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rd 3 Level Health Professionals Galway 2017 rd 3 Level Health Professionals Galway 2017

TENI is a non-profit member-driven organisation, founded in 2006 and registered as a company TENI is a non-profit member-driven organisation, founded in 2006 and registered as a company limited by guarantee in February 2010. The governance is provided by a volunteer Board and operations are led by the Chief Executive and staff. • • TENI Founded in 2006 (Outhouse). • Volunteer Organization until 2010. • Atlantic Philanthropies (3 year program). • Health Service Executive (2014 -present)

Foundations • Magnus Hirschfeld • Harry Benjamin Standards of Care Foundations • Magnus Hirschfeld • Harry Benjamin Standards of Care

Defining Transgender Broad, umbrella term Where gender identity ≠ assigned sex Sexual Orientation is Defining Transgender Broad, umbrella term Where gender identity ≠ assigned sex Sexual Orientation is another issue Includes: Transsexuals Intersex Transvestites Gender variant Non-Binary

Transvestite/Crossdresser • A person who wears clothing, accessories, jewellery or make-up not traditionally or Transvestite/Crossdresser • A person who wears clothing, accessories, jewellery or make-up not traditionally or stereotypically associated with their assigned sex. • There are numerous motivations for crossdressing such as a need to express femininity/masculinity, artistic expression, performance (e. g. drag queen/king), or erotic enjoyment. However, people who crossdress generally have no intention or desire to change their gender identity or assigned sex, although some people may go on to identify as transgender or transsexual. www. teni. ie

Non-Binary • This term is generally used in two ways: • (1) an umbrella Non-Binary • This term is generally used in two ways: • (1) an umbrella term that includes all people whose gender varies from the traditional 'norm'; or • (2) to describe individuals who feel their gender identity is neither female nor male, both female and male, or a different gender identity altogether. • Gender Nonconformity www. teni. ie

Drag Queen/King • Drag king: A person with a female gender identity who performs, Drag Queen/King • Drag king: A person with a female gender identity who performs, dresses or presents in a stereotypically masculine role for entertainment purposes. • Drag queen: A person with a male gender identity who performs, dresses or presents in a stereotypically feminine role for entertainment purposes.

Intersex • An umbrella term used for a variety of conditions in which a Intersex • An umbrella term used for a variety of conditions in which a person is born with a reproductive or sexual anatomy that doesn’t fit the typical definitions of female or male. • Many individuals who are intersex do not identify as transgender or do not consider themselves covered by the transgender umbrella www. teni. ie .

Transsexual • A person whose gender identity is 'opposite' to the sex assigned to Transsexual • A person whose gender identity is 'opposite' to the sex assigned to them at birth. The term connotes a binary view of gender, moving from one polar identity to the other in a binary opposition. Transsexual people may or may not take hormones or have surgery. • The term ‘transsexual’ is hotly debated in trans communities with some people strongly identifying with the term while others strongly rejecting it. Moreover, for some, ‘transsexual’ is considered to be a misnomer inasmuch as the underlying medical condition is related to gender identity and not sexuality. www. teni. ie

Transitioning A process through which some transgender people begin to live as the gender Transitioning A process through which some transgender people begin to live as the gender with which they identify, rather than the one assigned at birth. Transition might include social, physical or legal changes such as coming out to family, friends, co-workers and others; changing one's appearance; changing one’s name, pronoun and sex designation on legal documents (e. g. driving licence or passport); and medical intervention (e. g. through hormones or surgery).

Prevalence • The prevalence of transgender people in Ireland is difficult to estimate as Prevalence • The prevalence of transgender people in Ireland is difficult to estimate as there is no official collection of this data. GIRES, a UKbased organisation, estimates that 1% of individuals may experience some degree of gender variance or non-conformity and approximately 0. 2% may undergo transition (Reed, 2011).

