Transcript Document

Gender Identity Dysphoria
The Nature of
Transsexualism
A Brief Overview
Lewis and Clark College
November 23, 2009
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Sara Kristine Becker, MD
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Sara Becker, MD
Sara Kristine Becker is a board certified Family Physician who has practiced Family
Medicine in Portland, Oregon for 30 years. She obtained a Bachelors of Science in
Computer Science at Michigan State University where she taught for two years. She
graduated from the University of Michigan Medical School with her MD Degree in 1977.
Her residency in Family Medicine was completed in 1980. She started her practice in
Milwaukie, Oregon in 1980. She is a Diplomat of the American Board of Family Practice
and an Associate Clinical Professor of Family Practice at Oregon Health Sciences University
in Portland, Oregon. She is a licensed multiengine; instrument rated commercial pilot and
an Aviation Medical Examiner for the Federal Aviation Administration. Her hobbies are
flying, computers, piano, guitar, growing orchids, walking, and teaching.
Her professional interests are general Family Medicine, Aviation Medicine, and hormone
replacement therapy. She is a member of the Harry S. Benjamin International Gender
Dysphoria Association, the Oregon Academy of Family Medicine, the Oregon Medical
Association, and the American Academy of Family Physicians. She is on the Active Staff of
Providence Milwaukie Hospital an the Courtesy Staff of Portland Adventist Medical Center.
She was the 1989 Chief of Staff for Providence Milwaukie Hospital
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Hobbies
Fly-fishing with
Brother-in-law
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Cases in Point
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To Change Ones Gender
Oddity, perversion or fact of nature
 Frequency
 Why is it important for health professionals to
understand gender change or transsexualism in
Human Beings?
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To Change Ones Gender
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Transsexualism or Gender Identity Dysphoria is a
condition where a person feels they are the opposite
gender.
At some point in their lives , they are no longer able to
live as the gender they have been assigned at birth.
The need to hide what they are is overwhelmed by
feelings of depression. (Man in a dress)
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Jurassic Park
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Finding Nemo
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The Variability of Nature
Many different types of expression of sex.
 Over 17 known intersexed conditions in Humans.
 Some are genetic others biochemical
 Understanding this variation may form the basis
for transsexualism.
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The Difference Between Sex and
Gender
Sex is the physical expression of genes.
 Gender is the concept of how one relates to
another in society (masculine vs feminine) and
self perception.
 The organic basis of gender identity may be a
reflection of hormonal effects in utero
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Gender Identity Dysphoria
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Considered to be a birth defect
Born with the body of one sex and the brain of another
The disparity between body and mind produces
depression which often becomes overwhelming
Most likely related to intrauterine hormone exposure but
true causes are unknown
Considered throughout the civilized world as a medical
condition not a psychiatric one
The German Prisoner
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Gender Identity Dysphoria
Transsexualism (Christine Jorgenson)
 History
 Incidence .2 to 1.0% (true incidence is unknown)
 Males to Females (M2F) or MTF
 Females to Males (F2M) or FTM
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Gender Identity Dysphoria
Who you are
 Who you love
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The Farthest Journey
A Journey too Far
 A Trip from one existence to another
 How long does it really take?
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Feelings and Memories
Of Mind and Thought
The Deep Feelings
The Bedtime Prayer
Living “The Lie”
The False Construct
Puberty the “Treason of the Body”
The Wakening Dream
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The Shell Cracks
The pain of not being--?relation to testosterone
 The emergence of Gender Identity Dysphoria
 The Ultimate Dilemma
 Addressing the mirror
 The spiral downward
 Facing the end of being or a new being in the end
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The Shell Cracks
Gender Identity Dysphoria is a situational
depression.
