Counseling People Who Are Transgender and Gender Nonconforming
Counselor Toolbox for Mental Health...

 
 
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Caring for Transsexual, Transgender & Gender Nonconforming People
Dr. Dawn-Elise Snipes
Executive Director: AllCEUs Counselor Education
Host: Counselor Toolbox Podcast

CEUs are available for this podcast https://www.allceus.com/member/cart/index/search?q=transgender

Based in Part On
~ Standards of Care for Transsexual, Transgender & Gender Nonconforming People a publication by The World Professional Association for Transgender Health
Objectives
~ The Difference between Gender Nonconformity and Gender Dysphoria
~ Epidemiologic Considerations
~ Explore the sources of stigma and discrimination and their impact on health
~ Overview of Therapeutic Approaches for Gender Dysphoria
~ Assessment and Treatment of Children and Adolescents with Gender Dysphoria
~ Mental Health

Introduction
~ Both across and within nations, there are differences in all of the following: social attitudes towards transsexual, transgender, and gender nonconforming people; constructions of gender roles and identities; language used to describe different gender identities; epidemiology of gender dysphoria; access to and cost of treatment; therapies offered; number and type of professionals who provide care; and legal and policy issues related to this area of health care (Winter, 2009).
~ There are examples of certain cultures in which gender nonconforming behaviors are less stigmatized and even revered (e.g., in spiritual leaders)
Intro. Cont…
~ Even a similar proportion of transsexual, transgender, or gender nonconforming people existed all over the world, it is likely that cultural differences would alter both the behavioral expressions of different gender identities and the extent to which gender dysphoria –actually occurs.
~ Terminology is culturally and time-dependent and is rapidly evolving. It is important to use respectful language in different places and times, and among different people.
Intro cont…
~ Gender nonconformity is the 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 refers to distress caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth
~ Only some gender nonconforming people experience gender dysphoria at some point in their lives
~ Treatment for gender dysphoria depends on the individual
Intro cont…
~ A disorder is a description of something with which a person might struggle, not a description of the person or the person’s identity.
~ Transsexual, transgender, and gender nonconforming individuals are not inherently disordered. The distress of gender dysphoria may precipitate a diagnosable disorder.
Intro cont…
~ Some individuals describe themselves not as gender nonconforming but as unambiguously cross-sexed (i.e., as a member of the other sex)
~ Other individuals affirm their unique gender identity and describe their gender identity in specific terms such as transgender, bigender, or genderqueer, affirming their unique experience that may transcend a male/female binary understanding identifying with neither, both, or a combination of genders (agender, bigender, trigender, pangender, demigender, gender fluid or third or other-gendered)
Intro cont…
~ Gender identity is separate from sexual or romantic orientation
~ Importantly, some individuals may not experience their process of identity affirmation as a “transition” because they never fully embraced the gender role they were assigned at birth
Transgender Persons and Stigma
~ There is stigma attached to gender nonconformity in many societies around the world.
~ Stigma can lead to prejudice and discrimination, resulting in “minority stress”
~ Minority stress is unique (additive to general stressors experienced by all people), socially based, and chronic, and may make transsexual, transgender, and gender nonconforming individuals more vulnerable to developing mental health concerns
~ National Transgender Discrimination Survey
~ 90 percent reported experiencing anti-trans bias at work
~ 43 percent reported having attempted suicide

Transgender Stigma and Health
~ Stigma can contribute to abuse and neglect which in turn can lead to psychological distress which is socially induced and not inherent to being transsexual, transgender, or gender nonconforming.
~ Structural stigma refers to the societal norms, environmental conditions, and laws and practices that limit the opportunities, and wellbeing of stigmatized people
~ Central to structural stigma is power, which is used by the stigmatizing majority to exclude and marginalize those who are different
~ Labeling transgender people as non-normative legitimatizes social norms and bestows the cisgender majority with power and privilege

