Adult Transgender Care

An Interdisciplinary Approach for Training Mental Health Professionals

Michael R. Kauth, Jillian C. Shipherd, Michael R. Kauth, Jillian C. Shipherd

• Publisher: Routledge
• Year: 2017
• eBook ISBN: 9781315390482
• Topic: Psychology
• Subtopic: Human Sexuality in Psychology
• Index: Psychology

Adult Transgender Care provides an overview of transgender health and offers a comprehensive approach to training mental health professionals in transgender care. The book takes an interdisciplinary approach to transgender care, emphasizing the complementary contributions of psychiatry, psychology, and social work in providing transgender care within an integrated treatment team. Included in this text are overviews of how to conceptualize and provide treatment with complex and difficult clinical presentations and considerations for understanding how to address system-level challenges to treatment. Adult Transgender Care meets a unique need by providing detailed information, clinical interventions, case studies, and resources for mental health professionals on transgender care.

1 How to Begin

An Introduction to the Book

Michael R. Kauth, PhD
Jillian C. Shipherd, PhD

The views expressed in this material are those of the authors and do not reflect the official policy or position of the Department of Veterans Affairs or the U.S. Government.

Why write a book on adult transgender care for mental health professionals? The short answer—because there is a need to provide comprehensive information to mental health professionals who have been or will be providing care to transgender adults. There are good texts on transgender care for mental health professionals that discuss gender transitioning and mental health conditions, but these usually fail to discuss medical transitioning in sufficient detail and gloss over the mental health professional’s role in collaborating and coordinating with prescribing practitioners and medical providers. There are also proscriptive texts for medical providers that focus on meeting the health care needs of transgender people, including medical transitioning, but these usually do not appreciate the idiosyncrasies of gender transitioning, or fail to address the various psychosocial needs of the transitioning person, or inadequately describe the critical role of mental health professionals. This book is different, in that it takes an interdisciplinary approach to adult transgender care that emphasizes the unique and complementary contributions of mental health (i.e., psychiatry, psychology, social work, and counseling) within an integrated primary care treatment team, or at least coordinating with a medical team. There are also important medical aspects of adult transgender care (e.g., hormone therapy, surgical interventions) that mental health professionals need to understand and take into account in their evaluations and in order to provide competent psychological care and support throughout the client’s life course.

How many of you reading this text received any kind of training in transgender care in your graduate program? Probably very few, if any. This kind of content was not available when we were in graduate school. Not so long ago, graduate mental health professional programs viewed transgender people as curiosities—as something exotic—but also as a largely invisible population. There was no expectation that mental health professionals would routinely see transgender people in their clinical practice. And if one did see a transgender individual, the standard approach, not so long ago, was to focus on the individual’s presenting problems of depressive or anxiety symptoms or relationship difficulties—and ignore any gender-related distress Gender dysphoria, when present, was viewed as peripheral. At the time, the prevailing view was that if the depression, anxiety, or relationship difficulties were well treated, then gender-related concerns would naturally resolve.

How can mental health professionals provide competent care if they ignore gender dysphoria—if they have little understanding of the phenomena of gender dysphoria, gender transitioning, or minority stress? Fortunately, in recent years, graduate mental health professional programs, as well as medical schools, have begun including content on transgender health and on the health of sexual minorities too. Professional training programs are beginning to respond to the increased visibility of lesbian, gay, bisexual, and transgender (LGBT) people in society and of people with various other sexual and gender minority identities that could fall under the LGBT umbrella (which we view inclusively). This book is intended to help new and established mental health professionals become better informed with and comfortable providing adult transgender care, especially within an integrated care team.

Another goal of this book is to help mental health professionals understand the necessity of educating support staff and clinical colleagues to create a welcoming clinic experience for transgender clients. Other disciplines besides mental health, such as internal medicine and endocrinology also tend to lack professional training in transgender care. Mental health professionals have an obligation to educate health care colleagues who are less knowledgeable about transgender care so that clients referred for services receive respectful, competent care. Training and education for support staff is also absolutely critical and often neglected. Transgender clients who have negative, demeaning experiences within the clinic environment—before they reach your office—are unlikely to hear what you have to say. Or ever return.

