Presentation for psychiatrists on Trans * , Gender Dysphoria and management . Check updated Guideline

1. Trans*
What do you need to know
Dr P J Saju
Consultant Medical Psychotherapist
South West Yorkshire NHS Foundation Trust
Wakefield
21 January 2021

2. Experience
0 Consultant Psychiatrist at Leeds Gender Identity
Clinic ( 2011-2018).
0 Consultant Psychiatrist at Bradford District Care Trust
( 2002- 2006; part time from 2019 onwards );
Consultant Medical Psychotherapist from 2009.
0 Practicing in Psychiatry from 1990

3. Objectives
Background
Clinical approach
Gender History, Gender Identities & Dysphoria
Common psychosocial difficulties
Psychosocial care
Treatment Guidelines
Q& A

4. ‘’Normal’’ ‘’ Healthy’’
Assumptions
1. Sex is binary ( Male and Female)
2. Gender is binary ( Man & Woman)
3. Attraction is binary ( towards man or woman)
4. Sexual Morals are Binary ( Right and Wrong)
0 Cisnormative assumptions,
0 Institutionalised Cissexism,
0 Heteronormativity.
0 Bias, Stigma and Transphobia.

5. Queer Deconstructions
( Julie Tilsen 2015 -Therapeutic Conversations with Queer youth)
‘’ When the binary assumptions are broken, we think
people are ‘ wrong’. We do not think the model is
wrong’’
One way to shift our assumptions from unconscious to
conscious is to use self reflective questions
How did my culture/ faith community teach me about
gender , gender identity, gender expression, sexual
orientation, sexuality and romantic relationships?
‘

6. Sex and Gender
Sex :
( Male, Female & DSD)
biological construct based
on genital/ bodily
appearance and
Gender ( Man, Woman
&…)
Psychological, Social,
cultural construct
1. Chromosomes
2. Genes
3. Gonads
4. Hormones
5. Internal sexual organs
6. External genitalia

7. Gender
Cultural ideas, Identities , Roles and Expressions
The Assigned Gender
‘ She is a girl’
Gender Self Identity
‘I am a girl’
Gender Identity
experienced gender/ felt
gender / affirmed gender
Inherent sense of being a man
or woman or blend of man &
woman or some other gender
(Self Identification)

9. Cis Gender Identity Cis (on this side of)
someone who is comfortable in the assigned gender .
There are only 2 categories Man & Woman
CIS MAN
ROLE
IDENITY
ASSIGNED
GENDER
BODY
CIS WOMAN
ROLE
IDENITY
ASSIGNEDGEND
ER
BODY

10. Trans/ Transgender/ Trans*
Trans=over , across, on or to the other side of
pass beyond, transgress, transform
Umbrella term for
person who
crosses ANY traditional gender boundaries*
permanently or periodically
1. Gender identity: people with trans identity/ dysphoria
2. Expression e.g cross dressing people
3. Role- e.g drag queens

11. Spectrum
0 Sex :
Disorders of Sexual
Development.
e.g. XX male , XY female,
0 Gender Identity:
Man, Woman, Non Binary
Bigender, Agender,
Neutrois, Gender fluid,
3rd gender, Gender Queer,
Gender Blenders,
Pangender, Trans Masculine
0 Gender roles:
Masculine, Feminine
Androgynous, gender
neutral, Gender Non
Conforming, Trans
Masculine, Transfeminine
0 Sex orientations:
Straight, Gay, Bisexual,
Sexual fluid,
Pansexual, Asexual

12. Gender Diversity
is not a new phenomenon
0 Hijra of India
0 Two Spirit: Native American
0 Travesti -Brazil
0 Maa khii –Thailand
0 Acault –Myanmar
Reference:
Gender Diversity :cross cultural
variations (2000) by Serena Nanda

13. Fluid boundaries/
terminology
Trans
Gender
non
conform
Gender
Questioning
Transsexualism
Gender
Dysphoria
Incongruence

14. Diagnostic Terms
Transsexualism:
Dated diagnostic term; used in ICD 10
Gender Dysphoria
Term used in DSM5 , discarding Gender Identity
Disorder ( DSMIV)
Gender Incongruence
Term used in ICD 11

