Providing Trans-Specific Health Care to Transgender Students in the College Health Setting

1. Providing Trans-Specific Health Care to Transgender Students in the College Health Setting Michelle Famula MD, UC Davis Nick Gorton MD, Lyon-Martin Health Services Alexandra Hall MD, Cornell Seth Pardo MA, Cornell

2. Overview • Brief discussion of gender identity • Discussion of Transsexuality • Explain the WPATH Standards of Care, and how they can be used to provide needed care • Discuss the provision of hormonal and other therapies, as well as primary care • Identify resources and strategies for providing and maintaining quality care for transgender students on our campuses

3. Defining the need…A Vignette • Rick, 21 yo undergraduate • Presented to CAPS for counseling and medication in Summer ’05 • Struggled with gender dysphoria, felt he was a male born into a female body • Saw CAPS regularly for a year, decided that the appropriate thing for him was to transition • Also saw a community therapist with experience in gender dysphoria, who wrote a letter affirming his readiness for hormonal therapy

4. Diagram of Sex and Gender Biological Sex (anatomy, chromosomes, hormones) male intersex female Gender Identity (Sense of Self) man Twospirit/third gender woman Gender Expression (Communication of Gender) masculine androgynous feminine Sexual Orientation (Erotic Response) attracted to women Bisexual/asexual/pansexual attracted to men

5. Biological Sexanatomy, chromosomes, hormones

6. Biological Sexanatomy, chromosomes, hormones

7. Fetal genital differentiation Spectrum in-between 18% of all “congenital anomalies” are differences in genito-urinary tract. 1 in 100 live births are individuals who are not strictly “normal” male or female, and 1 in 1000 will undergo some type of genital surgery.

8. Gender Identity Internal sense of self, may or may not be expressed Only the individual can say for themselves, cannot be “measured”

9. Gender Expression

10. Sexual Orientation / Attraction

11. Diagram of Sex and Gender Biological Sex (anatomy, chromosomes, hormones) male intersex female Gender Identity (Sense of Self) man Twospirit/third gender woman Gender Expression (Communication of Gender) masculine androgynous feminine Sexual Orientation (Erotic Response) attracted to women Bisexual/asexual/pansexual attracted to men

12. “Trans” or Transgender An umbrella term / a spectrum Other terms: Gender Non-Conforming, Gender-Queer Gender identity and/or gender expression differ from the conventional gender expectations for biological males and females OR A gender identity not adequately defined by conventional ideas of male and female. NOTE: Sexual orientation is not in any way a part of this description!

13. How do our trans students define themselves? What is their experience of gender?

14. When “She” graduates as “He”: Trans identity development and navigating sexual boundaries in college Seth T. Pardo, M.A. Department of Human Development Cornell University Ithaca, NY 14853

15. Study design • Questionnaire • Recruited individuals who were “gender non-conforming” • GLBT Centers • List-serves • Conferences and Meetings • Public Events • 299 surveys: 204 were natal females: 170 respondents • Mean age 28.6 +/- 9.4 • Asked open-ended, “in your own words, how do you describe…” • Your gender identity • Your daily behavior, dress style, and appearance • Asked partner preference (sexual orientation) • Asked “at what age, if any, did you first…” • Wish to have been born a boy • Pass as the other sex • Feel a need for surgery/hormones

16. Who is Transgender? Conceptualizations & Expressions

17. Gender Identity

18. “Naming” Transgender (88% of all respondents) That’s about 4 terms per person!

19. In your own words, how do you describe your gender identity? • Range of Responses: More Fixed • “I identify as female.” • “Just male. I feel that we have chosen the most obvious variable (genital appearance) to distinguish between the sexes, but it is not the most accurate. I feel that I am (and always have been) male, just a male of the XX variety (rather than XY).”

