Gender Identity Dysphoria
GLBT Health
A Brief Overview
Physician Assistance Program
OHSU
August 5, 2010
4/13/2015
Sara Kristine Becker, MD
1
Sara Becker, MD
Sara Kristine Becker is a board certified Family Physician who has practiced Family
Medicine in Portland, Oregon for 30 years. She obtained a Bachelors of Science in
Computer Science at Michigan State University where she taught for two years. She
graduated from the University of Michigan Medical School with her MD Degree in 1977.
Her residency in Family Medicine was completed in 1980. She started her practice in
Milwaukie, Oregon in 1980. She is a Diplomat of the American Board of Family Practice
and was an Associate Clinical Professor of Family Practice at Oregon Health Sciences
University in Portland, Oregon. She is a licensed multiengine; instrument rated
commercial pilot and an Aviation Medical Examiner for the Federal Aviation
Administration. Her hobbies are flying, computers, piano, guitar, growing orchids, walking,
and teaching.
Her professional interests are general Family Medicine, Aviation Medicine, and hormone
replacement therapy. She is a member of the World Professional Association for
Transgender Health , the Oregon Academy of Family Medicine, the Oregon Medical
Association, and the American Academy of Family Physicians. She is on the Active Staff of
Providence Milwaukie Hospital an the Courtesy Staff of Portland Adventist Medical
Center. She was the 1989 Chief of Staff for Providence Milwaukie Hospital
4/13/2015
Sara Kristine Becker, MD
2
Hobbies
Fly-fishing with
Brother-in-law
4/13/2015
Sara Kristine Becker, MD
3
Three Percent of Humans
4/13/2015
Sara Kristine Becker, MD
4
Cases in Point
4/13/2015
Sara Kristine Becker, MD
6
Cases in Point
4/13/2015
Sara Kristine Becker, MD
7
Goals of Presentation
To encourage Physician Assistants to understand
and facilitate care for these patients
 To understand that gender and sexuality are a
spectrum in Humans
 To adopt the larger view of caring for your fellow
Human Being
 To remember the true role of the Healer.

4/13/2015
Sara Kristine Becker, MD
8
Why is this important to know?
A 2004 study of 350 substance abuse counselors
in the Midwest reported little formal education in
the needs of LGBT clients
 A 2006 study of 248 medical students with
increase clinical exposure to LGBT patients had
better attitudes, performed more comprehensive
exams and demonstrated greater knowledge than
those with no prior education

4/13/2015
Sara Kristine Becker, MD
9
4/13/2015
Sara Kristine Becker, MD
10
Barriers to Care for GLBT
Fear of Disclosure
 Fear of asking by Health Professionals
 Lack of knowledge and research
 Lack of Insurance /Benefits
 Discrimination by Health Providers and their staff
 Fear of offending straight / conservative patients

4/13/2015
Sara Kristine Becker, MD
11
Cigarettes and Smoking
2004 study in California lesbians smoked at at
rate 70% higher than heterosexual women
 1998 WHI showed lesbians were twice as likely
as heterosexual women to smoke heavily
 Gay men are 50% more likely to smoke

4/13/2015
Sara Kristine Becker, MD
12
Alcohol
Random sample of 722 college students WSW in
SE United States are 10 times more likely to drink
 WHI data shows lesbians are more likely to report
recovering alcoholism
 A telephone survey showed very high levels of
both recreational drug (52%) and Alcohol use
(85%) in MSM

4/13/2015
Sara Kristine Becker, MD
13
Drugs

High rate of drug usage in MSM
4/13/2015
Sara Kristine Becker, MD
14
Breast Cancer
2006 Population based study in NY showed
WSW 4 times less likely to receive a
mammogram
 Less Likely to give birth by age 30
 Have a higher BMI
 May use alcohol more

4/13/2015
Sara Kristine Becker, MD
15
STDs
In a study of 7000 lesbians , 77% had one or more
male partners
 WSW are more likely to have unprotected sex
with IDU, bi and gay individuals
 Lesbians are less likely than bisexual or
heterosexual women to be tested for STDS

