Wednesday, May 29, 2013

On Psychological Care In Managing Gender Dysphoria

This will be a somewhat lengthy post.  In part, because I find the space I am about to discuss multi-faceted, and the discussion around each facet of the conversation is non-trivial.  The involvement of mental health professionals in the process of Gender Transition (I will use the term "transition" from here on in) is complex and the subject of many strongly-held opinions within the transgender community.    This essay will be my attempt to lay out for readers my perspective on things.

Readers should note that these are my opinions today.  Time, evidence and rational counterpoint may well convince me to revise my position.

[Warning:  Lengthy Essay Follows The Jump]

Facet #1:  Is Therapy Necessary For Gender Transition?

It is not essential for everybody.  I will turn briefly to the 7th Edition of the WPATH Standards of Care, which states the following:

1. Psychotherapy is not an absolute requirement for hormone therapy and surgery
A mental health screening and/or assessment as outlined above is needed for referral to hormonal and surgical treatments for gender dysphoria. In contrast, psychotherapy – although highly recommended – is not a requirement.
The SOC do not recommend a minimum number of psychotherapy sessions prior to hormone therapy or surgery. The reasons for this are multifaceted (Lev, 2009). First, a minimum number of sessions tends to be construed as a hurdle, which discourages the genuine opportunity for personal growth. Second, mental health professionals can offer important support to clients throughout all phases of exploration of gender identity, gender expression, and possible transition – not just prior to any possible medical interventions. Third, clients differ in their abilities to attain similar goals in a specified time period.
 [WPATH SOC v7 p. 28]
This is a subtle, and very interesting paragraph.  It makes clear that ongoing psychotherapy is not an essential part of successful gender transition.  At the same time, it does point out the need for some kind of assessment prior to hormones or surgery.

While psychotherapy isn't strictly necessary for someone undertaking gender transition, I do think that there are compelling reasons to engage with a therapist at least while actively working towards your goals as they relate to gender identity.

At the very least, a therapist will be able to help you identify and work through other comorbid (concurrent) psychological conditions that may be colouring your sense of gender.  I have long felt that there is something about being transgender which is inherently traumatic, and that trauma has a nasty tendency to leave damage in our psyches that is not always obvious to us.  I have seen enough people in the trans community to be fairly certain that the rates of unaddressed problems are higher than in the general population.  Those who fail to deal with those conditions can have tragic outcomes if they pursue gender transition without addressing them.  In this respect, as I have pointed out in my essay on Walt Heyer, there is an excellent objective example of how far awry things can get if we are not handling these conditions appropriately.  There are other people I have met whose stories are examples that I find similarly troubling.

Fortunately, not everybody who needs to transition has comorbid issues that arise from their pasts.  In today's world of parents who actively support their children in transitioning at young ages, there is hope that more transgender people will be able to transition without having to clean up the emotional scars of living a life in the wrong skin.

At the very least, I believe that it is to the benefit of someone considering Gender Transition to undergo a formal psychological assessment.  If there are additional issues identified, work them through as part of the transition process.

Facet #2:  The Language of Diagnosis

Both the DSM and ICD-10 carry in their lexicons a set of criteria which are used to describe transgender people.

Many people have criticized the diagnostic criteria for a variety of reasons.  Kelley Winters made some very compelling arguments with respect to problems that she saw in the DSM-IV's language.

There have been calls for the diagnostic categories to removed altogether from the DSM and ICD documents.  Mostly these arguments have been rooted in the concerns that many transsexuals have about being stigmatized simply because there is language describing them in these diagnostic dictionaries.

While I am sympathetic to such calls, I do not yet believe that there is an adequate alternative which can be used as a replacement.  There is a growing body of evidence that hints at a set of biological factors that are involved, but as yet there is no conclusive diagnostic criteria which has been derived from that work.

I think it is important to recognize that the DSM and ICD documents are descriptive documents.  These documents serve only to describe a wide range of conditions, and do not make statements about how conditions should be treated.  They ultimately provide a common set of definitions which can then be used by the various treatment professionals to ensure that there is a minimal amount of misunderstanding in professional communications.

