Trans Mental Health and Social Work Resources, Harry Dixon, M.A., Katrina Hale, MSW, & Kelly Serafini, Ph.D.
1 Agenda
• Prevalence of Mental Health Disorders
• Safety (Suicide/Homicide)
• Treatment Outcomes & Mental Health
• Psychotherapeutic Considerations
• Patient Resources
2 BACKGROUND Kelly Serafini, Ph.D.
3 Being Transgender is Not a Mental Disorder
• Although Gender Dysphoria is a mental illness, being transgender itself is not a disorder and it is not pathological
• The dysphoria that is caused by the incongruence between physical anatomy and gender identity is distressing and it is treatable
4 Gender Dysphoria Disorder (Adults & Adolescents)
• Difference between one’s experienced/expressed gender and assigned gender, and significant distress or problems functioning
• Lasts at least 6 months
• And 2 of the following criteria are met: A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics A strong desire to be rid of one’s primary and/or secondary sex characteristics A strong desire for the primary and/or secondary sex characteristics of the other gender A strong desire to be of the other gender A strong desire to be treated as the other gender A strong conviction that one has the typical feelings and reactions of the other gender
5 Gender Dysphoria Disorder (Children)
• Lasts at least 6 months
• And 6 of the following criteria are met: A strong desire to be of the other gender or an insistence that one is the other gender A strong preference for wearing clothes typical of the opposite gender A strong preference for cross-gender roles in make-believe play or fantasy play A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender A strong preference for playmates of the other gender A strong rejection of toys, games and activities typical of one’s assigned gender A strong dislike of one’s sexual anatomy A strong desire for the physical sex characteristics that match one’s experienced gender
6 Among Children: Is it just a phase?
• Gender ‘atypical behavior’ is common among children, and likely developmentally appropriate
• The predictors that are most associated with Gender Dysphoria persisting into adulthood are: More intense symptoms and distress More persistence in gender identity Insistent and consistent in cross-gender statements and behaviors Use of more declarative statements (“I am a boy or girl” vs. “I want to be a boy or girl”)
• Estimated that between 12-50% of children diagnosed with Gender Dysphoria Disorder may identify as transgender as an adolescent or young adult (Drummond et al., 2008)
7 Gender Dysphoria is Not Body Dysmorphic Disorder
• Body Dysmorphic Disorder is based on the premise that one holds a distorted belief about the body, and treatment focuses on altering the beliefs.
• Gender Dysphoria, on the other hand, operates from the premise that the beliefs causing distress are valid. Instead of focusing on changing beliefs, treatment addresses altering the body in order to be in alignment with gender identity.
8 Being Transgender is not the same as Transvestic Disorder
• Transvestic Disorder is characterized by cross-dressing for sexual arousal
• Causes clinically significant distress and impairment
• Not centered on gender identity
9 Being Transgender is not the same as Drag
• Drag tends to center on performance and entertainment
• Most commonly associated with gay male (the community is also evolving to include trans individuals and female)
• Drag can vary substantially by background, gender identity, and reasons for participating in drag performances
10 Mental Health & The Scientific Data
• Growing body of research
• Historically a neglected area in the scientific literature
• 85% of trans identified persons have sought some form of mental health care
11 Prevalence of Mental Health Disorders (2015 US Transgender Survey Report)
• 39% of respondents were currently experiencing serious psychological distress, nearly eight times the rate in the U.S. population (5%).
• 29% of respondents reported illicit drug use, marijuana consumption, and/or nonmedical prescription drug use in the past month, nearly three times the rate in the U.S. population (10%).
• 40% of respondents have attempted suicide in their lifetime— nearly nine times the attempted suicide rate in the U.S. population (4.6%).
• Many also report elevated levels of trauma
12 13 14 15 Mental Health Concerns May or May Not Be Related to Gender Identity
• Directly Related: Gender dysphoria Mood changes as a result of treatment with hormones
• Indirectly Related: Minority stress Oppression/discrimination/hostility Sexual Objectification Secondary to other disorders (Ex: Eating disorder for the purposes of amenorrhea)
• Unrelated: Life stressors, substance use, psychiatric illness, etc.
