{"id":1793,"date":"2020-09-10T15:34:06","date_gmt":"2020-09-10T15:34:06","guid":{"rendered":"https:\/\/courses.lumenlearning.com\/abnormalpsych\/?post_type=chapter&#038;p=1793"},"modified":"2024-09-23T19:56:16","modified_gmt":"2024-09-23T19:56:16","slug":"perspectives-and-treatments-related-to-gender-dysphoria","status":"publish","type":"chapter","link":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/chapter\/perspectives-and-treatments-related-to-gender-dysphoria\/","title":{"raw":"Perspectives and Treatments Related to Gender Dysphoria","rendered":"Perspectives and Treatments Related to Gender Dysphoria"},"content":{"raw":"<div class=\"textbox learning-objectives\">\r\n<h3>Learning Objectives<\/h3>\r\n<ul>\r\n \t<li style=\"font-weight: 400;\">Examine historical and current perspectives on gender dysphoria<\/li>\r\n \t<li style=\"font-weight: 400;\">Describe and evaluate treatments for gender dysphoria<\/li>\r\n<\/ul>\r\n<\/div>\r\n<h2>Historical and Modern Perspectives on Gender and Gender Identity<\/h2>\r\n<h3><span id=\"Early_medical_literature\" class=\"mw-headline\">Early Medical Literature<\/span><\/h3>\r\nIn late-19th-century medical literature, women who chose not to conform to their expected gender roles were called \"inverts,\" and they were portrayed as having an interest in knowledge and learning and a \"dislike and sometimes incapacity for needlework.\" During the mid-1900s, doctors pushed for corrective therapy on such women and children, which meant that gender behaviors that were not part of the norm would be punished and changed. The aim of this therapy was to push children back to their \"correct\" gender roles and thereby limit the number of children who became transgender.\r\n<h3><span id=\"Freud_and_Jung's_views\" class=\"mw-headline\">Psychodynamic Perspectives: Freud and Jung's Views<\/span><\/h3>\r\nIn 1905,\u00a0Sigmund Freud\u00a0presented his theory of\u00a0psychosexual development\u00a0in\u00a0<i>Three Essays on the Theory of Sexuality<\/i>, giving evidence that in the pregenital phase children do not distinguish between sexes, but assume both parents have the same genitalia and reproductive powers. On this basis, he argued that bisexuality was the original sexual orientation and that heterosexuality was resultant of repression during the\u00a0phallic stage, at which point gender identity became ascertainable. According to Freud, during this stage, children developed an\u00a0<strong>Oedipus complex<\/strong>\u00a0where they had sexual fantasies for the parent ascribed the opposite gender and hatred for the parent ascribed the same gender, and this hatred transformed into (unconscious) transference and (conscious) identification with the hated parent who both exemplified a model to appease sexual impulses and threatened to castrate the child's power to appease sexual impulses.\u00a0In 1913,\u00a0Carl Jung\u00a0proposed the\u00a0<strong>Electra complex<\/strong>\u00a0as he both believed that bisexuality did not lie at the origin of psychic life and that Freud did not give adequate description to the female child (Freud rejected this suggestion).\r\n<h3><span id=\"1950s_and_1960s\" class=\"mw-headline\">1950s and Beyond<\/span><\/h3>\r\nDuring the 1950s and '60s, psychologists began studying gender development in young children, partially in an effort to understand the origins of\u00a0homosexuality\u00a0(which was viewed as a\u00a0mental disorder\u00a0at the time). In 1958, the Gender Identity Research Project was established at the\u00a0UCLA Medical Center\u00a0for the study of\u00a0intersex\u00a0and transsexual individuals. Psychoanalyst\u00a0Robert Stoller\u00a0generalized many of the findings of the project in his book\u00a0<i>Sex and Gender: On the Development of Masculinity and Femininity<\/i>\u00a0(1968). He is also credited with introducing the term\u00a0<i>gender identity<\/i>\u00a0to the International Psychoanalytic Congress in\u00a0Stockholm, Sweden, in 1963. Behavioral psychologist\u00a0John Money\u00a0was also instrumental in the development of early theories of gender identity. His work at\u00a0Johns Hopkins Medical School's Gender Identity Clinic (established in 1965) popularized an\u00a0<strong>interactionist\u00a0theory of gender identity<\/strong>, suggesting that, up to a certain age, gender identity is relatively fluid and subject to constant negotiation. His book\u00a0<i>Man and Woman, Boy and Girl<\/i>\u00a0(1972) became widely used as a\u00a0college textbook, although many of Money's ideas have since been challenged.