Efforts have been made in the DSM-V to address some of the issues that have been raised regarding the consequences of the diagnostic language.  The change from Gender Identity Disorder to Gender Dysphoria brings with it some sense that there are exit criteria.  Gender Identity Disorder was criticized by some for lacking any way for the diagnosis to become resolved.  Although not entirely clear, the notion of Gender Dysphoria implies that once the patient is no longer experiencing the dysphoria, that the problem can be considered resolved and the diagnosis no longer applies.  Similarly, the WPATH SOC v7 document also addresses the issues of stigmatization to some degree.

Many transsexuals have called for the removal of these diagnostic criteria entirely.  Their argument is based largely on a desire to repeat the outcome of homosexual activism through the 1960s and early 1970s.  I appreciate the motive of these actions from a political perspective.  However, unlike homosexuality, transsexuals require the direct engagement of medical professionals to achieve their goals, and the consequences of treatment are profound both physically as well as socially and psychologically.  This alone requires the treatment community that transsexuals interact with to have a shared language, even if it is imperfect.

Further, I think it is vital to recognize that a surgeon is unlikely to have adequate training to make the kind of psychological assessment that would convince them that performing GRS on a patient would not be detrimental to that client's best interests.  They are going to find it essential to insist upon a formal assessment from a mental health professional.

Facet #3:  Access To Professional Treatment

A homosexual can quite comfortably live without engaging any kind of professional assistance to achieve their goals.  They may engage with a psychologist to help deal with stresses which arise from the consequences of social disapproval in the community in which they live, but beyond that there is no particular reason that someone who is homosexual to need to access specialized health care services.

This is not the case for transsexuals.  Transsexuals unquestionably require the support of specialized professionals.  Doctors are required in order to gain access to hormones; surgeons are essential for those whose needs include physical alignment of body structures - whether that is genital surgery or breast reduction for FtM patients.

Here is where the tension between the patients desires for access to treatment is at its greatest tension with the professional practice requirements of these professionals.  Most medical professionals are bound to ethical guidelines which prohibit them from "doing harm" to their patients.  With issues of malpractice litigation continuing to escalate, especially in North America, one can hardly be shocked about the prospect of these professionals being exceptionally cautious.

Unlike most other forms of treatment, transsexuality is engaging physical treatments such as hormones, but the effects need to be assessed in terms of whether they are addressing a set of symptoms which are described in terms of the patient's sense of well-being.  Ironically, the physical effects of hormones are relatively easily monitored and assessed.  Assessing how taking cross-sex hormones is affecting a transsexual's sense of well-being is much more difficult.

The consequences of these treatments on the patient are unique in that they have outcomes that are physical, psychological and social in nature.  Unlike most other medical treatments, where a physical treatment removes a tumor or a drug is used to kill off an infection, the treatments for transsexuals do not address physiological symptoms.

Herein lies the big conundrum between treatment professionals and transsexuals.  The treatment professional has a legitimate concern that they are not harming their patient.  But how to assess whether the treatment is effective for the patient?

Once again, I am going to refer to the WPATH SOC v7, which has a fairly clear set of criterion related to gender reassignment surgery:

Criteria for metoidioplasty or phalloplasty in FtM patients and for vaginoplasty in MtF patients:
  1. Persistent, well documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. Age of majority in a given country;
  4. If significant medical or mental health concerns are present, they must be well controlled;
  5. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (un- less the patient has a medical contraindication or is otherwise unable or unwilling to take hormones).
  6. 12 continuous months of living in a gender role that is congruent with their gender identity; [WPATH SOCv7 P. 60]

