Gender Transition

This chapter is intended to promote collaboration between clinicians and youth in assessing need/desire for gender transition. Worksheets are guided by the World Professional Association for Transgender Health (WPATH) Harry Benjamin Standards of Care (7th revision), so clinicians can document with risk management in mind. This chapter shifts the process of transitioning from one where clinicians judge who gets to transition to one of collaboration, affirmation, empathy, and compassion for gender expansive youth.

     WHICH ASPECTS OF TRANSITION APPEAL/DON’T APPEAL

LEARN

When considering transition, there are three components of the triadic therapeutic approach:

1.  Real life experience:

• Living life as one’s authentic gender

• Expressing gender in the ways that feel true to nature

• Name change

• Pronoun change

2.  Hormone treatment:

• Puberty blockers: suppress the onset of puberty by blocking the release of hormones that elicit testosterone/estrogen

• Androgen blockers: suppress the hormones that naturally arise in the body

• Estrogen/testosterone: infuses the body with hormones that produce secondary sex characteristics

3.  Surgery:

• Top surgery: for a transmale, top surgery is breast reconstruction. For a transfemale, it could be breast augmentation

• Bottom surgery: for transfemales, many choose the procedure to construct a vaginal canal out of a penis. These surgeries are not as common for transmales as they are for transfemales. The surgeries for transmales can include testicular implants, urethroplasty, scrotoplasty, mons resection, and metoidioplasty, which is less invasive and more affordable than a vaginectomy. Vaginectomy involves removal of the vaginal lining and sealing the opening. It provides more support for pelvic organs, while eliminating vaginal discharge.

• Orchiectomy: removal of testicles only, leaving the penis alone

• Chondrolaryngoplasty (commonly called tracheal shave): smoothes out the Adam’s apple on the neck of transfemales

The 3 ways of transitioning described above are influenced by the Triadic Therapeutic Approach in the Standards of Care. There are 2 more associated terms to be familiar with:

• Social Transition

• Medical Transition

Social Transition refers to #1: “Real Life Experience”

Medical Transition refers to #2 and #3: “Hormones” and “Surgical body modification.

PRACTICE

•   Evaluate the triadic therapeutic approach.

•   Which aspects appeal to you, and which do not?

•   Contemplate and consider the ramifications of the different parts of the triad.

•   Some people feel kids and teens can’t know if they should transition or not because they are still growing and changing. Do you ever feel this way? It’s ok to explore this topic and know it can change over time.

REFLECT

•   The process of transition looks very different for each person.

•   Ultimately, the goal is to come to a place of self-love and authentic gender expression.

•   Open to the possibility that your unique path to transition/or not will present itself to you as you continue to explore it.

     READINESS TO TRANSITION

LEARN

When a person decides they are ready to transition, it can involve a series of steps and events. For instance, the medical doctor who prescribes hormone treatments may require a letter of readiness, or affirmation, from a mental health professional before beginning treatment. The current practice around transition letters is moving away from the mental health professional being a gatekeeper of transitioning, but rather a collaborator with kids and teens seeking transition. In the collaboration, seek to identify:

•  Persistence

•  Consistency

•  Insistence

In joining with kids and teens to document transition readiness, mental health professionals need to assess the persistent nature of gender expansive presentations. Notice if it’s been going on consistently, and how much they insist on being another gender.

Explore Eligibility & Readiness:

•   Eligibility occurs when a person moves through the triadic therapeutic approach in the linear way. First, living real life as the other gender. Next, receiving hormone treatment before being eligible for surgery.

•   Readiness is assessed using clinical judgment and may vary between individuals. Kids and teens can progress through treatment without the linear progression of real life experience, hormones, and then surgery last—if clinical judgment suggests otherwise.

When evaluating readiness, consider the severity of gender dysphoria and the presence of suicidality.

PRACTICE

The following is a template of a readiness letter reflecting the World Professional Association of Transgender Health (WPATH) and Harry Benjamin International Association’s The Standards of Care (7th revision) for Gender Identity Disorders.

REFLECT

•   One letter is required for hormone treatment

•   Two separate letters from mental health professionals are required for surgery. One letter may come from the person’s primary therapist. If the primary therapist has a master’s degree, the second letter needs to be authored by someone with a doctoral or medical degree. If the first letter comes from a psychotherapist, the second letter can be authored by someone playing an evaluative role. One letter with two signatures also suffices the standards.

READINESS LETTER

To Whom It May Concern:

____________ (state person’s name, identifying characteristics such as: age, date of birth, race, ethnicity, nationality, sexual orientation, etc...) was assigned ___________ (include gender assigned at birth) at birth, and has been evolving in their gender expression.

Throughout the course of my treatment with ___________ (include person’s name) the following diagnoses have been rendered ___________ (state diagnoses, if any; Gender Dysphoria should be included.). Currently, these diagnoses are ___________ (state if they are ongoing conditions, in remission, re-classified with a different diagnosis, and/or if the severity of symptoms have changed.). The duration of treatment spans ___________ (insert date when treatment began), is ongoing, and consists of ___________ (state type of psychotherapy/number of sessions per week or all together.). The following evaluations were conducted: ___________ (List the type of assessments, the date of assessment, and the assessor’s name. If you are the assessor, state so. If there aren’t any evaluations/assessments, include a statement about why there aren’t any or simply that there aren’t any at this time.).

To date,___________ (insert name of person) has met the following eligibility criteria ___________ (state if the person has a) lived as their authentic gender, b) has taken hormone treatment/puberty blockers, and/or c) had any surgeries.).

