Transgender

Goal

At the completion of this module, the participant will better understand concepts of gender identity, transgender identity, and issues specific to transgender people. The participant will also increase knowledge of how a mental health provider can help a patient who is transgender.

Objectives

In order to reach this goal, the participant will:

Pre-Test

  1. Transsexualism is a phenomenon that arose in the 1950s
    • true
    • false
  2. Treatment for transgender people requires:
    1. Psychotherapy
    2. Hormones
    3. Sex reassignment
    4. All of these or possibly no medical treatment
  3. Male to female transgender people; are sexually attracted to:
    1. only men
    2. only women
    3. both men an women
    4. may be attracted to men, women, or both

Introduction

People who do not fit a conventional definition of male or female, masculine or feminine, have been a part of every culture in the world since our early history. These include people with an atypicial gender role (behaviors and appearance), to transgender people, whose gender identity (their sense of being male, female, or something in between) differs from their birth sex.

This module will discuss transgender history, the psychiatric diagnosis of Gender Identity Disorder, and issues specific to the transgender population, including treatment needs.

We use the term gender variance to mean any degree of cross-gender identification or gender non-conformity in gender role behavior, regardless of whether the child or adult meets criteria for Gender Identity Disorder (GID). The term transsexual, used less often today, means an adult who has changed sex through treatment with hormones and/or surgery. Transgender is a more inclusive term which can describe a person with cross-gender identification, in-between gender identification, or non binary or other gender identification, and does not imply whether or not the person has used medical interventions such as hormones or surgery.

A person who is born male and identifies as female is often called a male to female transgender person (MTF) or transgender woman. Similarly, someone born female who identifies as male is a female to male transgender person (FTM) or transgender man.

History

Our character, the manner in which we feel, our entire temperament is not masculine, it is feminine. We only act male. We play the male just as an actress plays a man on stage. . . . It is impossible for us to transform our female instinct into a male instinct.
-- Karl Heinrich Ulrichs

Karl Heinrich Ulrichs (1864) was describing men who in today’s lexicon would be called "gay." He coined the word "Urnings" for them. He characterized Urnings as having "a female psyche caught in a male body" and an erotic attraction exclusively to men. Subsequently, he recognized that there were also "sexually inverted" women. Although he wrote as a lawyer battling Prussian antisodomy laws, his evidence for the naturalness of this condition was drawn from biomedicine. In the second half of the nineteenth century, European forensic doctors and neuropsychiatrists became increasingly interested in the "sexual perversions": conditions that had previously been in the jurisdiction of moralists and lawyers. Indeed, Victorian physicians first described "sexual inversion" (1869), "exhibitionism" (1877), "homosexuality" (1880), "amorous fetishism" (1887), "sadism and masochism" (1890), and "heterosexuality" (referring to "inclination to both sexes") (1892). Ulrichs's condition was subsumed under the diagnosis of inversion or homosexuality, although the element of cross-dressing became an independent focus of attention after sexologist Magnus Hirschfeld coined the term "transvestite" in 1910.

Ulrichs’ characterization of gay men as being “females , in the early 20th century, caught in a male body” provides and early example of the confusion and interplay between gender identity and sexual orientation, concepts that remain both intertwined and incorrectly conflated with each other today.

Even though Hirschfeld had coined the term "transsexual" in 1923, in the early 20th century, homosexuality, transvestitism, and cross-gendered self-identification were regularly collapsed together in the medical literature. For example, the first two patients who underwent complete "genital transformation surgery" from male to female in 1931 were diagnosed as "homosexual transvestites" and the surgery was performed to "complete" their cross-dressing. Even Christine Jorgensen (whose sex change surgery brought transsexualism to broad public attention in 1952) was originally diagnosed with "genuine transvestitism."

In the 1950's, John Money and his colleagues at the Johns Hopkins University made the distinction between gender role (behavior that is typically masculine or feminine) and gender identity (self-identification as male or female) in arguing for early surgical sex assignment of hermaphroditic children.

Endocrinologist Harry Benjamin's seminal publications in the 1950s and 1960s were most important in disseminating the diagnosis of transsexualism. It first appeared in the Diagnostic and Statistical Manual (DSM)-III along with psychosexual disorders. However, in DSM-III-R , Transsexualism was included among the Gender Identity Disorders First Evident in Childhood or Adolescence. The essential features of these is an "incongruence between assigned sex... and gender identity," and resultant gender dysphoria or discomfort about one's assigned sex and sexual body. DSM-IV-TR groups Gender Identity Disorder with Sexual Dysfunctions and Paraphilias (the fetishes).

