Standards
Of Care For Gender Identity Disorders - Sixth Version (February 2001) -
Part Two
***
| IV.
The Mental Health Professional |
***
The
Ten Tasks of the Mental Health Professional -
***
Mental health professionals (MHPs)
who work with individuals with gender identity disorders may be regularly
called upon to carry out many of these responsibilities: |
***
1.
To accurately diagnose the individual's gender disorder;
2. 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. |
***
The
Adult-Specialist -
***
The education of the mental health
professional who specializes in adult gender identity disorders rests upon
basic general clinical competence in diagnosis and treatment of mental
or emotional disorders. Clinical training may occur within any formally
credentialing discipline -- for example, psychology, psychiatry, social
work, counseling, or nursing. The following are the recommended minimal
credentials for special competence with the gender identity disorders: |
***
1.
A master's degree or its equivalent in a clinical behavioral science field.
This or a more advanced degree should be
||||granted by
an institution accredited by a recognized national or regional accrediting
board. The mental health
professional
should have documented credentials from a proper training facility and
a licensing board.
2. Specialized training and competence in the assessment of the DSM-IV/ICD-10
Sexual Disorders (not simply gender
||||identity
disorders).
3. Documented supervised training and competence in psychotherapy.
4. Continuing education in the treatment of gender identity disorders,
which may include attendance at professional
||||meetings,
workshops, or seminars or participating in research related to gender identity
issues. |
***
The
Child-Specialist -
***
The professional who evaluates
and offers therapy for a child or early adolescent with GID should have
been trained in childhood and adolescent developmental psychopathology.
The professional should be competent in diagnosing and treating the ordinary
problems of children and adolescents. These requirements are in addition
to the adult-specialist requirement. |
***
The
Differences between Eligibility and Readiness -
***
The SOC provide recommendations
for eligibility requirements for hormones and surgery. Without first meeting
these recommended eligibility requirements, the patient and the therapist
should not request hormones or surgery. An example of an eligibility requirement
is: a person must live full time in the preferred gender for twelve months
prior to genital surgery. To meet this criterion, the professional needs
to document that the real-life experience has occurred for this duration.
Meeting readiness criteria -- further consolidation of the evolving gender
identity or improving mental health in the new or confirmed gender role
-- is more complicated, because it rests upon the clinician's and the patient's
judgment. |
***
The
Mental Health Professional's Relationship to the Prescribing Physician
and Surgeon -
****
Mental health professionals who
recommend hormonal and surgical therapy share the legal and ethical responsibility
for that decision with the physician who undertakes the treatment. Hormonal
treatment can often alleviate anxiety and depression in people without
the use of additional psychotropic medications. Some individuals, however,
need psychotropic medication prior to, or concurrent with, taking hormones
or having surgery. The mental health professional is expected to make this
assessment, and see that the appropriate psychotropic medications are offered
to the patient. The presence of psychiatric co-morbidities does not necessarily
preclude hormonal or surgical treatment, but some diagnoses pose difficult
treatment dilemmas and may delay or preclude the use of either treatment. |
***
| The
Mental Health Professional's Documentation Letter for Hormone Therapy or
Surgery Should Succinctly Specify: |
***
1.
The patient's general identifying characteristics;
2. The initial and evolving gender, sexual, and other psychiatric diagnoses;
3. The duration of their professional relationship including the type of
psychotherapy or evaluation that the patient
||||underwent;
4. The eligibility criteria that have been met and the mental health professional's
rationale for hormone therapy or
||||surgery;
5. The degree to which the patient has followed the Standards of Care to
date and the likelihood of future compliance;
6. Whether the author of the report is part of a gender team;
7. That the sender welcomes a phone call to verify the fact that the mental
health professional actually wrote the letter as
||||described
in this document. |
***
|
The organization and completeness of these letters provide the hormone-
prescribing physician and the surgeon an important degree of assurance
that mental health professional is knowledgeable and competent concerning
gender identity disorders |
***
One
Letter is Required for Instituting Hormone Therapy, or for Breast Surgery
-
****
One letter from a mental health
professional, including the above seven points, written to the physician
who will be responsible for the patient's medical treatment, is sufficient
for instituting hormone therapy or for a referral for breast surgery (e.g.,
mastectomy, chest reconstruction, or augmentation mammoplasty). |
***
Two
Letters are Generally Required for Genital Surgery -
***
Genital surgery for biologic
males may include orchiectomy, penectomy, clitoroplasty, labiaplasty or
creation of a neovagina; for biologic females it may include hysterectomy,
salpingo-oophorectomy, vaginectomy, metoidioplasty, scrotoplasty, urethroplasty,
placement of testicular prostheses, or creation of a neophallus.