16 Safety: Suicide
• Forty percent (40%) have attempted suicide in their lifetime, nearly nine times the rate in the U.S. population (4.6%).
• Seven percent (7%) attempted suicide in the past year—nearly twelve times the rate in the U.S. population (0.6%).
• Suicide is the leading cause of death in LGBTQ+ individuals aged 10-24, 4x’s more likely
• 38%-65% trans individuals will exp suicidal ideation
• If there’s a family rejection, the individual is 8xs more likely to attempted suicide
• Assess for suicidal ideation and have a pro-active safety plan in place
17 Safety: Homicide/Interpersonal Violence
• Overall homicide rate estimated to be lower than cis-gender individuals. (Dinno, 2017)
• Exception: Black and Latin@ transgender females are at a higher risk. (Dinno, 2017)
• Human Rights Campaign estimates 25 deaths in 2017 for transgender women of color
• Assess for perceived safety and have a plan in place (e.g., romantic partners; family members; etc.)
18 Social Support (2015 US Transgender Survey Report)
• 10% reported a family member was violent towards them
• 8% were kicked out of their homes
• 10% ran away from home
• 19% were rejected by spiritual communities
19 Social Support (2015 US Transgender Survey Report)
20 Treatment Outcomes
• Research supports positive treatment outcomes when patients receive trans-affirmative care, whether the treatment modality is psychotherapy, hormones, or surgery (Byne et al., 2012; Cohen- Kettenis et al., 2008; Davis & Meier, 2014)
• A meta-analysis found increased psychological wellbeing across 28 studies when participants received gender-affirming treatments (hormonal + surgery) (Murad et al., 2009).
21 Youth Treatment Outcomes
• N = 55
• Longitudinal
• Treatments: puberty suppression, hormonal replacement therapy, gender affirmation surgery
• After surgery in young adulthood, gender dysphoria was alleviated and the psychological functioning was comparable or better in comparison to the general population (de Vries et al., 2014)
22 Hormonal Treatment Outcomes
• Transgender males receiving hormonal treatment (testosterone) had lower levels of depression, anxiety, and stress in comparison to transgender males not receiving hormonal treatment (Colton Meier et al., 2011)
• Transgender females reported an increase in positive emotions following treatment (Slabbekoorn et al., 2001)
• Psychological relief reported following hormonal treatment (Slabbekoorn et al., 2001)
23 Surgical Treatment Outcomes
• Transgender females receiving hormonal treatment and had undergone genital reconstruction reported increased well-being (Kuiper & Cohen-Kettenis, 1988)
• In a sample of 232 transgender females, none reported outright regret with surgery. Only a few expressed occasional regret, which was due to unsatisfactory physical results of the surgery (Lawrence, 2003)
• Another sample of 107 transgender individuals reported no regret (De Cuypere et al., 2006)
• Even after surgery and with alleviated gender dysphoria, this population is at greater risk for suicide attempts and psychiatric inpatient care than the general population (Dhejne et al., 2011)
24 Family Outcomes
• A small body of research has found that the children of transgender parents do not suffer long-term negative impacts directly related to parental gender change (White & Ettner, 2004) Two primary factors associated with children's outcomes: Younger age at time of transition Good relationship between both parents during transition Only 4% had academic decline at the time of transition (which was confounded with parental divorce)