 It cannot be cured with drugs, therapy, or prayer
 Dysphoria means difficult to bear in Greek
 Some patients become acutely suicidal when the
feelings cannot be contained and they face a loss
of all they hold dear knowing the stigma of
changing gender
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From “True Selves “ by Mildred
Brown
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Gender Identity Dysphoria
Since the mind cannot be changed, the body must
be changed
 In modern therapy, no attempt is made to cure the
transsexual. Rather, options are explored
 Some exist living part-time in the gender of their
mind. Most seek to transition
 Our society is not geared for us to live “In
Between”
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Symptoms of GID
A situational depression
 Drugs and Alcohol abuse
 Devotion to profession, military commitment
 To transition or not-endless rumination
 The price of truth
 Mildred Brown
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The World Professional Association for
Transgender Health, Inc
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Treatment of Gender Identity
Dysphoria
The World Professional Association for Transgender
Health provides:
 Certification and guidelines for counselors who treat
transsexuals
 Provide guidelines for cross gender hormone therapy
 Provide guidelines for gender reassignment surgery
(sex change surgery)
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“Transition”
To change ones body and mind image to the gender
Opposite to the cage one is born to.
To learn to relate in society as one of the opposite
Gender.
The process of “Becoming” or “Transitioning”
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Steps in Transition
Counseling
 Electrolysis or Laser to remove the beard
 Hormone Therapy to change the body
 The Real Life Test
 Surgery
 Beyond
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To Find a Chiron
The importance of the therapist who is skilled in
treating transsexualism
 What am I?
 How do I adjust to what I am?
 How do I make myself understood?
 How do I forgive myself to not being “fixable”
 How do I deal with so many others
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Issues of Transition Dealt with in
Counseling
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Timing of transitioning
Hormone therapy
Informing spouses
Informing children
Informing friends
Informing relatives
Job preservation
Survival
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The Role of the Therapist
Weighing the options
Timing
No attempt to cure
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Educating Others
Being a transsexual means that one wishes to
change how one relates to others in society as a
member of the other gender. It does not mean one
is gay, trying to deceive others or that this is a
“life choice” Rather it is the way one has always
been.
 Mildred Browns book “True Selves”
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Issues of Transition
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Electrolysis
Hormone therapy
Preserving hair –Rogaine, Finasteride, Avodart
Voice
Walking
Mannerisms and clothing
Physical changes
Legal changes
Work
Surgery
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Issues of Transition
Economics
 Male to female $20,000-$100,000
 Female to male $10,000 (top) to $100,000
 Loss of job (70% of professional Ts in San
Francisco are unemployed)
 Physicians most likely to be fired
 Divorce
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Hormones
It is the human sex hormones which shape the
clay that becomes the being.
 Human beings are not fixed permanently into one
gender or another.
 To a great degree, feminization and
masculinization can occur in the same body at
different stages of life.
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Hormone Therapy
Estrogen to change the body to a feminine form
and soften the skin in M2F
 Antiandrogens to block testosterone so the
estrogen can work in M2F
 Testosterone injections to change female forms to
male
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Effect of Hormones
Physical changes
 Mental changes
 Emotional changes
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Estrogen in M2F
Conjugated estrogens (Premarin, Ogen) 0.625 to
7.5 mg.
 Ethiny Estradiol (Estinyl) .02 to2.0.
 Estradiol (Estrace) 0.5 to 6.0mg.
 Estradiol Transdermal (Fempatch, Alora, Climara,
Estraderm) .1 to .2.
 Delestrogen () 40 mg q 2 weeks.
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Antiandrogens
in M2F
Block the production and effects of testosterone.
 Use allows a lower dose of estrogen to produce
the same feminization but reduce the risks of
estrogen.
 Many different kinds but many are expensive.
 Spironolactone most common drug used
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Antiandrogens
in M2F
Spironolactone (Aldactone) 100-400 mg is a diuretic but
very effective at blocking testosterone, both synthesis and
at a receptor level.
 Side effects are- breast swelling, GI upset, drowsiness,
headache, rash, confusion, fever, decreased libido,
vomiting, balance problems, fever, elevated potassium.
 Very useful to measure free testosterone levels.
