The Ten Tasks of the Mental Health Provider

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The Ten Tasks of the Mental Health Provider: Recommendations for Revision of the World Professional Association for Transgender Health's Standards of Care Arlene Istar Lev a a Choices Counseling and Consulting, Albany, NY

Online Publication Date: 01 April 2009

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The Ten Tasks of the Mental Health Provider: Recommendations for Revision of the World Professional Association for Transgender Health’s Standards of Care

Arlene Istar Lev

ABSTRACT. This article outlines recommendations for the World Professional Association for Trans- gender Health’s (WPATH) Standards of Care (SOC) regarding the roles, responsibilities, and tasks of the mental health provider in assessing eligibility and readiness for medical and surgical treatment of gender nonconforming, transgender, and transsexual clients. It reflects a reconceptualization of the role of the mental health provider as a gender specialist and an advocate and educator for transgender people and their families utilizing a nonpathologizing assessment process. This article reflects a need for clinical SOC that minimize the role of “gatekeeping,” and increase the use of informed consent and harm-reduction procedures, while still providing guidelines for psychosocial evaluation. Recommendations are made for less pathologizing nomenclature, clearer definitions for the professional qualifications of those specializing in working with gender-variant people, and increased collaboration across disciplines. Suggestions are made for the SOC to recognize greater diversity in gender expression and identity, increased focus on the families and occupational environments of transgender people, and a broader view of gender issues throughout the lifecycle. Guidelines for psychosocial assessment and referral letters to physicians are outlined, including proposals to revisit the professional qualifications of letter writers and the need for two letters for surgical assessment. It is suggested that WPATH take leadership in the training and credentialing of gender specialists. These recommendations require a reorganization of the format of the SOC that will create a state-of-the-art standard of health care for transgender, transsexual, and gender nonconforming people and ensure the provision of high-quality clinical services for those individuals and their families. Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 KEYWORDS. Standards of care, transgender, transsexual, gender dysphoria, mental health

Standards of care (SOC) are the essential evidence-based, and effective treatment across clinical foundations for providing consistent, all disciplines and ﬁelds of medicine (Agency

Arlene Istar Lev, LCSW, CASAC, is a social worker and family therapist. She is the founder of Choices Counseling and Consulting (www.choicesconsulting.com) in Albany, New York,and is on the adjunct faculties of the State University of New York at Albany, School of Social Welfare, and of Empire College. She is on the editorial boards of the Journal of Lesbian Studies,theJournal of GLBTQ Family Studies, and the International Journal of Transgenderism. I want to thank my colleagues, including Kit Rachlin, D. Yonkin, Samuel Lurie, Helen Boyd, Jamison Green, Randall Ehrbar, and Reid Vanderburgh, whose ideas have helped to inﬂuence the development of this paper, although I am, of course, responsible for the ﬁnal manuscript. I also want to thank Allie Scheer, MSW, for all her help and support, enabling me to meet an impossible deadline. Address correspondence to Arlene Istar Lev, Choices Counseling and Consulting, 321 Washington Ave., Albany, NY 12206. E-mail: [email protected]

74 Arlene Istar Lev 75

for Healthcare Research and Quality, 2007; Kin- 1999; Wilchins, 1997). In many ways, the nu- ney, 2001). Trans-medicine is a rapidly evolving cleus of this tension rests on the clinical rela- field and the development of the highest stan- tionship between the person seeking medical and dard for medical and psychological treatment clinical treatment and the mental health profes- requires continuous modification and synthesis sional who serves as the initial contact and gate- of emerging knowledge. keeper to the medical community. Therefore, the The World Professional Association for first task for any mental health professional, es- Transgender Health (WPATH) has been a leader pecially those who view themselves as advocates in the development of Standards of Care for for the civil rights of transgender people, must be treating gender-variant people and reflects to acknowledge the challenges and implications the expanding knowledge of gender identity inherent in being a professional gatekeeper. development and gender dysphorias within the medical and clinical professions. WPATH attempts to provide an overarching standard of MENTAL HEALTH PROFESSIONALS care that is international in focus, incorporating AS GATEKEEPERS the needs of providers and consumers of services from vastly different countries, cultures, and The section of the SOC that will be examined backgrounds, with varying access to economic for revision in this article clarifies the responsi- resources. Originating within the scientific and bilities and expectations of mental health profes- medical community, the current revisions will sionals (MHPs) (Section IV). This is a complex attempt to incorporate the feedback and critique section precisely because the MHP’s role in pro- of the nascent, burgeoning, and organized trans- viding services for gender-variant people, as it gender civil rights movement that has challenged has been formulated and outlined in the SOC the medical model of treatment, specifically the has been much maligned, particularly by advo- role of gatekeeping as it has historically been cates for the civil rights of transgender people provided by mental health providers. This is part who view MPHs as gatekeepers who can selec- of an emerging dialogue between trans-activists tively block services for those seeking medical and professionals specializing in the needs of treatment. For physicians, MHPs are the source gender-variant clients (see Bockting, Knudson, of their referrals, essentially lower-status pro- & Goldberg, 2007; Lev, 2004; Rachlin, 1999) fessionals who are often viewed as adjunctive including the work of those who are both pro- to the medical services, which are often seen as fessionals and are themselves trans-identified the “real” treatments. The revision of this SOC Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 (Denny, 1992; Ehrbar, Witty, Ehrbar, & Bock- must be more than a modification of words with ting, 2008, Hale, 2007; Israel & Tarver, 1997; adaptations for new evidence-based research and Raj, 2002; Vanderburgh, 2007; Vitale, 1997). must reflect a reconceptualization of the role of These authors represent a diversity of viewpoints the MHP in the provision of services for people on many different topics, and the last revision of seeking treatment for gender dysphoria. the SOC included transgender professional rep- Perhaps the first questions to address are: Why resentation for the first time (Meyer, et al., 2001). do people desiring gender-related medical and WPATH stands at the crossroads where med- surgical treatments need to see a MHP first? Why ical hegemony meets a sociopolitical process of can’t they simply request treatment directly from identity and community development (Denny, a physician, much as one would go to dentist for 2004, Green, 2004, Lev, 2006; Whittle, 1998). a toothache? What purpose does a MHP serve in The SOC have been a major focal point of trans- the provision of trans-health services? These are gender community activism, a target of inci- salient questions, and since MHP’s are viewed sive criticism, specifically regarding the rights by some as sentinels at the gate of medical of gender-variant people to actualize themselves treatments, situated between the physician and without psychological scrutiny and consequent those requesting body-modification treatment, it “approval” to receive necessary medical treat- is necessary for the SOC committee to respond ments (Burns, 2004; Hale, 2007; MacDonald, to the accusation that psychosocial evaluation 76 INTERNATIONAL JOURNAL OF TRANSGENDERISM

and letters of approval are unnecessary, includ- Professionals who do not view gender- ing the insistence from some that hormones be variance as a mental disorder recognize, of available “on demand” of the clients (Pollack, course, that gender nonconforming experience 1997; Stryker, 1993). can be distressing (Lev, 2005; Winters, 2005) So what exactly are the sentinels guarding? and that those suffering with gender dissonance Who gets to pass through the gate and who should have access to quality mental health ser- does not? These questions are reminiscent of a vices. Referral for medical services should not scene in the Wizard of Oz, when Dorothy and her rely solely on meeting the criteria for a patholog- friends first reach the Emerald City. After a long ical diagnosis, although utilizing the DSM can and perilous journey, they are met at the door by remain one of many tools available to the MHP a gatekeeper, who, after they ring the doorbell, in a broader biopsychosocial evaluation and as- tells them to read a notice that is not there. When sessment process. the notice is then abruptly placed on the door it Diagnosis is particularly complex regarding says “Bell out of Order. Please Knock.” For the gender identity issues because they are mostly client seeking therapeutic help, the gatekeeper’s self-assessed, that is, clients seek out services rules of entry often appear equally cryptic and based on the symptoms they are experiencing confusing. Dorothy was able to enter because she and labeling. Richard Docter (1988) has said wore ruby slippers; even if those seeking treat- transsexual surgery is, “the only major surgical ment are lucky enough to own their own ruby procedure carried out in response to the unremit- slippers, few are granted such immediate ac- ting demands of the patient” (p. 25). This makes cess. Instead, many clients are scrutinized at the it very difficult for clinicians to “accurately diag- doorstep through a process of clinical inquiry, nose the individual’s gender disorder”—as out- complete with historical examination and hypo- lined in the first task of the MHP—and therefore thetical questions to determine their proper diag- the language of the SOC should acknowledge nosis (Speer, 2006). The MHPs primary respon- the lack of precision in making gender identity sibility is to make sure that the client does have diagnoses and the need to rely on information a bona fide gender identity disorder (GID) as it presented by the client (Riley, personal commu- is outlined in the DSM-IV-TR (APA, 2000) and nication, June 4, 2007). does not have some other disorder that may re- Setting aside the issue of whether distur- semble a gender identity issue. These are the first bances of gender identity are diagnosable mental two tasks of the MHP listed in the current SOC. illness does not allow us to set aside as eas- The problem, however, is that the DSM cri- ily the issue of other mental illnesses. Most Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 teria and the SOC, as they are presently writ- gender-variant people do not have mental ill- ten, rely on a limited, bipolar view of gender nesses; however, transgender and transsexual identity. A greater range of transgender expres- people are not immune from having mental dis- sions are recognized in the contemporary world orders (Lev, 2004). It would be irresponsible of trans-health than are reflected in current DSM medically and clinically to not assess for comor- diagnostic criteria (Carroll, 1999; Fraser, 2009/ bid mental health problems when recommending this issue; Raj, 2002; Devor, 2004; Vanderburgh, someone for medical treatments that will initi- 2007). In the absence of evidence-based criteria ate extreme body modification. Some people re- for the inclusion of GID in the DSM, gender questing medical services for gender issues have identity diagnoses often appear tautological— undiagnosed or untreated mental illnesses and He has GID because he wants to be a woman; previous unresolved traumas, (Bockting, Knud- he wants to be a woman because he has GID son, & Goldberg, 2007; Hartmann, Becker, & (Pilgrim, 2005). There currently is extensive Rueffer-Hesse, 1997). There is evidence that professional disagreement and discussion about those people who regret having had sex reas- whether GID should remain in the DSM (see signment procedures may suffer from more per- Bockting, 2009 ; Karasic & Drescher, 2006) and sonality disorders and other emotional instabili- surely the outcome of that discussion impacts its ties (Bodlund & Kullgren, 1996). There are also inclusion and utility in the revised SOC. people who confuse issues of sexual orientation Arlene Istar Lev 77