15. DSM IV ( Focus-Gender Identification) DSM 5 ( Focus -Gender Dysphoria)
Gender Dysphoria=Marked Incongruence
Felt
Gender
Sexual
characteristi
cs
Assigned
Sex

16. Gender Dysphoria in Adolescents & Adults: DSM 5
Marked Incongruence + 2 symptoms
Gender Identity Social Genital Dysphoria
1
A strong conviction that
one has typical feelings
and reactions of the other
gender or alternate
gender
2
Strong desire to be the
other / alt gender
3
Strong desire to be
treated as other /Alt
Gender
4
Incongruence between
gender and sexual
characteristics
5
Strong desire to
get rid of sex
characteristics
6
Strong Desire for sex
characteristics of the
other
No symptom is given
pre eminence
2 out of 6 must be
present for at least 6
months
The condition causes
significant distress or
impairment

17. DIAGNOSIS
ICD10
ICD 11 Gender
Incongruence
0 A. Desire to live and be accepted
as a member of the opposite sex,
usually accompanied by the wish
to make one's body as congruent
as possible with one's preferred
sex through surgery and
hormonal treatment.
0 B. Presence of the transsexual
identity for at least two years
persistently.
0 C. Not a symptom of another
mental disorder, such as
schizophrenia, or associated with
chromosome abnormality.
0 a marked and persistent incongruence between an
individual´s experienced gender and the assigned sex,
as manifested by at least two of the following:
0 1) a strong dislike or discomfort with the one’s
primary or secondary sex characteristics (in
adolescents, anticipated secondary sex
characteristics) due to their incongruity with the
experienced gender;
0 2) a strong desire to be rid of some or all of one’s
primary and/or secondary sex characteristics (in
adolescents, anticipated secondary sex
characteristics) due to their incongruity with the
experienced gender;
0 3) a strong desire to have the primary and/or
secondary sex characteristics of the experienced
gender. The individual experiences a strong desire to
be treated (to live and be accepted) as a person of the
experienced gender.
0 The experienced gender incongruence must have
been continuously present for at least several months.

18. Cases
1. 70 year old Professor
2. The Irish Catholic
Lecturer
1. The Chaotic Nurse
2. The Abused ASD
3. He/ She from Iran

19. Gender & Life Story
Gender
Identity
Desires
Beliefs
Fantasy
Feelings
Dysphoria
Fears
Expression
Role
Peers
Family,
Relational &
Life Events
Childhood Attachment
Abuse &
Neglect
Friends
Puberty Peer group
Body image
Sexuality
Self Esteem
Adulthood Relationships
Work
Later
adulthood
Meaning

20. Assessment: 2 sessions
Gender identity, role , behaviours & distress
Onset & course childhood, adolescence, adulthood
 Dysphoria : nature, extent, persistence
 Functional impairments- occupational/ relational
Sexuality-Androphilic, gynephilic, neither, both
 Support & Barriers family/ friends/ social network
Treatment expectations-commitment/ ambivalence

21. Gender Identity & Expression
an interactive process: Onset & course is variable
Dissonance,
Confusion,
Doubts &
Questioning,
Suppression,
Denial
Overcompensation
Seeking
information
Reaching out
Exploration of all
aspects of identities
Coming out
Re evaluation
Evolution
Identification
Acceptance

22. Affirmative Therapist
Therapist Attitudes Therapist Approach
Gender Variance is
0 Accepted
0 Respected
0 Understood
0 Validated
Building on client’s
0 Strengths, knowledge
0 Experience
0 Resilience
0 Resources ( inner,
outer)
0 Goals
0 Values

23. Gender Etiquette
Ask. Listen. Respect
The only way to know someone’s
gender identity is to ask the
person . Everyone experiences
gender differently
Always use the name and title
( Mr, Ms, Mx) the person wants
to be called, regardless of
transition or appearance
If you are unsure , of how the
person presents, ask discreetly
Transman; transwoman,
MTF, FTM, Man, Woman
0 Use the appropriate gender
specific pronouns in
conversation and in letters-He,
She,
Gender neutral pronouns
0 They,
0 s/he,
0 Zir
0 Ze ( prounounced ‘’zee’’)
0 Hir ( pronounced ‘’here’’)

