequences of gender transition and demonstrates an ability to function • The intention is to reduce the incidence of post-treatment regret but evidence for this is lacking

26. Transitioning The Process of Changing Gender • Coming out to family, friends, employers • Change of name socially and legally • Asking others to use the appropriate pronouns • Changing name and gender on official documents • Adapting to changes in • Personal relationships • Sexual functioning • Bringing outward appearance in line with internal feelings • Clothing, jewellery, accessories, makeup, mannerisms • Hormones • Surgery • Changing voice’s pitch • Gender Recognition Certificate

27. Potential Negative Consequences • Relationships • Family • Health • Surgery / Hormones • Morbidity / Mortality • Education • Finances • Employment • Housing • Access to Services • Substance misuse • Discrimination • Crime • Victims • Perpetrators • Social Isolation

28. Transphobic Crime • 46% of trans people had experienced harassment in their neighbourhoods • 73% had experienced some form of harassment in public • Hate crime research has found that nearly a third of hate crimes occur outside the victim’s home and 20% of incidents involve neighbours

29. Potential Positive Consequences • Relationships • Family • Health • Psychological well-being • Education • Finances • Employment • Sexual life • Access to Services • Substance misuse • Acceptance • Self expression • Social activities • Empowerment

30. Cross Gender Hormones • An individual must be living in their preferred gender role or intend to do so within the next 6 months (in our service) • We rely on general practitioners to prescribe the drugs and provide physical monitoring • The new international guidance supports hormones without changing gender

31. Important Considerations • Off licence • Irreversible consequences e.g. infertility • Impact on physical health • Safe in short to medium term but long term risks are unknown • Few absolute contraindications • Choice of product, dosage and method of delivery • Informed consent • Lack of research and data is often extrapolated from use in cisgendered people • Interactions • Alcohol intake, smoking, diet, obesity, drug use, prescribed medication

32. Estrogens • Weakening of beard and body hair growth, facilitating removal • Reduction in the size of the genitals • Erections and orgasm may be less readily achieved • Reduced libido • Breasts may feel tender and sometimes, but not always, increase modestly in size • Redistribution of fat to a more feminine pattern • Loss of muscle bulk and power • Estrogens may have a calming effect • Male-pattern baldness is arrested

33. Side Effects of Estrogens • Weight gain • Nausea and vomiting • Impaired liver function • Increased risk of gallstones • Depression • Infertility • Dry skin and brittle nails • Headaches / migraines • Decreased glucose tolerance

34. Serious Complications • Deep vein thrombosis • Pulmonary embolism • Cerebrovascular accident • Heart disease • Diabetes • Hypertension • Pulmonary embolism • Oestrogen-related cancers • Prolactinoma (extremely rare)

35. Testosterone • Beard and body hair growth • Male-pattern baldness • Clitoromegaly • Heightened libido • Increased muscle bulk • Irreversible deepening of the voice • Cessation of menstruation (occasionally there is break-through bleeding requiring adjustment of the dosage)

36. Testosterone – Side Effects • Polycythaemia /increased haematocrit • Nausea /vomiting • Abdominal pain • Headaches /migraines • Weight gain /Water retention • Skin changes (rashes) /acne • Infertility • Altered lipids and clotting

37. Serious Complications • Increased cardiovascular risk due to decreased insulin sensitivity, increased blood pressure, altered lipid profiles • Endometrial hyperplasia, polycystic ovaries, gynaecological malignancy (?) • Aggression • Exacerbation of obstructive sleep apnoea • Rarely liver tumours, breast cancer, osteoporosis, psychiatric disorders

38. Transwomen • Laser hair removal • Surgical Treatments • Breast augmentation • Tracheal shave /voice surgery • Genital surgery • Orchidectomy • Cosmetic vulvoplasty • Vaginoplasty • Facial surgery

39. Transmen • Mastectomy • Hysterectomy • Vaginectomy • Testicular implants • Metoidoplasty • Phalloplasty

40. Gender Realignment Surgery • Assessment of eligibility and readiness • Second psychiatric opinion required • Not all transsexual people want to or can proceed with genital surgery • Not a vital aspect of gender transition • Often seen as an endpoint in research which is not helpful

41. Important Points • Many patients find comfortable, effective ways of living that do not involve all components • Some individuals cannot have some physical treatments • Not every patient requires psychotherapy in order to proceed with hormone therapy, gender transition or surgery • Other models of care exist • Transgender care in the UK may change a great deal in the coming months and years • We appreciate your support

42. ANY QUESTIONS

43. Gender Recognition Certificate • It allows a transperson to change their legal birth gender and “the person’s gender becomes for all purposes the acquired gender” • Marriage / civil partnerships • Retirement / pensions / benefits • Obtain a new birth certificate (in the UK) showing his or her legally recognised gender • “It is an offence for a person who has acquired protected information in an official capacity to disclose the information to any other person.”

44. Changes to the law • The Gender Recognition Act was given Royal Assent in 2004 • The Sex Discrimination Act was amended in April 2008 to protect transsexual people against discrimination and harassment in the provision of goods, facilities and services • The Equality Act came into force on 1 October 2010 • “Working for Lesbian, Gay, Bisexual and Transgender Equality: Moving Forward” was published in March 2011

45. The Equality Act • The Equality Act simplifies, streamlines and strengthens the law • Eliminate unlawful discrimination, harassment and victimisation • Advance equality of opportunity between different groups • Foster good relations between different groups • It makes it easier for employers and companies to understand their responsibilities • It sets a new standard for those who provide public services to treat everyone, with dignity and respect • It covers equal pay, employment, schools, education, services, public functions and associations.....

46. Public Sector Equality Duty • Created by the Equality Act 2010 and replaces the race, disability and gender equality duties (came into force in April 2011) • It covers age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief and sexual orientation • Any organisation which carries out a public function

47. Provision of goods and services • The law applies to both public and commercially run services and enterprises • It is unlawful for • a shopkeeper to refuse to serve a customer because they are intending to undergo, are undergoing or have undergone gender reassignment • a leisure centre to refuse to permit a transsexual person to use their facilities • a housing association to refuse to offer accommodation to a transsexual person, or to offer housing of lesser quality or on different terms

48. Exceptions • Religious organisations • In hospitals and establishments for persons requiring special care and attention it may also be permissible to take a less favourable approach towards transsexual people provided that to do so is a proportionate means of achieving a legitimate aim • Similar limited exceptions are applicable to charities and communal accommodation

49. Relevant Guidance • Equality Act 2010 Code of Practice - Services, public functions and associations Statutory Code of Practicehttp://www.equalityhumanrights.com/uploaded_files/EqualityAct/servicescode.pdf • Provision of goods, services and facilities for trans people - Guidance for public authorities: meeting your equality duties and human rights obligationshttp://www.equalityhumanrights.com/uploaded_files/PSD/psd_trans_guidance.pdf • Public Sector Equality Dutyhttp://www.equalityhumanrights.com/advice-and-guidance/public-sector-equality-duty/

50. ANY QUESTIONS