Chapter 1. Introduction

For better or worse, transgender and gender-nonconforming (TGNC) people are now in the midst of national political and social spotlights. For the first time in history, large portions of the world population are aware that gender diverse people exist. However, those who don’t fit so neatly into the gender binary are marginalized and shunned from public society. Most cultures have little tolerance for individuals who don’t follow general social gender norms.

The growing number of gender diverse people in the world is something of a misconception. Gender diverse people have existed as long as people have existed. The fact that greater society is now aware of them is mostly due to increasing safety and acceptance by communities. This was partly accomplished through advocacy organizations educating policy makers; research and scientific organizations educating clinicians; and, to a greater extent, the media of movies and television educating the general public. Regardless of the reason for this awareness, gender diverse people are now feeling more comfortable to come out and express their gender identity.

Now that so many people are aware of the TGNC population, there are more reactions to being around those who are gender diverse. Seeing people who are not like ourselves makes us question our own sense of self, and the presence of TGNC people has encouraged individuals to examine their own gender and the gender of others. Ideas about what is masculine and feminine are being called into question, and even people who do not necessarily identify as gender diverse are bending gender with the way they dress, how they talk, and the activities in which they participate. Society is being forced to look at the historical institution of gender now more than ever.

Despite the growing presence of gender diverse people in the media, the medical and mental health communities’ responses have been lacking. Gender clinics sparsely populate large urban areas, and those clinics tend to be over capacity with referrals of gender diverse people seeking care. The great majority of patients needing treatment either get poor treatment from those who are not TGNC competent or simply don’t seek services out of frustration and an inability to connect with clinicians who work with and understand gender diversity.

Given this information, the purpose of this book, above all else, is to increase access to care for TGNC people. The information in this book was selected in order to increase awareness and educate clinicians on how to address basic TGNC needs. My hope is that by reading this book, many mental health professionals, especially those who are timid about working with TGNC people, will feel more comfortable and confident in their ability to provide basic and safe care to those people who, at this time, don’t have any good options.

This book is aimed at those mental health professionals who want to work with TGNC people but don’t know how. Professional training programs provide little to no teaching regarding sexual orientation or gender diversity. By reading the chapters of this book, you will become familiar with the major topics, in both medical and mental health, that will start you on the path to creating a TGNC-competent practice.

The scope of this book is to target all mental health professionals, including psychiatrists, psychiatric nurse practitioners, psychologists, social workers, mental health counselors, art therapists, family therapists, pastoral counselors, and school counselors. The topics covered and the manner in which they are covered are meant to be both accessible and applicable to all of these professions. The amount of detail is intended to supplement the knowledge base and scope of practice of most mental health professionals. There are topics in this book that deserve more attention, and more details could have been put in each chapter to deepen the amount of information provided. However, this book is not meant to serve as a TGNC textbook. Many readers might wonder why I have glossed over certain subject matters and focused so much on others. My answer would be to redirect the reader back to my original goal: to increase access to care. The best way to increase access to care is to provide a simple yet thorough guide covering major topics that will apply to the everyday practice of most mental health professionals. This book functions as a highly accessible guidebook to help clinicians start their journey into the world of gender diversity. Hitting the largest audience possible is the best way to expand access to care.

The majority of mental health professionals are not trained to work with gender diverse people. This book is meant for them by increasing general awareness and providing a basic guidebook by which to start treatment with the TGNC community. In addition, there are many mental health clinicians who are already experts in TGNC care. Although they may find helpful information throughout the chapters, particularly those focused on medical and surgical options for care, for these clinicians, the book will likely serve as a general review and help them solidify their knowledge and basic understanding of TGNC-competent treatment. This book is written in a way as not to be too clinical. Individuals who are not mental health professionals and even those not in the medical community will be able to read and digest the information provided.

Although the medical practice of working with TGNC people has existed for the past 80 years, at this particular time in history two co-occurring gender-related events are taking place. The first event has to do with the individual TGNC patient. Practitioners in the medical and mental health fields are starting to recognize the needs of this group of patients, who have been neglected and marginalized in the past. The medical community prides itself in standard practices, and these need to be developed for gender diverse people in order to provide appropriate care. Clinics are starting to provide TGNC people with a wide range of medical and mental health services. Insurance companies, both private and public, are starting to pay for gender-affirming procedures, and TGNC patients now have access to possibilities that were not available to them before.