Speaking from the Margins Trans Mental Health and Wellbeing in Ireland (Mc Neill, et, Speaking from the Margins Trans Mental Health and Wellbeing in Ireland (Mc Neill, et, al 2013)

Introduction • Largest study of trans people conducted in Ireland. • This study: 164 Introduction • Largest study of trans people conducted in Ireland. • This study: 164 respondents – Provides a nuanced understanding of trans people’s lives. – Illustrates the high levels of stigmatisation and discrimination that negatively impact our lives. – Highlights the barriers to accessing appropriate health care, particularly in terms of mental health and transition services. – Makes recommendations to positively address mental health and wellbeing.

Health care (N=115) • • 60% had at least one negative experience at a Health care (N=115) • • 60% had at least one negative experience at a GIC. 69% had at least one negative experience at a mental health service. 74% had at least on negative experience at a general health service. 38% of clinicians stated they did not know enough about a certain type of trans related health care to provide it. “The delays and the waiting and general unhelpfulness of medical professionals can be frustrating. I once had to go and collect letters myself and drive them to {name) because {name} seemed to be incapable of posting a letter without losing it when the doctors finally wrote it”

Mental Health Services (N=85) • 69% had at least one negative experience at a Mental Health Services (N=85) • 69% had at least one negative experience at a Mental Health service: – 26% had been discouraged from exploring their gender. – 9% had been belittled or ridiculed for having a trans history or being trans. – 19% had been told that they weren’t really trans. – 22% said the provider used the wrong name or pronoun by mistake. – 14% said the provider used the wrong name or pronoun on purpose.

Self-harm & Suicide • 44% of respondents self-harmed (N=113). • 78% thought about suicide Self-harm & Suicide • 44% of respondents self-harmed (N=113). • 78% thought about suicide (N=113). – 28% had thought about taking their lives in the last week, with 2% thinking about it daily. • 40% attempted suicide at some point over the life course (N=87). “The uninhabited life, the pointlessness, the prejudice, the jokes, beatings, accusations, lectures, eventually you start to be all the things they hate and say you are, so when you hate yourself suicide is inevitable”.

Current Treatment Pathway Current Treatment Pathway

World Professional Association for Transgender Health (2011) • Standards of Care for the Health World Professional Association for Transgender Health (2011) • Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People • Distancing from the binary gender experience and, therefore, of service users’ needs… WPATH advises: “matching treatment approach to specific needs of patients” Informed Consent Model Not Disordered EPATH 2013 WPATH 2016 • • •

Options for Psychological and Medical Treatment of GD (Adults) (WPATH, 2011) Options for Psychological and Medical Treatment of GD (Adults) (WPATH, 2011)

Continued (WPATH, 2011) Continued (WPATH, 2011)

Criteria For Hormone Therapy (One referral) WPATH 2011 • 1. Persistent, well-documented gender dysphoria. Criteria For Hormone Therapy (One referral) WPATH 2011 • 1. Persistent, well-documented gender dysphoria. • 2. Capacity to make a fully informed decision and to give consent for treatment. • 3. Age of majority in a given country (if younger, follow the SOC for children and adolescents). • 4. If significant medical or mental concerns are present, they must be reasonably well controlled.

Medical Interventions • 1. Fully reversible interventions. These involve the use of Gn. RH Medical Interventions • 1. Fully reversible interventions. These involve the use of Gn. RH analogues to suppress oestrogen or testosterone production and consequently delay the physical changes of puberty. • 2. Partially reversible interventions. These include hormone therapy to masculinize or feminize the body. • 3. Irreversible interventions. These are surgical procedures.

Role of GP • Non-judgemental, understanding and supportive approach. • Maybe first contact. • Role of GP • Non-judgemental, understanding and supportive approach. • Maybe first contact. • Validation • Some people are more empowered, clear and have a vision. • At this point, it may be unhelpful to ask them to further delay their request for treatment.

