George R. Brown

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.

Prevalence of Gender Identity Disorder and Suicide Risk Among Transgender Veterans Utilizing Veterans Health Administration Care

OBJECTIVES We estimated the prevalence and incidence of gender identity disorder (GID) diagnoses among veterans in the Veterans Health Administration (VHA) health care system and examined suicide risk among veterans with a GID diagnosis. METHODS We examined VHA electronic medical records from 2000 through 2011 for 2 official ICD-9 diagnosis codes that indicate transgender status. We generated annual period prevalence estimates and calculated incidence using the prevalence of GID at 2000 as the baseline year. We cross-referenced GID cases with available data (2009-2011) of suicide-related events among all VHA users to examine suicide risk. RESULTS GID prevalence in the VHA is higher (22.9/100 000 persons) than are previous estimates of GID in the general US population (4.3/100 000 persons). The rate of suicide-related events among GID-diagnosed VHA veterans was more than 20 times higher than were rates for the general VHA population. CONCLUSIONS The prevalence of GID diagnosis nearly doubled over 10 years among VHA veterans. Research is needed to examine suicide risk among transgender veterans and how their VHA utilization may be enhanced by new VA initiatives on transgender care.

Access to Care for Transgender Veterans in the Veterans Health Administration: 2006–2013

A 2011 Veterans Health Administration directive mandated medically necessary care for transgender veterans. Internal education efforts informed staff of the directive and promoted greater access to care. For fiscal years 2006 through 2013, we identified 2662 unique individuals with International Classification of Diseases, Ninth Revision diagnoses related to transgender status in Veterans Health Administration medical records, with 40% of new cases in the 2 years following the directive. A bottom-up push for services by veterans and top-down education likely worked synergistically to speed implementation of the new policy and increase access to care.

70 U.S. Veterans with Gender Identity Disturbances: A Descriptive Study

ABSTRACT This study describes the largest population of veterans referred for a gender identity disorder (GID) evaluation. Most were self-referred, others were referred by their commanding officer. A search of the English language literature revealed no similar studies on veterans other than a pilot project by the second author. Methods: Retrospective descriptive data were obtained from chart reviews of 70 U.S. veterans who were evaluated by the second author for gender disturbances over a 20-year period (1987 to 2007). The modal veteran with gender identity disturbance was a natal male (91%) identifying as female, >40 years old, Caucasian, employed, with more than 12 years of education. Fifty-seven percent were parents with a history of sexual involvement with opposite sex individuals. Histories of autogynephilia were not elicited in vets interviewed since 1997. Classic “flight into hypermasculinity” was described by a majority of the natal male vets as a retrospective understanding of why they joined the military. Psychiatric comorbidities (43%) included post traumatic stress disorder (PTSD), depression, schizophrenia (N = 1), substance use disorders (17%), dissociative identity disorder (N = 1), and personality disorders (11%). Ninety-three percent met criteria for diagnosis of GID or GID not otherwise specified; suicidal ideation was reported by 61% with one or more suicide attempts by 11% of 56 responding; and 4% reported genital self-harm. Although 11% expressed active thoughts of surgical self-treatment, most expressed a desire for physician-performed sex reassignment surgery (SRS). Cross-dressing behaviors were common, and currently reported arousal with cross-dressing was reported by 13%, 63% of whom were not diagnosed with GID. Conclusion: Veterans often reported that they joined the military in an attempt to purge their transgender feelings, believing the military environment would “make men” of them. Most were discharged before completing a 20-year career. More than half received health care at veterans affairs medical centers, often due to medical or psychiatric disabilities incurred during service. Comorbid Axis I diagnoses were common, as were suicidal thoughts and behaviors.

Health Care Policies Addressing Transgender Inmates in Prison Systems in the United States

Inmates with gender identity disorders (GID) pose special challenges to policy makers in U.S. prison systems. Transgender persons are likely overrepresented in prisons; a reasonable estimate is that at least 750 transgender prisoners were in custody in 2007. Using the Freedom of Information Act, requests were mailed to each state, the District of Columbia, and the Federal Bureau of Prisons in 2007. The requests were for copies of policies, directives, memos, or other documents concerning placement and health care access of transgender inmates. By April 2008, 46 responses were received; 6 states did not reply. Information was qualitatively analyzed and summarized. There was substantial disparity in transgender health care for inmates with GID or related conditions. Most systems allowed for diagnostic evaluations. There was wide variability in access to cross-sex hormones, with some allowing for continuation of treatment and others allowing for both continuation and de novo initiation of treatment. There was uniformity in denial of surgical treatments for GID.

Advancing methods for US transgender health research

Purpose of reviewThis article describes methodological challenges, gaps, and opportunities in US transgender health research. Recent findingsLack of large prospective observational studies and intervention trials, limited data on risks and benefits of sex affirmation (e.g., hormones and surgical interventions), and inconsistent use of definitions across studies hinder evidence-based care for transgender people. Systematic high-quality observational and intervention-testing studies may be carried out using several approaches, including general population-based, health systems-based, clinic-based, venue-based, and hybrid designs. Each of these approaches has its strength and limitations; however, harmonization of research efforts is needed. Ongoing development of evidence-based clinical recommendations will benefit from a series of observational and intervention studies aimed at identification, recruitment, and follow-up of transgender people of different ages, from different racial, ethnic, and socioeconomic backgrounds and with diverse gender identities. SummaryTransgender health research faces challenges that include standardization of lexicon, agreed upon population definitions, study design, sampling, measurement, outcome ascertainment, and sample size. Application of existing and new methods is needed to fill existing gaps, increase the scientific rigor and reach of transgender health research, and inform evidence-based prevention and care for this underserved population.