<sup id=\"cite_ref-83\" class=\"reference\"><\/sup>\r\n<h3><span id=\"Butler.27s_views\"><\/span><span class=\"mw-headline\">Butler's views<\/span><\/h3>\r\n[caption id=\"attachment_4051\" align=\"alignright\" width=\"189\"]<img class=\"wp-image-4051\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/09\/03043257\/1024px-Judith-butler-frankfurt-2012-212x300.jpg\" alt=\"A portrait of Judith Butler looking to the right of the camera.\" width=\"189\" height=\"267\" \/> <strong>Figure 1.<\/strong> Judith Butler is an American philosopher and gender theorist.[\/caption]\r\n\r\nIn the late 1980s,\u00a0Judith Butler\u00a0began lecturing regularly on the topic of gender identity. In 1990, they published\u00a0<i>Gender Trouble: Feminism and the Subversion of Identity<\/i>, introducing the concept of<strong>\u00a0gender<\/strong> <strong>performativity,<\/strong>\u00a0arguing that both sex and gender are constructed.\r\n<h2><span id=\"Present_views\" class=\"mw-headline\">Present views<\/span><\/h2>\r\nGender dysphoria (GD) exists when a person suffers discontent due to gender identity, causing them emotional distress. Researchers disagree about the nature of distress and impairment in people with gender dysphoria. Some authors have suggested that people with gender dysphoria suffer because they are stigmatized and victimized by society; if the society was more accepting of transgender identities and non-binary expressions of gender, they would suffer less and\/or may not experience dysphoria at all. Other research into genetic variation, hormones, and differences in brain functioning and brain structures suggest evidence for the biological etiology of the symptoms associated with gender dysphoria; however, much of this research is preliminary and still controversial.\r\n\r\nAs you have read, in the past, gender identity development was mostly viewed through cognitive and behaviorist lens\u2014arguing that struggles with gender identity developed from the environment or cognitive schemas. More recent research has been done to understand biological and influences on gender variances and how early social experiences may create lasting epigenetic changes related to sex differences. Research suggests that, for example, early social experiences may act as such epigenetic influence that they ultimately shape lasting sex differences in brain and behavior,\u00a0but a lot more research is needed in this field to obtain solid knowledge relevant for understanding GD.\r\n\r\nFor example, early postmortem studies of transsexual neurological differentiation was focused on the hypothalamic and amygdala regions of the brain. Using magnetic resonance imaging (MRI), some transgender women were found to have female-typical putamina that were larger in size than those of cisgender males.[footnote]Saleem F, Rizvi SW (December 2017). \"Transgender Associations and Possible Etiology: A Literature Review\". Cureus. 9 (12): e1984. doi:10.7759\/cureus.1984[\/footnote] Some trans women have also shown a female-typical central part of the bed nucleus of the stria terminalis (BSTc) and interstitial nucleus of the anterior hypothalamus number 3 (INAH-3), looking at the number of neurons found within each.[footnote]Guillamon A, Junque C, G\u00f3mez-Gil E (October 2016). \"A Review of the Status of Brain Structure Research in Transsexualism\". Archives of Sexual Behavior. 45 (7): 1615\u201348. doi:10.1007\/s10508-016-0768-5[\/footnote]\r\n<div class=\"textbox exercises\">\r\n<h3>Changing the Stigma<\/h3>\r\nToday, most medical professionals who provide transgender transition services to adults now reject <strong>conversion therapies <\/strong>(the\u00a0pseudoscientific\u00a0practice of trying to change an individual\u2019s\u00a0sexual orientation\u00a0from\u00a0homosexual\u00a0or\u00a0bisexual\u00a0to\u00a0heterosexual\u00a0using psychological, physical, or spiritual interventions)\u00a0as abusive and dangerous, believing instead what many transgender people have been convinced of: that when able to live out their daily lives with both a physical embodiment and a social expression that most closely matches their internal sense of self, transgender and transsexual individuals live successful, productive lives virtually indistinguishable from anyone else.