Suggestions for GP’s Working with Trans People • 1. This may be the first Suggestions for GP’s Working with Trans People • 1. This may be the first time a patient has acknowledged or discussed their gender identity therefore it is imperative that the client feels understood and not judged as a negative reaction may cause significant distress and hopelessness. • 2. Ask the person what name and pronoun they would like you to use. • 3. Educate yourself about transgender issues by reading books, attending conferences, and consulting with transgender experts e. g. Transgender Equality Network Ireland (TENI

Suggestions for GP’s Working with Trans People • 4. Reassuring transgender patients that confidentiality Suggestions for GP’s Working with Trans People • 4. Reassuring transgender patients that confidentiality will be maintained by all staff within the service will ease anxiety and fears • 5. Gender identity and sexual orientation are not the same. Transgender people can be heterosexual, gay, lesbian, bisexual, queer or asexual. • 6. Questions regarding surgical status, if necessary as part of routine history-taking, should be approached sensitively.

Suggestions for GP’s Working with Trans People • 7. Not all transgender people medically Suggestions for GP’s Working with Trans People • 7. Not all transgender people medically transition (either hormonally or surgically). There is no one size fits all. • 8. If a transgender person is seeking to medically transition or is looking for psychological support, refer to the services detailed in GP Resource (attached). • 9. Be cognisant that co-existing health issues may not be linked to gender issues. • 10. Signpost to supports and further information is available at www. hse. ie, Primary Care Unit and from at www. teni. ie. Further details in the resource section.

5 Tips for Admin Support During Transition 1. Open communication and trust is key 5 Tips for Admin Support During Transition 1. Open communication and trust is key to supporting a trans person 2. Make sure you consult with the trans person before changing their details. This can be a particularly vulnerable moment of their transition and should be treated sensitively 3. Medical elements of transitioning are a private. Trans people should not be required to reveal the particular medical elements of transitioning 4. Ensure they have access to appropriate facilities e. g. toilets and changing rooms in the gender in which they identify. It is not appropriate to require a trans person to use separate facilities. However if a trans person asks for access to separate facilities for safety or privacy this should be taken seriously.

Regret • Landen, Walinder, Hambert, and Lundstrom, 1998: 3. 8% of 218 patients. • Regret • Landen, Walinder, Hambert, and Lundstrom, 1998: 3. 8% of 218 patients. • Research suggests that lack of Family acceptance, leads to regret. • Landen’s study also suggests, delayed transition also leads to regret. • Regret following hormonal or surgical treatment was in line with other Western European countries (1. 83%). (Judge, et, al, 2014)

Self-harm & Suicide (Mc Neill, et al, 2013) • Gender transition was shown to Self-harm & Suicide (Mc Neill, et al, 2013) • Gender transition was shown to drastically reduce rates of self -harm and suicidal ideation within this group: – 76% of those who had completed transition reported having selfharmed more prior to transition and none of self-harmed more after transition. – 81% thought about or attempted suicide more before transitioning, but this amount was reduced to 4% after transitioning. “Once I started transition/the doctor listened to me, I never felt the need to self-harm again”. “I couldn’t live anymore as male, however that has changed during and post transition. I love life and I love being able to enjoy it”

Effect of Transition (Mc Neill, et al, 2013) • 75% of the respondents felt Effect of Transition (Mc Neill, et al, 2013) • 75% of the respondents felt that their mental health had improved since transitioning. • 92% were more satisfied with their bodies • 84% more satisfied with their lives since transitioning. “I am much more comfortable in my own skin and my self-esteem and self-confidence are much higher”. “Yes I feel more at peace with myself and my body. I am more confident and happier in my daily life and with my life in general”.

