The transgender community is a diverse group of individuals who self-identify in many ways (eg, transsexual, transgender, gender nonconforming). Members of the community commonly transcend society’s gender binary and widely assumed definitions of gender roles and instead identify within a spectrum of gender expression.1,2 (The gender binary is the traditional framework for understanding gender, including the culturally maintained belief that there are only 2 genders [men and women] and that gender must conform to biological sex [male and female].) A deficit of knowledge about optimal treatment for this population exists within the mental and medical health provider community, which contributes to the marginalization of transgender persons, for whom frequent barriers to health care access pose significant risks.3
Using a question-and-answer format, we present a brief overview of issues that arise when mental health professionals explore how to best serve this population.
What terms referring to gender identity are most appropriate? How do I know which pronoun to use?
Many terms are used to refer to gender-nonconforming persons. The most common are transsexual, transgender, and gender nonconforming (Figure). It is important to understand that these terms are highly individualized and many have negative and/or suboptimal connotations.
The terms “MTF” (male-to-female) and “FTM” (female-to-male) are widely used in clinical notes and academic literature. However, the preferred terms are “transwoman” and “transman,” which are appreciated as the most affirming of the patient’s identity; they de-emphasize the pathology model, and reflect an active appreciation of the diversity model.2 The latter are more affirming terms and discourage users from thinking of transgender persons as “pre” and “post” surgery and/or “pre” hormone therapy, because these variables may or may not have any bearing on the person’s gender identity or the pronoun that is appropriate for the person.
If you are not sure which pronoun to use, you can ask the patient directly: “Which pronoun is appropriate?” rather than, “Which pronoun do you prefer?” For many people, the pronoun use is a clear identity rather than a preference.2 Your patient may respond with “he”; “she”; or a variety of other pronouns, such as “they” or “ze”—a commonly used gender-neutral pronoun in the English language. You can also ask, “How would you like to be addressed?” and “How would you like me to refer to you?”
Gender identity is about what’s between the ears rather than what’s between the legs. – Willy Wilkinson, MPH
What is the difference between gender nonconform-ing and gender dysphoria?
Gender dysphoria refers to a significant level of distress one may experience as a result of a gender identity that is incompatible with one’s sex at birth and/or primary and secondary sex characteristics.4 The distress is in response to having a different experience of one’s gender from societal expectations and the resulting discrimination, harassment, and lack of acceptance. The distress also arises from the commonly held belief that transgender persons are responsible for the discrimination they experience, rather than the idea that society should hold those who are biased against transgender persons accountable for their actions.
The term “gender nonconforming” refers to persons whose gender identity, role, or expression is distinct from cultural expectations of a particular sex.5 The concept of gender nonconforming is socially and culturally variable—what may be considered appropriate gender expression in one culture may be considered gender nonconforming in another, and vice versa. Not all gender-nonconforming individuals experience gender dysphoria.
What is already known about psychiatric care of transgender persons?
? Transgender patients are a diverse community. They are often underserved because of limited cultural competence on the part of their providers.
What new information does this article provide?
? This article describes the concept of a gender identity spectrum and defines key terms. It provides answers to clinicians’ frequently asked questions about working with transgender patients.
What are the implications for psychiatric practice?
? Transgender health care is a rapidly growing field. All clinicians should be comfortable working with transgender patients and familiar with current guidelines for providing care for this population.
What percentage of the general population is transgender or gender nonconforming?
A multitude of factors contribute to the difficulty of performing epidemiological studies for this population and, hence, no formal studies have been conducted to determine the number of people who identify as transgender or in whom gender identity disorder (GID) has been diagnosed. Researchers have focused their efforts on the most easily quantifiable within the spectrum of gender-nonconforming persons: transsexual persons who have received hormones and/or have had surgeries.6A review of 10 studies based in Europe suggests that the prevalence of transwomen (MTF) ranges from 1 in 11,900 to 1 in 45,000 and that of transmen (FTM) ranges from 1 in 30,400 to 1 in 200,000.7 Statistics from the World Professional Association for Transgender Health (WPATH) and DSM-IV are based on decades-old data and are widely considered inaccurately low. Some researchers have theorized that the true prevalence is much higher because of inherent difficulties in estimation.8
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3. Bockting WO, Avery E, eds. Transgender Health and HIV Prevention: Needs Assessment Studies From Transgender Communities Across the United States. Binghamton, NY: The Haworth Medical Press; 2005.
4. Knudson G, De Cuypere G, Bockting W. Process toward consensus on recommendations for revision of the DSM diagnoses of gender identity disorders by the World Professional Association for Transgender Health. Int J Transgend. 2010;12(2):54-59.
5. Institute of Medicine of the National Academies. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. March 31, 2011. http://www.iom.edu/Reports/2011/The-Health-of-Lesbian-Gay-Bisexual-and-Transgender-People.aspx. Accessed July 17, 2012.
6. World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011. http://www.wpath.org/documents/Standards%20of%20Care_FullBook_1g-1.pdf. Accessed July 17, 2012.
7. Olyslager F, Conway L. On the calculation of the prevalence of transsexualism. Paper presented at: World Professional Association for Transgender Health 20th International Symposium; September 5-8, 2007; Chicago.
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10. Dhejne C, Lichtenstein P, Boman M, et al. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLoS ONE. 2011;6:e16885.
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14. Informed Consent for Access to Trans Health. http://www.icath.org. Accessed July 17, 2012.
15. Hamzelou J. Transsexual differences caught on brain scan. January 2011. http://www.newscientist.com/article/mg20927962.800-transsexual-differences-caught-on-brain-scan.html. Accessed July 17, 2012.
16. Kruijver FPM, Zhou J-N, Pool CW, et al. Male-to-female transsexuals have female neuron numbers in the limbic nucleus. May 2000. http://jcem.endojournals.org/content/85/5/2034.full. Accessed July 17, 2012.
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20. Rametti G, Carrillo B, Gómez-Gil E, et al. White matter microstructure in female to male transsexuals before cross-sex hormonal treatment. A diffusion tensor imaging study. J Psychiatr Res. 2011;45:199-204.
21. DeCuypere G, Knudson G, Bockting W. Response of the World Professional Association for Transgender Health to the proposed DSM 5 criteria for gender incongruence. http://www.wpath.org/documents/WPATH%20Reaction%20to%20the%20proposed%20DSM%20-%20Final.pdf. Accessed July 17, 2012.
22. Transgender experiences—information and support. 2009. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_097168.pdf. Accessed July 17, 2012.
23. American Psychiatric Association. Summary of text changes from DSM-IV to DSM-IV-TR. http://www.psychiatry.org/practice/dsm/summary-of-text-changes-from-dsm-iv-to-dsm-iv-tr. Accessed July 17, 2012.
24. American Psychiatric Association. Sexual and gender identity disorders. 2012. http://www.dsm5.org/meetus/pages/sexualandgenderidentitydisorders.aspx. Accessed July 16, 2012.
25. Wilkinson W. Culturally competent approaches for serving transgender populations. 2009. http://www.lgbt-tristar.com/images/09_report_trans.pdf. Accessed July 24, 2012.