Notes on Gender Role Transition
By Anne Vitale Ph.D.

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Gender Identity Disorder Treatment Plan

Updated on 11/29/2011

Based on the WORLD PROFESSIONAL ASSOCIATION FOR TRANGENDER HEALTH STANDARDS OF CARE FOR GENDER IDENTITY DISORDERS -- SEVENTH VERSION

Triadic Treatment Sequence

Stage I: Establish a therapeutic relationship, evaluation, diagnosis, education and psychotherapy as required.

Stage II: If applicable, referral to Physician for Hormone Replacement therapy. Also used for confirmation or rejection of diagnosis. Continue individual psychotherapy as required.

Stage III: Monitor gender role transition, serve as an authoritative intermediary in matters pertaining to work and family. If applicable, make referral for Gender Reassignment Surgery after a minimum of 1 year of living full time in the preferred gender role. Post-op follow-up as necessary.


Stage I: Establish a therapeutic relationship, evaluation, diagnosis, education and psychotherapy as required.

First session: Intake... which includes an informal mental status exam and a preliminary exploration of the presenting problem. If client describes being gender dysphorhic consider Gender Identity Disorder (GID) 302.85 per DSM IV as the primary diagnosis. Evaluate for co-morbidity and check to see if patient is self medicating (taking cross sex hormones). If patient is self-medicating or reports abuse of controlled substances, make immediate referral to physician for a health evaluation. If patient is married, in an intimate relationship or has under age children, consider making a referral to a Marriage and Family therapist knowledgeable of gender identity issues.

Follow up sessions: Objectives and Progress Evaluation: Many adults with gender identity issues find comfortable, effective ways of living that do not involve all the components of the triadic treatment sequence. While some individuals manage to do this on their own, psychotherapy can be very helpful in bringing about the discovery and maturational processes that enable self-comfort.

Psychotherapy often provides education about a range of options not previously seriously considered by the patient. It emphasizes the need to set realistic life goals for work and relationships, and it seeks to define and alleviate the patient's conflicts that may have undermined a stable lifestyle.

The establishment of a reliable trusting relationship with the patient is the first step toward successful work as a mental health professional. This is usually accomplished by competent nonjudgmental exploration of the gender issues with the patient during the initial diagnostic evaluation. Other issues may be better dealt with later, after the person feels that the clinician is interested in and understands their gender identity concerns.

Ideally, the clinician's work is with the whole of the person's complexity. The goals of therapy are to help the person to live more comfortably within a gender identity and to deal effectively with non-gender issues. The clinician often attempts to facilitate the capacity to work and to establish or maintain supportive relationships. Even when these initial goals are attained, mental health professionals should discuss the likelihood that no educational, psychotherapeutic, medical, or surgical therapy can permanently eradicate all vestiges of the person's original sex assignment and previous gendered experience.

Psychotherapy is a series of interactive communications between a therapist who is knowledgeable about how people suffer emotionally and how this may be alleviated, and a patient who is experiencing distress. Typically, psychotherapy consists of regularly held 50-minutes sessions. The psychotherapy sessions initiate a developmental process. They enable the patient's history to be appreciated , current dilemmas to be understood, and unrealistic ideas and maladaptive behaviors to be identified. Psychotherapy is not intended to cure the gender identity disorder. Its usual goal is a long-term stable life style with realistic chances for success in relationships, education, work, and gender identity expression. Gender distress often intensifies relationship, work, and educational dilemmas. The therapist should make clear that it is the patient's right to choose among many options. The patient can experiment over time with alternative approaches.

Ideally, psychotherapy is a collaborative effort. The therapist must be certain that the patient understands the concepts of eligibility and readiness, because the therapist and patient must cooperate in defining the patient's problems, and in assessing progress in dealing with them. Collaboration can prevent a stalemate between a therapist who seems needlessly withholding of a recommendation, and a patient who seems too profoundly distrusting to freely share thoughts, feelings, events, and relationships. Patients may benefit from psychotherapy at every stage of gender evolution. This includes the post-surgical period, when the anatomic obstacles to gender comfort have been removed, but the person may continue to feel a lack of genuine comfort and skill in living in the new gender role.