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Typical Hormone Therapies in F2M
• Testosterone Cypionate 100 mg IM weekly or 200
mg. every two weeks
• In Portland, often bought at Stroheckers
pharmacy
• Cannot give testosterone orally because of liver
toxicity
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Steps Before Initiating Hormone
Therapy
The DSM IV criteria
 The WPATH standards
 “The Letter”
 Physical exam
 Laboratory tests
 Contraindications for therapy
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History and Physical Examination
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Must be done to look for preexisting medical conditions
which would complicate or preclude hormone therapy
After hormone therapy is instituted, regular visits should
be carried out at three to six month intervals to look for
complications and adjust doses
Insurances sometimes will cover this as hormone
replacement therapy
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Survival
Be flexible
 Support groups
 Churches
 Journal
 Internet
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Identification
The importance of proper identification
 The role of the therapist
 Drivers licenses
 Letter of passage
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Real Life Test
The real life test is the period of time that one
must work in the gender one is becoming
 With completion of the real life test, one can seek
the two letters for Gender Reassignment Surgery
(Sex Change Surgery)
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Real Life Test
Usually one year
 One has to work as the future gender
 Time off work for SRS
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Facial Surgery
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Forehead
Nose
Upper lip
Chin—sliding genioplasty
Jaw
Tracheal Shave
Doug Osterhoud, MD
Electrolysis
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Sex Reassignment Surgery
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Sex Reassignment Surgery is the goal of many but not all
who are transgendered
Can be offered only after the real life test
Not an option for physicians and certain other
professions
There is a harmony in having your body match your
mind
Less fear of being “caught” in social situations
The two letters—MA, PhD., MD
Ten surgeons in the world
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Sex Reassignment Surgery in
Females to Males
Sex Reassignment Surgery in F2M usually limited
to Breast reconstruction “top surgery”
 Genital surgery limited
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In The End
After all of the above what is left?
 Time and experience
 Posttraumatic Stess Disorder—regret, loss
 Memories and reflections
 Dreams, feelings and thoughts become one
 To gaze on ones own countenance with peace
 To savor the milieu, to just live
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How long Does it Take
Range is 2 to 5 years
 Real answer is at least 5 years
 Probably a lifetime
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Most Important
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It is not a choice of life, it is a biological imperative.
Individuals with this cannot make it go away. It is a pain
similar to what one feels in the death of a child. Often
face with loss of all they hold dear, transsexuals often
consider or attempt suicide. The transsexual is often an
individual of extraordinary courage.
It is not an attempt to deceive but to survive.
Who you are and who you love are different areas of the
brain. Over 30% male to female transsexuals stay with
their mate if they can.
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Why Is It Important For Professionals
to Understand Transsexuals
There are many of us--thousands
 We hide because of fear and prejudice
 We are 16 times more likely to be murdered
 We have the highest unemployment of any
minority group
 Not associated with any other mental or medical
condition
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Why is it Important For Professionals
to Understand Transsexuals
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Do we deprive the community of human beings because we do not
understand?
If a human were burned or paralyzed, would they be less a human
being?
Pope Innocent I removed the genitals from all the statures in the
Vatican in 1492 because souls do not have genitals
Transition does not change the essence of a Human being
Would any Medical Professional deny a patient the only
internationally recognized treatment for a condition because they
do not themselves understand it.
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Why is it Important For Professionals
to Understand Transsexuals
The Health Professional may be the first outside
of the transsexual themselves to know what is
really happening.
 How you respond may influence the future of that
patient.
 Almost all transsexuals consider suicide when the
shell breaks. Estimates of 20% active attempt.
 Suicide without a letter
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Gender Dysphoria
A human being who survives this has a unique
perspective on both genders that can be helpful to
others
 You may be the only professional between a
successful transition and failure
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Resources
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Web Resources
annelawrence.com
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Web Resources
sarabecker/t/index.htm
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Web Resources
sarabecker/t/index.htm
[email protected]
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Questions?
He who asks a question is a fool for five minutes
He who fails to ask a question is a fool for life
Old Chinese Proverb
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