4/13/2015
Sara Kristine Becker, MD
16
STDS WSW
Proven transmission: herpes, HPV, trichomonas
 Case reports HIV, Hepatitis B
 Possible Chlamydia, GC, syphilis
 BV from sex toys

4/13/2015
Sara Kristine Becker, MD
17
STDS MSM
Increased occurrence of syphilis, GC, Chlamydia.
 2000 Seattle study of 1000 MSM 43% never or
only occasionally used condoms during anal sex

4/13/2015
Sara Kristine Becker, MD
18
Anal Cancer
In gay individuals increased risk of anal cancer.
 HIV+ gay men have higher risk for anal dysplasia
then HIV – gay men.

4/13/2015
Sara Kristine Becker, MD
19
HIV

Men who have sex with men (MSM) accounted
for 53% of the estimated new HIV infections in
2006.
4/13/2015
Sara Kristine Becker, MD
20
Domestic Violence
2000 survey of over 8000 women, ,more than
11% in lesbian relationships reported rape, or
assault.
 Concern for police indifference
 Risk of being outed

4/13/2015
Sara Kristine Becker, MD
21
Marginalization in Medicine

Groups that are marginalized in the United States
tend not to have the best health care.
4/13/2015
Sara Kristine Becker, MD
22
To Change Ones Gender
Gender Identity Disorder/ Dysphoria
Transsexual
Transgender
Transition
Sex Reassignment Surgery
Intersexed
4/13/2015
Sara Kristine Becker, MD
23
To Change Ones Gender
Oddity, perversion or fact of nature
 Frequency
 Why is it important for health professionals to
understand gender change or transsexualism in
Human Beings?

4/13/2015
Sara Kristine Becker, MD
24
To Change Ones Gender



Transsexualism or Gender Identity Dysphoria is a
condition where a person feels they are the opposite
gender.
At some point in their lives , they are no longer able to
live as the gender they have been assigned at birth.
The need to hide what they are is overwhelmed by
feelings of depression. (Man in a dress)
4/13/2015
Sara Kristine Becker, MD
25
Jurassic Park
4/13/2015
Sara Kristine Becker, MD
26
Finding Nemo
4/13/2015
Sara Kristine Becker, MD
28
The Variability of Nature
Many different types of expression of sex.
 Over 17 known intersexed conditions in Humans.
 Some are genetic others biochemical
 Understanding this variation may form the basis
for transsexualism.

4/13/2015
Sara Kristine Becker, MD
29
The Difference Between Sex and
Gender
Sex is the physical expression of genes.
 Gender is the concept of how one relates to
another in society (masculine vs. feminine) and
self perception.
 The organic basis of gender identity may be a
reflection of hormonal effects in utero

4/13/2015
Sara Kristine Becker, MD
30
Gender Identity Dysphoria






Considered to be a birth defect
Born with the body of one sex and the brain of another
The disparity between body and mind produces
depression which often becomes overwhelming
Most likely related to intrauterine hormone exposure but
true causes are unknown
Considered throughout the civilized world as a medical
condition not a psychiatric one
The German Prisoner
4/13/2015
Sara Kristine Becker, MD
31
Gender Identity Dysphoria
Transsexualism (Christine Jorgenson)
 History
 Incidence .2 to 1.0% (true incidence is unknown)
 Males to Females (M2F) or MTF
 Females to Males (F2M) or FTM

4/13/2015
Sara Kristine Becker, MD
32
Gender Identity Dysphoria
Who you are
 Who you love

4/13/2015
Sara Kristine Becker, MD
33
The Farthest Journey
A Journey too Far
 A Trip from one existence to another
 How long does it really take?