Options for Gender Adaptation: The activities and processes that are listed below have, in various combinations, helped people to find more personal comfort. These adaptations may evolve spontaneously and during psychotherapy. Finding new gender adaptations does not mean that the person may not in the future elect to pursue hormone therapy, the real life experience, or genital surgery.

Activities:

Biological Males Cross-dressing: unobtrusively with undergarments, unisexually or in a feminine fashion. Changing the body through hair removal through electrolysis or body waxing. Having minor plastic cosmetic surgical procedures, Increasing grooming, wardrobe, and vocal expression skills.

Biological Females Cross-dressing: unobtrusively with undergarments, unisexually, or in a masculine fashion; Changing the body through breast binding, weight lifting, applying theatrical facial hair; Padding underpants or wearing a penile prosthesis.

Both Genders Learning about transgender phenomena from: support groups and gender networks, communication with peers via the Internet, studying the HBIGDA Standards of Care, relevant lay and professional literature about legal rights pertaining to work, relationships, and public cross-dressing; Involvement in recreational activities of the desired gender; Episodic cross-gender living.

Processes: Acceptance of personal homosexual or bisexual fantasies and behaviors (orientation) as distinct from gender identity and gender role aspirations. Acceptance of the need to maintain a job, provide for the emotional needs of children, honor a spousal commitment, or not to distress a family member as currently having a higher priority than the personal wish for constant cross-gender expression. Integration of male and female gender awareness into daily living. Identification of the triggers for increased cross-gender yearnings and effectively attending to them, for instance, developing better self-protective, self-assertive, and vocational skills to advance at work and resolve interpersonal struggles to strengthen key relationships.


Stage II: Hormone Replacement Therapy If applicable and patient feels a need to go further in cross gender exploration, a formal referral to physician for Hormone Replacement Therapy is made. It is well documented that the administration of cross sex hormones have a mitigating effect on patents suffering from severe gender dysphoria. The effect is so marked that the treatment is used to confirm or reject the GID diagnosis. Fortunately. psychological outcomes precede permanent physiological secondary sex characteristic changes, making it an ideal diagnostic confirmation/contraindicating tool. Referral is made to a physician who is well versed in the administration and monitoring of patients taking cross sex hormones.

Psychotherapy: Early Stage: Patient is closely monitored for adverse psychological effects of HRT. If no adverse effects are detected or reported and patient reports relief and wishes to continue HRT, patient is educated and prepared for psychological and physiological changes to secondary sex characteristics that are well known to result from the treatment.

Some individuals accept the physical and psychological changes brought about by HRT and incorporate them into their originally assigned gender role. Others may choose to transition to living full time in the new gender role.

Later Stages: If patient decides to transition, encourage and support new gender role behaviors and the start of living full time in the new gender role. Provide logistic support via letters and the signing of forms to aid in the changing of Driver’s License, Social Security status and other identification papers, educate family, friends, and employer. Continue to monitor progress via individual/group therapy.


Stage III Sex Reassignment Surgery: Although Sex Reassignment Surgery (SRS) is not required, it is often requested. If the patient has successfully completed at least one year of living full time in the new gender role, the individual is technically qualified for SRS. At this point in treatment, patient should be well educated about the choices of surgical procedures available and specialty surgeons of record. Final approval for SRS requires two letters of referral. Both must be from a mental health professional who is qualified to treat individuals with GID. One letter must be from the patient's primary therapist (in this case that would be me). The second letter serves as a second opinion as to the readiness of the patient to undergo surgery. A list of therapist qualified to give a second opinion will be provided.

Post-op: Psychotherapy to help patient make final adjustments to the realities of his or her new life.

Anne Vitale Ph.D. Licensed Psychologist California #PSY15764