Front Matter

About the Author

Foreword

Acknowledgments

General Topics

1 Introduction

2 Understanding the Gender Spectrum

3 Historical Background

4 Establishing a TGNC-Friendly Clinic

5 Advocacy

6 Letter Writing

Mental Health–Related Topics

7 The Gender Dysphoria Diagnosis

8 Gender-Affirming Mental Health

9 Transitions and Detransitions

10 Families

11 Plurality

12 Sexuality

Primary Care and Hormone Treatment

13 Primary Care

14 Transmasculine Hormones

15 Transfeminine Hormones

Surgical and Nonsurgical Gender-Affirming Procedures

16 Transmasculine Top Surgery

17 Transfeminine Top Surgery

18 Transmasculine Bottom Surgery

19 Transfeminine Bottom Surgery

20 Other Gender-Affirming Procedures

21 Conclusion

Index

Eric Yarbrough, M.D., is Director of Psychiatry, Callen-Lorde Community Health Center, New York, New York, and President of AGLP: The Association of LGBTQ Psychiatrists.

ERIC YARBROUGH’S Transgender Mental Health feels like a watershed moment in the history of American psychiatry. It is being published at a time when transgender rights are a flashpoint in the so-called culture wars. State legislatures are passing and proposing “bathroom bills” to deny transgender people use of facilities matching their gender identity. There is uncertainty about the future ability of openly trans people to serve in the military. Many religious denominations are grappling with the question of how to integrate (or expel) transgender people of faith and their families. There are political (as opposed to medical) controversies about the age at which young people should have access to medical and surgical treatment.

This volume, published by American Psychiatric Association Publishing, moves away from psychiatry’s historic pathologizing of trans individuals and instead seeks more accepting and respectful ways to improve their lives. It should be noted, however, that psychiatry’s acceptance and respect were not always forthcoming.

In the nineteenth century, Krafft-Ebing’s Psychopathia Sexualis labeled transgender presentations as forms of psychopathology (Krafft-Ebing 1886/1985). By the 1920s, however, European physicians began experimenting with gender reassignment surgery to change people’s bodies rather than their minds. Yet this work became known to the general public only when international headlines trumpeted Christine Jorgensen’s 1952 return from Denmark to the United States as a trans woman (Jorgensen 1967).

Although the account of Jorgensen’s treatment was published a year later in the Journal of the American Medical Association (Hamburger et al. 1953), for almost three decades, most physicians and mental health practitioners were either oblivious about or critical of medical and surgical gender reassignment. In Green’s (1969) survey, 400 physicians and psychiatrists criticized the use of surgery and hormones to irreversibly treat people suffering from what they perceived to be either a severe neurotic or psychotic, delusional condition in need of psychotherapy and “reality testing.”

Professional perceptions would eventually change following the decision to include a diagnosis of transsexualism in the third edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association 1980). The World Health Organization’s (WHO) International Classification of Diseases, Tenth Revision (ICD-10; World Health Organization 1990) included diagnoses of transsexualism and gender identity disorder of childhood (Drescher 2010; Drescher et al. 2012). With diagnoses in both manuals, a growing international community of clinicians began offering medical and surgical treatment of gender dysphoric individuals (World Professional Association for Transgender Health 2011).

In 2007, APA announced the DSM-5 revision, the first to take place in the age of social media (Drescher 2010). Consequently, the process was highly scrutinized, with controversies emerging and reported on in the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) press (Chibbaro 2008; Osborne 2008) as well as in mainstream media outlets such as the New York Times (Carey 2008). LGBTQ activists called for the removal of gender diagnoses, just as homosexuality was deleted from DSM-II in 1973 (Bayer 1981, 1987; Drescher and Merlino 2007). Arguments for removal included societal intolerance of difference, the human cost of diagnostic stigmatization, using the language of psychopathology to describe what some people consider to be normal behaviors and feelings, and, finally, inappropriately focusing psychiatric attention on individual diversity rather than opposing the social forces that oppress sexual and gender nonconformity (Karasic and Drescher 2005).