24. Pronoun spectrum

25. Intersecting Identities
privilege & oppression
0 Race/ ethnicity
0 Age
0 Education
0 Socio economic status
0 Occupation
0 Immigration status
0 Disability status
0 Sexual orientation
0 Relational status

26. Psycho social issues
1. Questioning identity
2. Decisions about coming out/ transitioning
3. Concerns about passing/ misgendering
4. Family :loss / grief/ betrayal/ intimacy/changed roles
5. Ageing : Grief about lost time, opportunities, regret
6. Intimacy , sexualities
7. Managing work/ social relationships
8. Fertility issues/ gamete storage
9. Preparing for losses & realistic outcomes
10. Delay & Drop outs
11. Role Reversals, Regret & De transitions

27. Role Transition
( ‘’real life test’’)
Living in gender congruent role for 12 months necessary before
genital surgery.
Role transition not necessary before hormone therapy and Chest
surgery. Emphasis on role transition is generally reducing.
Consider risks- in some parts of the world, coming out would be
too risky-should they be denied treatment?
What would be appropriate transition for
alternate gender/ third gender or gender queer individuals?

28. Comorbidity
. .
0 Depression
0 Anxiety
0 Social phobia
0 Addictions
0 Relationship issues
0 Aspergers/ ASD
0 Self harm/ suicide
0 Body dysmorphia
0 Eating disorders
0 Personality issues

29. Role of the professionals
• Assessment of gender dysphoria
• Assess & manage comorbidity
• Prepare for the various treatments
• Capacity for Informed consent and readiness
• Facilitate development of a valued identity
• Foster resilience in the face of discrimination & stigma
• Engage in advocacy to combat social stigma

30. ‘’Let old paradigms die and new ones emerge ‘’
( Coleman, 2007)
Then Brave New World Now
Then Now
’True Transsexuals only’’
Medical focus/ prescriptive
Diagnosis: Gate keeping
Standardised protocol for Rx
Cross sex Hormone treatment for life
‘’Transgender Model’’
Client focus
Understanding unique gender identity,
Individualised Rx, informed consent
Hormone treatment to Gender goals
Prepare client for
permanent gender change
Emphasis on passing/ blending
Explore gender identities
and desired expressions
Passing may not be desired or possible
Compliance with staged treatment
( Living in Role, Hormones, Surgery)
To a fixed cross gender identity
through hormones & surgery
Surgery may or may not be desired,
can occur early eg Mastectomy
Create tailored treatment based on
wishes and needs of patient.

31. Readiness for Treatment
Specialist
Opinion
Living in Role-
Transition
Hormone Therapy
Hormone 1 Not required NA
Mastectomy
Male chest
reconstruction
1 Not required Not required
Genital surgery
Phalloplasty
Vaginoplasty
2 12 months 12 months
Hysterectomy
Bilateral
Oophorectomy
2 12 months 12 months

32. Risks of cross hormone therapy
Oestrogen Testosterone
0 DVT & Pulm. Embolism
0 Cardiovascular risks
0 Hyperprolactinemia
0 L FT abnormalities
0 Hypertension
0 Type 2 diabetes
0 Weight gain
0 Breast Cancer
0 Polycythemia- Stroke &
CVA
0 Obstructive sleep apnoea
0 Hyperlipedemia
0 LFT abnormalities
0 Acne & balding
0 Type 2 diabetes
0 Weight gain
0 Gynec Cancer ( rare)

33. Other drugs
Gn RH agonists
( ‘’Blockers’’)
Goserelin, Leuprorelin etc
0 chemical gonadectomy
0 fully reversible ( ?
Children)
0 stop after gonadectomy
Anti Androgens
1. Spironolactone 100-
200mg
2. Finestride 2-5 mg/ day
3. Cyproterone acetate
100mg/ day

34. Eligibility for Surgery
Mastectomy Genital surgery
0 Persistent Dysphoria
0 Informed consent
0 Hormones not a pre
requisite
0 May be living in role
0 One recommendation
0 Persistent
Dysphoria
0 Informed consent
0 Hormones 12
months
0 Lived in role for 12
months at least.
0 2 recommendation

35. Surgery for Transmen (FTM)
‘’Top Surgery’’
Bilateral Mastectomy &
Male Chest reconstruction
‘’Bottom Surgery’’
0 Phalloplasty :3- 4 stages
each stage consist of one
or more operations
which may take 2 years
0 Metoidioplasty
0 Hysterectomy
0 Oophorectomy

