SECTION IV TRANSGENDER AND INTERSEX HEALTH

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1 SECTION IV TRANSGENDER AND INTERSEX HEALTH

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3 Chapter 12 Introduction to Transgender Identity and Health RANDI KAUFMAN, PSYD Introduction The Metamorphosis, Franz Kafka s well-known story, opens with the preposterous plight of an ordinary man who has been transformed into a giant insect. Despite being an insect, Gregor Samsa continues to think and feel like a human being. However, as an insect he is unable to communicate with his family and is unable to solicit their help, their empathy, or even the ability to tell them who he is. Time passes in this bizarre, tortuous state of affairs, and Gregor slowly becomes aware that his situation is insurmountable, as he does not turn back into a human being. His will to survive persists for a time but eventually fades away. The turning point comes when his sister cries out that if this insect were in fact Gregor, he would have gone away willingly, as he would understand that his family could not live with such a creature. Recognizing the agony his family feels, Gregor s wish to live is transformed into a wish to die. He dies in a state of meditation, suggesting that he wills himself into death, as a loving act toward his family. The Metamorphosis is often read as a metaphor for spiritual disintegration, resulting from the impossibility of escaping one s circumstances. It suggests confusion, humiliation, ridicule, and utter isolation when others cannot see oneself for who one is. The story suggests that even despite being rejected, one may desire to sacrifice one s self in order to spare one s family, as the ultimate act of love. In many ways, The Metamorphosis describes the predicament of a transgender person. In tandem with the realization that the relationship between their anatomical sex and gender identity is different from that of other people, transgender individuals quickly become aware that they are subject to rejection, ridicule, humiliation, and isolation. Like Gregor, some transgender individuals choose to sacrifice themselves in order to spare their loved 331

4 332 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health ones. This sacrifice can be concrete and permanent, as in the case of suicide, or abstract, as when a person keeps this identity repressed, resulting in psychic death. Fortunately, many transgender people choose to come out, rather than to surrender. Coming out as transgender is an act of courage that includes taking huge risks, being willing to test relationships, and trusting that peoples caring and respect will supersede a negative outcome. We are currently at a crossroads in our understanding and acceptance of gender identity development. On the one hand, the prevailing view of gender continues to be that a person is either a man or a woman and that their internal sense of being male or female is inextricably tied to their anatomy. This view is reflected by the fact that gender identity disorder is still listed as a diagnosis in the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), thus labeling gender identity differences as mental illness. On the other hand, it is becoming increasingly clear that gender identity questioning is occurring more frequently, and current clinical thinking suggests that gender identity issues are not a sign of psychopathology. 1 The high incidence of mental health problems and substance abuse found in people with gender identity issues is now believed to result from cultural discrimination and intolerance, often coupled with a lack of social and financial supports needed to respond to these challenges. Understanding transgender issues within this larger psychosocial context, rather than as a mental disorder, has resulted in a movement toward taking gender identity disorder out of the DSM, similar to the way in which homosexuality was removed in The purpose of this chapter is to provide a general context of transgender issues and experience so that healthcare providers may be more informed when working with the transgender population, and thereby offer more sensitive, pertinent, and supportive care. Definitions Sex, Gender, and Gender Identity The terms sex, gender, and gender identity tend to be used in different ways and can therefore be confusing. The two-sex, two-gender model that is most familiar to us today 2 uses the term sex to describe a person s body that is, the objective biological (chromosomal) and anatomical (internal and external genital) characteristics that society recognizes as male or female. Gender is used variously to describe a person s gender identity (the internal sense of being male or female, regardless of biology), or gender role (the roles, behaviors and attributes masculine or feminine that a society considers appropriate for men and women). According to this binary model, every person is defined as either a man or a woman, gender