20. How do you describe your gender identity? • Range of Responses: More Fluid • “Fluid. I'm definitely queer and find myself going through different phases in my gender identity. Sometimes I feel very male, sometimes I just want to be in a drag, sometimes I feel like a tomboy and sometimes I feel like a girl - not a girly girl, but female. So - if i had to give it one term, Genderqueer.” • “I identify as trans, I suppose. There are days when I feel like a boy or like a guy, but there are days when I just don't know what I am, although I'm sure that I'm NOT a girl.”

21. Who is Transgender? Conceptualizations & Expressions

22. Developmental Milestones

23. Proportion of Respondents by Time & Group Reporting a “Need for Surgery/Hormones”

24. Transsexual A subset of transgender, representing one end of the continuum, who are “born into the wrong body”; gender identity is highly discordant with biologic sex, resulting in gender dysphoria and the desire/need to modify the body to reflect the gender identity.

25. Transsexuality • Prevalence • Etiology • Morbidity & Mortality • Implications for College Health • Diagnosis • Treatment • Meeting the need in College Health

26. Prevalence of Transsexuality • Old statistics based on surgeries: • 1 in 30,000 for MtF • 1 in 100,000 for FtM • Newer estimate of MtF, based on number of male-to-female surgeries performed per male US population: • 1 in 2500 • These are individuals who can afford surgery • Many individuals never undergo surgery • FtM surgery is far less commonly performed • At Cornell • 19,800 students in Ithaca • Dr. Hall currently has 5 trans patients • Historically 5-12 students in trans support group • 19,800 / 8 = 1 in 2475 • This is a young population – many have not yet “come out” or transitioned

27. Prevalence of Transsexuality Prevalence/Incidence rates per 100,000 Adolescents, age 15-19 CDC national Vital Statistics Reports, Vol 56, No 5, Nov 20, 2007

28. Transsexuality - Etiology • Socialization or mental illness - NO • ? Part of nature’s variety • ? Dissonance in development • Gonadal differentiation begins 7th week of gestation • External genitalia develop 9th-14th weeks • Sexually dimorphic areas of the brain develop and mature from early gestation, beyond birth, into childhood and post-puberty

29. Brain anatomy of gender identityVolume of BST (bed nucleus of stria terminalis) in hypothalamus Heterosexual male Heterosexual female Homosexual male TransWoman (male to female) Zhou et al., A sex difference in the human brain and its relation to transsexuality. Nature. Vol. 378, 2 Nov. 1995

30. Transsexuality – Morbidity & Mortality- Extrinsic - • We live in a very strictly gender binary society • When a a baby is born… • Pink vs blue clothing, décor, bike, backpacks, etc. • Identifying documents • Medical forms • Bathrooms • Dorms • Little tolerance for any gender variance • Homosexuality can be seen as a form of deviance from expected gender role, and is still severely punished by some segments of society

31. Transsexuality – Morbidity & Mortality- Extrinsic - • 5-fold increased risk of murder • 1 in 800 in Netherlands study • www.rememberingourdead.org • Brandon Teena, Gwen Araujo • Harassment • Discrimination • Home / Family • Public • Work – still no gender-inclusive ENDA

32. Transsexuality – Morbidity & Mortality- Extrinsic - • Substandard health/medical care • Discrimination by providers (32%*) • Tyra Hunter – died after MVA due to EMS discontinuing care and then substandard ER care in Wash DC • Fear of discrimination – may not seek care (32%*) • Fear of disclosure • Due to SES factors, high number of uninsured (47%*) • Inadequately trained health personnel *Washington Transgender Needs Assessment Survey, Xavier, 2000

33. Transsexuality – Morbidity & Mortality- Intrinsic - • Mental Health Implications • Internalized transphobia • Suppression of feelings of gender identity • Shame, guilt • Social isolation • Gender Dysphoria • Depression • Anxiety • Social isolation • Stress of a highly persecuted minority

34. Transsexuality – Morbidity & Mortality

35. Transsexuality – Treatment Efficacy

36. Defining the need…Vignette cont. • Rick began to live as a male – clothing, hairstyle, pronoun, name • Legally changed his name to reflect male gender identity • Changed name with the registrar • Changed drivers license