36. Surgery for Transwoman (MTF)
0 Orchiectomy
0 Penectomy
0 Vaginoplasty-using penile skin
0 Vulvoplasty, labioplastly
0 Clitoroplasty
0 Creation of new urethral orifice

37. Other Surgeries
0 Breast Augmentation
0 Facial Feminisation Surgery
0 Voice Box surgery

38. Outcome
relief of dysphoria, satisfaction with surgery, regret
Satisfaction after surgery MTF
0 71.4 (Pfafflin & Junge 1992)
0 87%( Green & Fleming,1990)
Satisfaction after surgery FTM
0 89.5% (Pfafflin & Junge 1992)
0 97% ( Green & Fleming,1990)
Regret about Surgery
1-3%

39. Multidiciplinary team
not all teams may have the full complement of professions
0 Medics :Psychiatrist, Endocrinologist, Surgeons
0 Specialist nurses, pharmacists
0 Psychologists
0 Speech therapist, voice coach
0 Image consultant, occupational therapists
0 Counsellors & Psychotherapists
0 An effective admin team

40. Epidemiology
was thought to be rare; more common in natal males, but in clinic M=F
based from Gender Clinics
MTF = 1 in 15,000 (1 in 11,900 to 45,000)
FTM =1 in 30,000 ( 1 in 30,400 to 200,000)
Recent Population Surveys
Kuyper & Wijsen (2014) Dutch population survey (N=8064)
4.6% of natal males & 3.2 % females=ambivalent gender identity
1.1% natal males & 0.8% natal females reported an ‘incongruent gender
identity’ (defined as stronger identification with other sex as with sex
assigned at birth)
Caenegem et al. (2015) Belgium (N= 1832 + 2472) general population,
Gender ambivalence was present in 2.2% of male and 1.9% of female
Gender incongruence in 0.7% of men and 0.6% of women.

41. controversies
0 Children with Gender Dysphoria and treatment
0 Hospitalisation of Trans patients
0 Criminal Justice System and Trans prisoners
0 Gender Recognition Act
0 Biological Women

42. Children
Judicial review launched by
Keira Bell, who was born female
but began questioning her
gender identity at 14.
Began taking puberty blockers
at 16 after referral to the
Tavistock.
Now 23, also had a double
mastectomy, which she now
regrets.

43. High Court Judgement 2020
0 It was highly unlikely that a child aged 13 or under
would be competent to give consent .. and also
doubtful that a child aged 14 or 15 could understand
and weigh the long-term risks and consequences of
the administration of puberty blocking drugs.
0 In respect of young persons aged 16 and over, the
legal position is that there is a statutory presumption
that they have the ability to consent to medical
treatment.
0 Given the long-term consequences of the clinical
interventions at issue in this case, and given that the
treatment is as yet innovative and experimental, the

44. Trans in Hospital
0 Human Rights Act
0 Equality Act
0 Gender Recognition Act
0 Same sex wards
0 Privacy- curtains
0 No discrimination
0 Confidentiality
0 Protected characteristic
0 ( registered health
professionals exception, but
not for support workers)
0 Seek consent always!!

45. Trans Prisoners
MoJ Review Nov 2016
Main message: treatment has not kept up with social
values
0 All trans prisoners must be allowed to express their
gender with which they identify. ( even if they are not
seeking medical interventions or GRC)
0 Most trans prisoners can be accommodated in line
with the self identified gender
0 In a minority of cases this may not be possible.

46. Gender Recognition Act, 2004
Gender Recognition Certificate
Came to effect in April 2005; 4900 applications between 2005- 2016
Gender Recognition Panel( with legal and medical members)
2 medical opinions, diagnosis; lived in role for 2 years, intend to live
permanently- medical/ surgical treatments is not a requirement, but reasons
for this should be stated
The certificate can be used to get new birth certificate in the ‘aquired gender’
Marriage / civil partnerships
Retirement / pensions / benefits
Obtain a new birth certificate showing legally recognised gender
“It is an offence for a person who has acquired protected information in an
official capacity to disclose the information to any other person’’
DBS (CRB) - separate confidential application procedure.

