Towards a Collaborative Model for Transgender Health

Introduction

These 4 modules constitute the introductory training needed for clinicians wishing to offer transition-related services (including assessments for letters of support for hormone therapy and gender affirming surgeries) from a trans-affirmative, informed consent perspective.

Numerous studies have reported on the insufficient numbers of professionals available who possess the skills needed to welcome and serve transgender (trans) and gender variant individuals.

Research confirms the impacts of minority stress on the mental health and well-being of transgender or gender variant children, youth and adults. Studies have identified the urgent need to support access to transition-related services when trans individuals decide they are ready to do so. The lack of resources in the healthcare system contributes significantly to the suffering associated with gender dysphoria. The most critical training and sensitization needs are in the health and social services. Trans lives remain misunderstood by professionals mandated to welcome and support these populations.

Teaching method

Didactic presentations, vignettes.

---

Module 1

Gender diversity: Building the foundation

Summary

Gender diversity is considered an expression of human diversity and not the manifestation of a mental disorder, as it was believed for a good part of the 20th century. Any discussion about the needs of transgender, non-binary and gender creative people should start from a depathologized, paradigm that allows us to better understand and welcome the needs of individuals who come to us for transition related and general services while recognizing the impact of the stigma associated with the recent past.

Objectives

1. Develop the ability to question existing heteronormative paradigms and to situate gender diversity appropriately.
2. Demonstrate an understanding of gender and sexuality on a continuum rather than binary.
3. Identify the impact of minority stress on development, mental health and other determinants of health in transgender, non-binary and gender creative people.
4. Identify ways to adapt personal and institutional practices to welcome transgender, non-binary and gender creative people.

Content:

1. Definitions and basic concepts:
   • Heteronormativity and challenging the binary paradigm.
2. Stigma and minority stress:
   • Definitions: Minority stress, Transphobia, Transmisogyny.
   • Microagressions: impact on development and mental health, Impact on the therapeutic relationship.
   • Impact on the determinants of health.
   • Impact of family support.
3. Creating spaces welcoming of gender diversity:
   • Creating a welcoming environment (forms, respecting name and pronouns, gendered spaces, creating gender neutral spaces, etc.).
   • Changing name and gender marker.
   • Working with schools
   • Working with housing services
     • Homeless shelters
     • Hospitals
     • Youth protection services

---

Module 2

Gender diversity: clinical evaluation 

Summary

This module covers the tasks of professionals responsible for assessing transition-related requests by transgender and non-binary people. The DSM and ICD diagnostic criteria are discussed as well as the different critical perspectives surrounding the medicalization of gender diversity. The therapists’ work is framed by the WPATH standards of care which issues guidelines supported by the most recent research in the field. These guidelines will serve to inform the approach presented. The responsibilities of the prescribing physician and of the surgical center staff will be presented.

Objectives

1. Identify current and historical questions related to the diagnosis of gender dysphoria.
2. Demonstrate an ability to analyze a clinical case from a trans-affirmative and an informed consent perspective.
3. Become familiar with the medical and surgical aspects of the transition.
4. Develop a knowledge of the WPATH standards surrounding access to hormonal and surgical means of transition.

Content

1. Critical perspective on the assessment of gender dysphoria:
   • From DSM-IV to DSM-5: shifting the paradigm.
   • ICD-11: Depathologizing gender diversity.
   • Assessment of concomitant diagnoses.
2. Adopting an informed consent, gender affirming, approach:
   • Evolution the psychotherapist’s function in the health and well-being of trans and and gender diverse individuals.
   • Applying the principle of self-determination.
3. Developing a perspective on detransition, retransition and regret.
4. The WPATH standards of care:
   • Brief history of HBIGDA / WPATH.
   • Minimum requirements for providing surgical letters of support.
   • Conversion therapies: Position regarding attempts to transform gender identity.
   • Evaluation criteria for access to hormones and surgeries.
   • Looking ahead to WPATH SoC v.8.
5. The role of the family physician:
   • Assessment of needs.
   • Initiation and management of hormone therapy.
   • Preservation of gametes.
   • physical examination.
   • Preparation for surgery and post-operative care.
6. Becoming familiar with various trans affirming surgeries and aftercare needs.

---

Module 3

Transgender Health from a developmental perspective 

Summary

Working from a developmental perspective, we identify therapeutic challenges that gender diverse individuals can face at different stages of their life. This approach offers useful points of reference for our work to identify, for example, potential needs when working with a child or to identify past experiences that influence the well-being of a middle-aged adult.

Objectives

1. Describe the developmental landmarks associated with gender affirmation from childhood to adulthood.
2. Explore possible interventions for each of the life stages presented.
3. Put into practice individual and systemic intervention tools

Content

1. Childhood:
   • Development
   • Clinical intervention
   • School-based intervention
2. Adolescence
   • Development
   • Clinical intervention
   • School-based intervention
3. Adulthood
   • Relationships and sexuality
     • Catching-up on “lost” years
     • Beyond hetero and cissexual relational models
     • Navigating body complexities
     • Navigating the complexities of dating
     • Including gender diversity in STI prevention programs
   • Parenthood
     • Various pathways
     • When a parent transitions
       • Impact on the partner and the relationship
       • Impact on the children

---

Module 4

Transgender Health: Supporting transition goals 

Summary

In order to meet the needs of gender diverse individuals wishing to access transition care, we identify the nature of the request and carry out an assessment that takes into account both the WPATH Standards of Care and existing mental health issues. Working with a transaffirming approach can represent a significant challenge for many professionals. We will focus on our responsibility as clinicians to remove barriers to transition and ways to do so even when complex mental health issues are present.

Objectives

1. Assess common challenges that the person wishing to initiate a transition may face.
2. Identify the psychosocial issues associated with gender affirmation in various family and social contexts.
3. Develop a supportive approach to individuals’ transition goals
4. Demonstrate an ability to maintain an informed consent approach when significant mental health issues are present.

Content

1- Transition: Challenging the paradigm

2- Assessment and intervention stages

• Developing trust
  • Respecting name and pronouns
  • Avoiding the gatekeeping stance
  • Communicating a transaffirming stance
• Identifying needs, goals
  • Assessment
    • Putting a “minority stress” paradigm into practice
    • Transition as a process of individuation
    • On the use of psychometric tests
  • Distinguishing objectives
    • Transition support
    • Other objectives
• Confirm presence and degree of gender dysphoria
  • Perspectives on labelling gender identity
  • Perspectives on diagnosing gender dysphoria
• Assess general functioning and capacity to consent to care
  • Stress associated with gender affirmation
  • The challenge of internalized transphobia
  • The importance of social support

3- Assessing mental health issues

• Depathologizing gender
  • Position of professional organizations on gender diversity
  • Position on so-called “conversion” or “reparative”  therapies
  • Specific mental health issues
    • Anxiety and depression
      • Social anxiety
    • Borderline personality
    • Eating disorders
    • Autism/Neurodiversity
    • Dissociative Identity

4- Medical and surgical referrals

• Access to care
• Charting
• Letters of support
  • Hormone therapy
  • Surgeries