Eli Coleman

Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7

ABSTRACT The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.

Stigma, Mental Health, and Resilience in an Online Sample of the US Transgender Population

OBJECTIVES We assessed the association between minority stress, mental health, and potential ameliorating factors in a large, community-based, geographically diverse sample of the US transgender population. METHODS In 2003, we recruited through the Internet a sample of 1093 male-to-female and female-to-male transgender persons, stratified by gender. Participants completed an online survey that included standardized measures of mental health. Guided by the minority stress model, we evaluated associations between stigma and mental health and tested whether indicators of resilience (family support, peer support, identity pride) moderated these associations. RESULTS Respondents had a high prevalence of clinical depression (44.1%), anxiety (33.2%), and somatization (27.5%). Social stigma was positively associated with psychological distress. Peer support (from other transgender people) moderated this relationship. We found few differences by gender identity. CONCLUSIONS Our findings support the minority stress model. Prevention needs to confront social structures, norms, and attitudes that produce minority stress for gender-variant people; enhance peer support; and improve access to mental health and social services that affirm transgender identity and promote resilience.

Psychiatric comorbidity and compulsive/impulsive traits in compulsive sexual behavior.

In recent years there has been an increase in identifying and treating a clinical syndrome that has been given many different names, including compulsive sexual behavior (CSB). The purpose of this study was to determine the prevalence of psychiatric disorders in a sample of individuals with CSB, as evaluated by a structured psychiatric interview. A secondary focus of this research was to determine if individuals with CSB exhibit obsessive-compulsive characteristics or exhibit impulse control problems. Participants were 23 men and two women who responded to newspaper advertisements and met criteria for CSB according to diagnostic criteria established and assessed by expert clinicians. The Structured Clinical Interview for DSM-III, patient version (SCID-P) and the Structured Clinical Interview for Axis II Disorders (SCID-II) were used to interview all participants. To study compulsive or impulsive traits the authors developed a semistructured interview. Standardized rating scales were also administered. Eighty-eight percent of the sample met diagnostic criteria for an axis I disorder at the time of the interview, and 100% of the sample met criteria for an axis I disorder at some time in their lives. The most common diagnoses were mood and anxiety disorders. The sample exhibited more traits of impulsivity than compulsivity. The data are consistent with the suggestion proposed by others that argues for conceptualizing these disorders as impulsive/compulsive spectrum disorders. Attention must be given to addressing these traits, as well as to the treatment of other axis I and axis II disorders, when treating CSB.

Compulsive Sexual Behavior Inventory: A Preliminary Study of Reliability and Validity

This preliminary study was designed to develop empirically a scale of compulsive sexual behavior (CSB) and to test its reliability and validity in a sample of individuals with nonparaphilic CSB ( N = 15), in a sample of pedophiles ( N = 35) in treatment for sexual offending, and in a sample of normal controls ( N = 42). Following a factor analysis and a varimax rotation, those items with factor loadings on the rotated factors of greater than .60 were retained. Three factors were identified, which appeared to measure control, abuse, and violence. Cronbachs alphas indicated that the subscales have good reliability. The 28-item scale was then tested for validity by a linear discriminant function analysis. The scale successfully discriminated the nonparaphilic CSB sample and the pedophiles from controls. Further analysis indicated that this scale is a valid measure of CSB in that there were significant differences between the three groups on the control subscale. Pedophiles scored significantly lower than the other two groups on the abuse subscale, with the other two groups not scoring significantly differently from one another. This indicated that pedophiles were more abusive than the nonparaphilic CSB individuals or the controls. Pedophiles scored significantly lower than controls on the violence subscale. Nonparaphilic individuals with compulsive sexual behavior scored slightly lower on the violence subscale, although not significantly different. As a preliminary study, there are several limitations to this study, which should be addressed, in further studies with larger sample sizes.This preliminary study was designed to develop empirically a scale of compulsive sexual behavior (CSB) and to test its reliability and validity in a sample of individuals with nonparaphilic CSB (N = 15), in a sample of pedophiles (N = 35) in treatment for sexual offending, and in a sample of normal controls (N = 42). Following a factor analysis and a varimax rotation, those items with factor loadings on the rotated factors of greater than .60 were retained. Three factors were identified, which appeared to measure control, abuse, and violence. Cronbachs alphas indicated that the subscales have good reliability. The 28-item scale was then tested for validity by a linear discriminant function analysis. The scale successfully discriminated the nonparaphilic CSB sample and the pedophiles from controls. Further analysis indicated that this scale is a valid measure of CSB in that there were significant differences between the three groups on the control subscale. Pedophiles scored significantly lower than the other two groups on the abuse subscale, with the other two groups not scoring significantly differently from one another. This indicated that pedophiles were more abusive than the nonparaphilic CSB individuals or the controls. Pedophiles scored significantly lower than controls on the violence subscale. Nonparaphilic individuals with compulsive sexual behavior scored slightly lower on the violence subscale, although not significantly different. As a preliminary study, there are several limitations to this study, which should be addressed, in further studies with larger sample sizes.

Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder

Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA’s position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.