What about the Families • • Stages of Bereavement (Kubler-Ross, 1969) “Because the loss What about the Families • • Stages of Bereavement (Kubler-Ross, 1969) “Because the loss is intangible or uncertain, the mourning process for family members becomes complicated” (Betz & Thorngren, 2009) • Ambiguous loss provides a framework when investigating gender change in families (Mc. Guire, 2016). • • 6 Stages (Ellis & Ericksen, 2002) Stage 1. Shock and Denial Stage 2. Anger Stage 3. Searching for Support (Constructing Meaning) Stage 4. Self Discovery (Beginning to change) Stage 5. Acceptance Stage 6. Pride and Resilience

Trans. Paren. CI “they described their parent coming out, as a meteor that crashed Trans. Paren. CI “they described their parent coming out, as a meteor that crashed into their world and changed everything” Child of a Trans Person. • • • First meeting; Nov 2011 Carlow (n=14) Building Sustainability. ‘Getting your house sorted 2013, 2014, 2015’. (Reports available) Dublin Group Pilot November 2015 Limerick Group February 2016 “Seeing how much better we now get on as a family is amazing and seeing how more comfortable my son has been being himself since we attended the meetings and the weekend is incredible. We are like a different family now, so much closer than I could have imagined. ” – Father of a trans person” Father of a Trans Person

Transformers • Young persons travelling with Parents to Group • Child and Adolescent Psychotherapist Transformers • Young persons travelling with Parents to Group • Child and Adolescent Psychotherapist • Running concurrent to Trans. Paren. CI

Healthcare and School Trainings/Presentations • • Healthcare conf = 385 (Dec 2015) Healthcare Trainings/presentations Healthcare and School Trainings/Presentations • • Healthcare conf = 385 (Dec 2015) Healthcare Trainings/presentations 2016 =51 (Full day) People reached = 1, 356 (2016) 2017 in the process of developing higher level training

Holistic Approach Bernard & Terry Reed from Gender Identity Research and Education Society: “The Holistic Approach Bernard & Terry Reed from Gender Identity Research and Education Society: “The discomfort of both trans people and their families is seriously aggravated by the rigidity of a society that still fails to recognise the wide diversity of natural development in Human Beings […] If ever there was a situation which needed to be addressed holistically, this is it! “Under our holistic approach Mr Wyndot we not only treat your symptoms, we also treat your dog. ”

References • Zhou, J. N. , Hoffman, M. A. , Gooren, L. J. , References • Zhou, J. N. , Hoffman, M. A. , Gooren, L. J. , Swaab, D. F. (1995). A sex difference in the human brain and it’s relation to Transsexuality. Nature, 378(6552), 68 -70. • Mayock, P. , Bryan, A. , Carr, N. , Kitching, K. (2009). Supporting LGBT Lives. A study of the mental health and wellbeing of Lesbian, Gay, Bisexual and Transgender people. • Schaefer, L. C. , Wheeler, C. C. (1995). Guilt and Gender Identity Disorders and Condition: Understanding, recognising, diagnosing, and it’s treatments. Journal of the International Society for the Study of Personal Relationships.

References • Yolanda, L. S. Smith, M. Sc. , Stephanie, H. M. , van References • Yolanda, L. S. Smith, M. Sc. , Stephanie, H. M. , van Goozen, Ph. D. , Peggy, T. Cohen-Kettenis. (2001). Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: A prospective follow-up study • Viner, R. M. , Brian, C. , Carmichael, P, & Di Ceglie, D. (2005). Sex on the brain: Dilemmas in the endocrine management of children and adolescents with gender identity disorder. Archives of diseases in childhood, 90, A 78.

References • Cohen-Kettenis, P, T. , Schagen, E. E. S. , Steensma, T. D. References • Cohen-Kettenis, P, T. , Schagen, E. E. S. , Steensma, T. D. , de Vries, A. L. C. , Delemarre-van de Waal, h. a. (2011). Puberty suppression in a genderdysphoric adolescent: A 22 -year follow up. • Hembree, W. C. , Cohen-Kettenis, P. T. , Delemarre-van de Waal, H. A. , Gooren, L. J. , Meyer, W. J. , Spack, N. P. , et al. (2009). Endocrine treatment of Transsexual persons: An endocrine society clinical practice guideline. Journal of clinical endocrinology and metabolism, 94, 3132 -3154. • Ciaran Judge, Claire O’Donovan, Grainne Callaghan 1, Gadintshware Gaoatswe, Donal O’Shea. Department of Endocrinology, St. Vincent’s University Hospital, Dublin, Ireland (2014). • Annelou L. C. de Vries, Jenifer K. Mc. Guire, Thomas D. Steensma, Eva C. F. Wagenaar, Theo A. H. Doreleijers and Peggy T. Cohen-Kettenis • Pediatrics; originally published online September 8, 2014