***
It is ideal if mental health
professionals conduct their tasks and periodically report on these processes
as part of a team of other mental health professionals and nonpsychiatric
physicians. One letter to the physician performing genital surgery will
generally suffice as long as two mental health professionals sign it.
***
More commonly, however, letters
of recommendation are from mental health professionals who work alone without
colleagues experienced with gender identity disorders. Because professionals
working independently may not have the benefit of ongoing professional
consultation on gender cases, two letters of recommendation are required
prior to initiating genital surgery. If the first letter is from a person
with a master's degree, the second letter should be from a psychiatrist
or a Ph.D. clinical psychologist, who can be expected to adequately evaluate
co-morbid psychiatric conditions. If the first letter is from the patient's
psychotherapist, the second letter should be from a person who has only
played an evaluative role for the patient. Each letter, however, is expected
to cover the same topics. At least one of the letters should be an extensive
report. The second letter writer, having read the first letter, may choose
to offer a briefer summary and an agreement with the recommendation. |
***
| V.
Assessment and Treatment of Children and Adolescents |
***
Phenomenology
-
***
Gender identity disorders in
children and adolescents are different from those seen in adults, in that
a rapid and dramatic developmental process (physical, psychological and
sexual) is involved. Gender identity disorders in children and adolescents
are complex conditions. The young person may experience his or her phenotype
sex as inconsistent with his or her own sense of gender identity. Intense
distress is often experienced, particularly in adolescence, and there are
frequently associated emotional and behavioral difficulties. There is greater
fluidity and variability in outcomes, especially in pre-pubertal children.
Only a few gender variant youths become transsexual, although many eventually
develop a homosexual orientation.
***
Commonly seen features of gender
identity conflicts in children and adolescents include a stated desire
to be the other sex; cross dressing; play with games and toys usually associated
with the gender with which the child identifies; avoidance of the clothing,
demeanor and play normally associated with the child's sex and gender of
assignment; preference for playmates or friends of the sex and gender with
which the child identifies; and dislike of bodily sex characteristics and
functions. Gender identity disorders are more often diagnosed in boys.
***
Phenomenologically, there is
a qualitative difference between the way children and adolescents present
their sex and gender predicaments, from and the presentation of delusions
or other psychotic symptoms. Delusional beliefs about their body or gender
can occur in psychotic conditions but they can be distinguished from the
phenomenon of a gender identity disorder. Gender identity disorders in
childhood are not equivalent to those in adulthood and the former do not
inevitably lead to the latter. The younger the child the less certain and
perhaps more malleable the outcome. |
***
Psychological
and Social Interventions -
***
The task of the child-specialist
mental health professional is to provide assessment and treatment that
broadly conforms to the following guidelines: |
***
1.
The professional should recognize and accept the gender identity problem.
Acceptance and removal of secrecy can
||||bring considerable
relief.
2. The assessment should explore the nature and characteristics of the
child's or adolescent's gender identity. A complete
||||psychodiagnostic
and psychiatric assessment should be performed. A complete assessment should
include a family
||||evaluation,
because other emotional and behavioral problems are very common, and unresolved
issues in the child's
||||environment
are often present.
3. Therapy should focus on ameliorating any comorbid problems in the child's
life, and on reducing distress the child
||||experiences
from his or her gender identity problem and other difficulties. The child
and family should be supported in
||||making difficult
decisions regarding the extent to which to allow the child to assume a
gender role consistent with his or
||||her gender
identity. This includes issues of whether to inform others of the child's
situation, and how others in the child's
||||life should
respond; for example, whether the child should attend school using a name
and clothing opposite to his or
||||her sex of
assignment. They should also be supported in tolerating uncertainty and
anxiety in relation to the child's
||||gender expression
and how best to manage it. Professional network meetings can be very useful
in finding appropriate
||||solutions
to these problems. |
***
Physical
Interventions -
***
Before any physical intervention
is considered, extensive exploration of psychological, family and social
issues should be undertaken. Physical interventions should be addressed
in the context of adolescent development. Adolescents' gender identity
development can rapidly and unexpectedly evolve. An adolescent shift toward
gender conformity can occur primarily to please the family, and may not
persist or reflect a permanent change in gender identity. Identity beliefs
in adolescents may become firmly held and strongly expressed, giving a
false impression of irreversibility; more fluidity may return at a later
stage. For these reasons, irreversible physical interventions should be
delayed as long as is clinically appropriate. Pressure for physical interventions
because of an adolescent's level of distress can be great and in such circumstances
a referral to a child and adolescent multi- disciplinary specialty service
should be considered, in locations where these exist.