Rationale for a preoperative, 12-month experience of living in an identity-congruent gender role:
The criterion noted above for some types of genital surgeries – i.e., that patients engage in 12 continuous months of living in a gender role that is congruent with their gender identity – is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery. As noted in section VII, the social aspects of changing one’s gender role are usually challenging – often more so than the physical aspects. Changing gender role can have profound personal and social consequences, and the decision to do so should include an awareness of what the familial, interpersonal, educational, vocational, economic, and legal challenges are likely to be, so that people can function successfully in their gender role. Support from a qualified mental health professional and from peers can be invaluable in ensuring a successful gender role adaptation (Bockting, 2008).
The duration of 12 months allows for a range of different life experiences and events that may occur throughout the year (e.g., family events, holidays, vacations, season-specific work or school experiences). During this time, patients should present consistently, on a day-to-day basis and across all settings of life, in their desired gender role. This includes coming out to partners, family, friends, and community members (e.g., at school, work, other settings).
Health professionals should clearly document a patient’s experience in the gender role in the medical chart, including the start date of living full time for those who are preparing for genital surgery. In some situations, if needed, health professionals may request verification that this criterion has been fulfilled: They may communicate with individuals who have related to the patient in an identity-congruent gender role, or request documentation of a legal name and/or gender marker change, if applicable.  [WPATH SOCv7 P. 61]
Considering the difficulties in validating whether a treatment has the desired outcome, it seems not unreasonable that the patient fulfil their role in the treatment team by demonstrating at least a degree of consistency in their life.

When I consider the accusations that "regretters" like Walt Heyer regularly level at the treatment of transsexuals, not to mention the obvious problems with how Heyer allegedly got surgery in the first place, it does not strike me as particularly unreasonable that there are some checks and balances in the process which minimize the risk of someone undergoing an irreversible surgery when they are not ready for it.

In general, the longitudinal studies that I have seen do not show that there are high rates of regret among post-operative transsexuals.  There are some, to be sure, but fairly small numbers overall.  However, given the profound nature of the changes that result from treatment for Gender Dysphoria, it is not by any means surprising that practitioners providing hormones or surgery would be cautious.

Transsexuality presents a serious conundrum to treatment providers.  While it is all too easy for a prospective client to declare "I know what I need, and that is hormones/surgery/etc.", the practitioner is in a difficult place when it comes to validating that declaration.  How does the surgeon, who is not likely to be a mental health specialist as well, determine that the patient isn't simply repeating something that they had read in a book; or perhaps is arriving at that declaration as a result of a misinformed desire to address some other life issues they are facing?  These are difficult situations to sort out at best, but practically speaking, only psychological professionals are going to have the appropriate training to help ferret those issues out.

As much as I might like to see easier access to treatment, I can also appreciate the very complex issues that a treatment provider faces and I think that the WPATH SOC expresses an appropriate balance between the needs of transgender people to access treatment, and the caution that treatment providers must exercise in their professional practices.

Facet #4:  The Therapist Relationship

Frankly, selecting a therapist is an exercise in frustration.  Finding a good therapist can often be extremely difficult.  In my home town, which is a sizable city with a population of over 1 million citizens, there are but a handful of therapists who will work with transsexuals.  Every one of them has clients that speak very highly of them, and others who are very critical of their individual approaches.

In the wake of the "Gender Clinic" era of the 1970s and early 1980s (of which the CAMH Gender Program in Toronto may be the sole remaining vestige), it is unsurprising to me that many transsexuals are skeptical of the mental health community.  Far too many were forced into situations which did not address their needs, or rigid program structures that were absolutely baffling.  One program I heard about required the patient to live full time in role for a full year before they would even provide a referral for hormone treatment.  I can only imagine the horror of that experience for patients who weren't naturally androgynous.

Finding a therapist is not easy.  Finding one that is a good fit for you as an individual is that much harder.  That does not invalidate their role in the process.  Transition is a complex, multi-faceted process that requires a lot of support from a variety of sources - for many that legitimately includes a therapist for a variety of reasons.  Once again, I will point to the WPATH SOC v7's statements with respect to the purpose of psychotherapy:

Finding a comfortable gender role is, first and foremost, a psychosocial process. Psychotherapy can be invaluable in assisting transsexual, transgender, and gender nonconforming individuals with all of the following: (i) clarifying and exploring gender identity and role, (ii) addressing the impact of stigma and minority stress on one’s mental health and human development, and (iii) facilitating a coming out process (Bockting & Coleman, 2007; Devor, 2004; Lev, 2004), which for some individuals may include changes in gender role expression and the use of feminizing/ masculinizing medical interventions.
Mental health professionals can provide support and promote interpersonal skills and resilience in individuals and their families as they navigate a world that often is ill prepared to accommodate and respect transgender, transsexual, and gender nonconforming people. Psychotherapy can also aid in alleviating any co-existing mental health concerns (e.g., anxiety, depression) identified during screening and assessment. [WPATH SOC v7 P. 29]
My personal feeling is that if a therapist is not working well for a given client, it is the client's responsibility to address the issues directly with their therapist or to find a different therapist.  I have seen enough people who have transitioned - some with therapists, some without, and the outcomes in my experience reflect the effort that the person themselves put into their transition.  The therapist doesn't "make or break" anything, but can be an invaluable source of objective feedback.

