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Gender Identity Dysphoria The Nature of Transsexualism A Brief Overview

Gender Identity Dysphoria The Nature of Transsexualism A Brief Overview. Lewis and Clark College November 23, 2009. Sara Becker, MD .

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Gender Identity Dysphoria The Nature of Transsexualism A Brief Overview

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  1. Gender Identity DysphoriaThe Nature of TranssexualismA Brief Overview Lewis and Clark College November 23, 2009 Sara Kristine Becker, MD

  2. 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 Sara Kristine Becker, MD

  3. Hobbies Fly-fishing with Brother-in-law Sara Kristine Becker, MD

  4. Cases in Point Sara Kristine Becker, MD

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

  6. To Change Ones Gender • 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) Sara Kristine Becker, MD

  7. Jurassic Park Sara Kristine Becker, MD

  8. Finding Nemo Sara Kristine Becker, MD

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

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

  11. Gender Identity Dysphoria • 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 Sara Kristine Becker, MD

  12. Gender Identity Dysphoria • Transsexualism (Christine Jorgenson) • History • Incidence .2 to 1.0% (true incidence is unknown) • Males to Females (M2F) or MTF • Females to Males (F2M) or FTM Sara Kristine Becker, MD

  13. Gender Identity Dysphoria • Who you are • Who you love Sara Kristine Becker, MD

  14. The Farthest Journey • A Journey too Far • A Trip from one existence to another • How long does it really take? 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 Sara Kristine Becker, MD

  16. The Shell Cracks • The pain of not being--?relation to testosterone • The emergence of Gender Identity Dysphoria • The Ultimate Dilemma • Addressing the mirror • The spiral downward • Facing the end of being or a new being in the end Sara Kristine Becker, MD

  17. The Shell Cracks • Gender Identity Dysphoria is a situational depression. • It cannot be cured with drugs, therapy, or prayer • Dysphoria means difficult to bear in Greek • 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 Sara Kristine Becker, MD

  18. From “True Selves “ by Mildred Brown Sara Kristine Becker, MD

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

  20. Symptoms of GID • A situational depression • Drugs and Alcohol abuse • Devotion to profession, military commitment • To transition or not-endless rumination • The price of truth • Mildred Brown Sara Kristine Becker, MD

  21. The World Professional Association for Transgender Health, Inc Sara Kristine Becker, MD

  22. Treatment of Gender Identity Dysphoria • The World Professional Association for Transgender Health provides: • Certification and guidelines for counselors who treat transsexuals • Provide guidelines for cross gender hormone therapy • Provide guidelines for gender reassignment surgery (sex change surgery) 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” Sara Kristine Becker, MD

  24. Steps in Transition • Counseling • Electrolysis or Laser to remove the beard • Hormone Therapy to change the body • The Real Life Test • Surgery • Beyond Sara Kristine Becker, MD

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

  26. Issues of Transition Dealt with in Counseling • Timing of transitioning • Hormone therapy • Informing spouses • Informing children • Informing friends • Informing relatives • Job preservation • Survival Sara Kristine Becker, MD

  27. The Role of the Therapist Weighing the options Timing No attempt to cure Sara Kristine Becker, MD

  28. 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. • Mildred Browns book “True Selves” Sara Kristine Becker, MD

  29. Issues of Transition • Electrolysis • Hormone therapy • Preserving hair –Rogaine, Finasteride, Avodart • Voice • Walking • Mannerisms and clothing • Physical changes • Legal changes • Work • Surgery Sara Kristine Becker, MD

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

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

  32. Hormone Therapy • Estrogen to change the body to a feminine form and soften the skin in M2F • Antiandrogens to block testosterone so the estrogen can work in M2F • Testosterone injections to change female forms to male Sara Kristine Becker, MD

  33. Effect of Hormones • Physical changes • Mental changes • Emotional changes Sara Kristine Becker, MD

  34. Estrogen in M2F • Conjugated estrogens (Premarin, Ogen) 0.625 to 7.5 mg. • Ethiny Estradiol (Estinyl) .02 to2.0. • Estradiol (Estrace) 0.5 to 6.0mg. • Estradiol Transdermal (Fempatch, Alora, Climara, Estraderm) .1 to .2. • Delestrogen () 40 mg q 2 weeks. Sara Kristine Becker, MD

  35. Antiandrogensin M2F • Block the production and effects of testosterone. • Use allows a lower dose of estrogen to produce the same feminization but reduce the risks of estrogen. • Many different kinds but many are expensive. • Spironolactone most common drug used Sara Kristine Becker, MD

  36. Antiandrogensin M2F • Spironolactone (Aldactone) 100-400 mg is a diuretic but very effective at blocking testosterone, both synthesis and at a receptor level. • Side effects are- breast swelling, GI upset, drowsiness, headache, rash, confusion, fever, decreased libido, vomiting, balance problems, fever, elevated potassium. • Very useful to measure free testosterone levels. Sara Kristine Becker, MD

  37. Typical Hormone Therapies in F2M • 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 Sara Kristine Becker, MD

  38. Steps Before Initiating Hormone Therapy • The DSM IV criteria • The WPATH standards • “The Letter” • Physical exam • Laboratory tests • Contraindications for therapy Sara Kristine Becker, MD

  39. History and Physical Examination • 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 Sara Kristine Becker, MD

  40. Survival • Be flexible • Support groups • Churches • Journal • Internet Sara Kristine Becker, MD

  41. Identification • The importance of proper identification • The role of the therapist • Drivers licenses • Letter of passage Sara Kristine Becker, MD

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

  43. Real Life Test • Usually one year • One has to work as the future gender • Time off work for SRS Sara Kristine Becker, MD

  44. Facial Surgery • Forehead • Nose • Upper lip • Chin—sliding genioplasty • Jaw • Tracheal Shave • Doug Osterhoud, MD • Electrolysis Sara Kristine Becker, MD

  45. Sex Reassignment Surgery • 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, PhD., MD • Ten surgeons in the world Sara Kristine Becker, MD

  46. Sex Reassignment Surgery in Females to Males • Sex Reassignment Surgery in F2M usually limited to Breast reconstruction “top surgery” • Genital surgery limited Sara Kristine Becker, MD

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

  48. How long Does it Take • Range is 2 to 5 years • Real answer is at least 5 years • Probably a lifetime Sara Kristine Becker, MD

  49. Most Important • 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. Sara Kristine Becker, MD

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

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