\r\n\r\nThe\u00a0APA\u2019s guidelines for psychotherapy with lesbian, gay, and bisexual clients (American Psychological Association, 2000,\u00a02012) serve as a main reference for clinicians and highlight, among several issues, the need for clinicians to recognize that their own attitudes and knowledge about the experiences of sexual minorities are relevant to the therapeutic process with these clients and that, therefore, mental health care providers must look for appropriate literature, training, and supervision.\r\n\r\n<\/div>\r\n<h2>Treatment for Gender Dysphoria<\/h2>\r\nThe\u00a0<strong>World Professional Association for Transgender Health<\/strong>\u00a0(WPATH)\u00a0<strong>Standards of Care<\/strong>\u00a0(Version 7 from 2011) are considered by some as definitive treatment guidelines for providers. The\u00a0Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People\u00a0are international clinical protocols outlining the recommended assessment and treatment for gender non-conforming individuals across the lifespan or transgender or transsexual people who wish to undergo social, hormonal, or\u00a0surgical\u00a0transition to the other sex. Clinicians' decisions regarding patients' treatment are often influenced by this standard of care (SOC). They are most widespread standard of care (SOC) used by professionals working with transsexual, transgender, or\u00a0gender variant\u00a0people.\r\n\r\nOther standards of care (SOC) exist, including the guidelines outlines in Gianna Israel and Donald Tarver's classic 1997 book <em>Transgender Care<\/em>. Several health clinics in the United States (e.g., Tom Waddell Health Center\u00a0in San Francisco,\u00a0Callen-Lorde Community Health Center\u00a0in New York City, and Mazzoni Center\u00a0in Philadelphia) have developed protocols for transgender hormone therapy following a <strong>harm reduction model<\/strong> that is starting to be embraced by increasing numbers of providers.\u00a0Willingness to provide hormonal therapy based on assessment of individual patients needs, history, and situation with an overriding goal of achieving the best outcome for patients rather than rigidly adhering to arbitrary rules has been successful.\r\n\r\n<strong>Transgender transition services<\/strong>, the various medical treatments and procedures that alter an individual's primary and\/or secondary sexual characteristics, are thus now considered highly successful, medically necessary interventions for many transgender persons, including but not limited to transsexuals, especially those who experience the deep distress of body dysphoria.\r\n\r\nAchieving basic human rights for all transgender persons undoubtedly requires increased social acceptance of each individual's own expression of their identity, regardless of their biological gender or social role expectations. However, for those transgender individuals who experience the internal distress of body dysphoria, social acceptance of variation, while vastly important, will not be sufficient. For this segment of the transgender community, some medical services and procedures will also be required in order for these individuals to feel aligned with their bodies and for the distress of body dysphoria to be fully alleviated.\r\n<h2>Treatment<\/h2>\r\n[caption id=\"attachment_4037\" align=\"alignright\" width=\"312\"]<img class=\"wp-image-4037 \" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/09\/02221145\/A-genderqueer-person-sitting-in-a-hospital-gown-sitting-in-an-exam-room-300x200.jpg\" alt=\"A genderqueer person sitting in an exam room and wearing a hospital gown.\" width=\"312\" height=\"208\" \/> <strong>Figure\u00a0 2.<\/strong>\u00a0Some transgender individuals will undergo top or bottom surgeries, while others may choose not to have any surgery at all.