37. Defining the need…Vignette cont. • Made an appointment with one of our physicians to ask for testosterone rx • Researched the topic thoroughly • Sent copious reference materials to the physician in advance of the appt for the MD to review • Also sent letter from therapist certifying readiness/eligibility

38. Defining the need…Vignette cont. • At the appt, patient was told by the physician that s/he could not help him at that time: • Had no training in treatment of transsexuality • No previous experience, had never done it before • No one else was doing it • Didn’t have a good understanding of transsexualism / gender dysphoria, therefore couldn’t be confident in assigning him that diagnosis • Didn’t have a good understanding of the risks involved • Local endocrinologist also couldn’t help, didn’t know any other resources for information, support, or consultation • Physician didn’t know where else the patient could go

39. Why the college health provider is the perfect person to prescribe hormones • Good understanding of biopsychosocial model • We know about identity development • Familiarity with hormones • Comfortable discussing sexual health, anatomy, sexuality • The majority of trans people who will need hormones will need them starting ages 16-26 • It’s not technically difficult to do • Resources and training are available (here’s some!) • Many other college health centers are doing it • Strong sense of social justice

40. Our Students Need Us • Need for hormones and surgery arises at the same time they are on our campuses • Need holistic care, not just endocrinology • Trans-specific care is not available in many areas – they have no other local options • Economics – student health center may be only place they can afford care • Providing trans-specific care illustrates our commitment to diversity, inclusiveness, and social justice

41. Diagnosis

42. Diagnosing Gender Identity Disorder and Transsexualism • Listen to the patient • Obtain consult of trained mental health provider • Exclude other causes • Intersex • Psychosis • Major depressive disorder • Dissociative identity disorder • Other trans spectrum

43. DSM IV Diagnostic CriteriaGender Identity Disorder • A strong and persistent cross-gender identification manifest by a stated desire to be the other sex or to live or be treated as the other sex. • A persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex manifest by a strong desire to change their physical primary and secondary sex characteristics .

44. DSM IV Diagnostic CriteriaGender Identity Disorder • The disturbance is not concurrent with a physical intersex condition. • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

45. ICD-9 Coding for Diagnosis • TRANSSEXUALISM (F64.0) • Desire to live/be accepted as a member of the opposite sex with a desire to make body congruent with that gender. • Identity persistent at least 2 years • No mental health or chromosomal/anatomic abnormality • DUAL-ROLE TRANSVESTISM (F64.1) • GENDER IDENTITY DISORDER OF CHILDHOOD (64.2)

46. Importance of Establishing Diagnostic Criteria for Gender Identity Disorder and Transsexualism • Establishing medical standards of care • Securing insurance benefit coverage • Setting legal rights and responsibilities • Supporting research opportunities for medical care improvements

47. Diagnosis – Take Home • Listen to the patient – avoid assumptions • Important to distinguish gender “nonconformity” from gender “dysphoria” • If it’s not clear, if you’re not sure, or if the patient isn’t sure, refer to a provider with more expertise

48. The Care TEAM: Mental Health and Medical Providers • MENTAL HEALTH PRACTITIONER ROLE • Assess for accurate GID and co-occurring conditions • Counsel on medical/mental health care options • Assess for and document transition readiness • Provide mental health consultation to treatment team • Provide mental health care for patient /family • PHYSICIAN ROLE • Understanding of standards of care, eligibility criteria, readiness requirements and treatment needs • Assess for health status and co-occurring conditions • Prescribe, monitor and manage trans-care treatment as well as provide routine health and wellness care • Provide Medical/Legal documentation as needed

49. Transsexual Treatment Goals • To bring physical body more into alignment with person’s sense of self / gender identity in order to relieve gender dysphoria • Ability to live in the world in congruence with gender identity, hopefully without harassment • For different people, this means differing levels of treatment, spanning behavioral, medical, and surgical options • Ideally, something that looks good, feels good, and “works good”

50. Priority Treatment Goal Person is able to live their life in congruence with their gender identity