5 Introduction to Transgender Identity and Health 333 is fixed and rooted in biological sex, and the accepted gender role is dictated by apparent gender. This model excludes intersex people, who are born with sex chromosomes, external genitalia, and/or internal reproductive organs that are not exclusively male or female. In addition, it fails to account for people who perceive themselves to be a gender that is different from the one they were assigned at birth, and it negates the experience of an emerging group of people who describe gender as other than just male or just female. New models of sex and gender 3 are beginning to be described, moving us away from the familiar two-sex (male and female), two-gender (masculine and feminine) model where sex and gender are dichotomous constructs, toward models that might be described as polysex or polygender. These models provide a more complete understanding of the diversity and complexity of sex and gender, and permit greater self-expression. The models further distinguish the differences between sex (the objective categorization of one s biology as male, female, or intersex), sexual orientation (whom one is attracted to), gender identity (a subjective sense of oneself as male, female, or other), gender role (cultural expectations that one follows a set of prescribed behavioral norms based on one s gender), gender presentation (how one looks), 4 gender performance (how one acts), 4 gender assignment (gender that is assigned at birth by a medical provider, 5 usually based on appearance of the external genitalia), and gender attribution (attribution of one person s gender by another, based on cultural interpretation of gender cues). 5 What Does It Mean to Be Transgender? Transgender people are individuals who transgress societally constructed gender norms in one manner or another. However, the language in the field is still evolving: the term transgender is used in so many ways that it is not possible to define precisely. Some use the word transgender as an umbrella term to refer to people whose feelings or behaviors do not match their assigned gender: examples include cross-dressers and people who identify as MTF (male-to-female) or FTM (female-to-male). Others use the word to describe a gender outside the constructs of male/female, to describe the experience of having no gender or multiple genders: examples include people who define themselves as genderqueer, androgyne, gender bender, beyond binary, and polygender. Table 12-1 presents definitions of some common and less familiar terms that have been used to describe members of the transgender community. Transgender people choose to present themselves to the world in a wide variety of ways. Some transgender individuals decide to alter their bodies through hormones or surgery in order to make their anatomy concordant with their gender identity. Others opt to express their gender in a less permanent fashion, by changing hairstyle or manner of dress. Still others

6 334 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health Table 12-1 Definitions of Transgender Terms MTF: Male to Female A person born biologically male whose gender identity is female, (used with and who presents socially as a woman, and who often, but does not without transsexual ) always, makes physical changes through hormones or surgery. FTM: Female to Male A person born biologically female whose gender identity is male, (used with and who presents socially as a man, and who often, but does not without transsexual ) always, makes physical changes through hormones or surgery. Cross-dresser Anyone who dresses in clothing not associated with their assigned sex; generally refers to a male who dresses as female, who may or may not want to change his gender; considered more politically correct than transvestite. Transvestite Typically used to describe a biological male who dresses as a female, often for sexual gratification. This term tends to be viewed as disparaging and pathologizing. Drag queen A male who cross-dresses as a woman primarily for performance or show. Drag queens generally identify as males, often as gay males, and do not wish to change their gender. Drag king A female who cross-dresses as male and who may or may not want to change her gender. Transwoman Generally refers to someone who was born male and who identifies and portrays their gender as female. People will often use this term after taking some steps to portray their gender as female, or after fully transitioning; however, many who have fully transitioned prefer to be called women, rather than transwomen. Transman Generally refers to someone who was born female and who identifies and portrays their gender as male. People will often use this term after taking some steps to portray their gender as male, or after fully transitioning; however, many who have fully transitioned prefer to be called a man, rather than transman. Intersex A person born with genitalia that are neither exclusively male nor female, or that are inconsistent with chromosomal sex; sometimes not identified until puberty, when the person either fails to develop certain secondary sex characteristics, or develops characteristics that were not expected. Intersex is not considered a subcategory of transgender. However, people born with certain intersex conditions may be more likely than the general population to feel their gender assignment at birth was incorrect. The term Disorders of Sexual Development is recommended where the medical care of infants is considered. Hermaphrodite Previously used to describe intersex; now considered stigmatizing and outdated. Passing When someone is perceived as the gender they are presenting in their dress and mannerisms. For example: a male dressed as female is seen by others as female. Getting Clocked/ When a stranger sees through the gender someone is trying to Spooked portray. For example: a male who is dressed as female hears someone say, that is a man in a dress. Stealth When a transgender person has transitioned into a different gender, lives as if born in that gender, and does not divulge that he/she is transgender.