Like most established health care professionals who specialize in transgender health, we learned from experience—sometimes painful experience. In the process, we became educators about transgender health care. In 2011, when the United States Department of Veterans Affairs (VA) issued a national policy on transgender veteran care, we were asked to lead training for VA staff on the policy and its implementation. We leveraged that role into a formal LGBT Health Program within the VA Office of Patient Care Services, which put us in the position to educate the more than 305,000 clinical providers across 1,233 VA health care facilities on competent transgender care (VHA, 2016: www.va.gov/health/aboutvha.asp). Given the size of the VA health care system, educating clinical staff is an ongoing task. In an effort to expand clinical capacity for respectful competent transgender care in VA, we obtained resources to support training interdisciplinary treatment teams across the health care system using videoconferencing technology and case-based consultation by an expert team. At the time of publication, we will have trained 75 interdisciplinary teams and nearly 600 clinical providers through this tele-training/consultation program (Kauth, et al., 2015; Shipherd et al., 2016). We have discussed with our colleagues in the U.S. Department of Defense how to implement this model for training among military health care providers, who have recently (as of June, 2016) changed their policies to allow openly transgender service members. A more detailed description of our efforts in VA is presented in Chapter 14. We produced this book in part to share our experience and knowledge in training multiple disciplines in integrated adult transgender care and improve care for the transgender clients we serve.

This book is intended as a self-guide for mental health professionals who want to become more knowledgeable about transgender care. This book may also be useful to medical providers who wish to have a better appreciation for the contribution of the other team members they work with in treating transgender clients. We have structured this volume to function as readings for, or the entire content of, a graduate-level mental health course on adult transgender care. We have asked contributing authors to present practical clinical advice based on best practices and to illustrate their content with case examples where appropriate. In addition, we have asked authors to include a short list of foundational readings at the end of each chapter. One essential recommended reading for this book—and not repeated in each chapter—is the World Professional Association for Transgender Health’s (WPATH) Standards of Care (7th edition; 2011). The WPATH Standards of Care is a consensus document representing the minimum standard of practice for respectful, competent care of transgender people. All mental health professionals who work with transgender clients should be familiar with the WPATH Standards of Care, which provides guidance on gender counseling, conducting hormone and gender transitioning surgery evaluations, as well as how to write letters of support for name change or changing the sex listed on a client’s birth certificate. Further, we strongly encourage readers to research their professional organization’s policy position or code of ethics statement on working with transgender and/or LGBT clients. We have provided links to a few major mental health professional organizations at the end of this chapter.

The Words We Use

Readers who are even somewhat familiar with transgender issues will have noticed that language is important—finding a whole new vocabulary and sensitivity to language. Words matter. People are defined for better or worse by the words used to describe them or by the words they use to describe themselves. Words can exclude or include, control or liberate, demean or celebrate, make invisible or illuminate. Therefore, readers will find that contributors to this book have given great attention to language around transgender and gender non-conforming issues. However, language is also dynamic and evolving. The words we use today to replace outdated terms will themselves be replaced in the future. We will make mistakes and for that we apologize up front. For consistency and to show respect, we have made decisions about the language that we and contributing authors will use across chapters. For example, many terms are used to describe transgender and gender non-conforming people. The term “transgender” is employed in this volume as an umbrella term to describe a variety of presentations and a wide spectrum of gender identities. We intend this term to be inclusive of transgender-identified and gender non-conforming people, including those with non-binary identification. Some gender non-conforming clients will not identify as transgender persons. A general best practice is to reflect the words and labels that clients use to identify themselves.

Also, we view the term “transgender” as an adjective, as in “transgender men” or “transgender women,” rather than as a noun. In this volume, authors for the most part will refer to “transgender men and women” rather than use the abbreviated “transmen” or “transwomen” which is less formal and more appropriate for casual conversation. We have avoided referring to “male-to-female” or “female-to-male” transgender individuals in favor of “transgender women” and “transgender men,” respectively. We feel that referring to transgender people by their chosen gender identity, rather than by their sex assigned at birth, is respectful and a good model for mental health professionals. We have also avoided using the older clinical term “transsexual” unless it is employed for historical accuracy.

We recognize that not all gender non-conforming people identify with a transgender label. Some prefer terms such as trans*, non-binary, genderqueer, gender fluid, polygender, agender, and other identities. There is an ever-growing list of identity terms, but listing even some terms omits other possible terms. The client’s preferred identity term should be the one used by health care professionals. However, given that language is evolving, we have chosen to use the umbrella term “transgender” inclusively, although it may not be the term your client prefers.

