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Uncovering Medical and Mental Health Professionals' Decision- Making in the Treatment of Trans-Variant Patients

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Uncovering Medical and Mental Health Professionals' Decision- Making in the Treatment of Trans-Variant Patients Loyola University Chicago Loyola eCommons Dissertations Theses and Dissertations 2010 Uncovering Medical and Mental Health Professionals' Decision- Making in the Treatment of Trans-Variant Patients Jodie M. Dewey Loyola University Chicago Follow this and additional works at: https://ecommons.luc.edu/luc_diss Part of the Gender and Sexuality Commons Recommended Citation Dewey, Jodie M., "Uncovering Medical and Mental Health Professionals' Decision-Making in the Treatment of Trans-Variant Patients" (2010). Dissertations. 140. https://ecommons.luc.edu/luc_diss/140 This Dissertation is brought to you for free and open access by the Theses and Dissertations at Loyola eCommons. It has been accepted for inclusion in Dissertations by an authorized administrator of Loyola eCommons. For more information, please contact [email protected]. This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License. Copyright © 2010 Jodie M. Dewey LOYOLA UNIVERSITY CHICAGO UNCOVERING MEDICAL AND MENTAL HEALTH PROFESSIONALS’ DECISION-MAKING IN THE TREATMENT OF TRANS-VARIANT PATIENTS A DISSERTATION SUBMITTED TO THE FACULTY OF THE GRADUATE SCHOOL IN CANDIDACY FOR THE DEGREE OF DOCTOR OF PHILOSOPHY PROGRAM IN SOCIOLOGY BY JODIE M. DEWEY CHICAGO, IL AUGUST, 2010 Copyright by JODIE M. DEWEY, 2010 All rights reserved ACKNOWLEDGMENTS I would like to thank Dr. Anne Figert for helping to organize my thoughts and my writing. Without her guidance I would still be swimming in data. I also must acknowledge my husband, Scott, for being so generous with his time and energy. He encouraged me to continue this project, graciously dealt with my many melt-downs, and never made me feel guilty for taking up time which rightfully belonged to him and our son, Aedan. iii For My Two Guys TABLE OF CONTENTS ACKNOWLEDGEMENTS iii ABSTRACT viii CHAPTER ONE: INTRODUCTION 1 Definition of Terms 1 My Research: Filling Gaps in the Field 5 Dissertation Chapters 6 CHAPTER TWO: LITERATURE REVIEW 8 Historical Development of Trans-Variant Social and Medical Identities 12 Current Medical and Mental Health Documents 28 Standards of Care (SOC) 29 The Diagnostic Statistical Manual (DSM-IV-TR) 33 International Classification of Diseases (ICD-10) 35 CHAPTER THREE: METHODS 37 Data Collection 40 Challenges 41 Confidentiality 42 Interaction of Trans-patients, Medical and Mental Health Providers 44 Conclusion 46 CHAPTER FOUR: FORMAL AND INFORMAL KNOWLEDGE 47 Formal Training 47 Informal Knowledge 52 Finding Resources 52 Interactions 55 Interactions with Trans-Patients 55 Interaction with Other Professionals 60 Trial and Error 66 Conclusion 70 CHAPTER FIVE: PROFESSIONALS’ UNDERSTANDING OF OFFICIAL DOCUMENTS USED IN THE TREATMENT OF OF TRANS-PEOPLE 71 ICD-10 72 DSM-IV-TR 72 History 72 Purpose of DSM-IV-TR in Identifying and Treating Trans-People 73 Current DSM Debates 75 v SOC 76 History 76 Purpose of SOC in Treating Trans-People 76 Current SOC debates 77 Professionals’ Use of the DSM-IV-TR and SOC 80 Identifying ‘Real’ Transsexuals 81 Grappling with DSM Diagnoses and Language 90 DSM Needs to be Empirically Grounded 96 SOC Provides Credibility and Protection 98 Re-Working SOC and DSM Guidelines 105 DSM and Insurance Companies 105 SOC 113 Conclusion 116 CHAPTER SIX: TYPES OF PATIENTS 118 Difficult Patients 118 Patient Time Demands 119 Patient Unrealistic Expectations 123 Unrealistic Surgical Expectations 124 Unrealistic Social Expectations 126 Patient Co-Morbidity 128 Responses to Difficult Patients 133 Rewarding Patients 136 Making Professionals Feel Good 136 Making Professionals Work Easier 138 (Un)Successful Patients 140 Engaging in the Process 141 Function 144 Socially Functional 144 Sexually and Physically Functional 146 Conclusion 150 CHAPTER SEVEN: THE PARADOX MAKING DECISIONS IN LIGHT OFOFFICIALUNDERSTANDING AND IDIOSYNCRATIC USES OF KNOWLEDGE 151 Re-Interpreting the Professional Role 152 Addressing the Paradox: Professionally-Guided Patient Decision-Making 156 Ensuring Time and Process 157 Recognizing Co-Morbidity 167 Preparing Patients for Surgery 172 When Treatment is Not an Option 175 Conclusion 180 vi CHAPTER EIGHT: CONCLUSION 183 Knowledge Paradox 183 Decision-Making Paradox 188 Diagnosing 189 Treatment Path 191 Larger Messages for Gender and Medical Work 193 Doctor-Patient Messages 193 Gendered Messages 195 Research Implications 197 DSM-V 197 SOC (7 th Edition) 200 REFERENCE LIST 206 VITA 211 vii ABSTRACT This project is a study of medical and mental health professionals who treat trans- variant patients. Using in-depth interviews, I show how providers describe the process by which they make decisions with patients who