Facet #5:  Psychological Assessment As An Invasion Of Privacy And A Violation Of Human Rights

This particular aspect of the discussion is driven by commenter "HenryHall" back here.  I will reprise Henry's comments for your consideration here.

Comment #1:
Cracked Crystal Ball writes: ...counter-argument to those who argue that medical treatments related to cross-gender identity should be available on demand 

Actually the opposite conclusion is reachable and Heyer is a case in point as to why treatment should be available on an informed consent basis. (Which is not exactly on demand, since physical fitness at least is required).

Heyer's problem, put simply, is that Heyer has not grown up. Nothing more. Heyer fails to take adult responsibility for Heyer's own decisions. Instead Heyer relied on medical diagnosis, which obviously lacks validity (at best) and is a breach of human rights at worst.

Adults need to be empowered, not subjugated and forced to face taking adult responsibility for major life decisions. Heyer has been damaged by medical colonization of the transgender transsexual journey. And now blames medicine, society, and indeed anyone but Heyer.
Comment #2:
Just about no-one would propose on-demand surgery where somatic (physical health) requirements are not met. The issue centers around mental health diagnosis and mental health services.

The European parliament has called for removal of the GID and similar diagnoses from ICD-11 and that the transgender transsexual journey should be without mental health services (in most, not all, cases). Involving mental health services gives people false confidence (they believe diagnoses that lackvalidity ) and enables them to shirk adult responsibility. 

Mental health services are the problem, not the solution.
Comment #3:
One of the criteria of the EP in its decision is that under the ECHR, the medical exception to the human right of privacy of family life applies to diagnosis and to infectious diseases. It does not apply to treatment of non-infectious conditions. 
Which is why psychiatry in a context of so-called RLE (as contrasted with diagnosis) is unethical on a basis of human rights. 
That RLE is an effective treatment does not (of itself alone) create grounds for violation of human right to a private family life. It was very much the same for homosexual psychopathology. 
Comment #4:

Full text is at
Note particularly, but not only, paragraphs 13 and 16
No psychopathology and no psychiatry are two separate issues, both formally supported by the EP.
EP (27 nations) is not CoE (47 nations) but the EP rationale arises from the CoE ECHR right to a private family life. Medical exception is limited to infectious conditions. RLE is incompatible with private family life hence a violation of human rights.
I'm afraid that I have some difficulty with Mr. Hall's conclusions after reviewing the text of the resolution, I am of the opinion that he may well be inferring things that simply are not supported by the resolution itself.

I am going to restate the conclusions that I see drawn out in Mr. Hall's comments and I will address each in turn.

  1. Walt Heyer has not taken adult responsibility for his decisions.
  2. Walt Heyer was damaged by the medical treatment community that has injected itself into the transsexual treatment world.
  3. Mental Health services are the problem
  4. The European Parliament resolution of September 28, 2011 has the following implications:
    1. The ICD-10 (and DSM) should have the current diagnostic categories for transsexuals removed.
    2. That treatment related to transgender conditions should be separated from mental health services.
    3. The diagnostic categories in the DSM and ICD-10 are invalid
    4. That RLE (Real Life Experience) is a violation of human rights
1.  Walt Heyer has not taken adult responsibility for his decisions.

I am going to agree with Mr. Hall on this, and I think my analysis of his writings corroborates the position reasonably.

2.  Walt Heyer was damaged by the medical treatment community that has injected itself into the transsexual treatment world.