and gender identity, as well as many people who sent: the client must understand the information are uneducated or misinformed about the goals, presented, the consent must be given voluntarily, outcomes, or expectations of gender reassign- and the client must be competent to give consent. ment processes. Some clients, struggling with Gender-confirmation procedures are unique in long-term gender identity concerns, may have that clients are generally seeking surgical treat- concurrent substance-abuse problems or marital ments, so issues of consent are rarely the issue. problems, whose life circumstances would be The concerns in evaluating competence are more made far more complicated by beginning medi- often regarding the client’s ability to understand cal treatment without first addressing these other the information presented and whether they are psychosocial issues (Lev, 2004). People with un- competent to give consent. Hale (2007) iden- resolved mental health issues and psychosocial tifies the ethical concerns of inhibiting clinical instabilities are, in essence, not good candidates autonomy for those capable of informed consent for medical and surgical treatment at the time (i.e., “legally competent adults”). It is easy to they are seeking referral; they are neither eligi- understand how it can feel patronizing to many ble nor ready for medical treatments without first educated and informed people, who are not suf- addressing these other concerns. fering from mental illnesses or addiction and Medical and surgical treatments are perma- who have stable families and careers, to have to nently life altering, and in the absence of objec- undergo a routine and often invasive psychoso- tive or laboratory testing, physicians are justifi- cial assessment. However, a clinical assessment ably concerned that a person requesting services can also serve to confirm the client’s competence may not fully comprehend the treatments and in giving their consent and their ability to under- later regret them. The first rule of medicine is stand the information presented. Additionally, to “do no harm,” and, clearly, altering, hormon- the process of determining informed consent ally or surgically, the body of a person who may can assist in “promoting client autonomy and be suffering from a mental disorder, may not self-determination, minimizing the risk of ex- be capable of understanding the consequences ploitation and harm, fostering rational decision- of his or her actions and may ultimately come making, and enhancing the therapeutic alliance” to regret the decision would constitute “harm.” (Snyder & Barnett, 2006, p. 37). This process can Decision-making regarding harm in the area of be empowering and informative for the client, al- trans-medicine is particularly value-laden, since though certainly the fear of not being approved the need for body modification for transsexu- for the treatment one is desperately seeking can als has been poorly understood and culturally be emotionally challenging. Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 maligned. Indeed, resistance to and pathologiza- Given the historic control that medical tion of gender-confirmation procedures has of- and therapeutic establishment has had over ten been initiated by the medical and therapeutic transgender actualization (Denny, 1992), it has communities (Meyer & Reter, 1979). If clini- been assumed that most people would not be cians assume that gender dysphoria is a mental approved for transsexual medical treatments, illness, or that it is caused by a mental illness, due to the strict definitions for approval; hence they may infer that harm would result from med- the fury over the gatekeeper’s power. However, ical or surgical treatments. MHPs are placed in as transgenderism becomes better understood a very powerful position—gatekeeping access culturally, and more providers view gender to treatment—ostensibly to protect clients, al- nonconformity through a nonpathologizing though the MHPs may be potentially causing lens, it can be assumed that most people would more harm from withholding treatments then be found to be mentally competent of informed they would by providing a referral for reassign- decision-making. The assessment process ment would allow those with complex psychosocial The focal point of the dilemma is whether issues to be more easily identified, and therefore transgender people have the right to actualize to receive the treatments they need, including their bodies and are capable of the process of gender-related treatments, when they were eli- informed consent. According to Gross (2001) gible and ready. Disallowing access to medical three criteria are necessary for informed con- treatments that permanently alter the body, for 78 INTERNATIONAL JOURNAL OF TRANSGENDERISM

those unable to give informed consent, may feel ning treatment (Burns & Covington, 2000), in- harsh or even cruel; it may appear paternalistic. cluding those who are donating eggs to assist Indeed, it raises valid ethical issues. However, it others in having children (Lindheim, Frumovitz, is also within the logical, respectable, and legal &, Sauer, 1998). It is interesting to note, repro- limits for physicians to refuse serious and life- ductive endocrinology is also a field involving altering medical treatment for a patient without hormone therapies and potential surgical pro- a physical disorder or disease and who exhibits cedures, as well as an emotionally challenging serious mental health problems or cognitive journey. difficulties that might impact his or her ability Psychosocial evaluations are also sought for to understand the treatment or consent to it. The bariatric, or weight-loss, surgeries (Pratt, Cum- inability to give consent may not be a permanent mings, Vineberg, Graeme-Cook, & Kaplan, state; many people can become informed and 2004), and preabortion counseling (Breitbart, develop competence over time—a process with 2000). This last area is especially salient for which the MHP can assist the client. the discussion of gender dysphoria since crit- So if physicians can ultimately decide icism has been levied regarding “mandatory” whether or not to treat clients, why are they counseling for women seeking abortions that not the gatekeepers, which is what Hale (2007) is reminiscent of the criticism of the SOC re- recommends? Why the need for a MHP to assess quirement for mandatory psychological evalua- the client before they even meet the medical tions. Preabortion counseling has often meant expert? Simply put, most physicians generally counseling women away from having abor- do not have the skills or time to provide tions, rather than developing supportive, non- psychosocial assessment for gender identity judgmental, advocacy-based practices that em- concerns. Endocrinologists and surgeons have power women to make choices and understand generally not had the training necessary to their medical options (Ely, 2007). provide mental health assessment (including Along a similar vein, the psychological- substance abuse and familial components) or assessment process as outlined in the SOC has therapeutic evaluations for gender dysphoria. often served to block treatment for transgender To discern mental competence regarding gender people. Utilizing “options-counseling,” and “de- identity issues can be a time-consuming process cision support” techniques borrowed from coun- requiring substantial training in diverse issues seling women contemplating abortion (Balde,´ of mental health assessment. Certainly, if Legar´ e,´ & Labrecque, 2006) or men consider- physicians do have the training and time to ing vasectomy (Singer, 2004), the SOC can em- Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 complete their own assessments, there is no ploy assessment processes that empower clients reason why they should not provide that service in decision-making. These techniques focus on (Dahl, Felman, Goldberg, & Jaberi 2006). nonjudgmental support, education, and nondi- The SOC have been criticized because peo- rective advocacy, rather than leading the client ple seeking treatment for gender identity is- towards a particular solution or guiding the clin- sues are required to undergo evaluative processes ician through diagnostic criteria. This is simi- that clients in other settings seeking similar ser- lar to the psychosocial-evaluation process that vices (i.e., hormones, plastic surgery) do not prospective adoptive parents complete (Crea, have to submit (Denny, Green, & Cole, 2007; Barth, & Chintapalli, 2007). Hale, 2007). However, gender issues are not the Realistically not everyone is suited for sex only area of medical treatments where physi- reassignment procedures, which are considered cians employ the use of skilled MHPs to as- irreversible. A thorough evaluation can assist sess clients undergoing emotionally difficult and those who are ambivalent, confused, or mis- voluntary medical treatments. (The use of the informed in avoiding medical procedures that word voluntary here should not be construed they might later regret having undergone. Al- to imply “cosmetic.”) It is standard practice for though research has shown that post-surgical physicians treating clients for infertility to re- regrets are rare (Lawrence, 2001; Pfafflin¨ quire a psychosocial assessment before begin- & Junge, 1998), numerous researchers have Arlene Istar Lev 79

documented a small but consistent presence of and interferes with the MHPs ability to assess regrets in some transsexuals (Blanchard, Steiner, for comorbid mental health issues, let alone de- Clemmensen, & Dickey, 1989; Landen, Walin- termine whether or not the client has a “bona der, Hambert, & Lundstrom, 1998). It is worth fide” gender identity issue. It also maintains the noting that the incidence of regrets might be low fallacy that gender-variance has limited expres- precisely because the system has been so rigid; sions, reinforcing a rigid, diagnostic perspective. a less rigid system might result in an increase As Butler (2004) has pointed out, those seeking in medical treatments that show a higher per- medical treatments often subscribe to patholog- centage of regrets. As transgender treatments be- ical diagnoses for the sole purpose of receiving come increasingly obtainable due to more acces- referral for treatment. sible information, some post-operative people The current SOC states, “The establishment are expressing regrets (Olsson & Moller, 2006). of a reliable trusting relationship with the pa- Some people have taken their regrets to the ju- tient is the first step toward successful work as dicial system; in particular they are questioning a mental health professional. This is usually ac- whether they received adequate assessment be- complished by competent nonjudgmental explo- fore being referred for medical treatments (Pa- ration of the gender issue with the patient during padakis, 2003). the initial diagnostic evaluation” (Meyer et al., In one noteworthy situation a clinician, Dr. 2001). As they currently exist, the SOC and the Russell Reid in the United Kingdom, was ac- evaluative process interfere with the ability of cused by fellow colleagues of not providing MHPs to create a nonjudgmental therapeutic en- thorough evaluation before referring clients for vironment and an authentic helping relationship. medical treatment. The legal determination was As Speer (2006) says, “the interaction reflects, based on Dr. Reid’s lack of adherence to the constitutes and reconstitutes ...acertainkindof guidelines set forth in the SOC (Batty, 2007). institution or social structure” (p. 806), literally The SOC committee would be foolish to not take recreating itself over and over again, since the es- these litigious situations extremely seriously. tablished transsexual narrative remains the only On one hand, trans-activists say the system is story to be told, and each repetitive story-telling too rigid, keeping those out who should be in; reinforces it as the only narrative. The very struc- on the other hand, the judicial system harshly ture itself interferes with the ability to develop judges those who do not take their gatekeep- authentic therapeutic relationships and creates ing duties seriously enough. Additionally, in a an “adversarial encounter” between client and consumer-driven market, transsexual treatment therapist (Newman, 2000, p. 399). The discus- Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 is a commodity and gender dysphoric clients sion that follows below is an attempt to recognize desiring treatment are vulnerable to physicians this conundrum and honestly and respectfully without adequate training who might bypass any addresses it. assessment process. Schaefer, Wheeler, and Futterweit (1995) say So, the MHP is thrust into a complex situation, that “[t]he knowledgeable and empathic psy- guarding the gate for the protection of a client chotherapist should become a partner in the ther- who may resent being protected. Clients seeking apeutic alliance” (p. 2032). In order for this to medical services are compelled to pass through happen, the conceptualization of the gatekeeper the gate as quickly as they can (or to bypass the role needs to be expanded. The term gatekeeper gate altogether) and will go to extreme means to was first used by the brilliant social psychologist do so. It has been documented that clients are and systems thinker Kurt Lewin (1947) to de- well aware of what to say in order to receive the scribe the way mothers decide which foods end treatments they require and that they often lie to up on the family’s dinner table. Note the issue is the MHP, telling a predetermined story that they not simply what foods do not endupthetable,but hope will provide the referral letter they desire what is actually shopped for, cooked, presented (Denny & Roberts, 1997; Lewins, 1995; Stone, to, and imbibed by the family. A gatekeeper, in 1991; Walworth, 1997). This rote repetition be- addition to being someone who keeps out those comes the transsexual narrative (Prosser, 1998) who are not appropriate for treatment, must also 80 INTERNATIONAL JOURNAL OF TRANSGENDERISM

be someone who advocates for and supports pro- the family and the clients’ understanding cesses and procedures that efﬁciently move peo- of the potential consequences. ple through the health system so they receive the treatments they need. Like triage (“sorting”) in The educated and informed transgender or emergency medicine, many people seeking med- transsexual client who is not suffering from men- ical treatments for their gender dysphoria need tal illness or addiction, and is relatively stable to simply be evaluated and referred on to the next socially and vocationally, and who has the sup- level of care. port of loved ones, should be able to undergo People seeking services for gender-related is- a psychosocial assessment and referral process sues fall into three broad categories: clients who within a few sessions, typically between two and are struggling with gender-dysphoric feelings; six hour-long appointments. Anderson (1997) clients who are expressing gender variance and recommends that evaluations be conducted by seeking letters of referral for medical treatment; a different clinician than the one who is provid- and clients who present with family-related is- ing ongoing psychotherapy, which might help sues” (Lev, 2004). These three categories of peo- alleviate some of the tension between client and ple need and deserve different levels of treat- therapist; this is a workable system as long as ment, and the SOC can provide distinct guide- there remains communication between the clin- lines to ensure that people receive individualized icians. assessment and treatment. Although clients can, of course, always still rely on deceitful “transsexual narratives” to re- 1. Clients seeking medical and surgical treat- place their actual experiences, there is little that ments for unremitting gender dysphoria will necessarily surface in more sessions to en- who are ready, eligible, and mentally stable sure veracity on the part of the client. If the clini- should receive prompt and attentive eval- cian is seen as supportive and without an agenda uation and referral with the goal of allevi- then the client is far more likely to be receptive to ating their dysphoria and providing them the clinical process. From a therapeutic perspec- with medical services as quickly as is rea- tive the tension itself can be fodder for in-depth sonably possible. exploration. The dialectic between wanting to 2. Clients struggling with gender dysphoria move forward with transition and the fear associ- who are confused, ambivalent, mentally ated with doing so exists in various ways within ill, addicted, or intellectually or cognitively many clients seeking treatment. When clients impaired, should be very carefully evalu- trust their therapist, their internal dialogue can Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 ated before they are referred for medical become externalized; the therapist can “hold” treatments that they may be unable to con- both perspectives, transition AND caution, thus sent to or fully understand and therefore allowing the client to move forward hesitantly may come to regret. These clients must be and then retreat while they explore possible fu- offered supportive ongoing therapeutic as- tures. Indeed, when clients see the gatekeeper as sistance, with clearly stated guidelines of a welcoming door “man,” a greeter if you will— how treatment will impact a referral for someone who opens the door to welcome those medical treatments. seeking entrance —they are more likely to reveal 3. Clients who have family responsibilities themselves, and be open to advice, suggestions, and loyalties that are unresolved and prob- and discerning feedback, as well as share their lematic and interfere with their capacity fears and resistances and engage in a thoughtful for decision-making must be offered ap- dialogic process, which is the essence of all good propriate referral and/or treatment for fam- therapy. ily therapy and legal advice about how Nonetheless, the criticism that trans-activists their medical decisions can impact child have voiced about the SOC being tedious, expen- custody, employment, and other life cycle– sive, and creating strained relationships between related issues. Medical treatments must be clinician and client have much validity. Hale weighed carefully with the larger needs of (2007) suggests that the mental health evaluation Arlene Istar Lev 81