Throughout this book we primarily refer to “gender dysphoria” as a descriptive term for the distress that some transgender people experience. Our goal is to assist mental health providers in addressing this dysphoria utilizing an affirming framework. We sometimes refer to “Gender Dysphoria” which is a diagnosis in DSM-5 (American Psychiatric Association [APA], 2013) or “Gender Identity Disorder,” which is an ICD-10 (World Health Organization, 1992) and DSM IV-TR (APA, 2000) diagnosis. Capitalization of these terms indicates that we are referring to a diagnosis.

We recognize that the goal of gender transitioning is to become more comfortable with one’s physical body and gender presentation. The goal of gender transitioning is not necessarily to “change sex” or “become another sex” but rather to adopt a different gender role and identity from one’s assigned sex at birth. Gender transitioning has no pre-determined end point, and the transition pathways are individualistic. In keeping with this non-binary gender, non-determinist view of gender transitioning, we refer to androgens as “masculinizing hormones” and estrogens as “feminizing hormones” rather than as “male hormones” and “female hormones,” respectively. Of course, androgens are not exclusive to men, and estrogens are not exclusive to women.

Historically, gender transitioning surgeries have been referred to as “sex reassignment surgeries.” We find that terminology outdated and inaccurate and use it only within historical context. We have encouraged authors to refer to “gender affirming” treatments, including “gender affirming surgeries,” “gender transitioning surgeries,” and even “transition-related surgeries.”

By “mental health professionals or providers” we mean all mental health practitioners. There are a variety of mental health practitioners (e.g., psychologists, psychiatrists, social workers, counselors) who have distinct abilities, but here we focus mainly on the commonalities across mental health providers. We have tried to refer to specific kinds of mental health professionals only when referring to practices specific to those practitioners.

Because this text is focused on mental health professionals, we have adopted the less medical term “client” (rather than “patient”) to refer to the people who receive treatment services. We have also taken an “interdisciplinary” treatment approach to transgender care that integrates various health care disciplines, including mental health, as part of a cohesive treatment team. We contrast this approach to a “multidisciplinary” model where various health care disciplines work independently and collaborate as needed but are not necessarily colleagues on an integrated care team. Of course, many readers will be working in a system that is more multidisciplinary in structure, but we encourage the application of an interdisciplinary model to care for transgender clients.

While we have attempted to produce a volume that is useful to mental health professionals in English-speaking countries, we readily acknowledge our cultural and national biases. We and the contributing authors are Americans, and we best know our own cultural experiences, even as we try to be conscious of cultural differences and health care system differences across English-speaking countries. Throughout this book, we have emphasized similarities across cultures as best we know them and have recognized differences where they occur. In addition, most chapter authors are cisgender individuals, although at least four authors identify as transgender people.

An Overview of the Chapters

This book is organized in 14 chapters. This first chapter provides context and lays out the major assumptions of the volume. In Chapter 2, Dr. Laura Johnson, a clinical psychologist and Major in the United States Air Force, gives a brief history of gender variant people and development of the contemporary conceptualization of transgender identities. Dr. Johnson describes how transgender people have been viewed and treated, mostly negatively, by various cultural institutions such as the military and organized sports. Mental health as a discipline has also played a major role in pathologizing transgender identities. It is critical for mental health professionals to recognize that unpleasant history and stigmatization by our profession in order to understand why transgender clients may be reluctant to talk with providers. Fortunately, all major mental health organizations are now supportive of respectful gender affirming treatments. That said, the controversial need to have a mental health diagnosis to access medical treatments creates a unique and complicated context for the therapeutic relationship.

Dr. John Blosnich, a public health researcher, discusses minority stress and intersectionality of identities in Chapter 3. Minor...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of Figures
• List of Tables
• List of Contributors
• 1 How to Begin: An Introduction to the Book
• 2 Scientific and Cultural Perspectives on the Gender Binary
• 3 The Intersectionality of Minority Identities and Health
• 4 Providing a Welcoming Clinic Environment
• 5 Supporting the Transgender Individual in Deciding Their Pathway
• 6 Preparing Clients for Hormone Therapy
• 7 The High-Risk Client: Comorbid Conditions That Affect Care
• 8 Dialectical Behavior Therapy as a Treatment Option for Complex Cases of Gender Dysphoria
• 9 Pursuing Gender Transitioning Surgeries
• 10 Adjunctive Interventions: Supportive Services for Gender Role Transitions
• 11 Identity and Support Letters
• 12 Finding Additional Resources
• 13 Sexual Health Among Transgender People
• 14 Implementing a Transgender Care Policy in a National Healthcare System
• Index