***
Physical interventions fall into
three categories or stages: |
***
1.
Fully reversible interventions. These involve the use of LHRH agonists
or medroxyprogesterone to suppress estrogen or
||||testosterone
production, and consequently to delay the physical changes of puberty.
2. Partially reversible interventions. These include hormonal interventions
that masculinize or feminize the body, such as
||||administration
of testosterone to biologic females and estrogen to biologic males. Reversal
may involve surgical
||||intervention.
3. Irreversible interventions. These are surgical procedures. |
***
|
A staged process is recommended to keep options open through the first
two stages. Moving from one state to another should not occur until there
has been adequate time for the young person and his/her family to assimilate
fully the effects of earlier interventions. |
***
Fully
Reversible Interventions -
***
Adolescents may be eligible for
puberty-delaying hormones as soon as pubertal changes have begun. In order
for the adolescent and his or her parents to make an informed decision
about pubertal delay, it is recommended that the adolescent experience
the onset of puberty in his or her biologic sex, at least to Tanner Stage
Two. If for clinical reasons it is thought to be in the patient's interest
to intervene earlier, this must be managed with pediatric endocrinological
advice and more than one psychiatric opinion.
?***
Two goals justify this intervention:
a) to gain time to further explore the gender identity and other developmental
issues in psychotherapy; and b) to make passing easier if the adolescent
continues to pursue sex and gender change. In order to provide puberty
delaying hormones to an adolescent, the following criteria must be met: |
***
1.
Throughout childhood the adolescent has demonstrated an intense pattern
of cross-sex and cross-gender identity and
||||aversion
to expected gender role behaviors;
2. Sex and gender discomfort has significantly increased with the onset
of puberty;
3. The family consents and participates in the therapy. |
***
|
Biologic males should be treated with LHRH agonists (which stop LH secretion
and therefore testosterone secretion), or with progestins or antiandrogens
(which block testosterone secretion or neutralize testosterone action).
Biologic females should be treated with LHRH agonists or with sufficient
progestins (which stop the production of estrogens and progesterone) to
stop menstruation. |
***
Partially
Reversible Interventions -
***
Adolescents may be eligible to
begin masculinizing or feminizing hormone therapy, as early as age 16,
preferably with parental consent. In many countries 16-year olds are legal
adults for medical decision making, and do not require parental consent.
***
Mental health professional involvement
is an eligibility requirement for triadic therapy during adolescence. For
the implementation of the real-life experience or hormone therapy, the
mental health professional should be involved with the patient and family
for a minimum of six months. While the number of sessions during this six-month
period rests upon the clinician's judgment, the intent is that hormones
and the real-life experience be thoughtfully and recurrently considered
over time. In those patients who have already begun the real-life experience
prior to being seen, the professional should work closely with them and
their families with the thoughtful recurrent consideration of what is happening
over time. |
***
Irreversible
Interventions -
***
Any surgical intervention should
not be carried out prior to adulthood, or prior to a real-life experience
of at least two years in the gender role of the sex with which the adolescent
identifies. The threshold of 18 should be seen as an eligibility criterion
and not an indication in itself for active intervention. |
***
| VI.
Psychotherapy with Adults |
***
A
Basic Observation -
***
Many adults with gender identity
disorder find comfortable, effective ways of living that do not involve
all the components of the triadic treatment sequence. While some individuals
manage to do this on their own, psychotherapy can be very helpful in bringing
about the discovery and maturational processes that enable self-comfort. |
***
Psychotherapy
is Not an Absolute Requirement for Triadic Therapy -
***
Not every adult gender patient
requires psychotherapy in order to proceed with hormone therapy, the real-life
experience, hormones, or surgery. Individual programs vary to the extent
that they perceive a need for psychotherapy. When the mental health professional's
initial assessment leads to a recommendation for psychotherapy, the clinician
should specify the goals of treatment, and estimate its frequency and duration.
There is no required minimum number of psychotherapy sessions prior to
hormone therapy, the real-life experience, or surgery, for three reasons: |
***
1.
Patients differ widely in their abilities to attain similar goals in a
specified time;
2. A minimum number of sessions tends to be construed as a hurdle, which
discourages the genuine opportunity for
||||personal
growth;
3. The mental health professional can be an important support to the patient
throughout all phases of gender transition. |
***
Individual programs may set eligibility criteria to some minimum number
of sessions or months of psychotherapy.
***
The mental health professional
who conducts the initial evaluation need not be the psychotherapist. If
members of a gender team do not do psychotherapy, the psychotherapist should
be informed that a letter describing the patient's therapy might be requested
so the patient can proceed with the next phase of treatment. |
***
Goals
of Psychotherapy -
***
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.