On the other hand, there were also advocates for the transgender community who expressed competing concerns. For example, deleting the gender diagnoses from DSM-5 would lead third-party payers to deny access to medical and surgical care. In addition, transgender civil rights advocacy groups have used gender diagnoses successfully in court battles to improve access to care for incarcerated transgender prisoners in the United States, where denial of necessary medical care to incarcerated individuals is considered a “cruel and unusual punishment” in violation of the country’s constitution (Alexander and Meshelemiah 2010). Thus, the challenge of the DSM-5 revision process was how to balance the conflicting issues of maintaining access to care, which required retaining a medical diagnosis, while reducing stigma associated with being labeled with a psychiatric diagnosis (Drescher 2010).

In 2013, the APA issued DSM-5 (American Psychiatric Association 2013), which revised the DSM-IV-TR diagnosis of gender identity disorder (American Psychiatric Association 2000) to a new diagnosis called gender dysphoria. In doing so, APA chose to preserve access to care but changed the name of the disorder and modified the criteria to reduce stigma. Among other things, this included separating the gender diagnoses from the sexual dysfunctions and paraphilias and narrowing the diagnostic criteria to reduce false positives (Zucker et al. 2013).

During the revision process, APA also issued two positions statements, one supporting access to care (American Psychiatric Association 2012a) and the other opposing discrimination against transgender individuals (American Psychiatric Association 2012b). APA also appointed a task force to review and recommend treatment guidelines for transgender individuals (Byne et al. 2012).

APA’s decision had its intended effect of maintaining access to care. In May 2014, the U.S. Department of Health and Human Services reversed a longstanding 1981 ruling that classified gender reassignment as “experimental” treatment not reimbursable by Medicare (U.S. Department of Health and Human Services 2014). This reversal was based, in part, on the reasoning that DSM-IV-TR’s gender identity disorder and DSM-5’s gender dysphoria represented the view of American psychiatry that these disorders were medical conditions requiring treatment. Following that decision, many state Medicaid programs have begun to include some, if not all, transition services for eligible patients.

It should be further noted that at the time of this writing, WHO is revising ICD-11 for an anticipated publication date of 2018. WHO’s Working Group on the Classification of Sexual Disorders and Sexual Health has recommended changing transsexualism to gender incongruence and moving the diagnosis out of ICD’s mental disorders section into a new chapter called “Conditions Related to Sexual Health” (Drescher et al. 2012; Reed et al. 2016). At that juncture, retaining a mental disorder diagnosis in DSM-5 will no longer be necessary.

As medicine moves beyond a mental disorder model of gender variance, Transgender Mental Health is timely indeed. Dr. Yarbrough brings his experience and expertise from Callen-Lorde, one of the most gender-affirming treatment centers in the United States. He introduces mental health professionals to an “informed consent” model of care that includes respect for patient diversity, recognition of patients’ felt identities, and abandonment of the historic gatekeeping role. Instead, clinicians are invited to empathize with the subjectivity of gender dysphoric or incongruent patients and to offer them treatments proven to reduce their suffering and despair. There is much to learn here, and it is hoped that this volume will fill a much-needed gap in the training of mental health professionals of all disciplines.

I WOULD LIKE to acknowledge that this book would not have happened without the encouragement and forethought of Dr. Petros Levounis. It was he who saw the need for the American Psychiatric Association to have a book dedicated to the topic of transgender mental health.

Dr. Jack Drescher, who wrote the foreword for this book, has been a mentor, teacher, and supporter of my lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) education since I was a medical student. I depended on him as an expert to fine-tune the details and provide a historical background to the topics included in this book.

My education regarding gender diversity started in college with my professor Dr. Katharine Stewart. Her courses were transformative, and she still is probably the best teacher I have known.

The members of AGLP: The Association of LGBTQ Psychiatrists provided me with the resources and supervision that have led me down my career path. It has been an organization near and dear to my heart for many years.

The following people provided me with emotional support and/or feedback regarding the contents of this book: Khaldun Ahmed, Erin Black, Kevin Donnelly-Boylen, Victoria Formosa, David Guggenheim, Bill Lubart, Fred Martin, Angeliki Pesiridou, Morris Roy, Abraham Scott, Asher Sullivan, and Kathleen Yount.

Last, I would like to thank the staff and patients at Callen-Lorde Community Health Center. My experience working with them has been invaluable, enlightening, and heartwarming. It is a unique place to work and serves as a reminder to me that there is reason for hope.