Trans Mental Health and Social Work Resources, Harry Dixon, M.A., Katrina Hale, MSW, & Kelly Serafini, Ph.D. 1 Agenda • Gender Dysphoria Criteria • 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