7 Introduction to Transgender Identity and Health 335 Table 12-1 Definitions of Transgender Terms (continued) Tranny Tranny-chaser Genderqueer Boi/Tranny Boi Androgyne Gender bender, beyond binary, polygender and gender outlaw Short for transgender. Some people consider this term derogatory. Refers to someone who is attracted to and/or seeks out sex or relationships with transgender people. Some people consider this term derogatory. This new term is generally used in two ways: 1) as an umbrella term that includes all people whose gender varies from the norm, akin to the use of the word queer to refer to all sexual orientations different from the norm (heterosexual); or 2) to describe a subset of individuals who are born biologically female, but feel their gender identity is neither female or male. Clinical observation suggests that when seen in the binary of male/female, these individuals tend to feel more comfortable being seen as male and using male names and pronouns, but do not necessarily feel that their gender identity is male. Another term for someone born female who feels that this is not an accurate or complete description of themselves. Other similar terms on the FTM spectrum include Butch, Boychick, Shapeshifter, and Boss Grrl. Refers to someone whose gender identity is both male and female, or neither male nor female. An androgyne person might present as androgynous, and/or as sometimes male and sometimes female, and might choose to use an androgynous name. Pronoun preference typically varies, including alternately using male or female pronouns, using the pronoun that matches gender presentation at that time, or using newly developed gender-neutral pronouns. Similar to genderqueer and androgyne, these terms refer to gender variations other than the traditional, dichotomous view of male and female. People who self-refer with these terms may identify and present themselves as both or alternatively male and female, as no gender, or as a gender outside the male/female binary. choose to do nothing at all. No matter how they choose to present themselves, most transgender individuals share one common desire: to be seen and respected for who they are. Gender Identity versus Sexual Orientation While gender identity and sexual orientation are distinct, they are closely intertwined; the process of exploring gender identity invariably includes exploring sexual orientation as well. The frequent misconception that transgender means gay may result from the tendency of some gay and lesbian people to present themselves in ways that depart from stereotypical gender norms or from the association of gay men with female impersonators. Gender identity and sexual orientation can be aptly distinguished by thinking about gender identity as the way a person feels inside about their gender (self) and thinking about sexual orientation as the gender(s) a person is attracted to (other).

8 336 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health A model developed by Grace Sterling Stowell, the executive director of the Boston Alliance of Gay, Lesbian, and Transgender Youth, depicts a triangle, with sex, gender, and sexual orientation being the three separate points. 6 Visually, this model describes both the ways in which these categories are separate, as well as the fact that they are related. Transgender people can have any sexual orientation; sexual orientation may change as they explore, and become more clear about, their gender identity. It is not helpful to use labels to describe a transgender person s sexual orientation, as labels can be confusing and misleading. Consider a biological male who has the gender identity of a female. For this person, being gay may mean feeling attracted to women; being heterosexual could mean feeling attracted to men. To further add to the confusion, sexual orientation labels may be used differently depending on whether someone is out about her or his gender identity. A biological male who identifies as female but who keeps her gender identity closeted may call herself gay to let others know that she likes men. On the other hand, a biological male who identifies as female and is out about her gender identity may call herself straight to let others know that she likes men. Clearly, if we want to know about someone s sexual orientation, we need to ask what gender(s) they are attracted to, and refrain from making assumptions based on commonly used, but imprecise terminology. Gender Identity Disorder and Gender Dysphoria Gender identity disorder (GID) is a diagnosis defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 7 to aid in the identification of transgender individuals who might benefit from clinical intervention. On the positive side, inclusion of this category legitimizes gender issues as worthy of scientific investigation, which facilitates clinical research; it also validates the need for clinical care, which may in turn help facilitate change in medical insurance policies that currently exclude coverage for care related to gender identity issues. Criteria for establishing a Sex Gender Sexual Orientation Figure 12-1 orientation Stowell model, depicting relationships between sex, gender, and sexual

9 Introduction to Transgender Identity and Health 337 diagnosis of GID are presented in Table It should be noted that the diagnosis of GID only describes transsexuals one subset of people who are transgender. The field of gender identity is still so new that the DSM description of GID has already become outdated. On the negative side, the diagnosis of gender identity disorder has been criticized both as a diagnosis and in terms of its language. The word disorder indicates that a variation from gender norms is disordered or deficient, rather than simply different. It suggests that gender identities held by transgender people are not legitimate, but instead represent perversion, delusion, or immature development. Therefore, many people use the term gender dysphoria, instead. Gender dysphoria describes persistent aversion toward some or all of one s physical characteristics and/or social roles that are ascribed according to biological sex. Often experienced as depression, anxiety, irritation, and/or agitation, gender dysphoria describes the sense that something is very wrong; rather than implying pathology, this term portrays a transgender person s emotional experience more aptly. 8 How Does Gender Identity Develop? Increasing knowledge suggests that gender identity development is much more complex than previously assumed, and there is no scientific consensus about a single pathway which leads to gender dysphoria. 9 Theories of causation tend to fall into two categories: nature/biology and nurture/ socialization. The predominating biological theory suggests that a neuro- Table 12-2 Definition of Gender Identity Disorder Gender Identity Disorder in Adolescents and Adults, Diagnostic Criteria: A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that one has the typical feelings and reactions of the other sex. B. Persistent discomfort with one s sex or sense of inappropriateness in the gender role of that sex. In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that one was born the wrong sex. C. The disturbance is not concurrent with a physical intersex condition. D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if (for sexually mature individuals) Sexually Attracted to Males,... Females,... Both,... Neither.