interferes with gender-variant people’s right to if medical treatments are recommended, they autonomous decision making, and that the eval- will likely require ongoing support and advo- uation essentially infantilizes them. The extant cacy to manage the social impact of any gender process is unnecessarily paternalistic. Clients confirmation procedures. who are eligible for treatments should undergo Additionally, some clients who struggle with an efficient assessment process and referral for persistent and chronic mental illness, trauma- treatments in a timely manner. (Of course, there related symptomatology, debilitating physical is little about any aspects of the current health illness (e.g., AIDS, cancer), and/or addictions, systems in general that is either “efficient” or may also struggle with homelessness, poverty, “timely,” but certainly much in trans-health care and other psychosocial problems and may not can be streamlined.) Gatekeepers must develop have the financial means to access medical treat- an open door policy that is welcoming, offer- ments. Furthermore, many clients purposely re- ing support, advocacy, education, referral, and ject or sidestep the standard treatment protocols guidance. for financial, cultural, or political reasons. Lack- However, many clients reaching out for ser- ing health insurance or knowledgeable providers vices are not educated and informed consumers, within geographical reach, many gender-variant ready to begin medical treatments. Some are people receive their hormones and medical treat- suffering from severe gender dysphoria and ments through alternative means (legally and are emotionally distraught and in tremendous illegally) on the streets or from the Internet psychological pain. They come into treatment (Grimaldi & Jacobs, 1998; Lombardi, 2001; seeking “diagnosis” and “help,” and often the Lombardi & van Servellan, 2000). gender issues are only a piece of their presenta- Despite not having been assessed using tion, albeit a key piece. These clients are in need established protocols, gender-variant people of ongoing therapeutic care. The SOC currently in these circumstances will likely continue focuses on the physician referral process and taking hormones. Providing a harm-reduction does not provide the MHP with substantial approach to medical treatment can reduce guidance in the treatment of complex clinical potential negative consequences and ensures cases in which gender identity disturbances are medically monitored hormonal treatments. paramount. Harm reduction can diminish hazardous prac- Some clients with gender issues also struggle tices (“pumping” silicone and needle sharing) with cognitive deficits, pervasive developmental by providing access to medical treatments. disorders (PDD) and/or chronic and persistent Community-based programs can serve as Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 mental illnesses (Lev, 2004; Hartmann, Becker, frontline support for many clients in offering & Rueffer-Hesse, 1997; Parkes, 2006; Robinow overall health services to people who experience & Knudson, 2005, as cited in Bockting, Knud- multiple barriers to treatment. Additionally, son, & Goldberg, 2007) that manifest in limita- opening the door for marginalized groups can tions that may interfere with the clients’ ability provide a “bridge” to general medicine helping to make informed decisions about their medi- them access all kinds of care and social supports cal treatment. This group of people need more (Feldman & Goldberg, 2007; Goldberg, 2007). than referrals or even good psychotherapy; they This is an opportunity for providers of care to do need to be protected from making decisions serve as advocates for those most truly in need. that they may not be able to handle, that will Surely, the majority of clients seeking med- negatively impact their quality of life. That is ical treatments are not mentally ill or cogni- the reason many adults in these situations live tively impaired; the majority of people seeking with parents, in group homes, or in supervised treatment are mentally stable and cognitively as- housing. They may indeed have gender dyspho- tute regarding their gender issues and treatment ria, but they may not have the cognitive abil- needs. Indeed, for some people their refusal to ity to fully understand the implications of the access standardized protocols derives from so- medical treatments. This population requires ex- phisticated philosophical, moral, and ethical cri- tensive evaluation and psychosocial support, and tiques of the SOC highlighting their intellectual 82 INTERNATIONAL JOURNAL OF TRANSGENDERISM

TABLE 1. Recommendations Regarding Gatekeeping, Diagnoses, and Harm Reduction

No. Recommendation

1. The section on the MHP should be introduced with a discussion about the role of “gatekeeping” that reframes the role of the Gender Specialist as someone who is, not merely a sentinel guarding the gate, but also a skilled professional who can advocate, mediate, broker, and support persons seeking medical treatments by providing timely assessments and efficiently moving people through the health system so they receive the treatments they need. 2. Remove the necessity to diagnose utilizing the DSM. It is possible to provide thorough and accurate psychosocial assessment for people seeking referral to physicians without utilizing the DSM or ICD. Referral for medical services should not rely on meeting the diagnostic criteria of GID but should rely on broader psychosocial evaluative procedures that can include utilizing diagnostic manuals as one of many tools and skills available to Gender Specialists. 3. Different levels of care are needed for those who are seeking medical treatments and those who are seeking psychological services. The distinctions between psychosocial evaluation and ongoing psychotherapy needs to be made clearer, providing ways for clients who are seeking referral to physicians and who are assessed as capable of informed consent to move through that process with relative ease. 4. The SOC currently focuses on the physician-referral process and does not provide the Gender Special- ist/psychotherapist with substantial guidance in the treatment of complex clinical cases in which gender identity disturbances are paramount. The section on psychotherapy needs to be expanded to discuss issues related to assessment, treatment, and comorbid mental health issues. 5. Harm-reduction approaches should be developed to assist marginalized populations in gaining access to trans-specific and general medical needs, regardless of whether they have been previously assessed using the SOC. 6. Standard medical practice for prescribing physicians or for those performing surgery should include a signed informed consent and waiver of responsibility. This protects the physician/surgeon, and deflects the boomerang of litigation from the referring MHP. This should be outlined in the section pertaining to the provision of medical and surgical treatment.

and cognitive competence. The SOC must The term patient is a word commonly used address the needs of diverse populations if they in the medical ﬁeld, whereas the term client (or are to be effective. sometimes consumer) is more commonly used All clients desiring medical treatments for by those providing psychosocial evaluation and gender-related issues should be required to sign psychotherapy. As identiﬁed above, the process legal documents, acknowledging their ability to of providing mental health evaluations is only understand the procedures requested and their partially based in standard medical model diag- irreversibility. It is simply good medical prac- noses and can also include other psychological

Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 tice to have patients sign informed consent and assessment tools and corroborative information waiver of responsibility paperwork (Albany Law from family. Therefore it is suggested that the Review, 2001; Karasic, 2000). language of the SOC in the section on MHPs use The revised SOC can expand the gatekeeper the word “assessment” to replace the word diag- role, from one that restrains referral processes nosis (except when referring to actual diagnostic to one that can more efficiently provide refer- processes), and the word “client” to replace the ral and advocacy for those who are eligible and word patient. The word “patient” can certainly ready for medical services (see Table 1 for rec- continue to be used in the sections on medical ommendations). It is essential that WPATH ad- and surgical treatments. It is also suggested that dress the concerns of trans-activists for a more the term “management of GID” be removed. If efficient, respectful, and less-expensive process, trans-medicine is to be based on a collaborative and this can be accomplished without compro- client-centered approach, clinicians should not mising the need for a more thorough assessment have to “manage” their clients. and/or treatment for those who may need it. The SOC states that “professional involvement with patients with gender identity disor- LANGUAGE CONCERNS ders involves any of the following: diagnostic assessment, psychotherapy, real-life experience, This section outlines some suggestions for hormone therapy, and surgical therapy” (p. 8), language changes in the SOC. which is clearly a five-part process. It is unclear Arlene Istar Lev 83

how this five-part process becomes reduced to a and competence in the assessment of the DSM- three part “triadic” process, but the net result is IV/ICD-10 Sexual Disorders” (p. 12) sounds like excluding two of the three tasks that MHPs are one needs to be trained and competent in assess- expected to perform: diagnostic assessment and ing the DSM and ICD manuals themselves, a psychotherapy. lofty goal for sure, but outside of the scope of Triadic therapy, which is defined in the SOC the SOC. The SOC committee needs to clarify as “a real-life experience in the desired role, the language used throughout the document and hormones of the desired gender, and surgery ensure that there are quality clinical editors re- to change the genitalia and other sex charac- viewing the document before publication (see teristics” (p. 8) are all treatments that follow the Table 2 for recommendations). psychosocial evaluation completed by the MHP. The term “gender identity disorders” must be Eligibility and readiness under the current SOC examined, especially in light of the new name differs for hormones, chest or breast surgery, for WPATH and the controversies referred to and genital surgeries (see Bockting, Knudson, previously regarding the validity of GID as a & Goldberg, 2007), and all are dependent on the useful diagnostic category. Except when refer- real-life experience (RLE). Although the moni- ring directly to the DSM diagnostic criteria, the toring of the RLE is not listed in the Ten Tasks term “gender identity disorder” should be re- of the MHP, it is later stated that the MHP placed with “gender dysphoria” when referring is expected to supervise this process (p. 13, to the emotional or psychological pain caused p. 25). by gender dissonance; the terms “gender issues” The theory of triadic therapy that holds the and “gender concerns” could also be used to RLE as one of its focal points assumes that describe clients’ presenting problems. The con- complete transsexual transition is the founda- temporary language of “gender-variant,” “gen- tion of transgender medicine, ignoring the spec- der nonconforming,” “transgender,” and “trans- trum of gender expressions currently available. gender health” should be used when referring to There are numerous questions about the useful- more general issues of gender expression. The ness of the RLE—both Levine (in press) and term “transsexual” should be used when specif- Lawrence (2001) have identified potential prob- ically addressing people seeking full and com- lems with the RLE as a determination of eligibil- plete gender transitions. This would reflect the ity, readiness, and/or future success in the gender profession’s movement away from pathologiz- of choice—especially since there appears to be ing terminology. no evidence to show its efficacy. Some people Lastly, and foreshadowing the next section, Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 struggling with gender dysphoria seek the as- the term “mental health professional” is a com- sistance of helping professionals yet do not en- plex and cumbersome title, which is vague and gage in any part of the triadic therapy, and others not easily operationalized. The term does not choose medical treatments but do not desire to identify the specific and specialized tasks that the live full-time. The language “triadic therapy” ig- SOC address. It might be beneficial to develop a nores major aspects of the MHP role in gender specific designation for the unique role clinicians therapy, creating and reinforcing a view that the play in treating those with gender identity con- MHP is adjunctive to the medical procedures, cerns. Israel and Tarver (1997) have suggested which are the “real” treatments. The role of the the use of the word “gender specialist,” a word MHP in the RLE is unclear regarding the one as- conveying the unique identity and skills for those pect of the triadic therapy that they are expected of us who specialize in working with gender- to provide. variant clients. It is suggested the words “men- The language usage in the SOC is confusing tal health professional,” “clinical behavioral in parts, which is perhaps simply the result of scientist,” and “psychotherapist” be replaced having a large committee write the document with the term “gender specialist” and this term collectively. For example, “specialized training must be clearly defined in the revised SOC. 84 INTERNATIONAL JOURNAL OF TRANSGENDERISM

