1. Lori Becker, Ph.D., ABPP

2.  (Natal) Sex: The classification of individuals as female or male on the basis of their reproductive organs and functions.  Gender: Behavioral, cultural, or psychological traits that a society associates with male and female sex.  Transgender: Individuals who cross or transcend culturally defined categories of gender. The gender identity/expression differs (to varying degrees) from their natal sex.  Transsexual: Individuals who seek to change or who have changed their primary and/or secondary sex characteristics through medical interventions (hormones and/or surgery), typically accompanied by a permanent change in gender role.

3.  Gender nonconformity: 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: Discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (Knudson, De Cuypere, & Bockting, 2010).

4. “The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon [that] should not be judged as inherently pathological or negative.” (WPATH Board of Directors, May 2010).

5.  Affirm the veteran’s gender identity  Explore different options for expression of that identity  Help the veteran make decisions about medical treatment options.

6.  World Professional Association for Transgender Health promotes interdisciplinary evidence based care, education, research, advocacy, public policy, and respect in transgender health.  Coordination of care is recommended  HT can be initiated with a referral from a qualified MH professional or a health professional trained in behavioral health.

7.  Provider must be competent in:  Assessment of gender dysphoria  Assessment of eligibility & preparation for HT  Must provide documentation (chart or referral letter) of history, progress, eligibility.  Health professionals who recommend HT share the ethical and legal responsibility for that decision with the physician who provides the service.

8.  At least a Master’s in clinical behavioral science  Degree should be by accredited institution  Documented credentials from licensing board  Competence in using DSM and/or ICD  Ability to recognize and diagnose MH concerns, and distinguish them from gender dysphoria  Documented supervision in psychotherapy/counseling  Knowledge about gender nonconforming identities and assessment/tx of gender dysphoria  Continuing ed in assessment and tx of gender dysphoria (WPATH Guidelines)

9.  VA Mandate (June 2011): “Medically otherwise eligible intersex and transgender veterans, including hormonal therapy, mental health care, preoperative evaluation, and medically necessary post-operative and long- term care following sex reassignment surgery. SRS cannot be performed or funded by VHA.”

10.  62 y/o veteran presented stating he sometimes lives as a woman  Initially diagnosed with DID  Extensive trauma history: severe childhood abuse, childhood sexual assault, Army service in Vietnam on Cambodian border  Multiple suicide attempts (6+), ETOH Depend  Referred to MHC (Bipolar & PTSD)

11.  Presented to Dr. Goldman in acute distress  Ability to dress/live as a woman was negated  Transported to JC ER; admitted to JB inpatient  Sensitivity in notes: She is listed as “John” in the computer, but she prefers to be addressed as “Jane.” She is transgendered. She will need to be treated as a woman throughout her stay.

12.  Five inpatient hospitalizations in 2011.  Presents to ER or calls hotline when in acute distress.  Outpt care with Drs. Goldman & Agnihotri  Completed SARRTP, enrolled in PRRC  Consistently involved in MH care  Requested referral for Hormone Therapy  Dr. Goldman placed consult to Endo

13.  Veteran requested Hormone Therapy  VA staff endocrinologist refused treatment  COS approved fee-based consult to private endocrinologist  Conflict of interest for Dr. Goldman to provide letter of support to private endocrinologist.

14.  Permission sought to complete this eval  First clinician to do this at this VA  Research and consultation  Joined VHALGBT & APA Division 44 Listservs  Phone conferences with national experts  WPATH Guidelines

15.  3 meetings  2 (75’) extended diagnostic interview sessions  1 (50’) feedback session  Consulted with a family member  Sensitively informed clerical staff  Consulted with colleagues extensively - Requested feedback on my documentation Shout out to Drs. Heiland & Goldman!

16.  Highly disturbed self-image  Difficulty with mood regulation, sobriety  Self-perception of masculinity is distressing  Feels “disgusted” by her masculinity  Refers to her penis as “it”  Identifies self-stimulation as a trigger to drink  Only looks at full self in mirror if clothed

17.  “Assess eligibility, prepare and refer the patient for HT, particularly in the absence of significant co-existing mental health concerns”  Informed Consent: Does she have the capacity to understand the medical implications of hormone therapy on her physical condition?  Consultation with clinical pharmacist  Veteran was insightful about her health & congruent health behaviors

18.  FtM: Deepened voice, clitoral enlargement, growth in facial and body hair, cessation of menses, breast atrophy, increased libido, redistribution of body fat, increased muscle mass, roughening of skin  MtF: Breast growth, decreased libido and erections, decreased testicular size, redistribution of body fat, softened skin, decreased body hair, slowed balding patterns  Most physical changes occur over two years

19. Effect Expected Onset Expected Effect Skin oiliness/acne 1-6 months 1-2 years Facial hair growth 3-6 months 3-5 years Scalp hair loss >12 monthsvariable ^ muscle strength 6-12 months 2-5 years Body fat redistrib 3-6 months 2-5 years Cessation of menses 2-6 months n/a Clitoral enlargement 3-6 months 1-2 years Vaginal atrophy 3-6 months 1-2 years Deepened voice 3-12 months 1-2 years

20. Effect Expected Onset Expected Effect Body fat redistrib 3-6 months 2-5 years Decr muscle strength3-6 months 1-2 years Softer skin3-6 months unknown Decreased libido 1-3 months 1-2 years Decreased erections1-3 months 3-6 months EDvariable variable Breast growth 3-6 months 2-3 years Decr testicular mass 3-6 months 2-3 years Decr sperm prodvariable variable Thinning facial hair6-12 months > 3 years

21.  Venous thromboembolic disease  Cardiovascular, cerebrovascular disease  Lipids  Liver/gallbladder  Decreased nocturnal erections, libido, fertility  Type 2 diabetes mellitus  Hypertension  Prolactinemia  Breast cancer (minimal/questionable risk)

22.  Persistent, well-documented gender dysphoria  Capacity to make fully informed consent for treatment  Age of majority  Any significant medical or mental health concerns must be reasonably well controlled WPATH SOC, 7 th Version, p. 34

23.  “chicken and egg” problem  HT risks < Gender Dysphoria risks  Letter of support was drafted  Followed WPATH SOC guidelines for letter

24.  Patient’s general identifying characteristics  Results of client’s psychosocial assessment, including any dx  Duration of referring provider’s relationship with client, including type of evaluation and therapy to date  Note that criteria for hormone therapy have been met.  Brief description of the clinical rationale for supporting the client’s request for HT.  Statement that informed consent has been obtained.  Statement that the referring provider is available for coordination of care (and via telephone to establish this). (WPATH SOC, 7 th Version, p. 26)

25.  Current state of the field: Gatekeeper Model  Does the veteran need to demonstrate  “Persistent, well-documented gender dysphoria”?  Does the clinician need to demonstrate  “Clinical rational for supporting the client’s request”?  Move toward: Informed Consent Model  Pt has information to make an informed choice  Pt has cognitive ability to make informed choice

26.  Media focuses on SRS, but HT makes largest difference in lives of trans people.  The patient’s autonomy is underscored  Assumes that transgender is not a MI  Decreases patient’s jumping through hoops  DSM diagnosis, extensive counseling, “real-life experiences” (6-24 mos.)  Decreases use of Black Market hormones