Gender Dyshoria and Health

1
Gender Dyshoria and Health

• Dr Mary Samuhel
• Gender Dysphoria Clinic
• Monash Medical Centre
• Gender Competency Training for Medical
  Educators28th of April 2003

2
Health Issues in the Transgender Community

• Definitional difficulties
• Historical context
• Health Concerns
• Recommendations for health care professionals
• Future Directions

3
Definitions -Victorian Gay, Lesbian, Bisexual,
Transgender and Intersex Health Action Plan

• Gender identity- A persons 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).

4
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.

5
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 males
  testes at a young enough age would prevent his
  masculinisation. Slaves were castrated and
  became known as eunuchs.

6
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.

7
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"

8
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.

9
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

10
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 Elliss 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.

11
Sex reassignment surgery

• The first complete male to female SRS was
  reported in 1931, it was performed based on
  Hirschfelds recommendations by two co-workers in
  the institute, Dr Levy-Lenz and Dr Felix Abraham.
  Hirschfeld viewed transsexuality as a form of
  intersex.

12
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.

13
Public awareness of transsexuals
New York Daily Ex-GI becomes Blonde Beauty
Christine Jorgensen the first American to undergo
SRS in Copenhagen, 1952-1954
14
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 1950s
  pioneered a new form of SRS

15
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.

16
Other countries also developed Gender clinics

• 1967 the Charing Cross Hospital in England and
  other programs in Germany and Paris.
• Australia - In the 1960s 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.

17
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 1980s Professor Walters goes to
  Newcastle, Dr Kennedy becames coordinator and the
  clinic transfers to Monash medical Centre.

18
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.

19
Late 1960s

• 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.

20
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.

21
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).

22
Incidence rates of M-F F-M transsexuals

• Walinder , 1967 Sweden 1 37 000 (2.81)
• Pauly, 1968, USA, 1 100 000
• Hoenig Kenna, 1974, England 1 34 000
• Ross et al, 1981, Australia, 1 24 000 (611)
• 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.

23
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.

24
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 helping them.

25
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.

26
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.

27
Sources investigating health concerns for GLBIT

• GLMA. Healthy People 2010 - Companion Document
  for LGBT Health. April 2001 http//www.glma.org/po
  licy/hp2010/index.html

28
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.

29
Increased risks in transgender communities of

• Depression
• Suicide ideation
• Drug and alcohol problems
• Risk of sexual transmitted diseases
• Delayed health care

30
Possible risks of Hormone Therapy M-F

• 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

31
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)

32
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

33
Lesser Health Concerns

• Non-disclosure
• Allergies
• Eye infections
• If the clinician is not aware of a patients
  gender identity, he or she may fail to accurately
  diagnose, treat, or recommend appropriate
  preventative measures for a range of conditions.

34
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.

35
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.

36
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 individuals sexual
  orientation in their preferred gender) as well as
  acknowledging the variation that exists among
  trans individuals.

37
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