The second event involves culture. We are starting to see a more global shift regarding gender, gender roles, and gender diversity. The presence of gender diverse people in mainstream media has made the public aware of the variety of ways gender can present itself. People who identify as lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ) are making their presence known more in smaller communities, leading to an overall change in perception and getting those around them to think about gender and sexuality in a new way. Stereotypical roles of what it means to be a boy or girl, man or woman, are starting to be questioned. People have been departing from traditional gender norms in the way they dress, talk, act, work, and have sex. Stepping outside of the rules, or gender bending, is becoming more common. The long-held rules about what makes a person male or female are changing.

It might be difficult for a reader to trust the information in this book without a little background on me, the author. I am a cis white gay male (cis is explained in Chapter 2, “Understanding the Gender Spectrum”) who grew up in rural Alabama. Because of where I grew up, the early parts of my life were largely devoid of diversity in many aspects, but I was lucky to have exposure to people in my life who had me questioning social norms from an early age. One elementary school teacher I distinctly remember identified as female but presented herself as traditionally male. She had a short haircut and wore button-up shirts with a tie and men’s dress shoes. She was a woman of color in a mostly white part of the South. She was a wonderful teacher. Her presence in my life, along with that of many more of my early educators, created in me positive associations with those who didn’t fit neatly into the boxes they were supposed to fit in.

While studying psychology in college, I was fortunate to have access to several classes on sex, sexuality, and gender. Deconstructing what constituted a man or a woman was a regular part of my homework, and my teacher, an out lesbian-identified cis woman, opened my mind to noticing the arbitrary rules that dictate so much of our lives and behavior. She challenged her students to look at gender diversity and primed me to be open to gender diverse patients. While in college, I worked on a suicide hotline, and there I was exposed to transgender-identified people (both staff and callers) as well as callers with chronic and persistent mental illness. Listening to their stories, I started to understand the positions they find themselves in, the ongoing struggle with the way society treats them, and their need for help coupled with their inability to locate services.

After medical school, I matched in my psychiatric residency in New York City. There, I started to come across more TGNC patients. Many of my fellow clinicians would shy away from taking these patients because they said they felt untrained and generally unprepared to treat them. Luckily again, as a medical student, I had joined the Association of LGBTQ Psychiatrists (AGLP), many of whom are TGNC experts. By attending their meetings and getting to know the organization’s members, I was exposed to the basics of TGNC care and had mentors I could call for ongoing supervision. I fell in love with the organization so much that I joined the board and eventually came to serve as its president. Now I’m fortunate in that I can provide supervision and training regarding gender diversity to students, residents, and colleagues. If you are working in a clinic and say “yes” to one TGNC person, and that person has a good experience working with you, word of mouth quickly spreads, and both staff and other clinicians will refer TGNC people to you. With an open ear, an understanding mind, and a warm heart, you, too, can become the local expert.

My growing expertise with TGNC people got me connected to Callen-Lorde Community Health Center, where I now work as the Director of Psychiatry. Callen-Lorde is a Federally Qualified Health Center that focuses on the medical and mental health treatment of LGBTQ individuals. It is located in New York City and has more than 4,000 TGNC-identified patients.

This book is based largely on my life experiences working with TGNC people. Friends, colleagues, and patients have told me their stories, and I want them to know I have heard them. I have attempted to combine both the stories I have heard with the clinician’s experiences I have had into a volume that can take other mental health professionals down a similar educational road. It is a road, if you keep your mind and heart open to learning, that will instill in you a sense of compassion, empathy, and duty to help TGNC people get the care and treatment they deserve.

This book is meant to be read from cover to cover. It serves more as a guidebook rather than a reference or textbook. The topics covered in the earlier chapters will provide you with information that you will need in later chapters. The book is additive and works to build on each chapter. I would encourage you to start at the beginning and read through to the end. None of the chapters are too heavy in their treatment of the material, and this book should be an easy read for any mental health professional regardless of your specialty.