TABLE 2. Recommendations Regarding the Speciﬁcity of Language

No. Recommendation 7. The term “patient” should be replaced with the word “client” in the section(s) pertaining to the work of mental health professionals and psychotherapists. (Physicians can, of course, retain the word “patient” in the sections on medical and surgical treatments). The term “management of gender identity disorders” should be discontinued. 8. The term “diagnose” should be replaced with the term “assess,” allowing clinicians to utilize the DSM and ICD if they find diagnostic manuals useful, but also fostering a more inclusive psychosocial assessment process, utilizing other psychological evaluative tools and family corroboration. 9. The current use of the term “triadic therapy” should be discontinued since so many clients do not actually utilize all (or any) of these three elements, rendering the term obsolete. Additionally, “triadic process,” excludes two of the three tasks that MHPs are expected to perform: diagnostic assessment and psychotherapy. If the term triadic therapy is maintained, one aspect of the triad should include “clinical assessment and ongoing therapeutic support” (in addition to hormones and surgery). 10. The term “real-life experience” (the third element that the MHP should be addressing) should be removed from the SOC as an outdated term that does not acknowledge the diversity of solutions people find to resolve their gender dysphoria, or the variable time-frames available for “full-time” living. Alternative ways of determining eligibility and readiness should be explored. 11. The words, “specialized training and competence in the assessment of the DSM-IV/ICD-10 Sexual Disorders (not simply gender identity disorders),” should be replaced with “competent in utilizing the DSM and ICD for diagnostic purposes.” The current language infers that the DSM is being assessed, not the client. 12. The term “gender identity disorders” should be avoided, except when referring directly to the DSM diagnostic criteria, and replaced by the words “gender dysphoria,” “gender issues,” or “gender concerns,” when that is accurate. The contemporary language of “gender-variant,” “gender nonconforming,” “transgender,” “transsexual,” and “transgender health” should be adopted which would reflect the profession’s movement away from pathologizing terminology. 13. It is suggested that the words “mental health professional,” “clinical behavioral scientist,” and “psychotherapist” be replaced with the term “gender specialist” and that this term be clearly defined in the revised SOC. The section “Mental Health Professional” (Section IV) should be renamed “The Gender Specialist.”

DEFINITION AND QUALIFICATIONS says, “Clinical training may occur within any OF THE MENTAL HEALTH formally credentialing discipline—for example, PROFESSIONAL: “THE GENDER psychology, psychiatry, social work, counseling, SPECIALIST” or nursing.” This statement establishes a general

Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 broad categorization. The SOC later clarifies that The term “mental health professional,” which the professional must have is used throughout the document, is not adequately defined, nor does it describe who pre- [a] master’s degree or its equivalent in cisely qualifies for this title. MHP is an ambigu- a clinical behavioral science field. This ous term, and it must be assumed it is purposely or a more advanced degree should be vague in order to not alienate those in the thera- granted by an institution accredited by a peutic allied professions and to avoid creating a recognized national or regional accredit- hierarchy of qualified professionals. As an inter- ing board. The mental health professional national community, it must also be recognized should have documented credentials from that mental health care is managed in diverse a proper training facility and a licensing ways from one country to the next, university de- board. (p. 12) grees are conferred utilizing different academic standards, and national and state-wide creden- The problem stems from the fact that different tialing processes vary widely from one locale to academic programs accredit different learning another. experiences, and different countries, states, and The current SOC outlines the qualifications provinces have different time requirements for for an adult specialist and a child specialist. It clinical supervision. Conceivably, two MHPs Arlene Istar Lev 85

graduating from two different universities in related issues, the lack of clarity of language two different locations, both with master’s de- and expectations in this section leaves gender grees, may have widely different numbers of su- nonconforming clients at the mercy of treatment pervised hours, continuing educational credits, modalities and psychotherapists whose goal may and actual clinical experience, not to mention be to eliminate gender dysphoria through repar- completely different clinical training. For exam- ative therapies. ple, in the United Kingdom, referrals for sex The fourth revision of the SOC specified that reassignment procedures utilizing the National mental health professionals needed to demon- Health Services would generally be made by strate “specialized competence in sex therapy a psychiatrist or psychologist with significant and theory as indicated by documentable train- specific medical training (Whittle, 2007); in the ing and supervised clinical experience in sex United States, the same referral can be made by therapy” (Walker, 1979), a provision that has a psychotherapist in private practice, with a mas- been removed presumably since so many evalu- ter’s degree in any number of fields (e.g., social ators did not have this “specialized competence.” work, counseling) and a clinical license but no (The fourth revision addressed many issues in- specialized background in medicine. depth regarding the role of the MHP that were A master’s level psychologist who has studied removed in later versions.) behavioral research or experimental psychology The terms “mental health provider” and “clin- has a somewhat different skill set than one who ical behavioral scientist” which is used exten- has studied community mental health or edu- sively in the current SOC are specialized titles, cational psychology, although they may have not commonly used to describe social workers or the same university degree and even the same psychotherapists. It is unclear whether the SOC clinical credentials. The training of a psychi- is referring to “qualified mental health providers atric nurse practitioner is vastly different from a [QMHP],” which describes those with advanced licensed professional counselor (LPC) or a mar- degrees capable of receiving insurance reim- riage and family therapist (MFT). PsyD- and bursements in the United States, surely a salient PhD-level professionals both have advanced de- issue for countries without national health care grees and licensure, but different levels of educa- programs. According to a survey of U.S. state tion regarding clinical and research experiences; boards, MHPs can include the specialties of Doc- many MEds also practice psychotherapy, as do tor of Osteopathy (DO) and Certified Alcohol specialists in art and music therapy, with diverse and Substance Abuse Counselors (CASAC). A academic degrees and vastly different clinical DO generally has little training in mental health Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 perspectives. evaluation, although they do have an advance Additionally, the terms “psychotherapy” and degree; a CASAC may have extensive training “psychotherapist” are used throughout the SOC, in clinical evaluation, although not have the req- and psychotherapy is one of the tasks that MHP uisite master’s degree. It is unclear if the MHP are expected to perform. It is not clear in the is expected to have an advanced degree, and a SOC if all MHP are considered psychothera- license (this will vary across professions), and if pists, or if those who provide psychotherapy an academic degree is considered a “training fa- have some specific expertise. As suggested in cility,” although many academic degrees do not Recommendation No. 3 (see Table 1), there are require clinical internships. benefits to distinguishing between psychosocial- The impact of the weakness of the current assessment processes and psychological treat- language is evidenced in the controversy over ment. Psychotherapeutic treatment modalities Michael Bailey’s book, The Man Who Would can include diverse skill-sets, and clearly psy- Be Queen. One of the allegations levied at choanalytic psychotherapists will utilize differ- Bailey is that he was practicing psychology ent therapies with their transgender clients than without a license by writing referral letters marriage and family therapists or feminist and to surgeons for transsexual women seeking narrative post-modern clinicians. Given that few treatment (Dreger, 2008). He was reported to clinicians have had extensive training in gender- the Illinois state licensing board, since as a PhD 86 INTERNATIONAL JOURNAL OF TRANSGENDERISM

academic he was technically not a clinician 3. Documented supervised training and and, therefore, not trained to evaluate clients competence in psychotherapy. for medical treatments. Dreger places the onus 4. Continuing education in the treatment of on the surgeon as to whether she or he accepts gender identity disorders, which may in- the letter and bypasses the issue of whether this clude attendance at professional meetings, was within Bailey’s skill-set to offer; however, workshops, or seminars or participating in few surgeons will question the qualifications of research related to gender identity issues. a letter written and signed by a “doctor.” Some (p. 12) may argue that indeed a transgender person living full time should be able to simply get These three competencies use the terms “spe- a referral letter from a well-established friend cialized training,” “documented supervision,” with an academic degree. However, it is doubtful and “continuing education,” although it is not that this was the intent of the current SOC,and clear exactly what specialized training is, how it the credentialing standards should be explicit as should be documented, or where exactly a per- to “who” can write letters, precisely to avoid the son should receive continuing education. The kind of legal conundrum that Bailey could have SOC requires that MHPs be trained in the “Sex- (perhaps should have) faced. The fourth version ual Disorders” section of the DSM-IV. However, of the SOC explicitly stated, “Possession of in-depth sexuality education is uncommon in an academic degree in a behavioral science most social work, psychology, nursing, or med- does not necessarily attest to the possession of ical programs, and there are few specific train- sufficient training or competence to conduct ing centers, university departments, or clinical psychotherapy, psychologic counseling, nor training programs that offer specialized courses diagnosis of gender identity problems” (Walker, in transgender clinical treatment. To require et al., 1979), but this statement was removed “specialized training and competence” is logi- during later revisions. cal, and even necessary, but in fact, such train- Given the variations in training and licensing is not currently easily available, especially ing, and the broad scope of the mental health given the increasing need for services. Exactly professional’s skills, qualifications, and affilia- where do MHPs go to receive their specialized tions, it is essential for the SOC to specifically training? define what a “mental health professional” is and Assuming that training were available, the exactly who is qualified and has the necessary SOC request that this be “documented,” although training to provide services, including evalua- it is not clear who is doing the documentation Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 tion, assessment, referral, and psychotherapy, for and for whom it is being kept. Since there are the purposes of evaluation of gender dysphorias. no licensure or credentialing processes for MHP The subsection on the Adult-Specialist out- who specialize in gender identity issues, how can lines the requirements for “basic general clinical WPATH judge if someone has received the nec- competence in diagnosis and treatment of men- essary training? Many current “experts” in this tal or emotional disorders” (p. 12) and then lists field would have difficulty outlining how they re- four “recommended minimal credentials for spe- ceived gender-specific education and might not cial competence with the gender identity disor- be able to document the academic institutions or ders” (p. 12). The first competency, as discussed training centers where they studied. previously, is simply too broad and needs to be This highlights the ambiguous relationship carefully operationalized to be useful. Its ambi- between WPATH and the SOC; currently it guity is mirrored in the other three competencies seems that WPATH produces the SOC, but does that follow: not monitor them, publicize them, or in any way ensure that clinicians follow these guidelines. 2. Specialized training and competence At the time of this writing there were 64 mem- in the assessment of the DSM-IV/ICD-10 bers of WPATH who identified themselves as Sexual Disorders (not simply gender iden- social workers, 130 who identified themselves tity disorders). as having a specialty in psychology, and 11 who Arlene Istar Lev 87

