Gender Identity Dysphoria The Nature of Transsexualism A

Gender Identity Dysphoria The Nature of Transsexualism A Brief Overview Lewis and Clark College November 23, 2009 9/30/2020 Sara Kristine Becker, MD 1

Sara Becker, MD Sara Kristine Becker is a board certified Family Physician who has practiced Family Medicine in Portland, Oregon for 30 years. She obtained a Bachelors of Science in Computer Science at Michigan State University where she taught for two years. She graduated from the University of Michigan Medical School with her MD Degree in 1977. Her residency in Family Medicine was completed in 1980. She started her practice in Milwaukie, Oregon in 1980. She is a Diplomat of the American Board of Family Practice and an Associate Clinical Professor of Family Practice at Oregon Health Sciences University in Portland, Oregon. She is a licensed multiengine; instrument rated commercial pilot and an Aviation Medical Examiner for the Federal Aviation Administration. Her hobbies are flying, computers, piano, guitar, growing orchids, walking, and teaching. Her professional interests are general Family Medicine, Aviation Medicine, and hormone replacement therapy. She is a member of the Harry S. Benjamin International Gender Dysphoria Association, the Oregon Academy of Family Medicine, the Oregon Medical Association, and the American Academy of Family Physicians. She is on the Active Staff of Providence Milwaukie Hospital an the Courtesy Staff of Portland Adventist Medical Center. She was the 1989 Chief of Staff for Providence Milwaukie Hospital 9/30/2020 Sara Kristine Becker, MD 2

Hobbies Fly-fishing with Brother-in-law 9/30/2020 Sara Kristine Becker, MD 3

Cases in Point 9/30/2020 Sara Kristine Becker, MD 4

To Change Ones Gender Oddity, perversion or fact of nature l Frequency l Why is it important for health professionals to understand gender change or transsexualism in Human Beings? l 9/30/2020 Sara Kristine Becker, MD 5

To Change Ones Gender l l l Transsexualism or Gender Identity Dysphoria is a condition where a person feels they are the opposite gender. At some point in their lives , they are no longer able to live as the gender they have been assigned at birth. The need to hide what they are is overwhelmed by feelings of depression. (Man in a dress) 9/30/2020 Sara Kristine Becker, MD 6

Jurassic Park 9/30/2020 Sara Kristine Becker, MD 7

Finding Nemo 9/30/2020 Sara Kristine Becker, MD 9

The Variability of Nature Many different types of expression of sex. l Over 17 known intersexed conditions in Humans. l Some are genetic others biochemical l Understanding this variation may form the basis for transsexualism. l 9/30/2020 Sara Kristine Becker, MD 10

The Difference Between Sex and Gender Sex is the physical expression of genes. l Gender is the concept of how one relates to another in society (masculine vs feminine) and self perception. l The organic basis of gender identity may be a reflection of hormonal effects in utero l 9/30/2020 Sara Kristine Becker, MD 11

Gender Identity Dysphoria l l l Considered to be a birth defect Born with the body of one sex and the brain of another The disparity between body and mind produces depression which often becomes overwhelming Most likely related to intrauterine hormone exposure but true causes are unknown Considered throughout the civilized world as a medical condition not a psychiatric one The German Prisoner 9/30/2020 Sara Kristine Becker, MD 12

Gender Identity Dysphoria Transsexualism (Christine Jorgenson) l History l Incidence. 2 to 1. 0% (true incidence is unknown) l Males to Females (M 2 F) or MTF l Females to Males (F 2 M) or FTM l 9/30/2020 Sara Kristine Becker, MD 13

Gender Identity Dysphoria Who you are l Who you love l 9/30/2020 Sara Kristine Becker, MD 14

The Farthest Journey A Journey too Far l A Trip from one existence to another l How long does it really take? l 9/30/2020 Sara Kristine Becker, MD 15

Feelings and Memories Of Mind and Thought The Deep Feelings The Bedtime Prayer Living “The Lie” The False Construct Puberty the “Treason of the Body” The Wakening Dream 9/30/2020 Sara Kristine Becker, MD 16

The Shell Cracks The pain of not being--? relation to testosterone l The emergence of Gender Identity Dysphoria l The Ultimate Dilemma l Addressing the mirror l The spiral downward l Facing the end of being or a new being in the end l 9/30/2020 Sara Kristine Becker, MD 17

The Shell Cracks Gender Identity Dysphoria is a situational depression. l It cannot be cured with drugs, therapy, or prayer l Dysphoria means difficult to bear in Greek l Some patients become acutely suicidal when the feelings cannot be contained and they face a loss of all they hold dear knowing the stigma of changing gender l 9/30/2020 Sara Kristine Becker, MD 18