10 338 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health hormonal disturbance takes place in the brain during embryological development. While the genitalia of the human embryo become differentiated as male or female during the 12th week of fetal development, the gender identity portion of the brain differentiates around the 16th week. If there is a hormonal imbalance during this four-week period, gender identity may not develop along the same lines as the genitalia. 10 It is hypothesized that the state of the mother s overall physical and mental health during pregnancy could cause such an imbalance. Severe emotional trauma or other stress or the ingestion of certain prescription or illegal drugs during pregnancy could interfere with fetal brain chemistry. Theories of nurture claim that gender identity is taught through socialization. Early psychoanalytic theories suggested that gender identity disorder was due to disturbances such as difficulty separating and individuating from a parent, 11 an unresolved Oedipal complex, the physical or emotional absence of the primary caregiver during a child s early years, cross-gendered behaviors being reinforced, and the existence of a classically overbearing mother or a weak or absent father. These theories are inconsistent with clinical observation, which demonstrates that the psychosocial and familial experiences of transgender people, like those of everyone else, are extraordinarily diverse. Failure of the nurture/socialization theories to account adequately for the complexity of gender identity is vividly illustrated by the case of Canadian twin boys. 12 In 1967, one of two identical male twins had his penis severely injured in a botched circumcision. After consulting John Money, a renowned expert in gender identity, the family decided to raise this twin as a girl. Female external genitalia were created surgically while he was an infant, and female sex hormones were administered. For twelve years, he participated in a program of social, mental, and hormonal conditioning to make the transformation take hold in his psyche. 12 He was not told the truth about his history, however, and grew up believing he was born female. The case was presented as a success in the medical literature. The apparent outcome that gender was a result of socialization, rather than biology, gave credence to the women s movement in the 1970s, and was widely cited. The case brought fame to Dr. Money, who was called one of the greatest sex researchers of the century. 10 In 1997, the experiment was exposed as a failure. Dr. Milton Diamond, a biologist at the University of Hawaii, and Dr. Keith Sigmundson, a Canadian psychiatrist, documented how the twin rebelled against being socialized female. He resisted wearing dresses, insisted on standing up to urinate, and was bullied viciously at school. 13 When he was a teenager, he attempted suicide. His parents finally told him of his history at age 14; he then reverted back to male, taking male hormones. Although he lived the rest of his life as a man, David Reimer remained unhappy, and said: I d give just about anything to go to a hypnotist to black out my whole past... Because it s torture.... What they did to (me) in the body is sometimes

11 Introduction to Transgender Identity and Health 339 not near as bad as what they did to (me) in the mind. 13 Tragically, David Reimer killed himself in 2004, at age 38. This anecdote demonstrates the importance of helping individuals who are questioning their gender identity to define themselves and supporting them as they gradually choose to reveal themselves to others. Attempts to force transgender persons to live in a gender that feels alien are not effective, and can be extremely harmful. Normal Developmental Questioning versus Gender Dysphoria A certain amount of questioning gender and sexuality norms is a part of normal development, as discussed in the chapter on adolescence. It is important to note that questioning and/or exploring one s gender and/or gender identity does not necessarily indicate gender dysphoria or the diagnosis of GID. However, most transgender adults report knowing something was different about them at an early age. It is common to hear that by age four or five the person knew they were in the wrong body, or learned that their gender was different from what they believed. To quote one client: I thought I was a girl, and when we lined up in kindergarten I went to the girl s line. I was told go to the other line, you re a boy. That s how I learned I was a boy. Sometimes gender dysphoria can be avoided or tolerated in childhood, as the changes that come with puberty have not yet begun. Children may gravitate toward peers who mirror their gender identity or may choose to play stereotypical games associated with the gender they feel they are. However, children with gender dysphoria may show signs of distress very early. Biological girls may refuse to wear dresses, have long hair, or play with girls, and may try to stand up to urinate. Biological boys may want to dress up in their mother s (or sister s) clothing, play with girls, or sit down to urinate. Some children state or insist that they are the other gender or that they will become the other gender when they grow up. Diagnosing a child with GID can be tricky, as research shows that the majority of children with cross-gender behavior do not grow up to qualify for the diagnosis of GID in adulthood. 14 Puberty is often a time that gender dysphoria becomes more apparent, both to the individual who is undergoing physical changes, and to others. Although many people are able to either ignore or bear their gender issues as children, the drastic changes associated with puberty create a harsh reality that no longer permits denial. Clients often describe puberty as a horrific time, during which they felt shocked, humiliated, and betrayed by their bodies. Not surprisingly, transgender adolescents often express dislike or even disgust about their bodies after secondary sex characteristics