are nurses (T. L. Tieso, personal communica- the field of practice so that expert status is con- tion, August 11 2007). This figure must repre- ferred on those who have received training, yet sent only a small number of those who specialize does not disallow anyone else from providing in transgender health. It is not known how many the services (i.e., many psychologists and so- of those who are members of WPATH even ad- cial workers provide addiction-specific services here to the standards. Why are not more clini- without holding chemical-dependency creden- cians who specialize in gender issues members tials). of WPATH? Part of providing SOC also requires The development of trans-health and trans- that they are publicized (not just published) so medicine as a field of specialty requiring they become utilized by training programs and nonpathologizing gender-specific training institutions. allows the WPATH to be a world leader in Additionally, to have SOC that are not institu- establishing guidelines for practice. Therefore tionally monitored begs the question of why they the SOC committee should establish a creden- exist and whom they serve. If WPATH continues tialing process for gender specialists, whereby to establish guidelines for care, the organization professionals can document their academic de- must also create some way to monitor adherence gree, clinical supervision hours, and continuing to the guidelines. Although, it may be beyond education units and receive a credential that the scope of the current organizational possibil- reflects their expert status. Provisions should ities of WPATH, serious consideration should be made to “grandparent” those who have been be placed on the development of a credential- in long-term clinical practice specializing in ing program to ensure that there is are standard gender issues. This might include some kind of educational and licensing expectations for gen- “testing” process, which could be completed on- der therapists (see Table 3). Since the purpose line or through an interview with an established of the SOC rests on proper evaluation of gen- professional (which could be conducted on the der dysphoria and those who serve the gender phone), to establish basic levels of competence. community are perceived to have a unique skill- Additionally, continuing educational credits set, it is essential to clarify exactly “who” is could be offered through the WPATH newslet- competent to provide these services, what train- ter and post-test questions be mailed-in to ing and experience they need to have, and how WPATH. and with whom expertise is documented. Fi- Additionally, WPATH should develop a com- nally, if WPATH expects gender specialists to prehensive resource area on their Web site, a have training, supervision, and continuing edu- clearinghouse, where academic institutions and Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 cation, the organization needs to consider pro- clinical-training associations could announce viding it, or at least serving as a contact point their gender-specific training programs. Online for other training institutions that do provide the training opportunities, peer supervision, as well training. as conferences, could be listed as potential re- The field of addictionology and chemical de- sources for those seeking credentialing. Even- pendency treatment in the United States has tually, an “approval” or “sponsorship” proce- increased professional standards in the past dure could be developed, whereby educators few decades, developing credentialing programs would apply to have their trainings authorized by (that vary from country to country and state to WPATH. Please note that these last two recom- state) and providing academic and clinical train- mendations could also be potentially revenue- ing opportunities. Practitioners are awarded a producing opportunities for WPATH. certificate upon completion of training and a WPATH may not be in a position currently to credential to practice and are required to com- take on a task of this nature, financially or orga- plete continuing education units to maintain their nizationally. However, the whole section of the credential. This provides relative uniformity of SOC regarding licensing, documentation, and knowledge within the discipline, although it also professional expertise rests on having some way provides for great freedom in actual practice to ensure that those providing the services have techniques and treatment procedures. It elevates been approved by a credentialing body. WPATH 88 INTERNATIONAL JOURNAL OF TRANSGENDERISM

TABLE 3. Recommendations Regarding the Training and Credentialing of Gender Specialists

No. Recommendations

14. Before the tasks of the gender specialist are listed, the SOC should outline specifically the requirements for gender specialists. Below are some suggestions for how this section might look: A. Gender specialists should have at least a master’s degree, or its equivalent, from an established academic program that can grant a PhD, a PsyD, an MS, or an MA in psychology or an MEd, RN, etc. (Each professional field of study should be examined with all accepted degrees, or their international equivalents, explicitly included.) B. Gender Specialists should have received and be able to document x number of supervised clinical hours in general psychotherapy or family therapy. (A review of other credentialing associations and training programs, as well as surveying established WPATH members, would assist the SOC committee in a reasonable number of hours.) C. Gender Specialists should have received and be able to document specific training in gender identity, gender dysphorias, sexual identity, gender role development and sexual problems, including knowledge of diagnosis of gender identity disorders as they are currently explained in the DSM and the ICD. D. Gender Specialists should be knowledgeable about sociopolitical, legal, and activist issues currently being raised within the transgender, intersex, and transsexual communities. E. Gender Specialists should be knowledgeable about family-related concerns for gender-variant people and the needs of family members, as well as the normative stresses involved in living with gender dysphoria, especially during the process of transition. F. Gender Specialists should be able to recognize, diagnose, and treat comorbid mental health issues, including addictions, and distinguish them from the identity concerns of gender-variant people. G. Interns and those who are just beginning to work with gender-variant clients should be under the supervision of a trained Gender Specialist. H. Gender Specialists should adhere to these SOC and follow the ethical guidelines established by WPATH. 15. The SOC committee should establish a credentialing process for Gender Specialists, through which they document their academic degree, clinical supervision hours, and continuing education units and receive a credential that reflects their expert status. Provisions should be made to “grandparent” those who have been in long-term clinical practice specializing in gender issues. 16. WPATH should develop a comprehensive resource area on their Web site, a clearinghouse, where academic institutions and clinical training associations could announce their gender-specific training programs. Online training opportunities, peer supervision, as well as conferences, could be listed as potential resources for those seeking credentialing. Eventually, an “approval” or “sponsorship” procedure could be developed, whereby educators would apply to have their trainings authorized by WPATH.

Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 is the only international organization positioned Real-life Experience (RLE)” (Section IX) relies to take on this role. extensively on the clinical assessment of a MHP, who is expected to monitor the success of social gender transition, and should be placed within ORGANIZATION AND CONTENT this section “Psychotherapy with Adults.” DILEMMAS The specific tasks are listed without any de- scriptive directions or definitions, and have not The gender specialist has numerous tasks been significantly altered since they were first when working with clients seeking assistance outlined in the fifth version of the SOC (Levine, for gender dysphoria. Although ten specific tasks et al., 1998). Some of the tasks are explained are listed in this section, therapeutic and clinical directly below the listing of the tasks (i.e., eli- responsibilities are embedded in many other sec- gibility and readiness) and others appear in dif- tions of the SOC that seem to fall within the do- ferent sections (i.e., engagement in psychother- main of the MHP. For example, the section “As- apy). Some tasks are the focal point of entire sessment and Treatment of Children and Ado- sections whereas other tasks are never referred to lescents” (Section V) discusses in great depth again in the document. For example, task num- issues related to assessment and therapy, which ber four, “to engage in psychotherapy,” is the are absent in the adult section. The section “The subject of Section VI, and yet task number nine, Arlene Istar Lev 89

TABLE 4. Recommendations Regarding the Organization and Tasks Outlined

No. Recommendation

17. All of the information related to the Roles, Tasks, and Responsibilities of the Gender Specialist (i.e., Mental Health Professional) should be located in one inclusive section that contains the descriptions for the Adult Specialist and the Child Specialist and should add a section for the Adolescent Specialist. The section on medical treatment of the child and adolescent should be separate from the psychological treatment, as it is with adults. 18. Additionally, psychotherapy recommendations (for adults, children, youth, and families), and any suggestions involving the monitoring of transition (much of which is currently listed under Section IX (“The Real-Life Experience”) should be included in this section (either in subsections or separate sections that directly follow this section). 19. Sections not speciﬁcally related to the MHP’s tasks should be moved into other or separate sections. This includes the subsection entitled “Options for Gender Adaptation” (currently listed in Section VI, “Psychotherapy with Adults”), which should be expanded (and potentially renamed) under a separate session preceding medical, hormonal, and surgical interventions. Eligibility and readiness criteria could be included in this section also. 20. The Tasks of the Gender Specialist that are listed should be explained directly in the text of this section, following each description. Each task needs to be examined for its current usefulness and inclusion. Some tasks could be removed, some could be easily coupled, and still others could be further developed. 21. Psychosocial assessment of gender issues should expand beyond a binary medical model. Developmental trajectories and narrative perspectives offer alternative lenses through which to examine gender identity and should be recognized within the SOC alongside the diagnostic criteria. 22. There should be a separate section focusing on family issues that outlines tasks regarding spouses, partners, children of transgender parents, parents of transchildren, and extended family members. 23. Trans-health care involves the entire life cycle of the client, not just their initial referral process. Gender specialists should be prepared to work with clients at many stages of the life cycle, including post-operatively and at all stages following their transition process, and this should be reﬂected in the SOC. 24. Treatment-team collaboration can improve clinical care, but the responsibility of being a team player must rest equally on all the team members. MHP and physicians need to work together (for example, follow-up reports should be made by endocrinologists and surgeons). If it is necessary to document the MHP’s role in the treatment team as one of the tasks, then the same expectations for physicians should also be noted in the medical section.

“to educate family members, employers, and in- chotherapy. Finally, task number 10 seems self- stitutions about gender identity disorders,” is a evident; why would a gender specialist not be stand-alone statement without any further guid- available for follow-up, unless they had a per-

Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 ance as to how exactly the MHP should provide sonal problem or were no longer practicing? this education. Larger issues involving family There are a few additional areas that have not therapy during gender transition processes are been addressed previously in the SOC,orhave not addressed at all. The tasks of the gender not been addressed in signiﬁcant depth, and are specialist should not be simply listed, but be ex- essential tasks for the gender specialist (brieﬂy plained directly in the text of the tasks section, outlined in this list). These concerns should be following each item (see Table 4 for recommen- incorporated in the reorganization of the tasks. dations). The ten tasks listed need to be examined for 1. A binary diagnostic model for transgen- their usefulness; ten is a lovely number, but is der care is inadequate for the diverse gen- there a reason for ten tasks? Some tasks seem der expressions human beings exhibit. In redundant, for example, numbers 6 and 7 are recent years a number of gender special- “to make formal recommendations to medical ists have suggested developmental models and surgical colleagues” and “to document their that show the maturational process of gen- patient’s relevant history in a letter of recom- der identity and expression through time, mendation” (p. 12); both are part of a standard as well as narrative models that recog- psychosocial evaluative process. The majority of nize the salience and uniqueness of the the tasks seem focused on referral issues, rather personal autobiography (i.e., Bockting & than guidelines for gender assessment or psy- Coleman, 2007; Devor, 2004; Lev, 2004; 90 INTERNATIONAL JOURNAL OF TRANSGENDERISM

Rachlin, 1997; Vanderburgh, 2007). These ily member’s gender dissonance and desire developmental trajectories and narrative for gender congruence. perspectives offer an alternative lens with which to examine gender identity and In order to support their loved one, family should be recognized within the SOC in members themselves need support; sometimes addition to the medical model. This can be the struggles of addressing gender variance in added to the subsection entitled “Options a family member can create stress-related ill- for Gender Adaptation” (currently listed nesses or exacerbate other emotional problems. under in Section VI, “Psychotherapy with As important as it is to educate “employers and Adults”), which can be expanded (and po- institutions,” lumping those issues into the sec- tentially renamed) in a separate section, tion on family issues is problematic. The skills in preceding medical, hormonal, and surgical community psychology, organizational develop- interventions, or preceding the section on ment, and educational training are vastly differ- the MHP. These alternative treatment per- ent than the skills needed to help a teenage boy spectives are not limited to the work of the manage the confusion and fury he may experi- MHP and should be information available ence watching his father “become” a woman. to all professionals utilizing the SOC. Adult clients will often seek therapy on their 2. Trans-health care involves the entire life own, but many will come in to session with part- cycle of a client, not just the initial referral ners or spouses. All efforts should be made to process. Gender specialists should be pre- see clients with their families and to provide ad- pared to work with clients at many stages junctive counseling for the entire system. If sig- in the process, including post-operatively niﬁcant others are not included in the initial in- (Schaefer, Wheeler, & Futterweit, 1995) terview, attempts should be made to bring them and at all stages following the client’s tran- into the clinical process. When agency proto- sition process (Vanderburgh, 2007). The cols, personal style, or clinical training preclude SOC as they are currently written focus family-systems work, referrals should be made extensively on the referral process and the to appropriate colleagues to work with the larger initiation of medical treatments. family system. When working with children and 3. The ﬁeld of trans-health has ignored the youth, it is often the parents who seek out coun- importance of family in the lives of trans- seling, and indeed they may sometimes seek out gender people (Erhardt, 2007; Lev, 2004). therapy for themselves before they seek treat- Even contemporary attempts to address ment for their child. The needs of families with Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 this do not pay adequate attention to the young gender nonconforming children and those needs of families. For example, Bockting, of trans-youth are very different, clinically and Knudson, and Goldberg (2007) wrote an medically. Separate protocols need to be devel- excellent overview of contemporary trans- oped for these populations (see de Vries and health treatment, “Counseling and Men- Cohen-Kettenis, 2009/this issue). When fami- tal Health Care of Transgender Adults and lies are seeking support for children or youth, Loved Ones,” and recognized the salience or when adults who are parents are seeking of families in their choice of a title, but treatment for themselves, the family should be the authors actually direct fewer than four viewed as a system, and each member’s needs paragraphs detailing how to work with should be addressed individually, as well as to- family members in the nearly 50-page doc- gether as a family unit. Separating the adult sec- ument. The current SOC states the need “to tion from the child section in the SOC muddies educate family members, employers, and a holistic view of families coping with gender institutions about gender identity disor- transitions. ders,” but does not describe how this should be accomplished. Families undoubtedly 4. Task number 8 in the current SOC, requires need “education,” but they surely need the gender specialist to be “a colleague more than just education to adjust to a fam- on a team of professionals,” which is an Arlene Istar Lev 91