Transgender Stigma and Health
~ Structural stigma operates as a form symbolic violence in communities, institutions, or governments perpetrate violence through the laws and policies that restrict or forcibly reshape transgender individuals (DSM identified it as a disorder until 2013)
~ Lack of trained healthcare providers (due to curricula of medical and psychology programs) can limit access to care
~ As recently as 2000, state-level anti-discrimination policies excluded transgender individuals as a protected class
~ As of 2015, transgender people in MA could legally be refused access to public bathrooms, denied healthcare, and removed from public transportation
Transgender Stigma and Health
~ Interpersonal Stigma
~ While the ability to pass may help transgender individuals avoid stigma, concealing a core aspect of one’s self can impart profound stress on individuals who question when their stigma will be discovered and whether they should disclose their stigma to others
~ Transgender people with low visual conformity (other people can tell they are transgender) experience more discrimination and worse health outcomes than those with high visual conformity
Transgender Stigma and Health
~ Interpersonal Stigma
~ Transgender individuals who are unable or choose not to access gender affirmation procedures and individuals for whom medical interventions are less effective may be more at risk of experiencing enacted forms of stigma as their nonconforming appearance is visible
~ Prevalence of lifetime physical assault due to gender identity is 33–53%. It is theorized that gender nonconformity causes perpetrators to become anxious and angry, enacting violence as a means of rejecting and diminishing what they fear
Transgender Stigma and Health
~ Interpersonal Stigma
~ Violence against transgender people is often perpetuated by someone known to the victim, including family members
~ Rejection by one’s family of origin is common among transgender people
~ Mistreatment in everyday settings such as healthcare (28% had experienced harassment in medical settings, 19% were refused care)

Transgender Stigma and Health
~ Individual Stigma
~ Stigmatized individuals’ psychological processes are affected by stigma, which shapes their basic orientation to themselves (transphobia, self-hatred), others, and their environment
~ A 2014 study of college students (LGBTQ) had participants listen to a presentation on positive LGBTQ identities and write narratives related to their own positive identity experiences
~ Post-intervention, participants showed an increase in positive LGBTQ identity, self-esteem; but results were not maintained
~ More intensive interventions (e.g., more sessions, multiple components) have been conducted in non-transgender sexual minority populations with more sustained results

