Sam Winter

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.

Transgender people: health at the margins of society

In this paper we examine the social and legal conditions in which many transgender people (often called trans people) live, and the medical perspectives that frame the provision of health care for transgender people across much of the world. Modern research shows much higher numbers of transgender people than were apparent in earlier clinic-based studies, as well as biological factors associated with gender incongruence. We examine research showing that many transgender people live on the margins of society, facing stigma, discrimination, exclusion, violence, and poor health. They often experience difficulties accessing appropriate health care, whether specific to their gender needs or more general in nature. Some governments are taking steps to address human rights issues and provide better legal protection for transgender people, but this action is by no means universal. The mental illness perspective that currently frames health-care provision for transgender people across much of the world is under scrutiny. The WHO diagnostic manual may soon abandon its current classification of transgender people as mentally disordered. Debate exists as to whether there should be a diagnosis of any sort for transgender children below the age of puberty.

Synergies in health and human rights: a call to action to improve transgender health

2015 was an unprecedented year in the recognition of transgender rights in some high-income countries. However, this recognition in the public domain has yet to translate to a concerted eff ort to support the right to health of transgender people around the world. Transgender people continue to face a range of challenges that deprive them of respect, opportunities, and dignity and have damaging eff ects on their mental and physical health and wellbeing, as shown in the Lancet Series on transgender health. These “situated vulnerabilities”, as they are called in the Series paper by Sari Reisner and colleagues, can prompt or aggravate depression, anxiety, self-harm, and suicidal behaviour among transgender people, which are exacerbated by biological risks, and social and sexual network-level risks, for HIV and other sexually transmitted infections. In their Lancet Series paper, Sam Winter and colleagues write of a “slope leading from stigma to sickness”. Moving forward, these health needs and vulnerabilities can be better addressed through improved understanding of the legal and social policies that promote harms and diminish the potential impact of health programmes. There is also a need for increased knowledge of the optimal content and models of clinical service provision, as highlighted by Kevan Wylie and colleagues’ Series paper, and of the epidemiology of communicable and non-communicable diseases in transgender people globally. Ultimately, action is needed at and across multiple levels and sectors to optimise the provision and uptake of health services for transgender people (panel). Health policies must change to improve the health of transgender people. Transgender people worldwide report problems in accessing appropriate and equitable health care—whether related to gender affi rmation, sexual and reproductive health, or more general health. Steps need to be taken to ensure that national health policies are as inclusive as possible with regard to transgender health care. Such health care, including access to feminising and masculinising hormones, should be funded on the same Synergies in health and human rights: a call to action to improve transgender health

Depathologising gender diversity in childhood in the process of ICD revision and reform

ABSTRACT From 2007 on, the World Health Organisation (WHO) has been revising its diagnostic manual, the International Statistical Classification of Diseases and Related Health Problems (ICD), with approval of ICD-11 due in 2018. The ICD revision has prompted debates on diagnostic classifications related to gender diversity and gender development processes, and specifically on the ‘Gender incongruence of childhood’ (GIC) code. These debates have taken place at a time an emergent trans depathologisation movement is becoming increasingly international, and regional and international human rights bodies are recognising gender identity as a source of discrimination. With reference to the history of diagnostic classification of gender diversity in childhood, this paper conducts a literature review of academic, activist and institutional documents related to the current discussion on the merits of retaining or abandoning the GIC code. Within this broader discussion, the paper reviews in more detail recent publications arguing for the abandonment of this diagnostic code drawing upon clinical, bioethical and human rights perspectives. The review indicates that gender diverse children engaged in exploring their gender identity and expression do not benefit from diagnosis. Instead they benefit from support from their families, their schools and from society more broadly.

Psychometric properties of the Iranian version of the Sexual Modes Questionnaire (SMQ): to assess the association between automatic thoughts, emotions and sexual response

ABSTRACT The role of cognitive-affective factors on male and female sexual functioning has been studied in North America and European countries and there is a lack of validated measures available for use elsewhere. The aim of this study was to translate and validate the Sexual Modes Questionnaire (SMQ) to the Iranian context. The SMQ is a validated measure aimed at assessing the association between thoughts, emotions and sexual response during sexual activity. A total of 388 participants (224 women and 164 men) completed the SMQ. A principal component analysis with varimax rotation and subsequent confirmatory factor analysis (CFA) were performed. Three factors were identified in the male version: Failure Anticipation Thoughts, Erection Concern Thoughts, and Lack of Erotic Thoughts. In the female version, six factors were identified: Failure and Disengagement Thoughts, Low Self-Body Image Thoughts, Sexual Abuse Thoughts, Sexual Passivity and Control, Lack of Erotic Thoughts, and Partners Lack of Affection. Also, a consistent pattern of correlations was found between the three subscales of the SMQ (thoughts, emotions, and sexual response) supporting the interactional character of the measure. This study has provided some preliminary evidence of the reliability and validity of the SMQ for use in Iranian populations.