12 340 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health develop. 15 If these feelings of revulsion escalate, depression, suicidal feelings, and acts of self-harm may result. Normal questioning crosses into gender dysphoria or gender identity disorder when a person develops persistent and preoccupying symptoms that become the main focus of their life. When this happens, there are usually concomitant difficulties in many other realms, including social, academic or occupational functioning. Normal development may be arrested or delayed. Many clients report a fear or avoidance of growing up, and/or difficulty seeing the future: I couldn t imagine a future, because I could never see myself as a female. Consequences of Living in an Intolerant Society The consequences of living in a intolerant society can be readily understood by considering the following questions: Have you ever seen someone whose gender was unclear? Did you stare? Did you feel uncomfortable? Did you want to figure it out? Why? How did you feel? Uncomfortable? Confused? Nervous? Intrigued? Why? Cultural norms dictate how we should behave based on how our sex, gender, and/or sexual orientation are perceived. For most people this is not problematic. However, people who do not conform to societal expectations often experience: being stared at being ignored being engaged when otherwise they would have been left alone awkwardness in conversation discrimination violence. Gender identity impacts every aspect of a person s daily life: relationships with friends, family members, and romantic partners; work or school; and the ability to access healthcare. Consider the experience of a transgender person who needs to use a restroom, and discovers that rather than single-occupant (unisex) bathrooms, segregated facilities (male only or female only) are the only available options. How much time will a transgender person spend thinking about which restroom to use? How much will they worry about being hassled or harassed if they use the one that feels right? How uncomfortable will they feel if they have to use the one that does not feel right? What if someone calls the police while they are in the bathroom? This is just one example of the kinds of challenges transgender people encounter every day. Lack of acceptance frequently leads to low self-esteem, shame, humiliation, and isolation. Transgender individuals are at extremely high risk for

13 Introduction to Transgender Identity and Health 341 discrimination, lack of access to basic medical and mental healthcare, unemployment and underemployment, homelessness, substance abuse, HIV, depression, anxiety, suicidal feelings and/or attempts, sex work, and violent hate crimes. A problem in one area quickly leads to a problem in another. For example, financial problems resulting from unemployment can lead to loss of medical insurance (and subsequent poorer access to healthcare), as well as homelessness and reliance on sex work for income (with associated increased risk for various negative outcomes, including violence, substance abuse, and HIV). Once established, this vicious cycle can be hard to break. Many medical and mental health providers lack knowledge about the specific health needs of the transgender population. The remainder of this section will review data regarding key areas of risk. The section in this chapter entitled How Can We Help? Clinical Approach to Working with Transgender Patients outlines standards of care and presents practical tips to help clinicians communicate sensitively and provide appropriate mental health and referral services. Specific information regarding hormonal and surgical management is presented in Chapter 13. Depression Depression is likely the most frequent symptom associated with gender dysphoria. 1 The depression is often chronic, as the majority of gender dysphoric people have been aware of their gender dysphoria from an early age, even as early as three or four. However, certain situations can increase the severity of the depression. These situations can easily be overlooked, however, as they are ordinary events to those who do not experience gender dysphoria. Without an understanding of gender dysphoria, these situations will not be recognized as possible precipitating events that can increase depression and/or suicidal feelings or attempts. As noted previously, puberty is a particularly vulnerable time. As their bodies begin to show secondary sex characteristics of a gender that feels wrong, people with gender dysphoria often experience feelings of shock, confusion, horror, anger, upset, and betrayal, despite the fact that most understand puberty intellectually and anticipate the changes their bodies are likely to undergo. Before puberty, some transgender individuals believe either that their bodies will change into the gender with which they identify, while others believe that their bodies will remain androgynous, without secondary sex characteristics. Once physical changes begin, it is no longer possible to hide in these fantasies. Monthly menstrual periods and premenstrual symptoms in biological females who feel male, and erections, ejaculation, and nocturnal emissions in biological males who feel female can increase feelings of humiliation and depression acutely. For example, one client developed suicidal ideation