The relationship between homosexuality, internalized homo-negativity, and mental health in men who have sex with men

ABSTRACT Whether homosexuality or internalized homo-negativity is the critical variable affecting the mental health of men who have sex with men has long been debated. As part of a larger study, 422 Midwestern homosexual men completed questionnaires examining degree of homosexuality, internalized homo-negativity, and depression. Logistic regression modeling identified internalized homo-negativity, but not degree of homosexuality, as significantly associated with greater adjustment depression (OR = 1.5), major depression (OR = 2.6), dysthymia (OR = 1.5), and likelihood of being in therapy (OR = 1.4). Internalized homo-negativity was also negatively associated with overall sexual health, psychosexual maturation, comfort with sexual orientation, “outness,” and peer socialization. Internalized homo-negativity, not homosexuality, appears associated with negative health outcomes. Providers should promote sexual health and avoid interventions that reinforce internalized homo-negativity.

Treatment of compulsive sexual behaviour with naltrexone and serotonin reuptake inhibitors: two case studies.

Although there is no universally accepted definition of compulsive sexual behaviour (CSB), the term is generally used to indicate excessive sexual behaviour or sexual cognitions that lead to subjective distress, social or occupational impairment, or legal and financial consequences. Similar to impulse control disorders, CSB is characterized by a failure to resist the impulse for sex. Opioid antagonists have been effective in treating urge-driven disorders, such as pathological gambling disorder, alcoholism, borderline personality disorder with self-injurious behaviour, cocaine abuse, mental retardation with self-injurious behaviour and eating disorders. Based upon the efficacy of opioid antagonists in treating disorders associated with urges, we hypothesized that naltrexone would reduce both the urges associated with CSB and therefore reduce the sexual behaviour. We present two case reports of individuals with CSB treated successfully with naltrexone, a novel treatment for CSB. In both cases, symptoms dramatically decreased and psychosocial functioning improved with the use of naltrexone. Although more research is needed to determine the mechanism that leads to the excessive sexual behaviour in individuals with CSB, the present case reports suggest that naltrexone may be effective in treating some cases of CSB.

Compulsive Sexual Behavior and Risk for Unsafe Sex Among Internet Using Men Who Have Sex with Men

The present study explored the relationship between compulsive sexual behavior (CSB) and unprotected anal intercourse (UAI) for men who have sex with men (MSM) across a number of ethnic/racial groups and who used the Internet to seek sexual partners. A sample of 2,716 MSM (512 Asian, 445 Black, 683 Latino, 348 Other, 728 White) completed on online survey that collected information about their sexual behaviors with partners met online and offline. The survey also included the Compulsive Sexual Behavior Inventory (CSBI). Consistent with the notion that CSB is a stable trait, higher scores on the CSBI were associated with greater odds for engaging in UAI, regardless of the context in which sex partners were met (online or offline). Differences in median CSB scores were generally similar across racial and ethnic groups. The median CSB score was significantly higher for HIV-positive participants than for HIV-negative participants. HIV-prevention interventions are needed among MSM, but should take into account that some may be resistant to risk reduction strategies because of CSB.

Homosexual and bisexual identity in sex-reassigned female-to-male transsexuals

Descriptions of female-to-male transsexuals who are sexually attracted to men are rare. This is a report on nine of them. Their awareness of gender dysphoria preceded their awareness of their attraction to men. Their wish to undergo sex reassignment as a means of resolving their gender dysphoria superseded any concerns about their sexual orientation or sexual adaptation after surgery. Several had had sexual relationships with men before sex reassignment which were unsatisfactory because these men viewed our subjects as women. After sex reassignment, the subjects successfully established sexual relationships with gay men; in some of them even penovaginal intercourse was part of their sexual activities. While hormonally and surgically reassigned, none of our subjects had had phalloplasty. All nine subjects were interviewed and given psychological tests measuring sexual satisfaction and psychological adjustment. Their results were compared to those of a group of self-identified gay men. No major differences in sexual satisfaction and psychological adaptation were found. The phenomenon of female-to-male transsexuals who develop a sexual orientation toward men may be more common than previously thought. Regarding female gender dysphoric individuals, our findings challenge the issue of using sexual orientation in classification systems of gender dysphoria syndromes and as a risk factor in the decision regarding sex reassignment. Further, our study invites us to rethink the genital criterion in the assessment of sexual orientation.

Drug Use, Unsafe Sexual Behavior, and Internalized Homonegativity in Men Who Have Sex With Men

Previous research has identified alcohol and drug use as predictive of unsafe sexual behavior among men who have sex with men (MSM). The purpose of this study was to assess whether substances associated with the greatest alteration in consciousness are associated with increased risk behavior, and to explore any relationship between internalized homonegativity and alcohol and other drug use. Participants in the study were 422 Midwestern MSM who volunteered to evaluate a seminar on sexuality and intimacy between men. Alcohol, chemical use, and dependency during the last 2 weeks were assessed using standardized questions and CAGE screening questions. Internalized homonegativity was assessed using the 26-item Reactions to Homosexuality scale. Components of unsafe sexual behavior during the preceding 3 months was assessed using dichotomous variables and collapsed into an overall measure of contextualized risk. Consistent and strong associations (ORs between 2.32 and 4.57) were found between unsafe sexual behavior and alcohol and other drug use. The greater the alcohol problem and the harder the drugs and the more they may impact consciousness or disinhibition, the greater the apparent association with unsafe sex. Degree of alteration of consciousness and disinhibition appear to be the common underlying dimensions of risk, although dose-level data were not available. The data did not support any consistent association between internalized homonegativity and use of drugs and alcohol.