From “True Selves “ by Mildred Brown 9/30/2020 Sara Kristine Becker, MD 19

Gender Identity Dysphoria Since the mind cannot be changed, the body must be changed l In modern therapy, no attempt is made to cure the transsexual. Rather, options are explored l Some exist living part-time in the gender of their mind. Most seek to transition l Our society is not geared for us to live “In Between” l 9/30/2020 Sara Kristine Becker, MD 20

Symptoms of GID A situational depression l Drugs and Alcohol abuse l Devotion to profession, military commitment l To transition or not-endless rumination l The price of truth l Mildred Brown l 9/30/2020 Sara Kristine Becker, MD 21

The World Professional Association for Transgender Health, Inc l 9/30/2020 Sara Kristine Becker, MD 22

Treatment of Gender Identity Dysphoria The World Professional Association for Transgender Health provides: l Certification and guidelines for counselors who treat transsexuals l Provide guidelines for cross gender hormone therapy l Provide guidelines for gender reassignment surgery (sex change surgery) l 9/30/2020 Sara Kristine Becker, MD 23

“Transition” To change ones body and mind image to the gender Opposite to the cage one is born to. To learn to relate in society as one of the opposite Gender. The process of “Becoming” or “Transitioning” 9/30/2020 Sara Kristine Becker, MD 25

Steps in Transition Counseling l Electrolysis or Laser to remove the beard l Hormone Therapy to change the body l The Real Life Test l Surgery l Beyond l 9/30/2020 Sara Kristine Becker, MD 26

To Find a Chiron The importance of therapist who is skilled in treating transsexualism l What am I? l How do I adjust to what I am? l How do I make myself understood? l How do I forgive myself to not being “fixable” l How do I deal with so many others l 9/30/2020 Sara Kristine Becker, MD 27

Issues of Transition Dealt with in Counseling l l l l Timing of transitioning Hormone therapy Informing spouses Informing children Informing friends Informing relatives Job preservation Survival 9/30/2020 Sara Kristine Becker, MD 28

The Role of the Therapist Weighing the options Timing No attempt to cure 9/30/2020 Sara Kristine Becker, MD 29

Educating Others Being a transsexual means that one wishes to change how one relates to others in society as a member of the other gender. It does not mean one is gay, trying to deceive others or that this is a “life choice” Rather it is the way one has always been. l Mildred Browns book “True Selves” l 9/30/2020 Sara Kristine Becker, MD 30

Issues of Transition l l l l l Electrolysis Hormone therapy Preserving hair –Rogaine, Finasteride, Avodart Voice Walking Mannerisms and clothing Physical changes Legal changes Work Surgery 9/30/2020 Sara Kristine Becker, MD 31

Issues of Transition Economics l Male to female $20, 000 -$100, 000 l Female to male $10, 000 (top) to $100, 000 l Loss of job (70% of professional Ts in San Francisco are unemployed) l Physicians most likely to be fired l Divorce l 9/30/2020 Sara Kristine Becker, MD 32

Hormones It is the human sex hormones which shape the clay that becomes the being. l Human beings are not fixed permanently into one gender or another. l To a great degree, feminization and masculinization can occur in the same body at different stages of life. l 9/30/2020 Sara Kristine Becker, MD 33

Hormone Therapy Estrogen to change the body to a feminine form and soften the skin in M 2 F l Antiandrogens to block testosterone so the estrogen can work in M 2 F l Testosterone injections to change female forms to male l 9/30/2020 Sara Kristine Becker, MD 34

Effect of Hormones Physical changes l Mental changes l Emotional changes l 9/30/2020 Sara Kristine Becker, MD 35

Estrogen in M 2 F Conjugated estrogens (Premarin, Ogen) 0. 625 to 7. 5 mg. l Ethiny Estradiol (Estinyl). 02 to 2. 0. l Estradiol (Estrace) 0. 5 to 6. 0 mg. l Estradiol Transdermal (Fempatch, Alora, Climara, Estraderm). 1 to. 2. l Delestrogen () 40 mg q 2 weeks. l 9/30/2020 Sara Kristine Becker, MD 36

Antiandrogens in M 2 F Block the production and effects of testosterone. l Use allows a lower dose of estrogen to produce the same feminization but reduce the risks of estrogen. l Many different kinds but many are expensive. l Spironolactone most common drug used l 9/30/2020 Sara Kristine Becker, MD 37

Antiandrogens in M 2 F Spironolactone (Aldactone) 100 -400 mg is a diuretic but very effective at blocking testosterone, both synthesis and at a receptor level. l Side effects are- breast swelling, GI upset, drowsiness, headache, rash, confusion, fever, decreased libido, vomiting, balance problems, fever, elevated potassium. l Very useful to measure free testosterone levels. l 9/30/2020 Sara Kristine Becker, MD 38

Typical Hormone Therapies in F 2 M • Testosterone Cypionate 100 mg IM weekly or 200 mg. every two weeks • In Portland, often bought at Stroheckers pharmacy • Cannot give testosterone orally because of liver toxicity 9/30/2020 Sara Kristine Becker, MD 39