14 342 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health every month when he had his period, but this resolved when he began taking testosterone and his menses ceased. People with gender dysphoria often avoid masturbation and sexual activity with others, due to discomfort or even disgust with their genitalia. Those who are sexual often fantasize that their body matches their gender identity; in fact, many people are only able to be sexually aroused if they hold this fantasy. Biological male clients who identify as female say they imagine having a vagina while they are being penetrated anally; often their penis is tucked away, not to be seen or touched, increasing the believability of the fantasy. One client, a biological female who transitioned to male, became aware of his attraction to other men when gay men responded to him as a male. When he was perceived as female, however, sexual interest shown by men became repulsive and upsetting. It is important to note, however, that feelings about one s body and with being sexual exist along a continuum of comfort. This range includes people who are only mildly unhappy with their bodies, to those who can hardly bear to wash themselves in the shower. There are also people who are not particularly uncomfortable with their bodies. Some clients say that if they were seen and treated as the gender they identify with, they would not feel the need to make any changes to their bodies. However, because gender identity is often perceived incorrectly, some of these individuals choose to change their bodies so they will be seen as the people they feel they are. Depression can also arise in persons who do not necessarily qualify for the diagnosis of GID, but do experience a certain amount of gender dysphoria. Such people may not identify as either male or female, and therefore do not gain outside validation of a gender identity different from the male/female binary. For example, one client who was born biologically male and identified as androgyne sought to present her gender as androgynous, as this felt most genuine to her (the client is comfortable using both male and female pronouns). However, she found that although she could convincingly present as either male or female, she was not able to find a way to appear androgynous. Eventually she came to accept her gender identity as separate from her gender presentation. However, the client continues to experience depression, low self-esteem, and feelings of rejection and isolation due to the inability of others to recognize her as androgyne. Despite gender dysphoria, some people do not seek medical or mental healthcare, and struggle with these issues without the benefit of professional help. Some manage to deal with their issues effectively; others continue to suffer the effects of being different, whether or not they come out about their gender variation. Depression often requires psychopharmacological intervention. Some transgender people are leery of beginning medication, as they fear this will mean that their gender issues will not be fully addressed. Providers should appreciate that while medication can help alleviate depression,

15 Introduction to Transgender Identity and Health 343 gender dysphoria will not resolve until underlying gender issues are addressed, using modalities such as individual psychotherapy, and/or participation in a support group. Hormone administration (generally female hormones) can also induce or increase depression. This type of depression can also be treated with medication. However, hormone administration often leads to a decrease in depression and brightening of mood, as the person sees tangible progress in resolving their gender dysphoria. Sudden withdrawal of hormones should generally be avoided, since this can precipitate mood swings and depression. Anxiety Some, but not all studies suggest that there may be a correlation between separation anxiety in childhood and later development of gender identity disorder. 16 However, consensus exists that anxiety disorders are common in people diagnosed with GID. Anxiety can be chronic, stemming from repression of gender dysphoria, as well as the fear that others will find out. Anxiety may also manifest more acutely, as is seen in situations that include being in public or anticipating being in public. In this case, the anxiety likely results from fear of or prior experience with public scrutiny, harassment, and/or violence. As with depression, management of anxiety disorders in this population often requires a multimodality approach that includes medications, psychobehavioral or cognitive behavioral therapy, and group support. Self-harm A review of the literature shows that populations who engage in self-mutilation include transsexuals, 17 people who self-mutilate for religious or cultural reasons, 18 people who suffer from psychosis, and individuals with severe personality disorders. 19 Among those with borderline personality disorder, self-mutilating behavior is an attempt to regulate affect. 20 Despite the abundance of information about self-mutilation in people with borderline personality disorder, reference to mutilation of the genitals in this population is virtually absent. In the transgender population, however, self-harm to the body is usually directed specifically towards the genitalia. 21,22 When a person s physical self is discordant with their gender identity, the body feels alien. The purpose of genital mutilation is to remove the most offending parts, 23 with or without a plan to fashion new, more appropriate ones. Self-castration is rarely an impulsive act; rather, it usually occurs after long-standing conflict. 22 Depression and anxiety due to the wait for sex reassignment surgery can be triggering factors. 24 Transgender people often have unrealistic expectations about what will happen after they harm their genitalia. Clients sometimes relate the belief

16 344 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health that they will heal easily and be fine without any medical attention, ignoring the fact that castration or amputation of the breasts represent major physical trauma. Magical thinking is also quite common: for example, one client described repeatedly trying to slam her penis in a drawer to cut it off, with the belief that severing her penis would result in a vagina. Suicide The literature is replete with studies linking suicide with GID. 25,26,27 Studies of transgender populations in Philadelphia, Washington, Chicago, San Francisco, and Houston report suicidal ideation rates ranging from 16% up to 64%, 27 with most people attributing their suicidal thoughts to gender dysphoria. Clements-Nolle found that 62% of 392 MTF individuals were depressed, and 32% had attempted suicide. 28 Recent studies have examined the relationship between gender role, sexual orientation, and suicide risk. Studies have found that cross-gender role is a unique predictor of suicidal symptoms, especially for boys; concluding that cross-gendered people, regardless of sexual orientation, appear to have a higher risk for suicidal symptoms. 26 Substance Abuse Substance abuse is also common. Transgender individuals are believed to be the most underserved group of substance abusers; however, few studies have been performed specifically in the transgender community. 29 The Transgender Community Health Project in San Francisco surveyed 392 MTF and 123 FTM individuals in In addition to extremely high levels of HIV risk behaviors, 34% of the MTF group and 18% of the FTM group reported injection drug use. 30 Of this latter group, 91% shared syringes. Available studies also suggest that the use of tobacco is common in the transgender community. 31 Obtaining treatment for substance abuse is frequently a problem for transgender individuals. Many treatment programs segregate people by sex, which can lead transgender patients to feel humiliated or to decline treatment. 27 Also common is the view that taking hormones, or even psychotropic medication, represents drug use and that cessation of hormone use is therefore required prior to enrollment in a substance abuse treatment program. 27 Unique features of substance abuse in the transgender community include the use of silicone to change the shape and appearance of the body and self-administration of illegally procured hormones. Since both may be injected, sharing works or failure to use a sterile technique can result in complications that include infections at the injection site, endocarditis, hepatitis, and HIV. The use of silicone, which has been condemned by the FDA and others, 25 is often of industrial-grade rather than medical-grade, which was once procured much more easily from breast implants. Undesired

