The DSM-IV and ICD-10 have defined hundreds of mental disorders which vary in onset, duration, pathogenesis, functional disability, and treatability. The designation of gender identity disorders (GID) as mental disorders is not a license for stigmatization, or for the deprivation of patients' civil rights. The use of a formal diagnosis is often important in offering relief, providing health insurance coverage, and guiding research to provide more effective care. DSM-5 Development Group indicate that GID can still be given to children who reject the assigned gender but who do not experience any anatomical dysphoria. To qualify as a mental disorder, a behavioral pattern must result in a significant adaptive disadvantage to the person or cause personal mental suffering. However, the removal of distress/impairment criterion can lead to over-diagnosis of children who do not meet criteria. Instead, it is argued that criterion should be kept based on distress resulting from living in the present gender as apposed to anguish stemming from societal prejudice and discrimination. It would be more appropriate and respectful if the diagnosis is written in language reflecting contemporary views of gender rather than views that are based on gender-specific games or clothing. Goals: Psychotherapy often provides education about a range of options not previously seriously considered by the patient. It emphasizes the need to set realistic life goals for work and relationships, and it seeks to define and alleviate the patient's conflicts that may have undermined a stable lifestyle. The Therapeutic Relationship: The establishment of a reliable trusting relationship with the patient is the first step toward successful work as a mental health professional. This is usually accomplished by competent nonjudgmental exploration of the gender issues with the patient during the initial diagnostic evaluation. Other issues may be better dealt with later, after the person feels that the clinician is interested in and understands their gender identity concerns. Ideally, the clinician's work is with the whole of the person's complexity. The goals of therapy are to help the person to live more comfortably within a gender identity and to deal effectively with non-gender issues. The clinician often attempts to facilitate the capacity to work and to establish or maintain supportive relationships. Language is very important to indicate that a community is making an effort to be trans-friendly. It often makes the difference in whether a transgender person will approach a community and/or clinician and whether they will choose to stay.

1. Transsexualism
Amirrah&Kulky
I n t r o To S e x T h e r a p y
J u l y 9 , 2 0 11
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2. Terms and Definitions
• Biological Sex
• Gender
o Gender Identity
o Gender Role
o Transgender and Transsexuals
• Sexuality and Sexual Orientation
(Dragowski, Scharron-del Rio, &Sandigorsky, 2011)
2

3. Process Questions:
How do children know what
their gender is and how to
behave?
Why do some children insist
that their gender is not the
one assigned to them at birth?
3

4. Famous Transgender People
4

5. Gender Identity Development:
Nature
• Anomalous prenatal hormonal influences
• Anatomic brain differences
• Genetic influences
5
(Gender Identity Research and Education Society, 2006)

6. Gender Identity Development:
Nurture
• Environmental influences begin before birth
• Intrapsychic conflict stemming from
environmental instability
• Child’s temperament and problematic family
environment
• Socialization on gender development include:
o Psychoanalytic theories
o Learning theories
o Social constructivism
o Cognitive theories
(Dragowski, Scharron-del Rio, &Sandigorsky, 2011)
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7. DSM-IV-TR Diagnostic Criteria
Gender Identity Disorder (GID)
Criterion A: A strong and persistent cross-gender identification (not
merely a desire for any perceived cultural advantages of being the
other sex)
1.
Repeatedly stated desire to be, or insistence that he or she
is, the other sex
2.
In boys, preference for cross-dressing or simulating female
attire; in girls, insistence on wearing only stereotypical
masculine clothing
3.
Strong and persistent preferences for cross-sex roles in
make-believe play or persistent fantasies of being the other
sex
4.
Intense desire to participate in the stereotypical games and
pastimes of the other sex
5.
Strong preference for playmates of the other sex
In adolescents and adults, disturbances are manifested by
symptoms such as a stated desire to be the other sex,
frequent passing as the other sex, desire to live or be treated
as the other sex, or the conviction that he or she has the
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(APA, 2000)
typical feelings and reactions of the other sex.

8. Criterion B: persistent discomfort with his or
her sex or sense of inappropriateness in
the gender role of that sex
Criterion C: disturbance is not concurrent
with a physical intersex condition
Criterion D: disturbance causes clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning
*Specify: Sexually attracted to males,
females, neither, or both
(APA, 2000)
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9. 9

10. DSM-V Revisions for GID
• Rename to Gender Dysphoria
• Integration of Criterion A and B into one criterion with at
least 6 of 8 indicators necessary for diagnosis
• Removal of distress/impairment criterion
• Demonstration of “a strong desire to be of the other
gender or an insistence that he or she is the other
gender” as necessary for diagnosis
• Replacement of the term sex with perceived gender to
accommodate persons with disorders of sex
development
• 6-month duration requirement to distinguish between
transient and more persistent conditions
(APA,
10

