Walter O. Bockting

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 Impact of Gender-Related Abuse Across the Life Course of Male-to-Female Transgender Persons

The psychiatric impact of interpersonal abuse associated with an atypical presentation of gender was examined across the life course of 571 male-to-female (MTF) transgender persons from the New York City Metropolitan Area. Gender-related abuse (psychological and physical), suicidality, and Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) major depression were retrospectively measured across five stages of the life course using the Life Chart Interview. Among younger respondents (current age of 19–39), the impact of both types of abuse on major depression was extremely strong during adolescence and then markedly declined during later stages of life. Among older respondents (current age of 40–59), the impact of both types of abuse on major depression was strong during adolescence and then marginally declined during later stages of life. The effects of both types of abuse on suicidality were weaker but more consistently observed across the life course among both the younger and older respondents. Gender-related abuse is a major mental health problem among MTF transgender persons, particularly during adolescence. As these individuals mature, however, the consequences of this abuse appear less severe, which may represent the development of moderately effective mechanisms for coping with this abuse.

Conducting internet-based HIV/STD prevention survey research: Considerations in design and evaluation

The aim of this paper is to advance rigorous Internet-based HIV/STD Prevention quantitative research by providing guidance to fellow researchers, faculty supervising graduates, human subjects’ committees, and review groups about some of the most common and challenging questions about Internet-based HIV prevention quantitative research. The authors represent several research groups who have gained experience conducting some of the first Internet-based HIV/STD prevention quantitative surveys in the US and elsewhere. Sixteen questions specific to Internet-based HIV prevention survey research are identified. To aid rigorous development and review of applications, these questions are organized around six common criteria used in federal review groups in the US: significance, innovation, approach (broken down further by research design, formative development, procedures, sampling considerations, and data collection); investigator, environment and human subjects’ issues. Strategies promoting minority participant recruitment, minimizing attrition, validating participants, and compensating participants are discussed. Throughout, the implications on budget and realistic timetabling are identified.

Meta-analysis of the effectiveness of HIV prevention interventions for women

The present study is a meta-analysis of the effectiveness of HIV prevention interventions for women in the USA. Twenty-four articles from 1989-1997 were included. We evaluated five ethnic groupings (All Ethnicities Combined, African-American, White, Hispanic and a Mixed Ethnicity group) over four time periods (post-test, less than two months after the intervention, 2-3 months after the intervention and 6-24 months after the intervention) on three HIV-related sexuality outcome variables (HIV/AIDS knowledge, self-efficacy and sexual risk reduction behaviour). The HIV interventions appear effective at improving knowledge about HIV/AIDS and increasing sexual risk reduction behaviours for all ethnicities examined at all follow-up periods, with one exception. The findings for self-efficacy are less consistent. The interventions were less consistently effective for African-American women, for whom significant improvements in feelings of self-efficacy were only seen six months or longer after the intervention. The present analysis elucidates ethnic differences which may have previously been obscured while demonstrating convincingly that HIV interventions are generally effective for women of many different ethnicities.

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.

Lifetime risk factors for HIV/sexually transmitted infections among male-to-female transgender persons.

Objectives:To describe and evaluate risk factors for HIV/sexually transmitted infections (STIs) among male-to-female (MTF) transgender persons. Methods:Using the life chart interview, potential lifetime risk factors for HIV/STIs among MTFs were measured and evaluated in conjunction with lifetime exposures for HIV, syphilis, hepatitis B, and hepatitis C. The participants were 517 MTFs between the ages of 19 and 59 years from the New York metropolitan area. Results:HIV/STIs were low among white Americans and very high among Hispanics and African Americans. In the latter groups, HIV and hepatitis B were associated with an androphilic sexual orientation, lifetime number of commercial sex partners (sex work), and the social expression of transgender identity; syphilis was associated with lifetime number of casual sex partners; and hepatitis C was associated with injection drug use, unemployment, and social expression of transgender identity. In multivariate models, the social expression of transgender identity was the strongest and most consistent predictor of HIV/STIs. Consistent with their lower levels of infections, white Americans reported significantly lower levels of the risk factors found to be predictive of HIV/STI among Hispanics and African Americans. Conclusions:HIV/STI prevention in this population should be targeted at Hispanic and African Americans. Prevention programs should incorporate multiple components designed to address the diverse issues confronting ethnic minority transgender persons, with an emphasis on the social expression of transgender identity.

Sexual difficulties, concerns, and satisfaction in homosexual men: An empirical study with implications for HIV prevention

Minimal research has investigated the prevalence of sexual disorders in homosexual men. We examined sexual performance concerns, problems, and satisfaction in a convenience sample of 197 homosexual men who attended a health seminar. Sexual dysfunction and sexual concerns were found to be common problems. Almost all men reported some sexual difficulty over their lifetime, and more than half reported a current sexual difficulty. A further 25% of the sampled men identified other sexual concerns as well. Despite these figures, most participants-whether single, dating, or in a relationship-reported average to above-average sexual satisfaction. Correlates of sexual satisfaction included more liberal attitudes toward human sexuality, greater comfort with mens sexual attractions to other men, lower levels of internalized homophobia, and greater satisfaction with ones relationship status. Painful receptive anal intercourse appeared to be a common, yet previously underacknowledged, difficulty. Almost half of the respondents described HIV/AIDS as having a negative impact on their sexual functioning, with most reporting an increase in fear of sex as the major negative outcome.

Views from both sides of the bridge? Gender, sexual legitimacy, and transgender people’s experiences of relationships

The aim of this paper is to examine whether transgender peoples experiences of relationships are influenced by heteronormativity, the related concept of sexual legitimacy, and gender as a binary construct. Data from an Internet-based study of transgender people in the USA was used. Findings seem to indicate that participants were strongly influenced by heteronormative discourses. However, less rigid gender beliefs are associated with lower levels of internalised transphobia, which, in turn, are associated with higher levels of self-esteem. Transgender people can therefore find themselves in a double-bind where, on one hand, conforming to gender and sexual norms leads to validation by mainstream US society, but could possibly entail diminished psychological well-being.

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.