4/13/2015
Sara Kristine Becker, MD
34
Feelings and Memories
Of Mind and Thought
The Deep Feelings
The Bedtime Prayer
Living “The Lie”
The False Construct
Puberty the “Treason of the Body”
The Wakening Dream
4/13/2015
Sara Kristine Becker, MD
35
The Shell Cracks
The pain of not being--?relation to testosterone
 The emergence of Gender Identity Dysphoria
 The Ultimate Dilemma
 Addressing the mirror
 The spiral downward
 Facing the end of being or a new being in the end

4/13/2015
Sara Kristine Becker, MD
36
The Shell Cracks
Gender Identity Dysphoria is a situational
depression.
 It cannot be cured with drugs, therapy, or prayer
 Dysphoria means difficult to bear in Greek
 Some patients become acutely suicidal when the
feelings cannot be contained and they face a loss
of all they hold dear knowing the stigma of
changing gender

4/13/2015
Sara Kristine Becker, MD
37
From “True Selves “ by Mildred
Brown
4/13/2015
Sara Kristine Becker, MD
38
Gender Identity Dysphoria
Since the mind cannot be changed, the body must
be changed
 In modern therapy, no attempt is made to cure the
transsexual. Rather, options are explored
 Some exist living part-time in the gender of their
mind. Most seek to transition
 Our society is not geared for us to live “In
Between”

4/13/2015
Sara Kristine Becker, MD
39
Symptoms of GID
A situational depression
 Drugs and Alcohol abuse
 Devotion to profession, military commitment
 To transition or not-endless rumination
 The price of truth
 Mildred Brown

4/13/2015
Sara Kristine Becker, MD
40
The World Professional Association for
Transgender Health, Inc

4/13/2015
Sara Kristine Becker, MD
41
Treatment of Gender Identity
Dysphoria
The World Professional Association for Transgender
Health provides:
 Certification and guidelines for counselors who treat
transsexuals
 Provide guidelines for cross gender hormone therapy
 Provide guidelines for gender reassignment surgery
(sex change surgery)

4/13/2015
Sara Kristine Becker, MD
42
“Transition”
To change ones body and mind image to the gender
Opposite to the cage one is born to.
To learn to relate in society as one of the opposite
Gender.
The process of “Becoming” or “Transitioning”
4/13/2015
Sara Kristine Becker, MD
44
Steps in Transition
Counseling
 Electrolysis or Laser to remove the beard
 Hormone Therapy to change the body
 The Real Life Test
 Surgery
 Beyond

4/13/2015
Sara Kristine Becker, MD
45
To Find a Chiron
The importance of the therapist who is skilled in
treating transsexuals
 What am I?
 How do I adjust to what I am?
 How do I make myself understood?
 How do I forgive myself to not being “fixable”
 How do I deal with so many others

4/13/2015
Sara Kristine Becker, MD
46
Issues of Transition Dealt with in
Counseling








Timing of transitioning
Hormone therapy
Informing spouses
Informing children
Informing friends
Informing relatives
Job preservation
Survival
4/13/2015
Sara Kristine Becker, MD
47
The Role of the Therapist
Weighing the options
Timing
No attempt to cure
4/13/2015
Sara Kristine Becker, MD
48
Educating Others
Being a transsexual means that one wishes to
change how one relates to others in society as a
member of the other gender. It does not mean one
is gay, trying to deceive others or that this is a
“life choice” Rather it is the way one has always
been.
 Mildred Browns book “True Selves”

4/13/2015
Sara Kristine Becker, MD
49
Issues of Transition










Electrolysis
Hormone therapy
Preserving hair –Rogaine, Finasteride, Dutastaride
Voice
Walking
Mannerisms and clothing
Physical changes
Legal changes
Work
Surgery
4/13/2015
Sara Kristine Becker, MD
50
Issues of Transition
Economics
 Male to female $20,000-$100,000
 Female to male $10,000 (top) to $100,000
 Loss of job (70% of professional Ts in San
Francisco are unemployed)
 Physicians most likely to be fired
 Divorce

4/13/2015
Sara Kristine Becker, MD
51
Hormones
It is the human sex hormones which shape the
clay that becomes the being.
 Human beings are not fixed permanently into one
gender or another.
 To a great degree, feminization and
masculinization can occur in the same body at
different stages of life

4/13/2015
Sara Kristine Becker, MD
52
Hormones
To a great degree, feminization and
masculinization can occur in the same body at
different stages of life
 Bilbo Bagins (MTFTM)

4/13/2015
Sara Kristine Becker, MD
53
Hormone Therapy
Estrogen to change the body to a feminine form
and soften the skin in M2F
 Antiandrogens to block testosterone so the
estrogen can work in M2F
 Testosterone injections to change female forms to
male