Reference • Landen, M. , Walinder, J. , Hambert, G. , Lundstrom, B. , Reference • Landen, M. , Walinder, J. , Hambert, G. , Lundstrom, B. , 1998. Factors predictive of regret in sex reassignment. Acta Psychiatrica Scandinavica 97, 284– 289. • Zamboni, B. D. (2006). Therapeutic Considerations in Working With the Family, Friends, and Partners of Transgendered Individuals. The Family Journal April 2006 14: 174 -179.

Reference • Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming Reference • Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People The World Professional Association for Transgender Health. 7 th Version • Mental Health ; report of the US Surgeon General, 2001 • Fourth Annual Child & Adolescent Mental Health Service Report, 20112012

Reference • Brill, S. , Pepper, R. , (2008). The Transgender Child. A handbook Reference • Brill, S. , Pepper, R. , (2008). The Transgender Child. A handbook for families and professionals. • Boss. P. , (1999). Ambiguous Loss. Learning to live with unresolved grief. • Reed, T. (2005). Family Matters. Gender Identity Research and Education Society, GIRES) Families and Transsexualism – a better understanding

Where to find us office@teni. ie Vanessa 085 -1477166 www. teni. ie www. facebook. Where to find us [email protected] ie Vanessa 085 -1477166 www. teni. ie www. facebook. com/transequality Twitter: TENI_tweets

Research • Significantly positive changes in Gender Dysphoria post treatment (Cohen. Kettenis, et al, Research • Significantly positive changes in Gender Dysphoria post treatment (Cohen. Kettenis, et al, 2001) • Postponement of treatment can lead to lifelong suffering (Cohen-Kettenis, et al, 2001) • Gender Identity still fluctuating (Viner, et al, 2005) • Some reluctance to administering Gn. RH until later tanner stages • Physical Consequences eg; Bone mass, brain development, Growth,

First, long term follow up • Dutch study, significant results (22 years) • Not First, long term follow up • Dutch study, significant results (22 years) • Not 1 person refrained from further treatment (n=70) • Commencement of cross sex hormones led to significant growth in catching up • Pubertal Suppression averts despair of Gender Dysphoria • Puberty suppression can be a useful tool in the diagnoses and treatment of Gender Dysphoria (Cohen- Kettenis, et al 2011) • This view is also supported by Endocrine Society (Hembree et al, 2009)

Most Recent Data (de Vries, et, al. 2014) • Dutch Study; • This study Most Recent Data (de Vries, et, al. 2014) • Dutch Study; • This study is the first longer-term longitudinal evaluation of the effectiveness of this approach. • METHOD: A total of 55 young transgender adults (22 transwomen and 33 transmen) who had received puberty suppression during adolescence were assessed 3 times: before the start of puberty suppression (mean age, 13. 6 years), when cross-sex hormones were introduced (mean age, 16. 7 years), and at least 1 year after gender reassignment surgery (mean age, 20. 7 years). Psychological functioning (GD, body image, global functioning, depression, anxiety, emotional and behavioral problems) and objective (social and educational/professional functioning) and subjective (quality of life, satisfaction with life and happiness) well-being were investigated

Results • RESULTS: After gender reassignment, in young adulthood, the GD was alleviated and Results • RESULTS: After gender reassignment, in young adulthood, the GD was alleviated and psychological functioning had steadily improved. Wellbeing was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being. • CONCLUSIONS: A clinical protocol of a multidisciplinary team with mental health professionals, physicians, and surgeons, including puberty suppression, followed by cross-sex hormones and gender reassignment surgery, provides gender dysphoric youth who seek gender reassignment from early puberty on, the opportunity to develop into well-functioning young adults. Pediatrics 2014; 134: 1– 9

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