In the 1990s, there was an expansion of thinking in academia as part of a post-modern theory revolution, which significantly changed the landscape for transgender people. Scholars challenged the notion of the gender binary--the idea that one has to identify as male or female, and there is nothing in between. The simple notion that a transgender person is someone stuck in the body of the opposite gender was joined by more complicated analysis of the gender binary itself, which opened the way for the expression of multiple genders within and without the traditional confines of masculine and feminine. Some transgender people began claiming identities between male and female, using labels such as “genderqueer” or refusing to self-label at all. This has led to a need to re-conceptualize transgender. Is it pathological or is it part of the abundant variance that is part of human biology? How much does biology vs culture determine one’s gender?

The field of psychiatry is currently grappling with the DSM diagnosis of Gender Identity Disorder. There are arguments that debunk the existence of a disorder and arguments that support the need for a diagnosis. These arguments revolve around where the pathology lies, if there is indeed pathology. Advocates in favor of a diagnosis point to the need to diagnose and treat those whose gender sufferings induce severe psychiatric symptoms and suicidal thinking. Advocates in favor of removal of the diagnosis from the DSM argue that the diagnosis itself contributes to stigma and discrimination in a way that creates disorder for transgender people around the world, in a similar way that the diagnosis of homosexuality, no longer included in DSM, contributed to pathologization of the gay community. There is an accepted view that the removal of homosexuality from the DSM was a historically instrumental moment in the shift for civil rights for the gay community and that current trends in favor of civil rights for this group would not have occurred without the dismantling of that diagnosis. Questions remain as to whether or not the same holds true for transgender people.

Despite the historical lumping of homosexuality and transgender identity, the two are not the same. Someone with a transgender identity can be attracted to men, women, or both. The potential need for medical intervention (hormones, surgery) for gender transition keeps transsexuality in the medical realm. Psychiatry plays and important role for transgender people who need support exploring their psychological makeup, understanding the choices before them, navigating the medical system when transition technology is needed (including letters of support), and helping a person manage positive and negative aspects of a transition whether they chose medical, social, or a combination of changes. A new version of the DSM will be unveiled in May, 2013 with an updated diagnosis. The American Psychiatric Association has published position statements promoting transgender access to care and denouncing forms of discrimination, and is studying the need for published recommendations to guide psychiatrists on the mental health needs of this population.

Epidemiology

The best epidemiological data on transsexualism come from the United Kingdom, the Netherlands, and Denmark where sex reassignment treatment is largely centralized. Dutch studies suggest a prevalence of adult transsexualism of 1 male-to-female (MTF) transsexual in 11,900 males and 1 female-to-male (FTM) in 30,400 females. The broader category of cross-gender behavior is more difficult to estimate; however, in children it has been reported as high as 10-16 percent.

Early estimates of sex ratio suggested a preponderance of MTFs over FTMs. However, with greater cultural and professional awareness of FTMs, a sex ratio of 4 MTF: 1 FTM or even parity has been suggested in certain countries. In short, we have even a dimmer picture of how many transgender people live in the US or elsewhere than we do for LGB people.

The lack of reliable data to help clinicians predict if and when children with transgender behavior will persist into adolescence and adulthood makes it difficult to know how a child should be treated and if social or medical transition is warranted. Studies show that 6-27% will continue with transgender feelings and behavior into adulthood.

Studies of risk factors in the US transgender population are limited, and there are no studies using representative samples. However, the preliminary data that exists is troubling. In a sample of 515 trans individuals in San Francisco, rates of depression were 62% in trans women and 55% in trans men. In a New York City sample of trans women, 52-54% had a lifetime history of depression, with rates highest in adolescence. Higher rates of suicide attempts and being the victim of violence have also been found in the trans population. These burdens are likely to be a result of minority stress, stigma, discrimination, and bias against transgender people, resulting in actual violence and the stress of ongoing fear of violence.

Diagnosis

The DSM-IV-TR has two major diagnostic criteria for Gender Identity Disorder in children, adolescents, and adults:

Criterion B identifies the presence of discomfort, which can be thought of a gender dysphoria in today’s language.

Cross-gender identification is determined by age-appropriate tendencies. In children there may be the insistence or fantasy of being the other sex, gender-atypical dress, play, and roles, and preference for opposite sex playmates. In adults, there is passing as the desired sex and a sense of having the psyche of that sex. Persistent gender dysphoria is manifested by the feeling of having been born the wrong sex. There is discomfort with the genitals and secondary sexual traits, and a preoccupation with eliminating or transforming them. In children there is aversion to gender-typical play, clothes, and roles.

The exclusionary criterion is that the disturbance cannot be concurrent with an intersex or hermaphroditic condition. As with other disorders in the DSM, the disturbance must cause clinically significant distress and functional impairment. The ICD-10 adds the additional exclusion criteria that the disorder is not a symptom of another mental disorder such as schizophrenia. The DSM diagnosis is coded for GID in children versus adolescents or adults. Furthermore, sexual attraction--to males, females, both or neither--is specified. This avoids the confusion of labeling the patient homosexual or heterosexual based on born sex versus their self-identified sex.