11. Process Question:
Do you think GID
should be a mental
disorder?
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12. Treatment of GID
1) Diagnostic
Assessment
2) Psychotherapy
3) Real-Life
Experience
4) Hormone Therapy
5) Sex Reassignment
Surgery
(Jain &Bradbeer, 2007)
12

13. Diagnostic Assessment
• History related to experience of gender
discomfort
• General medical examination
• Psychiatric assessment
o Common Co-morbidities: anxiety, depression,
bipolar disorder, conduct disorder, substance
abuse, dissociative identity disorders,
borderline personality disorder, other sexual
disorders and intersexedconditions
• Assess need for psychotropic medications
(Jain &Bradbeer, 2007)
13

14. Psychotherapy with Adults
Goal 1: to provide education about alternative
solutions, and to set realistic life goals for work and
relationships while defining and alleviating person’s
conflicts
Goal 2: to help person live more comfortably with
gender identity and to deal effectively with nongender issues (i.e.: capacity to work and to establish
or maintain supportive relationships)
Therapeutic Alliance: to establish reliable, trusting
relationship accomplished by competent
nonjudgmental exploration of gender issues
(HBIGDA Standards of Care , 2001)
14

15. Process of Psychotherapy
• Developmental process that can occur at
every stage of gender evolution
• Collaborative effort: help person understands
concepts of eligibility and readiness
• Not intended to cure GID
• Long-term stable life style with realistic
chances for success in relationships,
education, work, and gender identity
expression
(HBIGDA Standards of Care , 2001)
15

16. Ten Tasks of the Mental Health
Professional
1.
2.
To accurately diagnose the individual's gender disorder
To accurately diagnose any co-morbid psychiatric conditions
and see to their appropriate treatment
3. To counsel the individual about the range of treatment options
and their implications
4. To engage in psychotherapy
5. To ascertain eligibility and readiness for hormone and surgical
therapy
6. To make formal recommendations to medical and surgical
colleagues
7. To document their patient's relevant history in a letter of
recommendation
8. To be a colleague on a team of professionals with an interest
in the gender identity disorders
9. To educate family members, employers, and institutions about
gender identity disorders
10. To be available for follow-up of previously seen gender
patients
(HBIGDA Standards of Care , 2001)
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17. Real-Life Experience
• Period of time (1-2 years) living in new or
evolving gender role
• Person must identify by change of name and
documents
• Person should continue employment,
education or voluntary work
• Provide evidence that others are aware of
their new role
(HBIGDA Standards of Care , 2001)
17

18. Hormone Therapy
• Letter of Recommendation required from
mental health professional
• Medically necessary for successfully living in
new gender role – lifelong process
• Must meet Eligibility and Readiness criteria
(HBIGDA Standards of Care , 2001)
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19. Eligibility Criteria
The administration of hormones is not to be lightly
undertaken because of their medical and social
risks. Three criteria exist.
1. Age 18 years
2. Demonstrable knowledge of what hormones
medically can and cannot do and their social
benefits and risks
3. Either:
a) A documented real-life experience of at least three
months prior to the administration of hormones; or
b) A period of psychotherapy of a duration specified by
the mental health professional after the initial
evaluation (usually a minimum of three months)
(HBIGDA Standards of Care , 2001)
19

20. Readiness Criteria
Three criteria exist:
1) The patient has had further consolidation of gender
identity during the real-life experience or
psychotherapy;
2) The patient has made some progress in mastering
other identified problems leading to improving or
continuing stable mental health (this implies
satisfactory control of problems such as
sociopathy, substance abuse, psychosis and
suicidality);
3) The patient is likely to take hormones in a
responsible manner.
(HBIGDA Standards of Care , 2001)
20

21. Process Question:
What if you are working
with a client who is
transitioning through
hormones acquired
illegally?
21

22. Sex Reassignment Surgery (SRS)
• Irreversible procedure
• Letters from 2 separate consultant
psychiatrists (or clinical psychologists) are
required
• Eligibility Requirements: 12 months of
continual hormonal therapy and 12 months of
successful continuous full-time real-life
experience, and also regular psychotherapy
• Surgical components of SRS: Male-toFemale (MTF) and Female-to-Male (FTM)
(HBIGDA Standards of Care , 2001)
22

23. People, Time, & Money
• Referral process through mental health
professionals and medical professionals
• Average length of time before SRS: 4.5 years
• Cost of Treatment (approx.)
Doctors visits and lab tests: $500
Therapy: $1000
Hormones: $1500
MTF surgery: $17,000
Over 2-year transition period: $20,000
(Retrieved from http://www.tgender.net/taw/tsins.html)
23