17 Introduction to Transgender Identity and Health 345 effects include respiratory stress, death, systemic illness, and disfiguration due to hardening and migration of the material. 25 Unsupervised use of hormones is also dangerous, as it is associated with increased risk for thromboembolism, abnormal liver function, 25 and adverse cardiac outcomes. Sex Work Sex work is common in the transgender community for a number of reasons. Sex work provides a means of financial support for transgender people who do not have other ways of supporting themselves. Transgender youth are at particular risk. Frequently banished from their homes when they come out, transgender youth often lack high school equivalency, and they may not even have reached the legal age of employment. Transgender adults who are fired because they come out at work often find it very difficult to get another job, either because they do not pass, or because their previous employer will not give them a good recommendation. In addition to being a means for survival, sex work may be viewed as a road to transition. Sex work can provide large amounts of money, often fairly quickly. This can be very tempting to a transgender individual who is desperate to transition but has no other ways to find the money to do so. The process and challenges of transition are described in more detail in the section entitled Transition. Besides providing financial help, sex work can be emotionally helpful. Transgender people often fear that no one will want to be romantic or sexual with them because of their gender identity. Being desired for one s body is incredibly powerful. It is something we all want, something we all seek. It is important for our self-esteem, for our need to be close to others, and our need to be loved. Sex work can provide the gratification and sense of normalcy a transgender person craves in being desired for their body and affirmed for their gender presentation. Unfortunately, sex work is associated with significant risks. Prostituting often requires following the demands of the person paying for these services. This means that the sex worker is less likely to practice safe sex and is therefore vulnerable to infection with hepatitis C, HIV, and other STIs. Transgender sex workers are also at high risk for interpersonal violence. HIV/AIDS Recent studies report high rates of HIV in MTF populations: 21% in Chicago, 27 22% in Los Angeles, 32 21% to 30% in New York, 27 27% in Houston, 27 32% in Washington, DC, 27 and 26%, 35%, and 47% in San Francisco. 28,33 High levels of lifetime HIV-risk behaviors are observed among transgender women: in one study of 392 MTF individuals in San Francisco, 80% reported a history of sex work and 85% had participated in unprotected receptive anal sex. 30 The same study found that HIV prevalence

18 346 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health was much lower in a second group of 123 FTM individuals (1.6%); however, this may not continue to be the case, as 28% of this group reported a history of unsafe receptive anal sex. Information from eleven focus groups with 100 MTF and FTM people in San Francisco found that low self-esteem was the main reason for sexual risk taking. 31 Thus, it appears that for some transgender individuals, the risk of contracting HIV is considered less important than the gratification and sense of normalcy they experience in being desired for their body, and affirmed for their gender presentation. The importance of addressing selfesteem issues with transgender clients cannot be overemphasized; clearly, clinicians also need to work hard on developing effective risk-reduction counseling techniques. Violence and Safety Issues Violence toward transgender individuals is common, both within and outside the home. Transgender people can enrage others by their mere existence. 25 Looking androgynous, or having mixed gender characteristics, appear to be triggering factors for trans-bashing. Kenagy found that 53.8% of 78 transgender people had been forced to have sex, 56.3% of 80 transgender people had experienced violence in their home, and 51.3% of 80 transgender people had been physically abused. 34 In each case, MTF individuals were significantly more likely to have experienced this violence than FTMs. Transgender women of color are at highest risk. 27 The murder rate of transgender people is extremely high. Statistics show that prior to 1999, a transgender murder occurred approximately once a month. Since then the number has increased to two murders per month. 35 According to transgender historian Candice "Kay" Brown, a murder rate of one MTF transsexual person each month computes to an average of 119 murders per transsexuals, or six times greater than the national average. 35 This murder rate is more than three times that of African American men, who have the next highest recorded incidence. 35 It should be noted that much of the violence experienced by transgender people is not reported, due to internalized transphobia, shame, and lack of confidence in authorities. In addition, violence against transgender people is often attributed incorrectly as gay bashing. Furthermore, transgender murders are often not reported in the news. In reaction, the Web site Remembering Our Dead ( was created to keep more accurate track of transgender murders. Healthcare Access Despite being at such high risk for adverse health effects, many transgender people are routinely refused care, 26,34 are unable to afford healthcare