Finally, GID should also be distinguished from homosexuality. Most gender-atypical boys will grow up to be gay men and not transgender women. In certain cultures (particularly East Asian) where male homosexuality is not tolerated except in extremely gender-inverted manifestations, transsexualism may be the only acceptable adjustment for same-sex erotism. Therefore, cultural meanings of gender and sexuality must be carefully examined during evaluation and treatment of individuals with gender dysphoria.

As mentioned in the introduction, the DSM diagnosis is under review for the upcoming DSM5. Questions up for discussion include whether the diagnosis of GID only stigmatizes gender-atypical children and transgender adults, or whether it serves an important purpose in helping people get access to needed medical treatments for their distress. In acknowledgement of these concerns, the American Psychiatric Association has issued position statements opposing discrimination against transgender people and advocating for access to treatment

Treatment

The Harry Benjamin International Gender Dysphoria Association (HBIGDA, now known as the World Professional Association for Transgender Health,first published its Standards of Care (SOC) for transsexuals in 1979. The SOC 7, pulblished in Septermber, 2011, represents an integrated effort between researchers, clinicians, and transgender people to establish a standard that accurately depicts modern scientific knowledge and is sensitive to the various and diverse issues faced by transgender people aroud the world. The SOC 7 do not prescribe a specific timeline for transition steps such as real life experience (living as the other gender), hormones, breast surgery (“top surgery”) and genital surgery (“bottom surgery”). Rather the SOC 7 provide flexible guidelines aimed at helping “transgender people find lasting comfort with their gendered selves, to maximize well-being, and to reduce harm.” There is also a recognition that every transgender person will not and need not choose to have every possible medical treatment. Some transgender people will choose to live as the other gender without taking hormones or having surgery. Some will use hormonal treatment but not surgery. These choices may stem out of concerns about medication and/or surgery effects, a desire to maintain reproductive function, personal medical history or risk factors, cost of treatments, or other individual reasons. The role of the treatment provider is to be knowledgeable about available treatments, to provide education and informed consent about risks and benefits, and to help the patient access care when needed.

Mental health professionals have traditionally been gatekeepers to hormone therapy, and many endocrinologists still require a letter from a therapist before they will initiate hormone treatment in a transgender person. The current SOC does not require psychotherapy to make a medical transition, but highly recommends it, not simply as a means to getting hormones and surgery, but as a source of support and guidance through the process of transition. Mental health clinicians can help patients through the person’s process of coming out as trans, as well as adjusting to their own bodies and others’ reactions to them as they transition.

A trans-affirmative therapist’s goals are to maximize the patient’s wellbeing, to expand exploration and understanding of their gender identity, and to support resiliency and coping during coming out and transitioning. Therapy should help the person look at their own expectations, whether realistic or not, in order to optimize their chance of satisfaction. It should allow for complex and not reductive exploration, including exploring the past and fantasy, and should include a history of the role of gender across the person’s life span. The cultural dynamics of race, ethnicity, age, gender, sexual identity, and socio-economic status and other aspects of human identity can be examined and integrated in a way that can help the transgender person move towards greater fulfillment.

Treatment for children is controversial and more complicated than that for adults, given that children’s bodies and brains are developing, and that we do not have great ability to predict which children will persist in their cross-gender identity. Gender dysphoria, distress due to discrepancy between gender identity and birth sex, can appear as early as age 2. It can also appear first or worsen at puberty, when the child’s body is changing in a way contrary to his or her felt identity. Studies have shown that 6-27% of children and adolescents with gender dysphoria will persist into adulthood.

The position of the WPATH, American Psychiatric Association (APA), and the American Academy of Child and Adolescent Psychiatry is that therapy with a gender atypical child should allow their gender identity to unfold without trying to influence the outcome one way or the other. The APA Task Force on the Treatment of GID identified the following aims of the mental health professional treating a gender variant child or child with GID: evaluation, diagnosis of GID, diagnosing co-morbid conditions and family disorders, introducing and discussing treatment options, psychotherapy for the child, educating family and institutions (such as school), and assessing safety of the child and family. An important need is for the therapist to assess the risk of bullying or other danger, and to integrate a safety plan into the treatment plan.

Puberty suppression, to buy a child time to come to a gender identity resolution, is becoming a standard of care for adolescents with GID. Cross-gender hormone treatment is much more controversial for adolescents. Two clinics that have done the most study on children and adolescents with GID are in Amsterdam and Toronto. While the Dutch clinic is more supportive of and assertive with full gender transition for adolescents, both clinics have access to puberty suppression treatment.