[\/caption]\r\n\r\nToday, gender affirming surgery\u00a0is performed on people who choose to have this change so that their anatomical sex will match their gender identity. Transgender\u00a0individuals sometimes wish to undergo this type of surgery to refashion their\u00a0primary sexual characteristics, secondary characteristics, or both, because they feel they will be more comfortable with different genitalia. This may involve removal of penis, testicles or breasts, or the fashioning of a penis, vagina, or breasts. In the past, sex assignment surgery has been performed on infants who are born with ambiguous genitalia. However, current medical opinion is strongly against this procedure on infants since many adults have regretted that these decisions were made for them at birth.\r\n\r\n<b>Gender confirmation surgery<\/b>\u00a0(or gender affirming surgery) refers to any form of surgical procedure performed on a\u00a0transgender\u00a0person in order to change their\u00a0sex characteristics\u00a0to better reflect their\u00a0gender identity. Surgical procedures are usually preceded by\u00a0hormone replacement therapy.\r\n\r\nSome forms of gender confirmation surgery include\r\n<ul>\r\n \t<li><strong>bottom surgery<\/strong>, or surgery to alter the genitalia.<\/li>\r\n \t<li><strong>top surgery<\/strong>, or surgery to alter the chest and breast tissue.<\/li>\r\n \t<li>facial reconstruction surgery, to alter the appearance of the face.<\/li>\r\n<\/ul>\r\nThose who plan to have surgery but not yet done so are often referred to as\u00a0<strong>pre-op<\/strong>\u00a0while those who have already had surgery are referred to as\u00a0<strong>post-op<\/strong>. Those who do not wish to include surgery in their transition are referred to as\u00a0<strong>non-op<\/strong>.\r\n\r\nSex reassignment surgery performed on nonconsenting minors (babies and children) may result in catastrophic outcomes (including\u00a0PTSD\u00a0and suicide\u2014such as in the\u00a0<em>David Reimer\u00a0<\/em>case following a botched circumcision) when the individual's sexual identity (determined by neuroanatomical brain wiring) is discrepant with the surgical reassignment previously imposed. Milton Diamond\u00a0at the John A. Burns School of Medicine of the University of Hawaii\u00a0recommended that physicians do not perform surgery on children until they are old enough to give informed consent and to assign such infants in the gender to which they will probably best adjust. Diamond believed introducing children to others with differences of sex development could help remove shame and stigma. Diamond considered the intersex condition as a difference of sex development, not as a\u00a0disorder.\r\n<div class=\"textbox exercises\">\r\n<h3>The History of Transition SurgerY<\/h3>\r\nThe goal of early transition surgeries was the removal of hormone-producing organs (such as the testicles and the ovaries) in order to reduce their masculinizing or feminizing effects. Later, as surgical technique became more complex, the goal became to produce functional sex organs from sex organs that are already present in the patient.\r\n\r\nIn the United States in 1917, Dr.\u00a0Alan L. Hart, an American tuberculosis specialist, became one of the first female-to-male transsexuals to undergo\u00a0hysterectomy\u00a0and\u00a0gonadectomy\u00a0for the relief of gender dysphoria.<sup id=\"cite_ref-6\" class=\"reference\"><\/sup>\r\n\r\nIn Berlin in 1931,\u00a0Dora Richter, became the first known transgender woman to undergo the\u00a0vaginoplasty\u00a0<sup id=\"cite_ref-7\" class=\"reference\"><\/sup>surgical approach.\r\n\r\nThis surgery was followed by\u00a0Lili Elbe\u00a0in Dresden during 1930\u20131931. She started with the removal of her original sex organs, the operation supervised by Dr.\u00a0Magnus Hirschfeld. Lili went on to have four more subsequent operations that included an\u00a0orchiectomy, an\u00a0ovary\u00a0transplant, a\u00a0penectomy, and ultimately an unsuccessful\u00a0uterine transplant, the rejection of which resulted in death. An earlier known recipient of this was Magnus Hirschfeld's\u00a0housekeeper,\u00a0<sup id=\"cite_ref-8\" class=\"reference\"><\/sup>but their identity is unclear at this time.\r\n\r\nIn 1951, Dr.\u00a0Harold Gillies, a plastic surgeon active in World War II, worked to develop the first technique for\u00a0female-to-male gender affirming surgery, producing a technique that has become a modern standard, called\u00a0phalloplasty.