Here is where I start to disagree with Mr. Hall.  Based on Mr. Heyer's own narratives as published in his books, it is quite clear that he engaged in a series of practices in order to achieve his goals that included lying to the treatment providers.  Further, it also appears to me that Heyer did not work with any one treatment professional for an extended period of time until after being diagnosed with a dissociative disorder.  That largely rendered it impossible for any one practitioner to pick up on the inconsistencies and lies being told.  

It is difficult for me to accept that this can be pinned on the treatment community through the rubric of "colonization".

Further, I find the notion of "colonization" to be ill-defined in this situation.  The presence of treatment professionals in the world of transgender people is an unavoidable reality.  The language of "colony" fails to recognize that there is a legitimate need for the professionals to understand and engage with those that they provide treatment to.

3.  Mental Health Services are the problem

Sorry, but I just flat out disagree with this.  Anecdotally, I have had the opportunity to get to know enough transsexuals to be fairly convinced that those who chose to take advantage of the opportunity to sort out concurrent life and mental health issues with their therapists during gender transition profited from the process.

Not all do, but enough benefit from it for me to feel quite comfortable in disagreeing with such a sweeping claim.

4.1  The ICD-10 (and DSM) should have the current diagnostic categories for transsexuals removed.

Agreed.  The resolution seems quite clear on this.  

4.2  That treatment related to transgender conditions should be separated from mental health services.

Clause 13 of the resolution states:  "...calls in particular for the depsychiatrisation of the transsexual, transgender, journey...

As I have discussed earlier in this post, this is an impractical objective given today's diagnostic capabilities.  It runs quite firmly in opposition to the legitimate needs of the treatment community to ensure that they are not providing harmful treatment to their patients.  This is true for both hormones and for surgeries.  (See my comments in Facet #3 above)

 4.3  The diagnostic categories in the DSM and ICD-10 are invalid

Actually, I would interpret the resolution as criticizing the stigma that arises from the current language of diagnosis rather than declaring them entirely invalid.  I have addressed this in considerable detail in Facet #2, and I would point out that the WPATH SOCv7 document also addresses those issues.

4.4  That RLE (Real Life Experience) is a violation of human rights

This one is a head-scratcher to me.  Frankly, lots of things about medical treatment are "violations" of human rights in the strictest sense.  Under various circumstances, a doctor can confine a patient to a hospital to ensure that treatment takes place.  That is also a violation of human rights at some level.

Frankly, I do not see the connection between the RLE (expressed as a precondition of living for at least a full year in the desired role prior to being recommended for surgery) and the text of the resolution.  Further, given that the requirement is for a psychological assessment as part of the referral process rather than as part of an ongoing process of psychotherapy, I am unconvinced that this represents an unreasonable intrusion into the patient's life with respect to the professional ethical considerations that a treatment professional is obliged to consider.  If the requirement was that the candidate for surgery be closely monitored by a psychologist as part of RLE, I might agree that to be an unreasonable level of intervention.

Human rights law does not work in the language of absolutes.  Rights are bounded by the intersection of individual rights with other individuals as well as local laws and other reasonable measures.  I think it reasonable to understand that under various circumstances, the rights of an individual may be limited or breached by outside concerns.  The discussion is not so much whether these breaches are reasonable but to what extent are they reasonable.

Having said that, I am writing this from Canada, and I do not have a great deal of expertise in the language of human rights as it is executed in the EU.  My position is undoubtedly influenced by my understanding of human rights law in Canada.

Please note:  That with the debate over Bill C-279 currently in the Canadian Senate, that there is some interesting material to be discussed with respect to what is being debated on the matter.  The debates over Bill C-279 will be the subject of another post entirely.

Facet #6:  Conclusions:

Overall, it is my opinion that there is a place for therapists in the management of Gender Dysphoria.  The fact is that Gender Transition is not just a physiological issue, but one that encompasses all aspects of a person's being - physical, social and psychological.

At the very least, the psychologist provides an objective assessment of a given patient's mental and emotional suitability for various treatment options.  In a more wholistic view of the process, the psychologist serves as a guide who helps the client address the overall picture of life issues that they are facing.