47. References
All are free to download
1. WPATH ( 2011) Standards of Care ( SOC-7)
2. Report of the APA Task Force on Treatment of
Gender Identity Disorder (2012)
3. RCPsych CR181( 2013). Good practice guidelines for
the assessment and treatment of adults with gender
dysphoria
4. APA ( 2015)Guidelines for Psychological Practice
With Transgender and Gender Nonconforming
People

48. Additional slides

49. The Gender Identity Development Service (GIDS)
0 The Tavistock and Portman
NHS Foundation Trust
Service started in 1989
London
Leeds
Exeter
0 Child and adolescent
psychiatrists.• Clinical
psychologists.
0 • Social workers.• Child and
adolescent psychotherapists.
0 • Paediatric endocrinologists •
Clinical Nurse Specialists
0 Prefer Local CAMS assessment
0 Assessments between 3-6
sessions,
0 Support for child & family
available till age 18

50. Tavistock service
To explore and understand the child or young person’s past
and current gender identification &their development across
a number of domains. Whole range of psychosocial
interventions
Prescribe hormone blockers,( Gn RH agonists) which can
stop the physical changes associated with puberty. This is
fully reversible.
Taking hormone blockers can allow time to think about and
explore feelings about gender identity, without having to
worry about the body changing in a way that is difficult to
cope with.

51. UK
support
0 GIRES ( Gender Identity Research & Education Centre)
0 Gendered Intelligence ( support young people 11-25)
0 The Gender Trust
0 Mermaids- children, young people and families

52. Definitions
Gender
Identity
Inherent sense of being a man or woman
Or blend of man & woman or
some other gender (Self Identification)
Gender
Expression
Appearance, clothing & accessories and behaviour
that communicates aspects of gender/ gender role .
( ? private or public)
May or may not conform to G Identity
Gender
Role
How gender is enacted/ performed consciously or
unconsciously through pattern of appearance,
interests, personality & behaviour in a given culture .
(? Social expression)
May or may not conform to G Identity
Gender
Non-Conforming
Gender identity or expression or role differs from
norms associated with assigned sex
Gender
Queer
Gender identity and / or role does not align with a
binary understanding of gender

53. Definitions
Gender Queer Gender identity or role does not align with binary
understanding of gender
Gender Non
Conforming
Identity or expression differs from social norms of
assigned gender
Gender
Role
How gender is enacted/ performed consciously or
unconsciously through pattern of appearance,
interests, personality & behaviour in a given culture .
May or may not conform to Gender Identity

54. 7 Gender Clinics in England
0 London, Exeter,Northampton,Nottingham
0 Leeds, Sheffield, Newcastle
0 Commissioned by NHS England
0 Service / Practice Guidelines :
1. WPATH Standards of Care 2011,
2. RCPsych, Council Report 181, 2013
3. NHS England Interim Policy, 2013

55. Kohlberg’s Cognitive Developmental Theory 1966
Warning: Traditional theories is less helpful in understanding Trans
 Are you a boy or a girl?
 When you were a baby
were you a boy or girl
 Will you be a mummy or
daddy when you grow up?
 if you put on girls/ boys
clothes , could you be a
girl/ boy
 If you wanted to, could
you be a daddy/mummy
when you grow up?
0 2-3 year Gender Labeling: Learn to
identify their own or others’ sex
0 3-4 year Gender Stability : Learn gender is
unchangeable over time, but based on
appearance, hair length, dress etc.
0 6-7 years: Gender Constancy: Gender is
permanent/ immutable ;not dependent on
appearance or activities. Children then
value & imitate behaviours and attitude
associated with their gender
0 But,below 2 yr children not aware of their
gender status-BUT can still show sex
typed behaviour.3 yr show preference for
same sex friends, playmates of same sex.
Gender Schema Theory-information
processing theory

56. Childhood Gender Cognition
3 Theories
Cognitive Developmental
Theory
( Kohlberg 1966, 1969)
• Stage model of gender identity
• Intrinsic development
Challenge: children can differentiate sex before
they can label their gender
Gender Schema Theory
( Martin & Halverson, 1981)
• Information processing model
• In group / outgroup cognitions
• Gender Schemas guide thinking &behaviour
• Organise perception, memory & exploration
Multifactorial Gender Theory
( Spence, 1985, 1993)
Gender schemata is multifactorial.
Individuals develops a unique, idiosyncratic set of
associations with their gender. Children review
their sex typed attributes and reach a summary
judgement of their overall gender typicality-