Even when these initial goals are attained, mental health professionals
should discuss the likelihood that no educational, psychotherapeutic, medical,
or surgical therapy can permanently eradicate all vestiges of the person's
original sex assignment and previous gendered experience. |
***
Processes
of Psychotherapy -
***
Psychotherapy is a series of
interactive communications between a therapist who is knowledgeable about
how people suffer emotionally and how this may be alleviated, and a patient
who is experiencing distress. Typically, psychotherapy consists of regularly
held 50 minute sessions. The psychotherapy sessions initiate a developmental
process. They enable the patient's history to be appreciated current dilemmas
to be understood, and unrealistic ideas and maladaptive behaviors to be
identified. Psychotherapy is not intended to cure the gender identity disorder.
Its usual goal is a long-term stable life style with realistic chances
for success in relationships, education, work, and gender identity expression.
Gender distress often intensifies relationship, work, and educational dilemmas.
***
The therapist should make clear
that it is the patient's right to choose among many options. The patient
can experiment over time with alternative approaches. Ideally, psychotherapy
is a collaborative effort. The therapist must be certain that the patient
understands the concepts of eligibility and readiness, because the therapist
and patient must cooperate in defining the patient's problems, and in assessing
progress in dealing with them. Collaboration can prevent a stalemate between
a therapist who seems needlessly withholding of a recommendation, and a
patient who seems too profoundly distrusting to freely share thoughts,
feelings, events, and relationships.
***
Patients may benefit from psychotherapy
at every stage of gender evolution. This includes the post-surgical period,
when the anatomic obstacles to gender comfort have been removed, but the
person may continue to feel a lack of genuine comfort and skill in living
in the new gender role. |
***
Options
for Gender Adaptation -
***
The activities and processes
that are listed below have, in various combinations, helped people to find
more personal comfort. These adaptations may evolve spontaneously and during
psychotherapy. Finding new gender adaptations does not mean that the person
may not in the future elect to pursue hormone therapy, the real-life experience,
or genital surgery. |
***
***
***
1.
Cross-dressing: unobtrusively with undergarments; unisexually; or in a
feminine fashion;
2. Changing the body through: hair removal through electrolysis or body
waxing; minor plastic
||||cosmetic
surgical procedures;
3. Increasing grooming, wardrobe, and vocal expression skills. |
***
***
1.
Cross-dressing: unobtrusively with undergarments, unisexually, or in a
masculine fashion;
2. Changing the body through breast binding, weight lifting, applying theatrical
facial hair;
3. Padding underpants or wearing a penile prosthesis. |
***
***
1.
Learning about transgender phenomena from: support groups and gender networks,
||||communication
with peers via the Internet, studying these Standards of Care, relevant
lay
||||and professional
literatures about legal rights pertaining to work, relationships, and public
||||cross-dressing;
2. Involvement in recreational activities of the desired gender;
3. Episodic cross-gender living. |
***
***
1.
Acceptance of personal homosexual or bisexual fantasies and behaviors (orientation)
as distinct from
||||gender identity
and gender role aspirations;
2. Acceptance of the need to maintain a job, provide for the emotional
needs of children, honor a spousal
||||commitment,
or not to distress a family member as currently having a higher priority
than the personal
||||wish for
constant cross-gender expression;
3. Integration of male and female gender awareness into daily living;
4. Identification of the triggers for increased cross-gender yearnings
and effectively attending to them; for
||||instance,
developing better self-protective, self-assertive, and vocational skills
to advance at work and
||||resolve interpersonal
struggles to strengthen key relationships. |
***
|
|
|
Notes
On The Standards Of Care
***
The
Standards of Care are provided on this site for informational purposes
only -
***
The Standards of Care are intended
for use as guidelines, designed to promote the health and welfare of persons
with gender identity disorders, and exist for the protection of both the
patient and the theraputic provider of such treatment. As such, they are
not cast in stone but rather open to interpretation on a case by case basis
between the patient and the treatment professional involved, both should
be aware of these guidelines and the treatment standards they are designed
to maintain. |
***
| The
Standards of Care are created and maintained by - |
***
The
Harry Benjamin International Gender Dysphoria Association, Inc. (HBIGDA)
1300 South Second Street, Suite 180
Minneapolis, MN 55454 USA
(612) 625-1500
http://www.hbigda.org/ |
***
These
standards are updated and revised as new scientific information becomes
available -
***
The current edition of the Standards
of Care presented here was released in 2001, and is the sixth version since
the original 1979 document. Previous revisions were in 1980, 1981, 1990,
and 1998. See archives
for versions previously presented on this site. |
***
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Contributions
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