4/13/2015
Sara Kristine Becker, MD
54
Effect of Hormones
Physical changes
 Mental changes
 Emotional changes

4/13/2015
Sara Kristine Becker, MD
55
Estrogen in M2F
Conjugated estrogens (Premarin, Ogen) 0.625 to
7.5 mg.
 Ethiny Estradiol (Estinyl) .02 to2.0.
 Estradiol (Estrace) 0.5 to 6.0mg.
 Estradiol Transdermal (Fempatch, Alora, Climara,
Estraderm) .1 to .2.
 Delestrogen () 40 mg q 2 weeks.

4/13/2015
Sara Kristine Becker, MD
56
Antiandrogens
in M2F
Block the production and effects of testosterone.
 Use allows a lower dose of estrogen to produce
the same feminization but reduce the risks of
estrogen.
 Many different kinds but many are expensive.
 Spironolactone most common drug used

4/13/2015
Sara Kristine Becker, MD
57
Antiandrogens
in M2F
Spironolactone (Aldactone) 100-400 mg is a diuretic but
very effective at blocking testosterone, both synthesis and
at a receptor level.
 Side effects are- breast swelling, GI upset, drowsiness,
headache, rash, confusion, fever, decreased libido,
vomiting, balance problems, fever, elevated potassium.
 Very useful to measure free testosterone levels.

4/13/2015
Sara Kristine Becker, MD
58
Typical Hormone Therapies in F2M
• Testosterone Cypionate 100 mg IM weekly or 200
mg. every two weeks
• In Portland, often bought at Stroheckers
pharmacy which compounds the testosterone
• Cannot give testosterone orally because of liver
toxicity
4/13/2015
Sara Kristine Becker, MD
59
Steps Before Initiating Hormone
Therapy
The DSM IV criteria
 The WPATH standards
 “The Letter”
 Physical exam
 Laboratory tests
 Contraindications for therapy

4/13/2015
Sara Kristine Becker, MD
60
History and Physical Examination



Must be done to look for preexisting medical conditions
which would complicate or preclude hormone therapy
After hormone therapy is instituted, regular visits should
be carried out at three to six month intervals to look for
complications and adjust doses
Insurances sometimes will cover this as hormone
replacement therapy
4/13/2015
Sara Kristine Becker, MD
61
Survival
Be flexible
 Support groups
 Churches
 Journal
 Internet

4/13/2015
Sara Kristine Becker, MD
62
Identification
The importance of proper identification
 The role of the therapist
 Drivers licenses
 Letter of passage
 U.S. Department of State guidelines

4/13/2015
Sara Kristine Becker, MD
63
Real Life Test
The real life test is the period of time that one
must work in the gender one is becoming
 With completion of the real life test, one can seek
the two letters for Gender Reassignment Surgery
(Sex Change Surgery)

4/13/2015
Sara Kristine Becker, MD
64
Real Life Test
Usually one year
 One has to work as the future gender
 Time off work for SRS

4/13/2015
Sara Kristine Becker, MD
65
Facial Surgery








Forehead
Nose
Upper lip
Chin—sliding genioplasty
Jaw
Tracheal Shave
Doug Osterhoud, MD
Electrolysis
4/13/2015
Sara Kristine Becker, MD
66
Sex Reassignment Surgery







Sex Reassignment Surgery is the goal of many but not all
who are Transgendered
Can be offered only after the real life test
Not an option for physicians and certain other
professions
There is a harmony in having your body match your
mind
Less fear of being “caught” in social situations
The two letters—MA, PhD., MD
Ten surgeons in the world
4/13/2015
Sara Kristine Becker, MD
67
Sex Reassignment Surgery in
Females to Males
Sex Reassignment Surgery in F2M usually
limited to Breast reconstruction “top surgery”
 Genital surgery limited
 Full imitation not technically possible
 The metoidioplasty

4/13/2015
Sara Kristine Becker, MD
68
In The End
After all of the above what is left?
 Time and experience
 Posttraumatic Stess Disorder—regret, loss
 Memories and reflections
 Dreams, feelings and thoughts become one
 To gaze on ones own countenance with peace
 To savor the milieu, to just live