Autocastration and Autopenectomy as Surgical Self-Treatment in Incarcerated Persons with Gender Identity Disorder

ABSTRACT The author reports on a case series of four inmates who engaged in attempted or completed surgical self-treatment of their gender dysphoria via autocastration, autopenectomy, or a combination in the absence of concomitant psychosis, intoxication, or other comorbidities that could reasonably account for this rare behavior. These behaviors occurred in the context of persistent denials of access to transgender health care in prison settings. The literature on genital self-harm is also reviewed. Incarcerated persons with severe GID may resort to life-threatening surgical self-treatments when persistently denied access to psychiatric evaluation and cross-sex hormonal treatment. In all cases of surgical self-treatment (SST; i.e., autocastration with the primary intent to reduce circulating testosterone levels) the intensity of gender dysphoria decreased compared to reported baseline levels, although symptoms of GID were still present. Of the four inmates, two were able to obtain access to cross-sex hormones after successful litigation at the time of this writing; another was not. One case remains active. This case series expands the limited literature on surgical self-treatment in the form of autocastration and autopenectomy with a focus on the potential influence of incarceration with denial of access to transgender health care.

The Use of Methylphenidate for Cognitive Decline Associated with HIV Disease

Objective: Complaints of cognitive changes are often expressed by patients at all stages of HIV infection. Such changes include decreased memory and attention span, diminished concentration, apathy, and “slowing.” Methylphenidate (MPD) has been used in several clinical studies in men with late-stage HIV disease in an attempt to ameliorate these difficulties. The objectives of this review article are to review salient psychopharmacological characteristics of MPD and to describe the research and clinical literature supporting the use of MPD in patients at all stages of HIV infection. Methods: Seven studies, case reports, or abstracts from International Conferences on AIDS were available in the English literature through August, 1993, directly addressing the use of MPD in patients with HIV disease. Twenty-nine papers were reviewed for pharmacokinetic data, eighteen for safety and side effects issues, and seventeen for relevant contributions from the neuropsychological testing literature. Results: Studies in clinical settings have used doses ranges from 10–90 mg. per day in two or three divided doses with reportedly good results in improving both affective and cognitive symptoms associated with HIV disease. Side effects have been relatively mild and patient satisfaction with treatment has been high. However, no studies have been conducted in early stage HIV disease, where a significant minority of patients have similar complaints in the absence of clinically apparent immunosuppression. Likewise, placebo-controlled, dose-finding studies in AIDS patients are entirely lacking, and no studies in women with HIV disease and cognitive changes have been published. Conclusions: In spite of these important research shortcomings, clinical experience with MPD treatment of cognitive changes in men with HIV/AIDS is consistent with the notion that this medication holds significant promise to improve the quality of life for persons living with HIV/AIDS. Controlled studies to test this hypothesis are warranted.

Priorities for transgender medical and healthcare research.

Purpose of reviewTransgender individuals experience unique health disparities but are the subject of little focused health research. This manuscript reviews current literature on transgender medical and mental health outcomes and proposes research priorities to address knowledge gaps. Recent findingsPublished research in transgender healthcare consists primarily of case reports, retrospective and cross-sectional studies, involving largely European settings. Challenges to US-based transgender health research include a diverse population where no single center has sufficient patient base to conduct clinical research with statistical rigor. Treatment regimens are heterogeneous and warrant study for best practices. Current research suggests increased mortality and depression in transgender individuals not receiving optimal care, and possibly a modest increase in cardiovascular risk related to hormone therapy. Current evidence does not support concerns for hormone-related malignancy risk. SummaryThe priorities for transgender medical outcomes research should be to determine health disparities and comorbid health conditions over the life span, along with the effects of mental health, medical, and surgical interventions on morbidity and mortality. Specific outcomes of interest based on frequency in the literature, potential severity of outcome, and patient-centered interest, include affective disorders, cardiovascular disease, malignancies, fertility, and time dose-related responses of specific interventions.

Personality characteristics and sexual functioning of 188 cross-dressing men.

The literature on cross-dressing men has been primarily limited to self-identified patients at psychiatric clinics who are in distress. To understand the personality trait characteristics and sexual functioning of nonpatient cross-dressers, 188 non-treatment-seeking male cross-dressers completed the NEO Personality Inventory (NEO-PI) and the Derogatis Sexual Functioning Inventory (DSFI). Respondents were classified as transvestites (TV; N = 83), transgenderists (TG; N = 61), or transsexuals (TS; N = 44) based on self-report and the nature of their cross-gender activities (e.g., use of female hormones, desire for sex reassignment, and amount of time spent in female role). These diagnostic groups did not differ on the five broad personality domains of the NEO-PI, but TS men scored higher than TV and TG men on the Aesthetics facet scale of Openness to Experience (O). In terms of the DSFI scales, TS men reported lower sexual drive than TV and TG men, and TS and TG men exhibited greater psychiatric symptoms and feminine gender role, and poorer body image than TV men. Upon exclusion of a group of 49 respondents who previously sought treatment for psychological problems, no significant differences emerged among the three diagnostic groups on the NEO-PI domain and facet scales. Consideration of the DSFI scales showed that TS men experienced less sexual drive, more psychiatric symptoms, and a greater feminine gender role than TV or TG men. This study suggests that cross-dressers not seen for clinical reasons are virtually indistinguishable from non-cross-dressing men using a measure of personality traits, a sexual functioning inventory, and measures of psychological distress. These results emphasize the importance of using clinical significance criteria as required by DSM-IV guidelines before diagnosing men who cross-dress with an axis I disorder.