25 COURAGE
• Being one’s authentic self is an act of courage & vulnerability
• Recognize, respect, and affirm this with your patients
26 PSYCHOTHERAPEUTIC CONSIDERATIONS HARRY DIXON, M.A., L.M.H.C.
27 Current Status
• Respondents also reported the following problem areas that were present within the past 5 years • Did not know how to help me with my sexual orientation and/or gender identity/expression concerns • My sexual orientation and/or gender identity/expression became the sole focus of my mental health care despite not being the primary complaint • Provider made negative comments about my sexual orientation and/or gender identity/expression • Provider did not know how to help same-sex couples or mixed orientation couples
28 LGBTQ+ Specific Barriers
1. I do not know how to find a mental health provider that is LGBTQ+ competent
2. I cannot find a provider I am comfortable with who is also LGBTQ+ knowledgeable
3. I am concerned that my provider would not be supportive of my identity or behavior
4. There are no LGBTQ knowledgeable mental health services in my neighborhood/geographic region
5. I am afraid that my sexual orientation or gender identity will not be kept confidential
6. Several of the “out” providers I would visit are in the same social circle as me (e.g. attend the same social events)
Source: Mental Health America (MHA)
29 Risk factors
• Minority stress
• Prejudice, discrimination, and victimization
• External and Internalized homophobia
• Homonegativity AKA sexual identity distress
• Stigma and shame
• Family and peer rejection
• Lack of available resources and culturally competent treatment
• HIV status
• High risk behaviors
30 Minority Stress and Heterosexism
• Largest determinants of adverse mental health outcomes
• Often leads to shame, lower self-esteem, loss of belonging, and suicidal ideation
• Three major assumptions that underlie minority stress (Meyer, 2003) 1. Minority stress is a unique stressor that exists in addition to other stressors within an individual. Individuals experiencing minority stress are therefore required to make greater adaptation efforts than those who are not members of a stigmatized minority 2. It is chronic and pervasive 3. It is socially based and stems from social processes, institutions, and structures beyond the individual and which the individual has minimal to no control over
• The more exposed an individual is to minority stress the higher the probability of maladaptive behavior and psychiatric distress
• One focus of care should be on the minimization of the negative impact of minority stress and heterosexism
31 Shame
• Shame is “the intensely painful feeling or experience of believing that we are flawed and therefore unworthy of love and belonging…” – Brene Brown
• Given the prevalence of heterosexual privilege, many LGBTQ+ individual struggle with shame
• Shame is highly correlated with addiction, mood disorders, and problematic behaviors
• “The antidote to shame is empathy” – Brene Brown
32 Protective Factors
• Access to effective, sensitive, and affirming care
• Restricted access to lethal means
• Community support
• Increased coping skills
• Strong family and peer connection
• Spiritual connectedness
33 Major Mental Health Concerns
• Stigma and shame
• Anxiety
• Substance Abuse and other problematic high risk behavior
• PTSD
• Eating disorders, body dysmorphia, unhealthy perceptions of beauty standards
• Gender dysphoria
• Intimate Partner Violence/Domestic Violence
34 Treatment Options
• Cognitive Behavioral Therapy (CBT)
• Acceptance and Commitment Therapy (ACT)
• Motivational Interviewing (MI)
• Mindfulness/Self-Compassion Focused Therapies (DBT & CFT)
• Gay Affirmative Therapy (Kort, 2008)
• Gay Affirmative Practice Model (GAP) (Van der Bergh and Crisp, 2004)