Determinants of Women's Sexual Dissatisfaction: Assessing a Cognitive-Emotional Model

INTRODUCTION Recent studies have demonstrated the role of sexual dysfunctional beliefs, negative automatic thoughts, and emotional responses in relation to sexual functioning. Nevertheless, no studies seem to have evaluated the role of these cognitive-emotional factors in determining sexual dissatisfaction. AIM To test a cognitive-emotional model of sexual dissatisfaction in women. METHODS In total, 207 women answered questionnaires assessing sexual dissatisfaction and cognitive and emotional variables that might affect sexual dissatisfaction. MAIN OUTCOME MEASURES Sexual dissatisfaction was measured by the Index of Sexual Satisfaction, sexual beliefs were measured by the Sexual Dysfunctional Beliefs Questionnaire, and thoughts and emotional responses were measured by the Sexual Modes Questionnaire. RESULTS A path analysis was conducted to assess the conceptual model proposed. Results indicated that dysfunctional sexual beliefs work as predisposing factors by eliciting negative automatic thoughts and emotions, which impair the processing of erotic stimuli and interfere negatively with sexual satisfaction. CONCLUSION This finding suggests a role for cognitive and emotional factors in predisposing and maintaining sexual dissatisfaction in women, suggesting relevant implications for intervention.

Gender trouble: The World Health Organization, the International Statistical Classification of Diseases and Related Health Problems (ICD)-11 and the trans kids

The World Health Organization (WHO) is revising its diagnostic manual, the International Statistical Classification of Diseases and Related Health Problems (ICD). At the time of writing, and based on recommendations from its ICD Working Group on Sexual Disorders and Sexual Health, WHO is proposing a new ICD chapter titled Conditions Related to Sexual Health, and that the gender incongruence diagnoses (replacements for the gender identity disorder diagnoses used in ICD-10) should be placed in that chapter. WHO is proposing that there should be a Gender incongruence of childhood (GIC) diagnosis for children below the age of puberty. This last proposal has come under fire. Trans community groups, as well as many healthcare professionals and others working for transgender health and wellbeing, have criticised the proposal on the grounds that the pathologisation of gender diversity at such a young age is inappropriate, unnecessary, harmful and inconsistent with WHOs approach in regard to other aspects of development in childhood and youth. Counter proposals have been offered that do not pathologise gender diversity and instead make use of Z codes to frame and document any contacts that young gender diverse children may have with health services. The author draws on his involvement in the ICD revision process, both as a member of the aforementioned WHO Working Group and as one of its critics, to put the case against the GIC proposal, and to recommend an alternative approach for ICD in addressing the needs of gender diverse children.

Psychometric properties of the Persian version of the Questionnaire of Cognitive Schema Activation in Sexual Context (QCSASC) in unsuccessful sexual situations

ABSTRACT The aim of this study was to translate and adapt to Persian, and to assess psychometric properties of the Questionnaire of Cognitive Schema Activation in Sexual Context (QCSASC). A total of 265 Iranian participants (121 women and 144 men) were recruited for this study. A principal component analysis (PCA) with varimax rotation and subsequent confirmatory factor analysis revealed a best fitting five-factor structure similar to the original QCSASC: Incompetence, Undesirability, Abandon/Rejection, Powerless/Helpless, and Difference. However, in the Iranian sample, the original Self-Depreciation dimension was included in the Incompetence and Undesirability factors. An Abandon/Rejection dimension was also evident, and may be explained by cultural, social, and religious factors in the Iranian culture. Additionally, reliability analysis has supported the internal consistency (adequate Cronbachs alpha values) and temporal stability (test–retest reliability) of the QCSASC in an Iranian sample. The findings suggest the adequacy of the Persian version of the QCSASC to assess cognitive schemas in sexual context among Iranian men and women.