Prevalence
~ Prevalence for transsexualism was 4.6 in 100,000 individuals; 6.8 for trans women and 2.6 for trans men.
~ Time analysis found an increase in reported prevalence over the last 50 years.
~ The prevalence estimates are mainly based on persons presenting for clinical services and do not give a good picture of the actual prevalence.
https://www.ncbi.nlm.nih.gov/pubmed/26021270
~ Gender nonconformity among FtM individuals tends to be relatively invisible in many cultures, particularly to Western health professionals
Treatment Options
~ Hormone therapy and/or surgery have been found to be medically necessary to alleviate gender dysphoria in many (but not all) people
~ Some individuals integrate their trans- or cross-gender feelings into the gender role they were assigned at birth and do not feel the need to feminize or masculinize their body.
~ For others, changes in gender role and expression are sufficient
Mental Health of Transgender Children Who Are Supported in Their Identities
~ Gender-affirming medical therapy and supported social transition in childhood have been shown to correlate with improved psychological functioning for gender-variant children and adolescents, suggesting that psychopathology is not inevitable within this group.
~ Socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex.
Psychotherapy Goals
~ Exploring gender identity, role, and expression
~ Reducing a child’s or adolescent’s distress related to the gender dysphoria
~ Treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth and is considered highly unethical as well as ineffective
~ Addressing the negative impact of gender dysphoria and stigma on mental health
~ Alleviating internalized transphobia
~ Enhancing social and peer support
Psychotherapy Goals
~ Explore and anticipate the implications of changes in gender role, pace the process of implementing these changes
~ Improving body image
~ Promoting resilience
~ Ameliorating psychosocial difficulties
~ Facilitating a coming-out process if appropriate
~ For youth pursuing sex reassignment, supporting them before, during, and after reassignment
Physical Interventions For Adolescents
~ Categories
~ Fully reversible interventions. These involve the use of GnRH analogues to suppress estrogen or testosterone production and consequently delay the physical changes of puberty.
~ Partially reversible interventions. These include hormone therapy to masculinize or feminize the body. Some hormone-induced changes may need reconstructive surgery to reverse the effect (e.g., breast development caused by estrogens), while other changes are not reversible (e.g., deepening of the voice caused by testosterone).
~ Irreversible interventions. These are surgical procedures.
~ Moving from one stage to another shouldn’t occur until there’s adequate time for adolescents and families to fully experience the effects of earlier interventions.
Psychotherapeutic Treatment Considerations
~ Assessments are required for hormone or surgical procedures but psychotherapy is usually not.
~ Clinicians should be knowledgeable about
~ Current community, advocacy, and public policy issues relevant to these clients and their families.
~ Sexuality, sexual health concerns, and the assessment and treatment of sexual disorders
~ Professionals should give ample room for clients to explore different options for gender expression
~ Families should be supported in managing uncertainty and anxiety about their child’s or adolescent’s psychosexual outcomes and in helping youth to develop a positive self-concept
Psychotherapeutic Treatment Considerations
~ Clients and their families should be supported in making difficult decisions regarding
~ The extent to which clients are allowed to express a gender role that is consistent with their gender identity
~ The timing of changes in gender role and possible social transition. A client might attend school while undergoing social transition only partly (e.g. wearing clothing and hairstyle that reflects gender identity) or completely (e.g., By also using a name and pronouns congruent with gender identity).
~ Whether and when to inform other people of the client’s situation, and how others in their lives should respond.
Non-Psychotherapeutic Interventions
~ Peer support resources, groups, or community organizations that provide avenues for social support and advocacy
~ https://en.wikipedia.org/wiki/List_of_people_with_non-binary_gender_identities
~ Support resources for families and friends
~ Voice and communication therapy to help individuals develop verbal and non-verbal communication skills that facilitate comfort with their gender identity
~ Hair removal through electrolysis, laser treatment, or waxing
~ Breast/hip binding or padding, genital tucking, penile prostheses
~ Hormone therapy (suppression or augmentation)
~ Changes in name and gender on identity documents.
Gender Role Change in Early Childhood
~ Due to the relatively low persistence rates of childhood gender dysphoria, change back to the original gender role can be highly distressing and even result in postponement of this second social transition
~ Parents may present this role change as an exploration of living in another gender role, rather than an irreversible situation and explicitly let the child know that there is a way back.
~ Professionals can assist parents in identifying potential in-between solutions or compromises (e.g., only when on vacation)
Therapeutic Issues With Parents
~ A central component of many family support groups is education about transgender experiences which allows non-transgender participants to develop a humanizing perspective of their transgender family member and no longer see them as the “other”
~ If parents do not allow their young child to make a gender role transition, they may need counseling to assist them with meeting their child’s needs in a sensitive and nurturing way, ensuring that the child has ample possibilities to explore gender feelings and behavior in a safe environment
Therapeutic Issues With Parents
~ If parents do allow their young child to make a gender role transition, they may need counseling to facilitate a positive experience for their child in school, peer group settings, and when communicating with other people in the child’s life.
Mental Health and Addiction Issues
~ Transgender youth had a higher risk of reporting psychological distress, self-harm, major depressive episode, suicidal ideation, and suicide attempts.
~ Risk ratios ranged from 3.8 to 16.1
~ Transgender boys/men and non-binary youth were most likely to report self-harm and non-binary youth also reported lower overall mental health.
~ The prevalence of substance use was 2.5-4 times higher for transgender youth compared with their nontransgender peers (depending on the substance)
~ History of transphobic assault, homelessness or underhousing, and sex work were associated with greater drug use among transgender persons
Assessment
~ Only 6-27% of adults who experienced gender dysphoria present in prepubertal childhood continued to experience it in adulthood.
~ For those with continued dysphoria, the development of secondary sex characteristics can intensify feelings and lead to body aversion
~ The numbers are much higher if gender dysphoria was experienced during adolescence
~ Some children, but not others, demonstrate extremely gender nonconforming behavior and wishes, accompanied by persistent and severe discomfort with their primary sex characteristics.
~ It is relatively common for children with gender dysphoria to present with co-occurring mood disorder or ODD
Assessment
~ Many adolescents and adults presenting with gender dysphoria do not report a history of childhood gender nonconforming behaviors
~ Assessment and psychosocial interventions for children and adolescents are often provided within a multi-disciplinary gender identity specialty service.
~ If such a multidisciplinary service is not available, provide referrals to a pediatric endocrinologist for the purpose of assessment, education, and involvement in any decisions about physical interventions.
Assessment
~ Clinicians should acknowledge the presenting concerns of children, adolescents, and their families; offer a thorough assessment for gender dysphoria and any co-existing mental health concerns; and educate clients and their families about therapeutic options
~ Assessment should explore
~ Gender-Related
~ The nature and characteristics of a child’s or adolescent’s gender identity
~ Gender dysphoria, history and development of gender dysphoric feelings
~ The impact of stigma attached to gender nonconformity on mental health
~ The availability of support from family, friends, and peers