4/13/2015
Sara Kristine Becker, MD
69
How long Does it Take
Range is 2 to 5 years
 Real answer is at least 5 years
 Probably a lifetime

4/13/2015
Sara Kristine Becker, MD
70
Most Important



It is not a choice of life, it is a biological imperative.
Individuals with this cannot make it go away. It is a pain
similar to what one feels in the death of a child. Often
face with loss of all they hold dear, transsexuals often
consider or attempt suicide. The transsexual is often an
individual of extraordinary courage.
It is not an attempt to deceive but to survive.
Who you are and who you love are different areas of the
brain. Over 30% male to female transsexuals stay with
their mate if they can.
4/13/2015
Sara Kristine Becker, MD
71
Why Is It Important For Professionals
to Understand Transsexuals
There are thousands
 They hide because of fear and prejudice
 They are 16 times more likely to be murdered
 They have the highest unemployment of any
minority group
 Not associated with any other mental or medical
condition

4/13/2015
Sara Kristine Becker, MD
72
Why is it Important For Professionals
to Understand Transsexuals





Do we deprive the community of human beings because we do not
understand?
If a human were burned or paralyzed, would they be less a human
being?
Pope Innocent I removed the genitals from all the statures in the
Vatican in 1492 because souls do not have genitals
Transition does not change the essence of a Human being
Would any Medical Professional deny a patient the only
internationally recognized treatment for a condition because they
do not themselves understand it.
4/13/2015
Sara Kristine Becker, MD
73
Why is it Important For Professionals
to Understand Transsexuals
The Health Professional may be the first outside
of the transsexual themselves to know what is
really happening.
 How you respond may influence the future of that
patient.
 Almost all transsexuals consider suicide when the
shell breaks. Estimates of 20% active attempt.
 Suicide without a letter

4/13/2015
Sara Kristine Becker, MD
74
Gender Dysphoria
A human being who survives this has a unique
perspective on both genders that can be helpful to
others
 You may be the only professional between a
successful transition and failure

4/13/2015
Sara Kristine Becker, MD
75
Gender Dysphoria
A human being who survives this has a unique
perspective on both genders that can be helpful to
others
 You may be the only professional between a
successful transition and failure

4/13/2015
Sara Kristine Becker, MD
76
Approaches to Patients
Keep an open mind
 Employer limitations
 Let patients know you are accepting (websites,
teaching, literature).
 Ask patients who is important in their life.
 Who do they want to assist them in decisions of
health?
 The Three Questions

4/13/2015
Sara Kristine Becker, MD
77
Approaches to Patients
The Three Questions

What do I think is wrong with you?

What is really wrong with you?

What do you think is wrong with you?
 If you can think of it, as a rule the patient has
already thought of it.
 Labeling
 Recall

4/13/2015
Sara Kristine Becker, MD
78
GLBT Friendly Practices





Create GLBT inclusive intake and assessment
Post non-discrimination policies & GLBTwelcoming posters. Have gay-targeted reading
material in waiting room
Become familiar with appropriate GLBT
community referrals
Actively reassure GLBT patients about
confidentiality
Encourage visibility of GLBT employees
4/13/2015
Sara Kristine Becker, MD
79
The GLBT Friendly Practice




Realize transgendered people may be particularly
sensitive about disrobing.
Inquire which if any surgeries they have undergone and
do screening appropriate to birth gender as well as transgender.
Ensure GLBT employees have same benefits as other
employees
Ensure all staff are culturally competent
4/13/2015
Sara Kristine Becker, MD
80
Legalities



In some states, hospital visitation, notification, durable
POA, and parental rights for nonbiological partners are
not automatically granted to same-sex couples without
legal action.
Gay and lesbian people may be less tied to their families
of origin, but often have larger social networks
Partners and friends of GLBT people have often
commented to the lack of rights/recognition given them
in relation to visiting, decision making, and care giving
for their loved one
4/13/2015
Sara Kristine Becker, MD
81
Janice Longbehn and Lisa Pond