Steps Before Initiating Hormone Therapy The DSM IV criteria l The WPATH standards l “The Letter” l Physical exam l Laboratory tests l Contraindications for therapy l 9/30/2020 Sara Kristine Becker, MD 40

History and Physical Examination l l l Must be done to look for preexisting medical conditions which would complicate or preclude hormone therapy After hormone therapy is instituted, regular visits should be carried out at three to six month intervals to look for complications and adjust doses Insurances sometimes will cover this as hormone replacement therapy 9/30/2020 Sara Kristine Becker, MD 41

Survival Be flexible l Support groups l Churches l Journal l Internet l 9/30/2020 Sara Kristine Becker, MD 42

Identification The importance of proper identification l The role of therapist l Drivers licenses l Letter of passage l 9/30/2020 Sara Kristine Becker, MD 43

Real Life Test The real life test is the period of time that one must work in the gender one is becoming l With completion of the real life test, one can seek the two letters for Gender Reassignment Surgery (Sex Change Surgery) l 9/30/2020 Sara Kristine Becker, MD 44

Real Life Test Usually one year l One has to work as the future gender l Time off work for SRS l 9/30/2020 Sara Kristine Becker, MD 45

Facial Surgery l l l l Forehead Nose Upper lip Chin—sliding genioplasty Jaw Tracheal Shave Doug Osterhoud, MD Electrolysis 9/30/2020 Sara Kristine Becker, MD 46

Sex Reassignment Surgery l l l l Sex Reassignment Surgery is the goal of many but not all who are transgendered Can be offered only after the real life test Not an option for physicians and certain other professions There is a harmony in having your body match your mind Less fear of being “caught” in social situations The two letters—MA, Ph. D. , MD Ten surgeons in the world 9/30/2020 Sara Kristine Becker, MD 47

Sex Reassignment Surgery in Females to Males Sex Reassignment Surgery in F 2 M usually limited to Breast reconstruction “top surgery” l Genital surgery limited l 9/30/2020 Sara Kristine Becker, MD 48

In The End After all of the above what is left? l Time and experience l Posttraumatic Stess Disorder—regret, loss l Memories and reflections l Dreams, feelings and thoughts become one l To gaze on ones own countenance with peace l To savor the milieu, to just live l 9/30/2020 Sara Kristine Becker, MD 49

How long Does it Take Range is 2 to 5 years l Real answer is at least 5 years l Probably a lifetime l 9/30/2020 Sara Kristine Becker, MD 50

Most Important l l l It is not a choice of life, it is a biological imperative. Individuals with this cannot make it go away. It is a pain similar to what one feels in the death of a child. Often face with loss of all they hold dear, transsexuals often consider or attempt suicide. The transsexual is often an individual of extraordinary courage. It is not an attempt to deceive but to survive. Who you are and who you love are different areas of the brain. Over 30% male to female transsexuals stay with their mate if they can. 9/30/2020 Sara Kristine Becker, MD 51

Why Is It Important For Professionals to Understand Transsexuals There are many of us--thousands l We hide because of fear and prejudice l We are 16 times more likely to be murdered l We have the highest unemployment of any minority group l Not associated with any other mental or medical condition l 9/30/2020 Sara Kristine Becker, MD 52

Why is it Important For Professionals to Understand Transsexuals l l l Do we deprive the community of human beings because we do not understand? If a human were burned or paralyzed, would they be less a human being? Pope Innocent I removed the genitals from all the statures in the Vatican in 1492 because souls do not have genitals Transition does not change the essence of a Human being Would any Medical Professional deny a patient the only internationally recognized treatment for a condition because they do not themselves understand it. 9/30/2020 Sara Kristine Becker, MD 53

Why is it Important For Professionals to Understand Transsexuals The Health Professional may be the first outside of the transsexual themselves to know what is really happening. l How you respond may influence the future of that patient. l Almost all transsexuals consider suicide when the shell breaks. Estimates of 20% active attempt. l Suicide without a letter l 9/30/2020 Sara Kristine Becker, MD 54

Gender Dysphoria A human being who survives this has a unique perspective on both genders that can be helpful to others l You may be the only professional between a successful transition and failure l 9/30/2020 Sara Kristine Becker, MD 55

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Resources 9/30/2020 Sara Kristine Becker, MD 57

Web Resources annelawrence. com 9/30/2020 Sara Kristine Becker, MD 59

Web Resources sarabecker/t/index. htm 9/30/2020 Sara Kristine Becker, MD 60

Web Resources sarabecker/t/index. htm sara@sarabecker. com 9/30/2020 Sara Kristine Becker, MD 61

Questions? He who asks a question is a fool for five minutes He who fails to ask a question is a fool for life Old Chinese Proverb 9/30/2020 Sara Kristine Becker, MD 62