In my professional opinion, ___________’s (insert person’s name) ability to follow the Standards of Care, particularly around medical after care is ___________ (state: poor/fair/adequate/good/excellent.). They have the following sources of support: ___________ (name any and all sources of support including private family, friends, public assistance and organizations.). My care of (insert person’s name) includes the following other members of the gender team: (name all the people you consult and collaborate within treating this person. If not working with a gender team, state so.). Please feel free to call me at ___________ (include a telephone number where you can be reached directly) to verify the authenticity of the letter.

Sincerely and kindly,

_______________
(your name)

     GENDER SUPPORT AND TRANSITION PLANS

LEARN

Our friends at Gender Spectrum have created two sets of forms to support transitioning youth. The Gender Support Plan is a document that creates a shared understanding of how a student’s authentic gender will be recorded in school documents. When used in collaboration with school staff, the Gender Support Plan eases transition, improves team communication, and reduces instances of discrimination.

The Gender Transition Plan is another document that shares information about youth transition, so that they can do so in a healthy, supportive environment.

PRACTICE

The Gender Support Plan and Gender Transition Plan can both be found in Appendix F. There is another document in Appendix F that assist in talking about gender and transgender students.

REFLECT

•   The documents created by Gender Spectrum represent leading-edge communication templates for supporting gender-creative youth.

•   Please support Gender Spectrum in any way you can – their work saves lives and helps us do our work more effectively.

     GENDER AFFIRMATION

LEARN

Gender identity and expression take on many different forms. For some people, transitioning is an important part of their gender affirmation and expression. For others, it is not. In the following practice, explore the varied and many details that you feel affirm/would affirm your gender identity.

PRACTICE

•   Take a deep breath, allowing the air to pass through your nostrils, filling your lungs and belly.

•   Feel your body and take a moment to scan it for any tingling, tightness, or other sensations. Just notice your body and gender, and make contact with them in this very moment.

•   Next, allow yourself to consider all the different ways you want to present your gender in the world, and be seen by others.

•   Allow the thoughts, images, and feelings about it to float into your awareness.

•   Take a few minutes to rest quietly in this space, allowing different aspects of gender identity and presentation to come to consciousness.

•   When you’re ready, take a deep cleansing breath, open your eyes, and return to the room.

•   Now, take a pen (or an electronic device) and write down everything that came to mind, and/or continues to come to mind.

REFLECT

•   This practice invites you to become more intimate with yourself. It leads to greater ease and familiarity with needs and wants.

•   It’s ok if some uncomfortable ideas, memories, or thoughts come to you. Try to let them go, and focus back on the task at hand.

•   If the discomfort is too great or persists, talk with someone you trust.

     DEVELOPMENTAL GENDER AND CHRONOLOGICAL GENDER

LEARN

For transpeople, awareness of the difference between assigned gender at birth and authentic gender identity can happen at any time in life. For some, it is known early and strongly. For others, the awareness comes a little later on, say the teen years or adulthood.

• Chronological Gender is how long you’ve been living with the gender you were assigned at birth.

• Developmental Gender is how long you’ve been living as your authentic self. This refers to people who are/have actively and outwardly began their transition. Some people are trans or non-binary and don’t transition for a wide range of reasons. This concept is more narrow in its application to transpeople who have and are outwardly transitioning.

The practice below reflects these different stages of gender identity development. See where you’re at!

PRACTICE

How old are you?_______________

This is your chronological gender.

How long ago did you transition?_______________

This is your developmental gender. It corresponds to transition, not the moment you realized you’re trans.

REFLECT

•   Explore the different ages of your chronological and developmental gender.

•   See if one feels more true, and/or if one feels less different.

•   Looking at chronological and developmental gender identity ages facilitates the integration of self. It is one step towards noticing where you’re at, and where you’ve been. It’s also a mindfulness practice to become aware of nuances and details about yourself.

•   Remember some transpeople go through puberty more than once. It’s ok if your chronological and developmental gender ages are wide apart.

     ASSESSMENT OF LEVEL OF DISTRESS ASSOCIATED WITH GENDER ASSIGNED AT BIRTH

LEARN

One of the critical aspects to consider when thinking about transitioning is how much distress you feel about your gender, your body, and the gender you were assigned at birth.

PRACTICE

Thinking about the following aspects of your identity, rate your distress level from 0-10 (0 = no distress at all; 10 = so much distress that you even think about killing yourself sometimes):

REFLECT

•    It’s ok to admit you’re suffering, and that it has profound effects on you.

•    The trusted adult who gave this to you is here to help. Turn to them with the distress you feel so you can get the support and relief you deserve.

•   Oftentimes, transitioning helps ease the distress transpeople feel around their body and gender identity.

•   It’s important to look at how much distress and suffering is going on. When suicide is in the mix, transitioning could be a better option.

     VARIATIONS IN GENDER EXPRESSION

LEARN

Gender expression varies among people. It varies in different cultures, too! When transgender people think about transitioning, gender expression is at the forefront. You can practice different forms of gender expression at any time, without committing to transition. It’s ok to explore, and maybe you already have.

PRACTICE

1.  Which aspects of gender expression appeal to you?

                                 

2.  Do you like any aspects of the gender you were assigned at birth?

                                 

3.  Which aspects of no gender appeal to you?

                                 

4.  Do any aspects of expressing another gender appeal to you? If so, what are they?

                                 

5.  Have you experimented with different forms of gender expression? If so, how did it go?

                                 

6.  Have you had positive/negative/neutral experiences exploring your gender identity and expressing it? If so, what were they?

                                 

REFLECT

•   You can explore the questions with someone you trust, or keep it to yourself.

•   Remember, it’s also an act of self-compassion to become aware of yourself and bring kindness to that knowing.