Assessment
~ Assessment should explore
~ General
~ Emotional functioning
~ Peer and other social relationships
~ Intellectual functioning/school
~ Strengths and weaknesses of family functioning and unresolved issues in a child’s or youth’s environment

Criteria for Hormone Therapy
~ The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed)
~ Gender dysphoria emerged or worsened with the onset of puberty
~ Any co-existing psychological, medical, or social problems that could interfere with treatment have been addressed, so the adolescent is stable enough to start treatment
~ The adolescent has given informed consent
~ If the adolescent has not reached the age of medical consent, the guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.
Referral Letter for Hormone Therapy
~ The letter should document:
~ The client’s general identifying characteristics
~ Results of the client’s psychosocial assessment, including any diagnoses
~ The duration of the referring health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date
~ An explanation that the criteria for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy
~ Informed consent
~ Availability for coordination of care
Physical Effects of Hormone Therapy
~ In FtM patients
~ Deepened voice
~ Clitoral enlargement (variable)
~ Growth in facial and body hair
~ Cessation of menses
~ Atrophy of breast tissue
~ Increased libido
~ Decreased percentage of body fat compared to muscle mass
~ MtF patients
~ Breast growth (variable)
~ Decreased libido and erections
~ Decreased testicular size
~ Increased percentage of body fact compared to muscle mass.

Barriers to Care
~ The majority of respondents to the National Transgender Discrimination Survey were 33 percent more likely than the general sample to report forgoing healthcare due to fear of discrimination than the general sample
~ Inexperienced clinicians may mistake indications of gender dysphoria for delusions.
~ Studies demonstrate improvement in attitudes towards transgender individuals amongst healthcare professionals after education, suggesting that familiarity with terminology might help overcome negative preconceptions
Barriers and Best Practices cont…
~ People who enter an institution on an appropriate regimen of hormone therapy should be continued on the same, or similar, therapies and monitored.
~ A “freeze frame” approach is not considered appropriate care in most situations
~ Housing and shower/bathroom facilities for transsexual, transgender, and gender nonconforming people living in institutions should take into account their gender identity and role, physical status, dignity, and personal safety.
~ Placement in a single-sex housing unit, ward, or pod on the sole basis of the appearance of the external genitalia may not be appropriate and may place the individual at risk for victimization
Summary
~ Transsexual, Transgender & Gender Nonconforming People are still inundated with stigma and discrimination
~ Being Transsexual, Transgender or Gender Nonconforming is not a pathology or diagnosis
~ Diagnostic issues arise from the distress and internal transphobia which may develop from a society that embraces a binary notion of sexuality
~ Effective treatment requires clinicians to address the client’s distress triggers and assist them in integrating all parts of themselves
~ Hormone treatments for some may begin as early as 9 years old to suppress secondary sex characteristics.
~ Some treatments are permanent while others are reversible
~ Essential to the wellbeing of the client is assisting family (as defined by the client) in understanding transgender and providing support
Summary
~ To reiterate
~ Treatment involves addressing the distress caused by gender dysphoria and the overt and covert stigma and discrimination experienced by the individual
~ Clinicians should assist the clients in
~ Anticipating and developing skills to deal with stigma and discrimination
~ Deciding on the course and timing for embracing their gender identity
~ Accessing resources for medical treatment and social support in the community.