Trans Issues

Some issues for transgender people are parallel to those of LGB people. For example, transgender people go through a coming out process of self-awareness of transgender identity and disclosure to others. Like coming out for LGB people, this process is often lifelong. And like coming out for LGB people, transgender people can have awareness of gender dysphoria or gender difference from a very early age, or come to that awareness later in life.

Another commonality between LGB and transgender individuals is the experience of discrimination and bias. Transgender adults may be even more at risk for violence than LGB adults, and gender-atypical children and adolescents, whether gay or not, transgender or not, are at the highest risk of bullying.

The literature, whether clinical, research, or life stories by trans people themselves, is still more limited for transgender people as compared to LGB people. The 2011 Institute of Medicine Report, "The Health of LGBT People,” recommends more research into the needs of transgender people, including but not limited to access to medical treatments for transition

Awareness of the transgender community and transgender people has grown in recent years, partly due to the willingness of some public figures to be open about their transgender identity. Trans people like authors Patrick Califia and Leslie Feinberg, composer Wendy Carlos, biologist Joan Roughgarten, and advocates Jamison Green and Chaz Bono have done much to increase acceptance of transgender people and to break down stereotypes.

Post-Test

  1. The estimated prevalence of male-to-female transsexualism is
    1. 1:1000 people born male
    2. 1:12,000 people born male
    3. 1:35,000 people born male
    4. 1:100,000 people born male
  2. The WPATH Standards of Care require what length of psychotherapy before approval for hormone treatment:
    1. 1 month
    2. 3 months
    3. 1 year
    4. no psychotherapy is obligatory
  3. The DSM excludes which of the following in the criteria for making a diagnosis of GID:
    1. psychosis
    2. intersex condition
    3. homosexuality
    4. major depression

Internet Resources

Benjamin, Harry. 1966. The Transsexual Phenomenon.

FTM International: primarily for female-to-male transgender people

International Foundation for Gender Education: has links and address for resources around the world

International Journal of Transsexualism

Harry Benjamin International Gender Dysphoria Association. (Feb. 2001). Standards of Care For Gender Identity Disorders (Sixth Version).

National Center for Transgender Equality

Transgender Law Center

References

Bayer, R. 1987. Homosexuality and American Psychiatry: The Politics of Diagnosis. Princeton: Princeton University Press.

Benjamin, H. 1966. The Transsexual Phenomenon. New York: Julian Press.

Brown, GR, Wise, TN, Costa, PT, Jr, Herbst, JH, Fagan, PJ, Schmidt, CW, Jr. 1996. Personality characteristics and sexual functioning of 188 cross-dressing men. J Nervous Mental Dis 184(5):265-73.

Cohen, L, de Ruiter, C, Ringelberg, H, Cohen-Kettenis, PT. 1997. Psychological functioning of adolescent transsexuals: personality and psychopathology. J Clin Psychology 53(2):187-96.

Eldh, J., Berg, A., Gustafsson, M. 1997 Long-term follow up after sex reassignment surgery. Scan J Plastic and Reconst Surg and Hand Surg 31(1):39-45.

Green, R. 1987. The "Sissy Boy Syndrome" and the Development of Homosexuality . New Haven: Yale University Press.

Leli, U. and Drescher, J. 2004. Transgender Subjectivities:   A Clinician's Guide.   New York:   Harrington Park Press.

Rosario, V. 1996. "Trans[Homo]Sexuality? Double Inversion, Psychiatric Confusion, and Hetero-Hegemony." In Queer Studies: A Lesbian, Bisexual, Gay, Transsexual Anthology, ed. B. Beemyn and M. Eliason, 35-51. New York: New York University Press.

Stoller, RJ. 1975. Sex and Gender, vol. 2, The Transsexual Experiment. New York: Aronson.

Stryker, S. (ed.). 1998. The Transgender Issue. GLQ 4(2).

Ulrichs, KH. [1864-79] 1994. Forschungen über das Räthsel der mannmännlichen Liebe. Trans. M.A. Lombardi-Nash as The Riddle of "Man-Manly" Love: The Pioneering Work on Male Homosexuality. Buffalo, N.Y.: Prometheus.

Zhou J-N, Hofman, MA, Gooren, LJ, Swaab, DF. 1995. A sex difference in the human brain and its relation to transsexuality. Nature 378: 68-70.

Zucker, K, Green, R. 1993. Psychological and familial aspects of gender identity disorder. In Sexual and Gender Identity Disorders, ed. A. Yates. Child and Adolescent Psychiatric Clinics of North America. Philadelphia: WB Saunders.

Christine Jorgensen

Sylvia R. Rivera, transgender activist

Loren Cameron, photographer

Georgina Beyer, Labour Party MP, New Zealand

Patrick Califia, Author

Author Leslie Feinberg


Joan Roughgarten, biologist


Transgender advocate Jamison Green