admirable goal, but this task should also supportive and welcoming environment be listed clearly under the tasks for physi- for clients seeking assistance for gen- cians. Unless the gender specialist is in the der identity concerns, including gender position of being a case manager, or a team dysphoria. This includes creating a leader of a gender team, the responsibility nonjudgmental atmosphere in order to of being a team player must rest equally on establish a reliable trusting relationship. all the players. Furthermore, it is suggested Ideally, the clinician’s work is with the that the communication between gender whole of the person’s complexity. Part specialists and physicians be a two-way of the initial interview should include street, including follow-up reports from en- the Gender Specialist sharing his or her docrinologists and surgeons, as originally background, training, expertise, and expe- suggested by Israel and Tarver (1997). If rience in working with clients with gender this task is to be retained, it should be clari- concerns. Issues regarding confidentiality, fied what it means to be on a team, and what fees, and insurance reimbursement should responsibilities each team member has. also be established in the initial sessions. Maintaining ongoing clinical contact is The Gender Specialist should determine necessary for the provision of coordinated the purpose of the visit and clarify whether and consistent clinical care. Treatment- the client is seeking evaluation and referral team collaboration can improve clinical for medical services or psychotherapeutic care, but this is not just the work of the assistance to explore gender issues and po- gender specialist: it must be shared by all tential resolution. Clients who are seeking professionals working with an individual. an evaluation should be informed of the length of time the process will take, the The Tasks of the Gender Specialist cost involved, and assured that if there are any potential concerns that would delay re- for Adults ferral for medical treatment, the client will Suggested revised “Tasks of the MHP/Gender be notified of this promptly. Clients who Specialists for Adults” are listed below. This sec- are seeking more in-depth psychotherapy tion should be followed directly by “The Tasks should be apprised of the therapist’s clin- for Gender Specialists Working with Children ical background and theoretical approach and Adolescents.” Both sections should be orga- to ensure compatibility. nized in similar ways, listing the specific tasks. 2. Assessment of Gender Identity Concerns Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 These two sections should follow one another in The Gender Specialist must assess the a similar organizational pattern. The words in client’s gender concerns through a psy- italics are quoted from the extant Standards chosocial evaluation process, including the of Care, Version 6. history of gender identity issues, current feelings and experiences, exploration The Gender Specialist serves clients and the client’s self-definition (i.e., transsex- their families in many ways: as an advo- ual, genderqueer, etc.), discussion of pre- cate, an educator, a diagnostician, a psy- vious attempts at resolution and adapta- chotherapist, and a family therapist, de- tion, and reasons for currently seeking pro- pending on the needs of the client. The fessional assistance. This process may in- tasks below are general guidelines to effec- clude diagnosis utilizing the most current tively serve people struggling with issues edition of the DSM or ICD, developmen- related to their gender. tal trajectories, or may involve employing 1. Create a Supportive Environment and a broader understanding of the range of Determine Purpose of the Visit gender expressions available. The focus The first, and most important, task of the clinical interaction must be trans- for the Gender Specialist is to create a positive and affirming, not pathologizing. 92 INTERNATIONAL JOURNAL OF TRANSGENDERISM

The clinician’s role is to assess for gender permanently alter their bodies, and their so- identity issues as precisely as possible with cial relationships” (Lev, 2004, p. 226). Ad- the current available information reported ditionally, if the Gender Specialist should by the patient. determine that clients have “serious mental 3. Assessment of Mental Stability health problems that are likely to interfere with their ability to adjust to a life in a new All clients need to be assessed for a gender, or with the process of transition” range of mental health issues that can (p. 226), the Gender Specialist must ensure impact gender issues and/or transition, that this is being addressed clinically in or- including substance abuse, depression, der to assist the client in resolution of his anxiety, cognitive impairments, psychotic or her gender issues. disorders, personality disorders, and developmental or learning difficulties. This can 4. Education Regarding Treatment Options include information from previous psycho- and Advocating for Support logical treatment, general assessment by Clients seeking medical treatments as the Gender Specialist, or referral for more well as those seeking psychotherapeutic extensive exploration or testing with a help are often misinformed, confused, and Psychiatrist, Developmental Psychologist, overwhelmed with their gender dysphoria or other professional. Additionally, the and the therapeutic, medical, and social Gender Specialist will assess other issues dilemmas they are facing. An important in the client’s environment, including task of the Gender Therapist is to educate familial relationships, work and career and inform clients of their treatment op- issues, and financial stability in order to tions (including nonmedical options), the evaluate additional psychosocial stressors. range of adaptations available, the pros and The presence of psychiatric comorbidi- cons of treatments, and the psychological, ties does not necessarily preclude refer- social, sexual, occupational, and financial ral for hormonal or surgical treatment, implications of the transition and how but some diagnoses pose difficult treat- these decisions may affect family mem- ment dilemmas and may delay or prevent bers and their overall social environment. medical treatments. Some issues, like ac- The Gender Specialist should be able to tive substance abuse, chronic and persistent provide the client with reading material, mental illness, complex personality disor- information about support groups, and In-

Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 ders, cognitive impairment, and develop- ternet resources, as well as assist the client mental disabilities, may require treatment, in connecting with other treatment profes- stabilization, or ongoing monitoring con- sionals (endocrinologists, electrologists, current with or preceding medical treat- etc.). Exploration of sources of support ment for gender identity issues. In addition should be part of the evaluation, including to treating the mental health or medical local and online support groups. Addition- conditions, clients should be assessed for ally, knowledge of procedures on name and their ability to provide educated and in- gender change for legal documents would formed consent. also be an important resource for clients. The Gender Specialist’s job is not to 5. Responsibility for Integrated Services serve as a psychological detective seeking for Family Members reasons to disqualify the client but, rather, to provide a general mental health assess- Clients seeking services for gender- ment to rule out any serious comorbid psy- related issues invariably are part of larger chiatric difﬁculties. The Gender Special- family systems. They may have spouses ist’s role is to determine if clients are “men- or partners, signiﬁcant others, parents tally, cognitively, and emotionally capable and/or children, and siblings and extended of making an informed decision that will relatives who are impacted by the client’s Arlene Istar Lev 93

gender dysphoria as well as any life particular focus on the environmental im- changes they make to resolve them. It is pact on the client and the resources the responsibility of the Gender Special- available for responding to the problem” ist to assist the client in making thoughtful (Lum, 1992, p. 167). Lum suggests that decisions about communicating with their in assessing ethnic-minority clients, it family members, as well as to be available is important to identify positive cultural to family members or to make referrals to strengths in the client’s ethnic background; colleagues trained in family systems issues indeed a psychosocial assessment should for education, ongoing support, clinical ad- always highlight the client’s strengths. A vice, and referral to other professionals as psychosocial evaluation includes: client necessary. Reality-testing regarding poten- identification, reason for evaluation, tial job loss, child custody problems, and familial history, current living situation, relationship separation is necessary to ex- work and educational background, thor- plore, especially for how it may impact ough evaluation of gender issues, social those who are financially dependent on the supports, and psychosocial stressors, transitioning person. including eligibility and readiness. Hep- worth & Larsen (1990) emphasize the 6. Determine Eligibility and Readiness for need to explore (1) the nature of clients’ Referral to Medical Treatment problems, including special attention Eligibility is defined as meeting the ba- to developmental needs and stressors sic requirements necessary to receive a associated with life transitions that require particular service. To be eligible for a major adaptations; (2) coping capacities medical referral a client must have been of clients and significant others (usually assessed for gender identity issues; have family members), including strengths, been assessed and treated when neces- skills, personality assets, limitations and sary for any comorbid mental health is- deficiencies; (3) relevant systems involved sues; have been educated about the medical in clients’ problems and the nature of treatments requested and their associated reciprocal transactions between clients and risks; and be able to give informed consent these systems; (4) resources that are avail- to the procedures. A client who is eligi- able or are needed to remedy or ameliorate ble meets the basic qualifications for re- problems; and (5) clients’ motivation to ceiving medical treatment. Readiness im- work on their problems (p. 193). Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 plies that the person is psychologically pre- The basic outline for complete psy- pared to cope with the effect of the medical chosocial assessment is available from the treatments in terms of occupation, family American Psychiatric Association and in- responsibilities, finances, and social reac- cludes risk assessment, information from tions. A client who is eligible and ready has collateral sources, diagnostic tools, and consolidated a gender identity that will be working with a treatment team (APA, supported by medical treatments, is men- 2006). Coolhart, Provancher, Hager, and tally stable, and will be responsible regard- Wang (2008) developed an assessment tool ing following medical advice (e.g., will to examine client readiness for medical take hormones in a responsible manner, treatments and outline the important areas will comply with post-surgical treatment to review in a psychological evaluation. A recommendations). general outline for a psychosocial assessment should be included in the revised SOC 7. Completion of Psychosocial Assessment (see Appendix). The Gender Specialist is expected to complete a psychosocial assessment that 8. Documentation Letter for Hormone is defined as an “in-depth investigation of Therapy or Surgery the psychosocial dynamics that affect the A referral to initiate medical treatment clientandtheclient’senvironment...with for gender confirmation to alleviate gender 94 INTERNATIONAL JOURNAL OF TRANSGENDERISM

dysphoria or assist a client in gender con- 10. Be Available to Educate or Train Em- gruity can be written to any physician who ployers, Schools, and Institutions can provide services, including an endocri- Many clients will have difficulties in nologist, internist, family or general prac- jobs and professional settings, school and titioner, surgeon, etc. A letter can be writ- university settings, and various institutions ten for any client who is seeking medi- as they actualize their gender and espe- cal treatment who does not exhibit any cially if they are transitioning or chang- comorbid mental illness and/or has been ing their gender presentation. Gender Spe- treated for these conditions, and who has cialists should be able to talk with human been educated and informed about treat- resources, personnel managers, employment choices. Clients must be, to the best ers, heads of schools, deans, and agency judgment of the Gender Specialist, capa- directors regarding gender identity issues ble of providing informed consent. The and how to facilitate necessary changes in letter should follow the form of a gen- institutions regarding bathrooms, training eral psychosocial assessment that would be of staff, and respectful treatment. Gender used in any mental health setting, with an Specialists may also serve as expert wit- emphasis on the person’s history of gen- nesses in the judicial system. If a Gen- der dysphoria. A shorter letter detailing der Specialist is not comfortable educat- the gender issues, eligibility, and readiness ing and training, they should be able to re- may be sent; however the psychosocial fer to another qualified professional in the history should be maintained on file with community. the Gender Specialist. (The letter, which is essentially a medical referral, is not in- tended to be used as an “identity docu- Requirements for Referral Letters ment” by clients. If clients request a letter In the current SOC, one letter is required from from a therapist to acknowledge their cho- a MHP for hormones, and two for surgical proce- sen gender, in case they are stopped by dures. The SOC states, “Because professionals the police, this should be a separate docu- working independently may not have the bene- ment, less psychological and more factual.) fit of ongoing professional consultation on gen- When working with a physician for the first der cases, two letters of recommendation are re- time, a letter of introduction from the refer- quired prior to initiating genital surgery.” It is ring clinician stating their credentials and

Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 the responsibility of the professional to ensure experience can help establish a working that they have all the professional support, su- relationship. pervision, and consultation necessary to make 9. Provision of Collaborative Services an informed decision for surgical referral. The The relationship between the referring onus of ﬁnancial cost should rest with the profes- Gender Specialist and the physicians or sional, not the client forced to pay for the second other professionals working with the same consultation. client should remain collaborative. The Additionally, the SOC states, “If the ﬁrst letter Gender Specialist should have clients sign is from a person with a master’s degree, the sec- a consent letter to release information from ond letter should be from a psychiatrist or a Ph.D. all other professionals with whom they are clinical psychologist, who can be expected to ad- working, and clinical dialogue should take equately evaluate co-morbid psychiatric condi- place as necessary. Open and consistent tions.” The inference is that master’s-level clin- communication may be necessary for con- icians are not capable of adequately assessing sultation, referral, and post-operative con- psychiatric conditions. This is condescending cerns. [This task should also be clearly and feeds into a clinical hierarchy that is un- stated in the section pertaining to physi- necessary in an international, multidisciplinary cians.] organization. Many master’s-level clinicians are Arlene Istar Lev 95

TABLE 5. Recommendation Regarding Letters recognizes the unique professional skill-sets that of Referral gender specialists bring to this work serving the transgender community as compassionate advo- No. Recommendation cates and skilled, professional caregivers.