The questions at the end of each chapter are multilayered. Not only do they test your comprehension of the material you have read, but they will also provide further information and help you to see the complicated political, social, and cultural barriers most TGNC people experience when trying to get adequate care. Some of the multiple-choice answers may seem obvious, with even ridiculously wrong answers provided for distraction, but I assure you that most of the answers provided will describe experiences I have either witnessed myself or was told of by patients and colleagues. The wrong answers will teach you about what the medical and mental health community is doing wrong in much the same way the right answers will give you guidance.

Each chapter includes only a select group of references. These references were picked not only to cite certain information provided in the book but also to serve as excellent resources for further learning in topics you will want to know more about. The references are largely new in that most of them were published post-2010. There are many excellent TGNC articles published prior to 2010, but I wanted to keep the research current. Keeping research current communicates to readers the contemporary nature of what they are reading and gives them more confidence, knowing they are being brought up to date on the most recent research and standards of care. The references are also multidisciplinary in that the authors are professionals from various mental health backgrounds, including psychiatrists, psychiatric nurse practitioners, psychologists, social workers, and counselors. The references will provide you with the voices of all types of mental health professionals contributing to TGNC knowledge.

The chapters include a collection of case presentations. These presentations are intended to solidify previous topics and help you apply what you have read to a clinical situation. The stories provided are real, although significantly disguised. Patient names, ages, gender identities, and locations have been shifted and merged with other cases to ensure confidentiality. The heart of each case, however, is a true story that has happened to a TGNC individual. Some of them are heartbreaking, and all of them will show you the definite need for TGNC-competent clinicians and access to care.

This might be the most difficult and controversial topic to write about, but the word choices I made when writing this book were deliberate. The way people describe themselves, their identity, and their gender are very personal. Words that are appropriate in some groups may be not be appropriate in others. The word choices I have made serve as a representation of the majority of words both patients and staff have used in my work with them. This language will not be universal, and I dare say it may even be offensive to some. My intention with my wording is to convey the spirit of TGNC care I have both participated in and witnessed in my career.

The book is written through experiences that have taken place in the United States, although I have interacted with many colleagues and supervisors from other countries. That means the way I write about medicine and the way the cases are presented will be with a Western style and bias. TGNC care in other parts of the world might not describe gender diverse people the way I do or purpose treatment for them in the way this book is arranged. Practitioners should pay attention to cultural sensitivity, particularly when working with patients who grew up in other parts of the world.

Throughout the chapters, you will notice that sometimes I will say TGNC person/people and other times I will say TGNC patient. The world patient is used when the focus of the topic is on clinical interventions or clinical situations. People who are TGNC are not inherently ill, and they certainly do not automatically have a psychiatric disorder. TGNC people do, however, seek treatment, and my personal preference is to respect the clinician-patient relationship by using these word choices.

In the same vein, the DSM-5 (American Psychiatric Association 2013) diagnosis of gender dysphoria is used throughout the book as well. TGNC people are said to have “dysphoric” symptoms in relation to their body. This is not true for all TGNC people. Some TGNC people might have feelings about their gender and gender identity, but they are not dysphoric about their body, nor do they wish to seek treatment with gender-affirming procedures. There are many TGNC people who do have dysphoric symptoms and would very much like to make adjustments to their body through medicine or surgical means. The details of gender dysphoria will be explained more in Chapter 7, “The Gender Dysphoria Diagnosis,” but it is essential to realize that the diagnosis of gender dysphoria was included in DSM-5 as a means to provide an avenue for care and treatment. Diagnosis is required by insurance companies for patients seeking to cover the cost of hormones and gender-affirming procedures. A growing number of mental health professionals do not believe that TGNC people have a mental illness, and the diagnosis of gender dysphoria remains a means to an end, with that end being access to care.

My use of the acronym TGNC throughout the book is on purpose as well. Transgender and gender nonconforming are two aspects of the gender spectrum. Persons who are gender nonconforming may not necessarily consider themselves transgender. Including the nonconforming part of TGNC is important so that you will remember that gender is on a spectrum and is not a binary concept. People don’t just transition from male to female or from female to male. They may shift on the gender spectrum, but how and in which way is a personal decision.