19 Introduction to Transgender Identity and Health 347 due to being unemployed or underemployed, 27 or do not seek care due to traumatic experiences in the past. There are documented cases of transgender deaths due to the delay, or even refusal, to provide urgent medical treatment. 31 Transgender youth, in particular, may not be able to access appropriate medical treatment for gender identity disorder, due to being underage. Ironically, failure to take proactive steps is a primary reason for the escalation of psychological problems, including suicide, alcohol and drug abuse, and homelessness, 26 creating a self-reinforcing cycle. Given such high risks, coupled with the incredible difficulty accessing medical and mental healthcare, the importance of developing programs that provide outreach services to the transgender community cannot be overemphasized. Outreach programs should take into account populations that are least likely to seek care, such as injection drug users, sex workers, youths, and the homeless. Example of model health access programs include: the Gay, Lesbian, Bisexual and Transgender Health Access Project in Boston, Mass ( and the Transgender Healthcare Access Project at the Transgender Law Center in San Francisco, Calif ( Reaching Self-Acceptance As discussed in detail in Chapter 3, the process of reaching self-acceptance and developing a positive identity follows a very similar course for transgender individuals as it does for people who define themselves as lesbian, gay, or bisexual. The first step is to define oneself; subsequently, one must decide how much to reveal that identity to other people. Unlike LGB individuals, however, transgender people are often in the unique position of being less able to conceal their identities that is, in living in a gender role that conflicts with their biological sex, they are frequently conspicuous to others. This lack of privacy poses particular challenges for transgender individuals who choose to undergo a real life experience on the road to making a more permanent physical transition toward a body that is in accord with their gender identity. This section reviews the three major important tasks transgender individuals must traverse on the path toward self-acceptance: self-exploration, coming out, and transitioning. Self-exploration A certain amount of questioning and experimentation around gender identity and sexual orientation is common in many adolescents and young adults as part of normal psychosexual development. For transgender people, the gradual realization that they are truly different from most of their peers, rather than merely experimenting, is often a daunting process. Some

20 348 The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health individuals, particularly those who have positive role models and strong supports, feel validated and euphoric when they discover that there are words to describe their experience and that they are not alone. For others, this time may be punctuated by feelings of confusion, anxiety, and depression. Not surprisingly, therefore, many transgender individuals find it helpful to consult a mental health professional during the process of questioning and clarifying their gender identity. The tasks of psychotherapy are reviewed below, in the section entitled Mental Health Evaluation and Management. Coming Out When a transgender individual has reached a certain comfort level in exploring their gender issues, a frequent next step is to begin coming out to others. For transgender people, the coming out process strongly resembles that of LGB people. Coming out as transgender helps reinforce a person s identity, as well as making space to allow others to shift their perspective. Coming out is a life-long process. However, there is often a concentrated period of time during which a person first begins to come out to key people in their life. Similar to coming out about sexuality, people make different choices about how, when, and to whom they choose to come out as transgender. Unlike sexual orientation, however, gender identity cannot be easily hidden if the person chooses to make physical changes to their body. Therefore, the person may need to come out to people they would not ordinarily choose to come out to if they could keep their identity private. Some transgender people feel their identity will be taken more seriously if they have already started the process of transition: It would be hard for my family to see me as female if I still look completely male. They may therefore choose to begin hormone therapy first, so that their bodies will display the physical attributes of their gender. The process of coming out may result in feelings of relief, euphoria, anxiety, or any combination of these and other emotions. Some transgender individuals report successful, easy experiences of coming out that go better than expected; others describe difficult, upsetting experiences that include being rejected, being challenged, and being misunderstood. A frequent occurrence is the need to educate people about what transgender is and is not: this can feel like a burden to a vulnerable person who longs for support and understanding. Some clients resent having to educate others: one person stated bluntly, That s not my job. There is also a risk that the person coming out will take on, or be expected to adopt, the role of caretaker for friends and family who are having emotional difficulty handling the news. This, too, can cause resentment. As one client put it: I m the one who needs the support and understanding, but my family wants me to take care of them, because they re so upset about this. What about me?