35 Treatment Goals
• Reduce impact of psychiatric symptoms on client’s daily functioning
• Learn effective coping skills
• Help client identify and reduce the impact of shame
• Help client understand the impact of heterosexual privilege on their lives
• Assist client in their coming out process and identity formation
• Help client create and maintain meaningful and supportive relationships
36 Gay Affirmative Therapy (Joe Kort Ph.D.)
• GAT explores the trauma, shame, alienation, isolation, and neglect that occur to LGBTQ+ clients
• It is not supposed to explain all the problems but be an essential inclusion to therapy
• Emphasizes depathologization and acceptance of the client’s lived experiences
• Key Focus: • Understand the impact of heterosexual privilege on LGBTQ+ client • The grief associated with the loss of heterosexual privilege can manifest as a factor in their mental health • Use appropriate self-disclosure to facilitate rapport building and understanding • Make the therapeutic setting as welcoming and positive as possible
37 Gay Affirmative Practice Model
• 6 Major Themes for garnering cultural competence • Attitudes 1. Same gender sexual desires and behaviors are viewed as a normal variation in human sexuality 2. The adoption of LGBTQ+ identity is a positive outcome of any process in which an individual is developing a sexual identity. • Knowledge 3. Service providers should not automatically assume that a client’s sexual orientation and/or gender identity/expression 4. It is important to understand the coming out process and its variations • Skills 5. Practitioners need to be able to deal with their own heterosexual bias and homophobia 6. When assessing a client, practitioners should not automatically assume a client is heterosexual • Core of this model is an “unconditional positive regard and acceptance of a client that affirms a client’s sense of dignity and worth”
38 Self-Compassion Focused Therapy (CFT)
• Based on Buddhist traditions and philosophies and mindfulness and neuroscience
• CFT is focused on attempting to cultivate compassionate coping skills to manage emotional pain
• Compassion is necessary for us to turn our attention toward, and open to, uncomfortable emotions and physical sensations in order for us to better understand ourselves and our experiences
• Compassion motivates us to make positive actions
• Teaching clients the skills to practice compassion and empathy for themselves helps alleviate the pain of shame
• Targets the activation of the soothing system so that it can be more readily accessed and used to regulate threat based emotions
39 Intersectionality: Multiple Marginalized Identities
• Older Adults Transgender older adults are at a higher rate of suicide, even when compared to LGB older adults (Auldridge et al., 2012) May face increased discrimination from those that question if they are really invested into transitioning so late in life May face discrimination from friends and loved ones that are surprised to learn of the ‘new’ transgender identity
• Racial/Ethnic Minorities Increased risk for homicide and interpersonal violence (Dinno, 2017)
• People with Disabilities Transgender people with disabilities were more likely to be currently experiencing serious psychological distress (59%) and more likely to have attempted suicide in their lifetime (54%). They also reported higher rates of mistreatment by health care providers (42%). (2015 US Transgender Survey Report)
40 SOCIAL WORK AND PATIENT RESOURCES KATRINA HALE, MSW
41 Social Work’s Role in Care
•Advocate •Facilitate •Support •Connect
42 Social Work’s Role: Community Resources specifically for the trans* population Many organizations serve the trans* community, but these organizations specifically serve the trans* population: Ingersoll: provides list of trans* friendly healthcare providers, trans competency training for professionals, and peer support groups. Great resources online at http://ingersollgendercenter.org/*
Gender Justice League: Advocacy, community building (Trans*Pride), trainings for professionals, and leadership building*
Washington Gender Alliance: Weekly support meetings in Everett, Bellingham, and Shoreline.
Utopia: Serves the Pacific Islander trans* community*
Trans Lifeline: hotline staffed by trans* people for trans* people
43 Social Work’s Role: Community Resources for youth/young adults
• Gender Clinic, Seattle Children’s Hospital (under 21)*
• Youth Care: (Ages 12-24) Serves homeless and at-risk youth. LGBTQ Friendly. Job training, drop-in center, meals, case management, and shelter.
• Lambert House: (Ages 11-22): Drop-in Center, support groups, workshops, case management and more!*
• New Horizons Ministry: (Ages 13-23) Serves homeless and at-risk youth. LGBTQ friendly. Drop- in center, meals, activities, and shelter.
• Camp Ten Trees: camp for youth of LGBTQ and nontraditional families, LGBTQ youth, and their allies.*
• Gender Diversity: Support groups for families with trans and gender diverse youth; host Gender Odyssey conference for professionals and families; trainings for health care providers and much more!*
44 Social Work’s Role: Community Resources for LGBTQ Adults Northwest Network : provides advocates and support for survivors of violence and abuse (hotline), community engagement and education (such as Relationship Skills classes), trainings for community members, and programs for youth
Center for Multicultural Health: Hosts Emerald City Black Pride and provides HIV testing/counseling for African American MSM*
Pride Asia: empower, celebrate and nurture the multi-cultural diversity of the LGBTQ community through the Asian Pacific Islander lens*
Gay City: Provides health services and connects people to community resources. www.gaycity.org*
45 Social Work’s Role: Community Resources for LGBTQ Adults Seattle Counseling Services: Provides counseling services to the LGBTQ community*
Entre Hermanos: Provides support to the Latinx LGBTQ community through disease prevention, education, support services, advocacy, and community building*
POCAAN: predominately serves communities of color and those hardest to get into care. Programs include education, outreach, HIV prevention/awareness, criminal justice programs and health advocacy.*
46 Where to find Mental Health Providers • Seattle Counseling Services • Ingersoll Gender Center Provider List: http://ingersollgendercenter.org/providers List of providers who have experience serving the transgender community (including medical providers) • www.psychologytoday.com • And more…(e.g., community mental health agencies, programs, specific providers, etc.)