\u00a0<sup id=\"cite_ref-9\" class=\"reference\"><\/sup>Phalloplasty is a cosmetic procedure that produces a visual penis out of grafted tissue from the patient.\r\n\r\nFollowing phalloplasty, in 1999, the procedure for\u00a0metoidioplasty\u00a0was developed for female-to-male surgical transition by Drs. Lebovic and Laub.\u00a0Considered a variant of phalloplasty, metoidioplasty works to create a penis out of the patient's present clitoris. This allows the patient to have a sensation-perceiving penis head.\u00a0Metoidioplasty may be used in conjunction with phalloplasty to produce a larger, more \"cis-appearing\" penis in multiple stages.\r\n\r\nOn 12 June 2003, the\u00a0European Court of Human Rights\u00a0ruled in favor of Van K\u00fcck, a German trans woman whose insurance company denied her reimbursement for gender affirming surgery as well as\u00a0hormone replacement therapy. The legal arguments related to the\u00a0Article 6 of the European Convention on Human Rights\u00a0as well as the\u00a0Article 8. This affair is referred to as\u00a0<i>Van K\u00fcck vs Germany<\/i>.\r\n\r\nIn 2011,\u00a0Christiane V\u00f6lling\u00a0won the first successful case brought by an\u00a0intersex\u00a0person against a surgeon for non-consensual surgical intervention described by the\u00a0International Commission of Jurists\u00a0as \"an example of an individual who was subjected to sex reassignment surgery without full knowledge or consent.\"\r\n\r\n<\/div>\r\n<h3>Psychological Treatments<\/h3>\r\nTreatment for a person diagnosed with GD may include psychotherapy or to support the individual's preferred gender through hormone therapy, gender expression and role, or surgery.\u00a0<span style=\"font-size: 1em;\">Psychotherapy is any therapeutic interaction that aims to treat a psychological problem.\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">This may include psychological counseling, resulting in lifestyle changes or physical changes resulting from medical interventions such as hormonal treatment, genital surgery, electrolysis or laser hair removal, chest\/breast surgery, or other reconstructive surgeries.\u00a0<\/span><span style=\"font-size: 1em;\">Psychotherapeutic treatment of GD involves helping the patient to adapt.\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">The goal of treatment may simply be to reduce problems resulting from the person's transgender status, for example, counseling the patient in order to reduce guilt associated with cross-dressing or counseling a spouse to help them adjust to the patient's situation.<\/span>\r\n\r\nUntil the 1970s, psychotherapy was the primary treatment for gender dysphoria and generally was directed to helping the person adjust to the gender of the physical characteristics present at birth. Though some clinicians still use only psychotherapy to treat gender dysphoria, it may now be used in addition to biological interventions. Attempts to alleviate GD by changing the patient's gender identity to reflect birth characteristics have been ineffective.\r\n<h3>Biological Treatments<\/h3>\r\nBiological treatments physically alter primary and secondary sex characteristics to reduce the discrepancy between an individual's physical body and gender identity. Biological treatments for GD without any form of psychotherapy is quite uncommon. Researchers have found that if individuals bypass psychotherapy in their GD treatment, they often feel lost and confused when their biological treatments are complete.[footnote]Hakeem, Az (2008). \"Changing Sex or Changing Minds: Specialist Psychotherapy and Transsexuality\". Group Analysis. 41 (2): 182\u2013196. doi:10.1177\/0533316408089883. S2CID 143359476.[\/footnote]\r\n<h3>Prepubescent Children<\/h3>\r\nThe question of whether to counsel young children to be happy with their sex assigned at birth or to encourage them to continue to exhibit behaviors that do not match their sex assigned at birth\u2014or to explore a transgender transition\u2014is controversial. The follow-up studies of children with gender dysphoria consistently show that the majority cease to feel transgender during puberty and identify instead as gay or lesbian.