57. Janet Spence’s Model
Gender identity: ‘’weighted summary judgement’’
M salient
M
salient
M Not salient
F N. salient
M
salient
F salient

58. Gender Self Socialization Model
( Tobin et al 2010)
Gender Attribute
Self
Gender Identity
(Gender Self associations)
1. Membership
knowledge
2. Gender typicality
3. Gender Contentedness
4. Felt pressure
5. Gender Centrality

59. Self Identities
Internal Self Intentional Self
0 ’Who am I ? ’’
Assumes an
essential,
stable,
individual self
0 ‘’ Who do I want to
be?’’
0 To do with peoples
intentions-their hopes,
dreams and
commitments.
Contextual
Changeable (fluid)
Relational Self

60. Narrative therapy’s
Relational understanding of identity
Combs & Friedman, 2016, Family Process, 55, 211-224
0 Relational: our stories of who we have been and who we can be
would not exist outside of relationships with people
0 Distributed: stories and experiences that shape our moment to
moment sense of ‘self’ are located in different places-in other
peoples memories, hosp records, anecdotes. Focus on various
identities people experience in different contexts helps to resist
totalizing descriptions
0 Performed: we constitute ourselves through the actions we take
in each others presence
0 Fluid: the performed identity is a process, not a fixed possession
Becoming other than what we have been, rather than becoming
more true to who we are

61. History
1903 Krafft-Ebbing ( case reports in Psychopathia Sexualis)
1910- Magnus Hirschfield ( case reports in ‘Transvestites’)
1949- David Cauldwell used term Transsexualism in a case report
1952- Christine Jogerson’s surgery
1966- Harry Benjamin -The Transsexual phenomenon
1968- Robert Stoller ‘Sex and Gender-The Transsexual experiment’
1969- Green & Money’ Transsexualism and Sex Reassignment’
1973- Fisk coined term Gender dysphoria
1975- Transsexualism included in ICD9 under sexual Deviations
1980- included in DSM III under psychosexual disorders
1994- Gender Identity Disorder (DSM IV)

62. Self harm & Suicidality
Systematic review by Marshall, Claes et al, 2016
0 Higher level of self harm in trans population, particularly in
transmen.
0 Cutting most common method.( Claes et al 2015)- clinic, waiting
for treatment:38% life time history of self harm Prevalance 58%
in transmen; 26%in transwoman.

63. Suicide
Self harm rates may reduce after transition, but
suicidal attempts & Suicide rates remains high even
after transition
Dhejne et al 2011: Swedish register 324 post surgery
trans patients: median 10 yr follow up .
suicide rate 2.7%; 0.1% in matched controls
MTF more at risk. Suicide rate diverges 10 yrs after
transition.
Asscheman et al 2011 , Danish study 1331 patients on
hormone: 966 MTF pts. Median follow up 18.5 years
suicide rate in MTF increase six fold ( SMR 5.7)
population.Mortality rate increase mainly due to
suicide & other health problems. Suicide increased in
MTF, but not in FTM

64. Kate Bornstein Video Clip
6 Minutes
https://www.youtube.com/watch?v=KzKnivc2LK4

65. Questions for exploration
( Kate Bornstein, Gender Outlaw-1994)
1. What is your gender?
2. When did you decide that?
3. How much say you have in your gender?
4. Is there anything about your gender or gender role that you don’t like?
5. Are there 1 or 2 qualities about another gender that are appealing to you,
enough so you’d like to incorporate it into your daily life?
6. What would happen to your life if you did that?
7. What would be your gender then?
8. How do you think people would respond to you?
9. How would you feel if they did that?

66. Additional Questions
( after Karisa Barrow, 2014)
1. What is your gender identity. ..(on a 0-100 scale)
2. How old were you when you realised you were a boy or a girl
3. Who and what made this clear to you
4. What activities did / do you enjoy.. Was this your free choice
5. Have you expressed your gender identity or role differently
6. Were you ‘’policed’’ by others around your identity, gender roles and social
practices or body
7. How has your gender shaped your beliefs and practices
8. What have you been allowed/ dicouraged from doing because of gender
identity?