47 Resources
• Rainbow Health Initiative (http://www.rainbowhealth.org/)
• LGBTQ Clients in Therapy: Clinical Issues and Treatment Strategies (book by Joe Kort)
• Mental Health America, First Do No Harm (brochure)
• PFLAG (http://pflag.org)
48 References
• Auldridge, A., Tamar-Mattis, A., Kennedy, S., Ames, E., & Tobin, H. J. (2012). Improving the lives of transgender older adults: Recommendations for policy and practice. New York, NY: Services and Advocacy for LGBT Elders & Washington. DC: National Center for Transgender Equality. Retrieved from http://www.lgbtagingcenter.org/resources/ resource.cfm?r520
• Byne, W., Bradley, S. J., Coleman, E., Eyler, A. E., Green, R., Menvielle, E. J., . . . American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. (2012). Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Archives of Sexual Behavior, 41, 759 –796.
• Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., & Gooren, L. J. G. (2008). The treatment of adolescent transsexuals: Changing insights. Journal of Sexual Medicine, 5, 1892–1897.
• Colton Meier, S.L., Fitzgerald, K.M., Pardo, S.T., & Babcock, J. The effects of hormonal gender affirmation treatment on mental health in female-to-male transsexuals. Journal of Gay and Lesbian Mental Health, 15, 281-299.
• Davis, S. A., & Meier, S. C. (2014). Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female-to-male transgender people. International Journal of Sexual Health, 26, 113–128.
• De Cuypere, G., Elaut, E., Heylens, G., Van Maele, G., Selvaggi, G., T’Sjoen, G., Rubens, R., Hoebeke, P., & Monstrey, S. (2006). Long-term follow-up: Psychological outcome of Belgian transsexuals after sex reassignment surgery. Sexologies, 15, 126-133.
• de Vries, A.L.C., McGuire, J.K., Steensma, T.D., Wagenaar, E.C.F., Doreleijers, T.A.H., & Cohen-Kettenis, P.T. (2014). Young adult psychological outcome after puberty suppresion and gender reassignment. Pediatrics,134, 696-704.
• Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A.L.V., Langstrom, N., & Landen, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden. PLOS One, 6, e16885.
49 References
• Dinno, A. (2017). Homicide rates of transgender individuals in the United States: 2010-2014. American Journal of Public Health.
• Drummond, K. D., Bradley, S. J., Peterson-Badaali, M., & Zucker, K. J. (2008). A follow- up study of girls with gender identity disorder. Developmental Psychology, 44, 34 – 45.
• Kuiper, B., & Cohen-Kettenis, P. (1988). Sex-reassignment surgery: A study of 41 Dutch transsexuals. Archives of Sexual Behavior, 17, 439–457
• Lawrence, A.A. (2003). Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Archives of Sexual Behavior, 32, 299-315.
• Murad, M.H., Elamin, M.B., Garcia, M.Z., Mullan, R.J., Murad, A., Erwin, P.J., & Montori, V.M. (2009). Hormonal therapy and sex reassignment: A systemic review and meta-analysis of quality of life and psychosocial outcomes. Clinical Endocrinology, 72, 214-231.
• Slabbekoorn, D., Van Goozen, S.H.M., Gooren, L.J.G., & Cohen-Kettenis, P.T. (2001). Effects of cross-sex hormone treatment on emotionality in transsexuals. The International Journal of Transgenderism, 5, 2.
• Steensma, T.D., McGuire, J.K., Kreukels, B.P.C., Beekman, A.J., & Cohen-Kettenis, P.T. (2013). Factors associated with desistence and persistence of childhood gender dysphoria: A quantitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 582-90.
• White, T., & Ettner, R. (2007). Adaptation and adjustment in children of transsexual parents. European Child and Adolescent Psychiatry, 16, 215–221.
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