Transcript The Gender Dysphoria Clinic past and current practices

Gender Dyshoria and Health
Dr Mary Samuhel
Gender Dysphoria Clinic
Monash Medical Centre
Gender Competency Training for Medical
Educators
28th of April 2003
Health Issues in the Transgender
Community
 Definitional difficulties
 Historical context
 Health Concerns
 Recommendations for health care
professionals
 Future Directions
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).
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.

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”.
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.
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"
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.
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
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.
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.
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.
Public awareness of
transsexuals
New York Daily “Ex-GI
becomes Blonde
Beauty”
Christine Jorgensen the first
American to undergo SRS in
Copenhagen, 1952-1954
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
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.
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.
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.
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.
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.
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.
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).
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.
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”.
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
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.
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.
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
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.
Increased risks in transgender
communities of:
 Depression
 Suicide ideation
 Drug and alcohol problems
 Risk of sexual transmitted diseases
 Delayed health care
Possible risks of Hormone
Therapy M-F
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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
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)
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
“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”.
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.
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.
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.
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