Transgender Care: The Clinician’s Journey

1. Transgender Care:The Clinician’s Journey Lori Becker, Ph.D., ABPP

2. 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.

3. 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).

4. 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).

5. 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.

6. 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.

7. WPATH Guidelines • Provider must be competent in: • Assessment of gender dysphoria • Assessment 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.

8. 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)

9. 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.”

10. 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)

11. 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.

12. 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

13. 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.

14. 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

15. 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!

16. 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

17. 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

18. 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

19. 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 months variable ^ muscle strength 6-12 months 2-5 years Body fat redistrib 3-6 months 2-5 years Cessation of menses 2-6 months n/a Clitoral enlargement 3-6 months 1-2 years Vaginal atrophy 3-6 months 1-2 years Deepened voice 3-12 months 1-2 years

20. Timeline: Feminizing Hormones Effect Expected Onset Expected Effect Body fat redistrib 3-6 months 2-5 years Decr muscle strength 3-6 months 1-2 years Softer skin 3-6 months unknown Decreased libido 1-3 months 1-2 years Decreased erections 1-3 months 3-6 months ED variable variable Breast growth 3-6 months 2-3 years Decr testicular mass 3-6 months 2-3 years Decr sperm prod variable variable Thinning facial hair 6-12 months > 3 years

21. 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)

22. 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

23. Formulation: Appropriate for HT? • “chicken and egg” problem • HT risks < Gender Dysphoria risks • Letter of support was drafted • Followed WPATH SOC guidelines for letter

24. 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)

25. 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 Model • Pt has information to make an informed choice • Pt has cognitive ability to make informed choice

26. 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 hoops • DSM diagnosis, extensive counseling, “real-life experiences” (6-24 mos.) • Decreases use of Black Market hormones