Towards a Collaborative Model for Transgender Health

Introduction

These 4 modules constitute the introductory training needed for clinicians wishing to offer transition-related services 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, case studies, role-plays, vignettes, testimonials.

Module 1

Gender diversity: Building the foundation (7 hours)

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.

Module 2

Gender diversity: clinical evaluation (7 hours)

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

Counselling and psychosocial support in transition (7 hours)

Summary

This module, based in part on the WPATH standards of care, emphasizes the decision-making tools and the therapeutic approaches necessary to support gender diverse people in their gender affirming journeys.

Objectives

Identify:

1. Common issues and challenges that may arise for the person wishing to initiate a transition process.
2. The potential stresses associated with coming out in various family and social contexts.
3. The needs associated with the transition in a context of mental health challenges.
4. The needs and challenges of gender diverse parents

Content

1. Transition related support:
   • The person in transition: Psychosocial and mental health needs, letters of recommendation.
   • Spouses: Psychoeducation, management of changes, losses, etc.
   • Parents: Psychoeducation, management of changes, losses, etc.
2. Gender diverse parents: Needs and challenges
3. Developing a perspective on detransition, retransition and regret.
4. Post-transition support: Loss management, integration into the social role, ongoing management of minority stress.

Module 4

Gender diverse children and youth (7 hours)

Summary

Gender diverse individuals often recognize their gender identity at an early age. TransPulse Ontario found that the majority of gender diverse individuals knew before the age of 10 that they did not identify with their assigned gender. Understanding these gender journeys from a developmental perspective helps to identify the needs of children and youth at different stages and ways to best support them and their families.

Objectives

1. Describe the social, family and interpersonal reality of gender diverse children and youth
2. Describe the developmental path of these children and youth.
3. Put into practice individual and systemic intervention tools in support of these children and youth and their families.

Content

Developmental journey

1. Children:
   • Early childhood and exploration of gender expression.
   • Gender constancy: Emergence of gender identity.
   • The prepubertal child and social transition.
2. Youth:
   • The stress of puberty in children with gender dysphoria.
   • Puberty blockers and medical transition.

Therapeutic and psychosocial support

1. 0-6 years:
   • Addressing parents’ questions and concerns.
   • Addressing issues related to the child’s social environments (extended family, daycare, school, etc.).
2. Prepubertal:
   • Assessment and support of the child.
   • Supporting the parents.
   • Addressing issues related to the child’s social environments (extended family, school, extracurricular groups, etc).
3. Puberty:
   • Assessing and supporting gender diverse youth.
   • Support and accompaniment of parents.
   • Addressing issues related to the youth’s social environments (extended family, school, extracurricular groups, etc.).
   • Navigating issues surrounding sexuality.
   • Addressing issues surrounding fertility.