24. Pre-Operation Health
• The coming-out process among family and
friends, and in the work environment
• Those who choose not to get surgery, or who
are waiting for surgery, may still experience
social stigma or become preoccupied with the
concept of “passing”
(Retrieved from, http://www.videojug.com/expertanswer/transgender-what-does-it-mean/what-is-passing-for-atransgender-person#.TkBWfPC17NU.google)
24

25. Post-OperationSexual Health
• 1 out of 4 Male-To-Females (MTF) reported
decrease in libido
o Low testosterone?
• Female-To-Male (FTM) reported more difficulty in
establishing a stable relationship post-op
• Found that informing new partners on past has a
positive effect on the relationship
(de Cuypere et al., 2005)
25

26. Post-Op Sexual Health (cont’d)
• Improved sex life
• Contingent on finally having the right body
with the right genitals
• Some dissatisfaction in MTF occurred when
there was dysfunctional vaginas
• FTM reported masturbating more frequently
(de Cuypere et al., 2005)
26

27. Post-Op Sexual Health (cont’d)
• FTMs who chose to have penile prosthesis
implanted had their sexual expectations more
realized
o Reported more pain during intercourse
Could be due to reconstructed neural
pathways
Could be due to the prosthesis putting
pressure on places where the constructed
penis is attached.
(de Cuypere et al., 2005)
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28. Transition Considerations
• Saving eggs or sperm prior to transition
• Setting realistic goals and expectations
• Teaching clients how to conduct Self-Breast
Exams
• Hormone therapy is life long
• Instructing how to use vaginal dilators to avoid
vaginal stenosis (built-up scar tissue that
makes the vagina narrower)
• Supportive relationships
(Jain &Bradbeer, 2007)
28

29. Complications
•
•
•
•
•
•
Infection
Pain
Regret
Request for reversal
Fistula Formation
Scrotal tissue used for the neovagina may
grow soft hair in the vaginal wall
• Disappointment related to poor function
and/or physical outcome
• Suicide
(Jain &Bradbeer, 2007)
29

30. General Guidelines When Asking
Clinically Relevant Questions
• Respect each person’s identity and experience
• Instead of asking “What are you?” or “Are you a
man or a woman?” try:
“What is the respectful pronoun to use for you?” or
“I’m interested in hearing about your gender identity
if you are comfortable sharing” or
“Is there anything that I/we/the community can do to
make this a more comfortable place?”
• Instead of asking about a person’s genitals or
medical procedures, try:
“How is your health?”
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(Retrieved from http://amikaplan.net/trans.html)

31. General Guidelines (cont’d):
Don’ts
• Don't unnecessarily refer to a person's
previous gender status
• Don't insist that someone must be either a
man or a woman
• Don't say things like: "But you look like a
woman!" or "But I've always known you as a
man" or "But you made such a
good/attractive woman”
• Don't be afraid to say, "I don't understand, but
I want to be respectful of you."
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(Retrieved from http://amikaplan.net/trans.html)

32. General Guidelines (cont’d):
Do’s
• Do take other people's identities seriously,
even though it may not conform to your own
ideas about gender or sex
• Do respect a person's choice of
name/gender/pronoun
• Do act as an ally
• Do remember that you may be interacting
with a transgender person and not know it
• Do seek out information on your own
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(Retrieved from http://amikaplan.net/trans.html)

33. 33

34. Recommended Resources
• http://www.nationalhomeless.org/factsheet
s/lgbtq.html
• http://www.videojug.com/interview/sexchange-and-surgery-2
• http://ai.eecs.umich.edu/people/conway/T
S/SRS.html#anchor50968
• http://www.katebornstein.typepad.com/
• http://amikaplan.net/trans.html
• http://hbigda.org/Documents2/socv6.pdf
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35. References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text
rev.). Washington, DC: Author.
American Psychiatric Association. (2010). DSM-5 development: 302.6 Gender identity disorder in children:
Proposed revision. Retrieved from
http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rig=192.
Carroll, L., Gilroy, P. J., & Ryan, J. (2002). Counseling transgendered, transsexual, and gender-variant clients.
Journal of Counseling and Development, 80(2): 131-139.
Dragowski, E. A., Scharron-del Rio, M. R., &Sandigorsky, A. L. (2011). Childhood gender identity…Disorder?
Developmental, cultural, and diagnostic concerns. Journal of Counseling & Development, 89: 360-366.
Gender Identity Research and Education Society. (2006). Atypical gender development: A review.
International Journal of Transgenderism, 9: 22-44.
HBIGDA Standards of Care 6th version. (February 2001). Retrieved on July 2011, from
http://hbigda.org/Documents2/socv6.pdf.
Jain, A. &Bradbeer, C. (2007). Gender identity disorder: Treatment and post-transition care in transsexual
adults. International Journal of STD & AIDS, 18: 147-150.
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