desire, through formal means, to hormonally and/or surgically transition from one gender to the other. This work uncovers the ways professionals make decisions in the absence or limitation of formal knowledge while simulaneously attemping to ground their work in this same knoweldge to obtain respect and legitimacy. Professionals must also acknowledge that they relinquesh some power to patients to make decisions which involve high risk for them. Providers attempt to balance these demands all while attempting to be viewed by their trans-patients as ‘good’ doctors and therapists and not gatekeepers. viii CHAPTER ONE INTRODUCTION In an earlier project, I interviewed 23 trans-identified indivdiuals about their biggest concern related to discrimination and harassment (Dewey 2008). Overwhelmingly, respondents stated that navigating medical and mental health insititutions as one of their most profound concerns. From sensing evaporation of professionals’ warm bedside manner after discovering their trans-status to believing that professional’s blantantly disregarded their medical and therapuetic needs, many trans- people experienced various forms of mistreatment. These findings were the impetus for my interest in studying medical and mental health professionals’ perceptions of treating the trans-identified patient. Definition of Terms “Trans-identified individuals” are people who have cross-gendered identification. They permanently live, or occasionally present in the gender opposite to the one they were assigned at birth. Some may also choose to present or live between the dichotomy of male and female, as neither always, or fully, one or the other. Trans-identified individuals, a more recent term, stems from the word ‘Trans’ which was first used by a parliamentary discussion group in London (1998) in hopes of being inclusive when urging for equality legislation (Whittle 2006). While many people identify as Trans, there are various ways that one may choose to transition to the gender they believe 1 2 themselves to be. Some may choose to physically, surgically, and/or hormonally adapt their bodies to their gender identity while others cannot or choose not to transition in these ways. Some may formally, through medical and psychiatric systems, or informally, such as illegal means, seek out ways to physically and/or medically transition from one gender to the other. Genetic males, who wish to transition to female, may choose to take hormones in order to physically alter their body by using estrogen to femininze the body; genetic females may take testosterone to masculinze the body. Some trans-identified people decide to surgically transition. Examples of surgical transition may include masectomy, penectomy, orchiectomy, hysterectomy, breast augmentation, and gender confirmation surgery (CGS). There are many reasons why trans-people may decide to obtain these interventions and many reasons why they may not, such as cost, health problems, or disinterest in transitioning in this manner. In the U.S., those who choose to hormonally and/or medically transition through formal channels, must follow a particular process and involve specific types of professionals to obtain these services. Trans-identified individuals, who want to physically and medically transition from one gender to the other, must seek assistance from both medical and mental health professionals. This requirement is outlined in two main documents used by professionals: The Diagnostic Statistical Manual (DSM-IV-TR) and the Standards of Care (SOC) which I will describe in more detail in upcoming chapters. Medical professionals who provide transitioning-related services include plastic surgeons, endocrinologists, family physicians, and urologists. Medical 3 professionals will not perform these services until they receive verification, usually in the form of a letter, from at least one psychologist or psychiatrist that the patient has been diagnosed as having gender identity disorder (GID); however, surgeons performing gender confirmation surgery (GCS) require two letters of GID confirmation, at least one from a PhD-level therapist. Mental health providers include psychologists, licensed social workers, sex therapists, and psychiatrists. The letter is a requirement outlined in the SOC which clarifies that the letter must mention a DSM diagnosis of Gender Identity Disorder (GID) in order to access medical interventions. Therefore, the letter actually connects these documents together; each giving the other legitmacy. If patients want legally prescribed hormones, they must then seek out a family physician or endocrinologist who is willing to prescribe to trans-people. If they desire surgeries, they must find a plastic surgeon willing and able to perform the surgery they want. Therefore, this project is about a very specific group of medical and mental health professionals: those who medically
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