25. One letter each should be required for hormones and one letter should be required for surgery. If two letters for surgery are required, the letters should be accept- REFERENCES able if written by any MHP/Gender Specialist who is approved to write the ﬁrst letter. If the surgeon has any Albany Law Review. (2001). Health law standards of care further concerns, they can request an additional evalu- for transsexualism. Albany Law Review, 64(3), 1067– ation at that time. 1072. American Psychiatric Association. (2000) Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. qualiﬁed health professionals and experts in psy- American Psychiatric Association (APA). (2006). Practice chiatric disorders. Any gender specialist who guideline for the psychiatric evaluation of adults (2nd is capable of assessing gender issues (espe- ed.). Washington, DC: American Psychiatric Associa- cially if the guidelines are clearly delineated in tion (APA). the SOC), should be capable of writing refer- Agency for Healthcare Research and Quality (AHRQ). (2007). U.S. Department of Health and Human Services, ral letters and assessing comorbid mental health National Guideline Clearing House. Retrieved Au- concerns (see Table 5). gust 16, 2007, from http://www.guideline.gov/browse/ guideline index.aspx Anderson, B. F. (1997). Ethical implications for psy- CONCLUSION chotherapy. In G. Israel and E. Tarver (Eds.) Trans- gender Care. Philadelphia: Temple University Press. Balde,´ A., Legar´ e,´ F., Labrecque, F. (2006). Assessment of In conclusion, it is important to remember, needs of men for decision support on male sterilization. “Everyone has a right to their own gender ex- Patient Education and Counseling, 63, 301–307. pression; Everyone has a right to make informed Batty, D. (2007). Sex change doctor guilty of mis- and educated decisions about their own bodies conduct. (2002, May 25). The Guardian. Retrieved and gender expressions; Everyone has the right August 16, 2007, from http://www.guardian.co.uk/ to access medical, therapeutic, and technological uk news/story/0,3604,1126835,00.html services to gain the information and knowledge Blanchard, R., Steiner, B. W., Clemmensen, L. H., & Dickey, R. (1989). Prediction of regrets in postopera-

Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 necessary to make informed and educated de- tive transsexuals. Canadian Journal of Psychiatry, 34, cisions about their own bodies and lives” (Lev, 43–45. 2004, p. 185). It is the responsibility of the gen- Bockting. W. O. (2009) Are gender identity disorders der specialist to facilitate that process with as mental disorders? Recommendations for revision of much ease as is possible when dealing with the World Professional Association for Transgender complex, expensive, and life-altering and irre- Health’s Standards of Care. International Journal of versible medical procedures. Transgenderism, 11, 53–62. Gender specialists must remember that there Bockting, W. O., & Coleman, E. (2007). Developmental stages of the transgender coming out process: Toward is currently a dearth of scientific evidence back- an integrated identity. In R. Ettner, S. Monstrey, & E. ing up much of the current SOC. There is a great Evan (Eds.). Handbook of Transgender Medicine and need for evidence-based research to determine Surgery. New York: Haworth Press. the efficacy and effectiveness of the SOC, and Bockting, W. O., Knudson, G., & Goldberg, J. M. (2007). until the guidelines are determined to be effec- Counseling and mental health care for transgender tive, they must be considered flexible guidelines. adults and loved ones. International Journal of Trans- Steinbrook (2007) says, “Guidelines rely on both genderism, 9(3/4), 36–82. Bodlund, O., & Kullgren, G. (1996). Transsexualism: evidence and opinion; they are neither infallible General outcome and prognostic factors—A five-year nor a substitute for clinical judgment” (p. 332). follow-up study of nineteen transsexuals in the process This article recommends some ways to minimize of changing sex. Archives of Sexual Behavior, 25, 303– the “gatekeeping” function of the MHP and also 316. 96 INTERNATIONAL JOURNAL OF TRANSGENDERISM

Breitbart, V. (2000). Counseling for medical abortion. Docter, R. F. (1988). Transvestites and transsexuals: To- American Journal of Obstetrics and Gynecology, ward a theory of cross-gender behavior. New York: 183(2), 26–33. Plenum Press. Burns, C. (2004). Something rotten in the state of Dreger, A. D. (2008). The controversy surrounding The the profession. Press for Change. Retrieved August Man Who Would Be Queen: A case history of the politics 16, 2007, from http://www.pfc.org.uk/pfclists/news- of science, identity, and sex in the internet age. Archives arc/2004q4/msg00069.htm of Sexual Behavior, 37, 366–421. Burns, L. H., & Covington, S. N. (Eds.). (2000). Infertility Ehrbar, R. D, Witty, M. C., Ehrbar, H. G., Bockting, W. O. counseling: A comprehensive handbook for clinicians. (2008). Clinician judgment in the diagnosis of gender Nashville, TN: Parthenon Publishing. identity disorder in children. Journal of Sex & Marital Butler, J. (2004). Undoing gender. New York: Routledge. Therapy, 34, 385–412. Carroll, R. (1999). Outcomes of treatment for gender dys- Ely, G. E. (2007). The abortion counseling experience: A phoria. Journal of Sex Education and Therapy, 24, 128– discussion of patient narratives and recommendations 136. for best practices. Best Practices in Mental Health, 3(2), Coolhart, D., Provancher, N., Hager, A., & Wang, M. 62–74. (2008). Recommending transsexual clients for gender Erhardt, V. (2007). Head over heels: Wives who stay with transition: A therapeutic tool for assessing readiness. cross-dressers and transsexuals. Binghamton, NY: Ha- Journal of GLBT Family Studies, 4(3), 301–324. worth Press. Crea, T. M., Barth, R. P., & Chintapalli, L. K. (2007). Home Feldman, J. L., & Goldberg, J. (2007). Transgender primary study methods for evaluating prospective resource fam- medical care. International Journal of Transgenderism, ilies: History, current challenges, and promising ap- 9(3/4), 3–34. proaches. Child Welfare Journal, 86(2), 141–159. Fraser, L. (2009/this issue). Psychotherapy in the World Dahl, M., Felman, J., Goldberg, L., & Jaberi, A. (2006). Professional Association for Transgender Health’s Stan- Endocrine therapy for transgender adults in British dards of Care: Background and recommendations. Columbia: Suggested guidelines. Vancouver, Canada: International Journal of Transgenderism, 11, 112– Vancouver Coastal Health, Transcend Transgender Sup- 128. port & Education Society, and Canadian Rainbow Goldberg, J. (2007). Training community-based clinicians Health Coalition. in transgender care. International Journal of Transgen- Denny, D. (1992). The politics of diagnosis and a diagnosis derism, 9(3/4), 219–231. of politics: The university-afﬁliated gender clinics, and Green, J. (2004). Becoming a visible nan. Nashville, TN: how they failed to meet the needs of transsexual peo- Vanderbilt University Press. ple. Chrysalis: The Journal of Transgressive Gender Grimaldi, J., & Jacobs, J. (1998). The HIV hormone bridge: Identities, 1(3), 9–20. Connecting impoverished HIV+ transsexual sex work- Denny, D. (2004). Changing models of transsexualism. In ers to HIV medical care. AIDSLine, ICA12/98406957. U. Leli & J. Drescher (Eds.), Transgender subjectivi- Retrieved November 9, 2007, from http://www. ties: A clinician’s guide (pp. 25–40). Binghamton, NY: aegis.com/aidsline/1998/dec/m98c1575.html

Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 Haworth Medical Press. Gross, B. H. (2001). Informed consent. Annals of the Amer- Denny, D., Green, J., & Cole, S. (2007). Gender variability: ican Psychotherapy Association, 4, 24. Transsexuals, crossdressers, and others. In M. Tepper Hale, J. C. (2007). Ethical problems with the mental health & A. Owens (Eds.), Sexual health. Portsmouth, NH: evaluation standards of care for adult gender vari- Greenwood Publishers. ant prospective patients. Perspectives in Biology and Denny, D., & Roberts, J. (1997). Results of a question- Medicine, 50(4), 491–505. naire on the standards of care of the Harry Benjamin Hartmann, U., Becker, H., & Rueffer-Hesse, C. (1997). International Dysphoria Association. In. B. Bullough, Self and gender: Narcissistic pathology and personal- V. L. Bullough, & J. Elias (Eds.), Gender blending (pp. ity factors in gender dysphoric patients—Preliminary 320–336). Amherst, NY: Prometheus Books. results of a prospective study. International Journal of Devor, A. (2004). Witnessing and mirroring: A four- Transgenderism, 1(1). Retrieved August 16, 2007, from teen stage model of transsexual identity formation. http://www.symposion.com/ijt/ijtc0103.htm Journal of Gay and Lesbian Psychotherapy, 8(1/2), Hepworth, D. H., & Larsen, J. (1990). Direct social work 41–67. practice: Theory and skills. Belmont, CA: Wadsworth. De Vries, A. L. C, & Cohen-Kettenis, P. T. (2009/this Israel, G. E., & Tarver, D. E. (1997). Transgender care: Rec- issue). Review of World Professional Association for ommended guidelines, practical information, and per- Transgender Health’s Standards of Care for children sonal accounts. Philadelphia: Temple University Press. and adolescents with gender identity disorder: A need Karasic, D. H. (2000). Progress in health care for transgen- for change? International Journal of Transgenderism, dered people. Journal of the Gay and Lesbian Medical 11, 102–111. Association, 4(2), 157–158. Arlene Istar Lev 97