On April 15, 2010, President Obama issued a memorandum to the Secretary of
Health and Human Services, Kathleen Sibelius, directing her to issue new rules
to ensure that hospitals that participate in Medicare or Medicaid respect the
rights of patients to designate visitors and surrogate decision makers “ Hospitals
should treat all visitors, including people who are not immediate family, on the
same basis.” The memorandum stated that hospitals may not deny visitation
and decision making privileges on the basis of race, color, national origin, sex,
sexual orientation, gender identity or disability.

http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=4617&blogi
d=140#ixzz0vBEZrole
4/13/2015
Sara Kristine Becker, MD
82
4/13/2015
Sara Kristine Becker, MD
83
THE HIPPOCRATIC OATH: CLASSICAL VERSION
I swear by Apollo Physician and
Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses,
that I will fulfill according to my ability and judgment this oath and this covenant:To hold him
who has taught me this art as equal to my parents and to live my life in partnership with him,
and if he is in need of money to give him a share of mine, and to regard his offspring as equal to
my brothers in male lineage and to teach them this art—if they desire to learn it—without fee
and covenant; to give a share of precepts and oral instruction and all the other learning to my
sons and to the sons of him who has instructed me and to pupils who have signed the covenant
and have taken an oath according to the medical law, but no one else.I will apply dietetic
measures for the benefit of the sick according to my ability and judgment; I will keep them from
harm and injustice.I will neither give a deadly drug to anybody who asked for it, nor will I make
a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity
and holiness I will guard my life and my art.I will not use the knife, not even on sufferers from
stone, but will withdraw in favor of such men as are engaged in this work.Whatever houses I may
visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all
mischief and in particular of sexual relations with both female and male persons, be they free or
slaves.What I may see or hear in the course of the treatment or even outside of the treatment in
regard to the life of men, which on no account one must spread abroad, I will keep to myself,
holding such things shameful to be spoken about.If I fulfill this oath and do not violate it, may it be
granted to me to enjoy life and art, being honored with fame among all men for all time to come; if
I transgress it and swear falsely, may the opposite of all this be my lot.
Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text,
4/13/2015
Sara Kristine Becker, MD
84
The True Role of the Healer
Sumer in Mesopotamia dated from the Third
Millennium had the first tablets on surgery
 The earliest known regulation of medicine the
Code of Hammurabi (1700 BC)
 The greatest honor
 Morally pure
 Not there to judge- only to cure ,to improve, or to
comfort.

4/13/2015
Sara Kristine Becker, MD
85
Choosing for others
4/13/2015
Sara Kristine Becker, MD
86
Resources
4/13/2015
Sara Kristine Becker, MD
87
Web Resources
annelawrence.com
4/13/2015
Sara Kristine Becker, MD
89
Web Resources
sarabecker/t/index.htm
4/13/2015
Sara Kristine Becker, MD
90
Web Resources
sarabecker/t/index.htm
sara@sarabecker.com
4/13/2015
Sara Kristine Becker, MD
91
http://www.cdc.gov/lgbthealth/





Mayer KH, Bradford JB, Makadon HJ, et al. Sexual and gender minority health:
What we know and what needs to be done. American Journal of Public Health.
2008:98; 989-995.
Wolitski, RJ, Stall, R Valdiserri, RO. Eds. Unequal Opportunity: Health
Disparities Affecting Gay and Bisexual Men in the United States. New York:
Oxford University Press, 2008.
Clements NK, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviors,
health care use, and mental health status of transgender persons: implications
for public health interventions. American Journal of Public Health.
2001;91:915-921.
Meyer IL, Northridge ME. Eds. The Health of Sexual Minorities: Public Health
Perspectives on Lesbian, Gay, Bisexual and Transgender Populations. New
York: Springer. 2007.
Solarz, AL. Ed. Lesbian Health: Current Assessment and Directions for the
Future. Washington, DC: National Academy Press; 1999.
4/13/2015
Sara Kristine Becker, MD
92
Questions?
He who asks a question is a fool for five minutes
He who fails to ask a question is a fool for life
Old Chinese Proverb
4/13/2015
Sara Kristine Becker, MD
93