I do not think that psychotherapy itself is essential in all cases, but I continue to be of the opinion that a psychological assessment is still a key part of ensuring that irreversible treatments are not performed on those who are not ready for them.  Will those assessments filter out all of those who are not ready for surgery, or perhaps should not have it at all?  Unlikely.  There will always be those who can convince a psychologist of their legitimacy, or those psychologists who will write a referral letter simply for the money.  That is unavoidable to some degree.

Perhaps in the future there will be some kind of definitive set of tests that can be run to determine if a given person is transsexual or not.  Those tests do not exist to day, which leaves us with a less than perfect solution.

Given the impact of the psychosocial changes that are part of the transition process, it seems to me that there will still be a significant place for the therapist in the journeys of many transgender people.  The challenge will, as it has always been, to ensure that an appropriate balance is struck between the needs of the transgender people and the professional considerations of the treatment community.

That the language in the DSM has evolved considerably since transsexualism was first introduced in the DSM III and the WPATH Standards of Care continue to be a living document, I believe that there is a willingness to engage with the transgender community constructively on the part of the treatment community.


HenryHall said...

>> This one is a head-scratcher to me.  Frankly, lots of things about medical treatment are "violations" of human rights in the strictest sense.  Under various circumstances, a doctor can confine a patient to a hospital to ensure that treatment takes place.

- See Paragraph 2 of Article 8 of the European Convention on Human Rights. The medical exception that permits prying into "the private and family life … " is strictly limited to " … the protection of health …". The medical exception does NOT extend into the remedying of ill health nor the promotion of good health. So psychiatric interrogation of a patient about lifestyle is permitted under human rights to the extent needed to determine that the patient is not contagious, suicidal or violent. BUT NO FURTHER.

It is a violation of human rights to limit somatic medical treatment (pharmaceuticals, surgery) based on whether or not a patient is willing to reveal private real life experiences or not. As a matter of human rights IN EUROPE, medical treatment must not be denied or downgraded because the patient chooses to exercise the human right to refuse to disclose details of family relationships, employment, lifestyle, gender roleplaying and the like.

That treatment (RLE) is thought to be effective is not sufficient reason to flout human rights and deny medicine to those who choose not to give up their human right to privacy.
Which is why the EP resolution on human rights, sexual orientation and gender identity at the United Nations roundly denounces the use of psychiatry in the transgender transsexual journey. That is not to say that the patient must be refused psychiatry, only that hormones and surgery must not be denied if the patient chooses not to seek out, or to chooses to decline, mental health "services" (beyond an initial evaluation for suicidality).

MgS said...

@HenryHall: You appear to be taking an extremely (possibly even excessively) narrow view of what is in fact a very broadly written.

For the purposes of reference, I will refer to the Wikipedia article on Article 8 of the ECHR.

You argue that RLE is not "sufficient reason" to deny surgery to those who choose not to give up their rights to privacy.

I respectfully disagree, on the basis that a psychological assessment as part of the prerequisites to gender surgery largely serves as an ethical cross-check for the surgeon who likely does not have the appropriate training to make such an assessment themselves. (as previously discussed)

I will point out that this differs from Van Kuck v. Germany in that this is not placing the burden of proving medical necessity on the patient, but rather is asking the legitimate professional question of whether the surgery would in fact cause additional harm to the patient.

This is consistent with my arguments in this article, and I do not believe that a psychological assessment constitutes an unreasonable infringement in the circumstances.

You can argue that it is all you like, but unless you can show me a court case that agrees with your position - specifically WRT RLE, I'm not at all convinced that your position is tenable in either North American OR European courts. I am fairly certain that it is not in Canada or the US, and reasonably certain that an EU court would find similarly when faced with the ethical considerations that the treatment community faces when working with a transgender person.

HenryHall said...

@> You argue that RLE is not "sufficient reason" to deny surgery to those who choose not to give up their rights to privacy.

Not so. I assert that a belief that RLE is effective is not a sufficient reason to flout human rights by denying somatic medicine to those who choose not to give up their human right to privacy.

Which is entirely a different proposition.

MgS said...

Okay - I mischaracterized your phrasing. I apologize.

However, in no way does your phrasing address in any way, shape or form the ethical issues that I have discussed in considerable detail in this post.

Nor have you presented any evidence whatsoever that suggest your interpretation of things is substantially supported by EU court rulings on the matter.

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