Karasic, D. H., & Drescher, J. (Eds.). (2006). Sexual and Harry Benjamin International Gender Dysphoria Asso- gender diagnoses of the diagnostic and statistical man- ciation’s standards of care. Retrieved August 16, 2007, ual (DSM): A reevaluation. Binghamton, NY: Haworth from http://www.pfc.org.uk/node/638 Press. Meyer, J. K., & Reter, D. (1979). Sex reassignment: Follow- Kinney, E. D. (2001). The brave new world of medical up. Archives of General Psychiatry, 36(9), 1010–1015. standards of care. Journal of Law, Medicine, and Ethics, Meyer, W., Bockting, W., Cohen-Kettenis, P., Coleman, 29, 323–334. E., DiCeglie, D., Devor, H., et al. (2001). The Harry Landen, M., Walinder, J., Hambert, G., & Lundstrom, B. Benjamin International Gender Dysphoria Associa- (1998). Factors predictive of regret in sex reassignment. tion’s standards of care for gender identity disorder— Acta Psychiatrica Scandinavica, 97, 284–289. Sixth Version. International Journal of Transgen- Lawrence, A. (2001, November). SRS without a one year derism, 5(1). Retrieved December 8, 2008, from RLE: Still no regrets. Paper presented at the XVII Harry http://www.symposion.com/ijt/soc 2001/index.htm Benjamin International Symposium on Gender Dyspho- Newman, L. K. (2000). Transgender issues. In J. Ussher ria, Galveston, Texas. (Ed.), Women’s health: Contemporary international Lev, A. I. (2004). Transgender emergence: Counseling perspectives (pp. 394–404). Leicester: BPS Books. gender-variant people and their families. Binghamton, Olsson, S. E., & Miller, A. (2006). Regret after sex reassign- NY: Haworth Press. ment surgery in a male-to-female transsexual. Archives Lev, A. I. (2005). Disordering gender identity: Gender iden- of Sexual Behavior, 35, 501–506. tity disorder in the DSM-IV-TR. The Journal of Psychol- Papadakis, M. (2003, August 31). Second thoughts after ogy and Human Sexuality, 17(3/4), 35–70. sex change. Herald Sun. Lev, A. I. (2006). Transgender communities: Developing Parkes, G., & Hall, I. (2006). Gender dysphoria and identity through connection. In K. Bieschke, R. Perez, cross-dressing in people with intellectual disability: & K. DeBord (Eds.), Handbook of counseling and psy- A literature review. Mental Retardation, 44(4), 260– chotherapy with lesbian, gay, and bisexual clients (pp. 271. 147–175) (2nd ed.). Washington, DC: American Psy- Pfafflin,¨ F., & Junge, A. (1998). Sex reassignment thirty chological Association. years of international follow-up studies after sex re- Levine, S. B., Brown, G., Coleman, E., Cohen-Kettenis, P., assignment surgery: A comprehensive review, 1961– Hage, J., Van Maasdam, J., et al. (1998). The standards 1991 (R. B. Jacobson & A. B. Meier, Trans.) [Elec- of care for gender identity disorders—Fifth version. Re- tronic]. Dusseldorf,¨ Germany: Symposion Publishing. trieved August 16, 2007, from http://www.tc.umn.edu/ Retrieved August 16, 2007, from http://symposion.com/ ∼colem001/hbigda/hstndrd.htm ijt/pfaefflin/1000.htm Levine, S. B. (in press). Real life experience: Recommen- Pilgrim, D. (2005). Defining mental disorder: Tautology in dations for revisions of the World Professional Associ- the service of sanity in British mental health legislation. ation for Transgender Health’s Standards of Care. In- Journal of Mental Health, 14(5), 435–443. ternational Journal of Transgenderism. Pollack, R. (1997). What is to be done? A commentary Lewins, F. (1995). Transsexualism in society: A sociology on the recommended guidelines. In G. E. Israel and D.

Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 of male-to-female transsexuals. South Melbourne, Aus- E. Tarver II (Eds.), Transgender Care: Recommended tralia: MacMillian. Guidelines, Practical Information, and Personal Ac- Lewin, K. (1947). Frontiers in group dynamics. Human counts (pp. 229–235). Philadelphia: Temple University Relations, 1(2), 5–41. Press. Lindheim, S. R., Frumovitz, M., & Sauer, M. V.(1998). Re- Pratt, J. S., Cummings, S., Vineberg, D. A., Graeme-Cook, cruitment and screening policies and procedures used to F., & Kaplan, L. M. (2004). Case 25-2004: A 49-year- establish a paid donor oocyte registry. Human Repro- old woman with severe obesity, diabetes, and hyper- duction, 13, 2020–2024. tension. New England Journal of Medicine, 351, 696– Lombardi, E. (2001). Enhancing transgender health care. 705. American Journal of Public Health, 91(6), 869– Prosser, J. (1998). Second skins: The body narratives of 872. transsexuality. New York: Columbia University Press. Lombardi, E. L., & van Servellan, G. (2000). Building Rachlin, K. (1999). Factors which inﬂuence individual’s culturally sensitive substance use prevention and treat- decisions when considering female-to-male genital re- ment programs for transgendered populations. Journal constructive surgery. International Journal of Trans- of Substance Abuse Treatment, 19(3), 291–296. genderism, 3(3). Retrieved August 16, 2007, from Lum, D. (1992). Social work practice and people of http://www.symposion.com/ijt/ijtvo06no01 03.htm color: A process-stage approach. Paciﬁc Grove, CA: Rachlin, K. (1997, June). Partners in the journey: Psy- Brooks/Cole. chotherapy and six stages of gender revelation. Paper MacDonald, M. (1999). A horse designed by committee: presented at the Second Congress on Sex and Gender, A highly personal view of the 1998 version of the King of Prussia, Pennsylvania. 98 INTERNATIONAL JOURNAL OF TRANSGENDERISM

Raj, R. (2002). Towards a transpositive therapeutic APPENDIX: PSYCHOSOCIAL model: Developing clinical sensitivity and cultural ASSESSMENT competence in the effective support of transsexual and transgendered clients. International Journal of A. Client identification: This should include Transgenderism, 6(2). Retrieved August 16, 2007, from http://www.symposion.com/ijt/ijtvo06no02 04.htm client’s legal name as well as other names Schaefer, L. C., Wheeler, C. C., & Futterweit, W. (1995). the client may use, address, phone number, Gender identity disorders (Transsexualism). In G. O. e-mail, and any other client contact infor- Gabbard (Ed.), Treatment of Psychiatric Disorders (2nd mation. Additionally, information on the ed., vol. 2). Washington, DC: American Psychiatric client’s birth date/age, relational and fam- Press. ily status, and employment and/or educa- Singer, J. (2004). Options counseling: Techniques for car- tional situation should be briefly outlined. ing for women with unintended pregnancies. Journal of Midwifery & Women’s Health, 49(3), 235–242. The client should be referred to by the pre- Snyder, T. A., & Barnett, J. E. (2006). Informed consent and ferred pronoun, except when he or she is the process of psychotherapy. Psychotherapy Bulletin, still living in the natal sex. (It is accept- 41, 37–42. able to use natal pronouns when discussing Speer, S. A. (2006). Gatekeeping gender: Some features childhood and history.) Race/ethnicity, re- of the use of hypothetical questions in the psychiatric ligion, disability, or any other pertinent in- assessment of transsexual patients. Discourse & Society, formation about the client’s identity should 17(6), 785–812. be mentioned, as appropriate. Steinbrook, R. (2007). Guidance for guidelines. New Eng- land Journal of Medicine, 356(4), 331–333. B. Reason for evaluation: This section should Stone, S. (1991). The empire strikes back: A posttranssex- include information about the length ual manifesto. In J. Epstein & K. Straub (Eds.), Body of evaluation and/or psychotherapy and guards: The cultural politics of gender ambiguity (pp. the results of any psychological testing, 280–304). New York: Routledge. ecomaps, or genograms. The reason the Stryker, S. (1993). Transgender rage against the psychi- client is seeking medical treatment at this atric establishment. Retrieved August 16, 2007, from time should be noted. http://www.spunk.org/texts/pubs/cf/sp000562.txt Vanderburgh, R. (2007). Transition and beyond: Observa- C. Familial history: Information regarding tions on gender identity. Portland, OR: Q Press. the client’s family of origin should be de- Vitale, A. (1997). The therapist versus the client: How the scribed, including parent and sibling rela- conflict started and some thoughts on how to resolve tionships, past and current. A basic out- it. In G. E. Israel and D. E. Tarver II (Eds.), Transgen- line of the client’s upbringing should be der care: Recommended guidelines, practical informa- described including information on famil- Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 tion, and personal accounts (pp. 251–255). Philadel- ial deaths, divorces, the functioning of the phia: Temple University Press. Walworth, J. (1997). Sex reassignment surgery in male- family as a whole, salience of any cul- to-female transsexuals: Client satisfaction in relation to tural themes in the family, values expressed selection criteria. In B. Bullough, V. L. Bullough, & J. within family, and characteristics of their Elias (Eds.), Gender blending (pp. 352–373). Amherst, communication style. Any pertinent in- NY: Prometheus Books. formation regarding the client’s childhood Walker, P. A., Berger, J. C., Green, R., Laub, D. R., (for example, poverty, health issues, fam- Reynolds, C. L., & Wollman, L. (1979, 1990). The ily member’s disability, involvement in the “Standards of Care” (Version4, 1990). Harry Benjamin military, frequent moving, living in mul- International Gender Dysphoria Association. Retrieved on August 16, 2007, from http://www.pfc.org.uk/ tiple households, adoption or fostering, node/636 additional members living in the home) Wilchins, R. A. (1997). Read my lips: Sexual subversion should also be listed here. When possible, and the end of gender. Ithaca, NY: Firebrand. the therapist is basing this knowledge on Winters, K. (2005). Gender dissonance: Diagnostic reform information corroborated through contact of gender identity disorder for adults. Journal of Psy- with family members. chology and Human Sexuality, 17(3/4), 71–91. D. Current living situation: Information re- Whittle, S. (1998). The trans-cyberian mail way. Social & Legal Studies, 7, 389–408. garding the client’s current living situation Arlene Istar Lev 99

should be described. If the client is in a be offered, as appropriate, to those in ongo- significant intimate relationship, and/or is ing relationships with the client beginning parenting children, this should be noted, medical treatments. as well as any past marriages or commit- H. Psychosocial Stressors: Any mental ted relationships. Identify who is living in health or medical issues, criminal history, the current household, the quality of the and pending legal problems or probation client’s relationship with his or her child should be outlined, as well as the current or children, and whether the child or chil- status of those issues. A thorough drug dren are currently living with the client. and alcohol evaluation should be part of Describe the quality, duration, and com- the assessment. Any history of domestic munication patterns of any intimate rela- violence, sexual assault, childhood sexual tionships, including issues of power and or physical abuse or neglect, or being the decision-making. Note whether the family victim of a bias-related crime should be is supportive of the client’s decision. thoroughly explored. An assessment of the E. Work and Education: Discuss the client’s client’s relationship to his or her fertility, educational background or current school- desire to have biological children, and ing. Identify any history of learning prob- potential plans to preserve fertility should lems, or developmental challenges that be thoroughly explored. Previous therapy have impacted schooling or work life. should be noted, including in- or outpatient The client’s current work and career goals mental health or substance-abuse treat- should be outlined, including the likeli- ment or psychiatric hospitalization. The hood of maintaining employment through client should be evaluated for anxiety, de- his or her transition and plans for transition pression, characterological disturbances, at work. and suicidality. Skills of daily living, in- F. Gender Issues: The client’s relationship to cluding basic hygiene, eating and sleeping his or her gender, from early childhood patterns, and relationship to social service through the present, should be thoroughly agencies should also be noted. Approval outlined. This establishes the history of for hormones depends on the client’s sta- gender-related issues. Examples of cross- bility, and issues that may prove stressing dressing, discomfort in his or her gen- should be addressed so that the treatment der role, body dysphoria, development of team (i.e., the mental health counselor transgender identity, and family reaction making the referral and the physician Downloaded By: [Lev, Arlene Istar] At: 14:09 12 July 2009 to the gender issues should be discussed. receiving the referral) can work together to Information about the current gender ex- support the client through any difficulties. pression, and the anticipated trajectory re- I. Summary: A description of the client’s garding transition should be outlined. behavioral characteristics, attitudes, affect, G. Social Support: This section should iden- maturity level, attitudes toward self, ability tify the client’s social supports, includ- to cope with stress, familial and social ing hobbies, community involvement, supports, strengths, and general outlook on friends, and social activities. Relationship life should be outlined. In the final section, to transgender-community resources and the clinician shares his or her observations access to information (including Internet of the client, including any concerns access) is also important to identify. Fa- about transition issues that might require milial support, or resistance, for transition continuing psychotherapy. Diagnostic should be noted. If the client is living at eligibility and readiness are established— home with parents, or living on a college potentially including an appropriate campus or in a work situation that is prob- diagnosis—and the recommendation for lematic, education and counseling should medical treatment is clearly stated.