LGBTQ stands for lesbian, gay, bisexual, transgender, and queer/questioning and will also make an appearance throughout the chapters. Individuals who are diverse on the spectrum of sexual orientation and gender frequently are grouped together historically, mostly in political ways. Gender and sexuality are two separate phenomena and should be treated as such; however, some things are unique and particular to both groups. These phenomena overlap and interact in complex ways. Internalized homophobia and internalized transphobia, which will be explained in Chapter 8, “Gender-Affirming Mental Health,” are shared experiences among all LGBTQ people. LGBTQ is substituted for TGNC when a topic applies to the larger group.

The use of the word therapist as a substitute for practitioner will happen frequently. I am a psychiatrist, but this book is intended for all mental health professionals. Few areas in the book have information that will pertain only to psychiatrists. All psychiatrists are trained to be therapists, and many do only therapy in their full-time work. All psychiatrists, whether they are aware of it or not, are doing supportive therapy with all of their patients. When I use the term therapist, it pertains to all mental health professionals, whether a psychiatrist, psychologist, social worker, counselor, or case manager.

Mental illness is not the focus of this book, and it should not be the focus of treatment when working with someone who is TGNC. Treatment with TGNC people is about embracing the varied ways the world can express gender. Mental health professionals spend their careers diagnosing people and assigning them treatments depending on the symptoms they are presenting with. It is a fortunate position to be in when working with TGNC people because the focus of treatment is not about treating gender diversity. It is about accepting gender diversity.

The TGNC population does have disproportionate amounts of depression, anxiety, trauma, substance abuse, and suicide attempts. Much of the discrepancy when compared with the general population can be explained by transphobia and stigma. Gender diverse people are ingrained with negative images and ideas about themselves from an early age. Over time, this negativity turns into internalized transphobia. Internalized transphobia can lead to a myriad of symptoms.

All mental health diagnoses aside, working with TGNC people is an opportunity to focus on positive treatment options for people to better express themselves externally on the basis of their internal gender identity. Providing space for gender diverse persons to express themselves and, over time, discover who they are is an extremely rewarding opportunity.

The contents of this book are broken down into four major parts. The first part focuses on general topics with TGNC people such as understanding gender diversity. The second covers mental health–related topics, including diagnosis and mental health particulars related to gender diverse people. The third part focuses on medicinal or hormone treatment options as well as general primary care topics. The last part discusses surgical gender-affirming procedures as well as nonsurgical interventions.

You are about to start on a journey to become a TGNC-competent clinician. Provided for you in these chapters are my best organization and presentation of the material that is absolutely necessary to know when working with someone who is TGNC. Each chapter will provide you with references for further reading. How deep you delve into the world of gender diversity will depend on your interest in and desire to provide care for gender diverse people.

The study of TGNC people remains in its infancy. The recommendations and suggestions in this volume will change over time as more knowledge and understanding are acquired. There may be many who don’t agree with the recommendations I have to offer, and I would encourage you to get as much information as you can from as many sources as possible. Others will have insight into topics and experiences that I might be blind to. Other references have already been written from medical and social perspectives, and they deserve your attention should you wish to get more details. The focus of this volume will be ultimately on the mental health of TGNC people.

As you gather information from this and other volumes, your understanding of and ability to work with gender diversity will increase. You will probably interact with other clinicians who have no knowledge or understanding of TGNC care. Some may even be hostile or discriminatory toward TGNC individuals. I would encourage you to approach the lack of education in others just as you will with yourself as you read this book. You will be new to this material just as others will be new to it. By learning ourselves, we can teach others. If you are to have any hope of getting other clinicians on board with TGNC care, you will need to approach them in a nondefensive and noncritical way. Clinicians should be encouraged to learn, not be critiqued for their lack of knowledge, especially when they are seeking out that knowledge.

All of us, no matter where we fall on the gender spectrum, should approach each other with new eyes, appreciating the individual nature and expression each of us possesses. Only by truly seeing each other and supporting each other can we start to provide a fertile ground for learning and nurture a larger and more general understanding of gender diversity. By approaching individuals this way, we can engender and foster mental health care that will embrace gender diversity and help us to provide the most compassionate care possible.