[footnote]Wallien, M. S. C., &amp; Cohen-Kettenis, P. T. (2008). Psychosexual outcome of gender-dysphoric children. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1413\u20131423.[\/footnote][footnote]Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., &amp; Cohen-Kettenis, P. T. (2013). Factors associated with desistence and persistence of childhood gender dysphoria: A quantitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 582\u2013590.[\/footnote] Other clinicians also report that a significant proportion of young children diagnosed with gender dysphoria later do not exhibit any dysphoria.[footnote]Spiegel, Alix (May 8, 2008). \"Q&amp;A: Therapists on Gender Identity Issues in Kids\". NPR. Retrieved September 16, 2008.[\/footnote]\r\n\r\nProfessionals who treat gender dysphoria in children have begun to refer and prescribe hormones, known as puberty blockers, to delay the onset of puberty until a child is believed to be old enough to make an informed decision on whether hormonal gender affirmation leading to gender affirming surgery will be in that person's best interest.\r\n<h3>Psychological and Social Consequences<\/h3>\r\n<p style=\"margin-top: 0px;\">Overall, psychotherapy, hormone replacement therapy, and gender affirming surgery together can be effective treating GD when the WPATH standards of care are followed. The overall level of patient satisfaction with both psychological and biological treatments is very high.<\/p>\r\nAfter gender affirming surgery, <strong>transsexual <\/strong>individuals\u00a0(people who underwent gender affirming hormone therapy and gender affirming surgery) tend to be less\u00a0gender dysphoric. They also normally function well both socially and psychologically. Anxiety, depression, and hostility levels were lower after gender affirming surgery. They also tend to score well for self-perceived mental health, which is independent from sexual satisfaction. Many studies have been carried out to investigate satisfaction levels of patients after gender affirming surgery. In these studies, most of the patients have reported being very happy with the results and very few of the patients have expressed regret for undergoing gender affirming surgery.\r\n\r\nAlthough studies have suggested that the positive consequences of gender affirming surgery outweigh the negative consequences, it has been suggested that most studies investigating the outcomes of gender affirming surgery are flawed as they have only included a small percentage of gender affirming surgery patients in their studies. These methodological limitations such as lack of double-blind randomized controls, small number of participants due to the rarity of transsexualism, high drop-out rates, and low follow-up rates, which would indicate need for continued study.\r\n\r\nPersistent regret can occur after gender affirming surgery. Regret may be due to unresolved gender dysphoria, or a weak and fluctuating sense of identity, and may even lead to suicide. Risk categories for post-operative regret include being older, having characterized personality disorders with personal and social instability, lacking family support, lacking sexual activity, and expressing dissatisfaction with the results of surgery. During the process of gender affirming surgery, transsexuals may become victims of different social obstacles such as discrimination, prejudice, and stigmatizing behaviors. The rejection faced by transsexuals is much more severe than what is experienced by LGB individuals. The hostile environment may trigger or worsen internalized transphobia, depression, anxiety, and post-traumatic stress.\r\n\r\nMany patients perceive the outcome of the surgery as not only medically but also psychologically important. Social support can help them to relate to their minority identity, ascertain their trans identity, and reduce minority stress. Therefore, it is suggested that psychological support is crucial for patients after gender affirming surgery, which helps them feel accepted and to have confidence in the outcome of the surgery; also, psychological support will become increasingly important for patients with lengthier gender affirming surgery processes.\r\n<div class=\"textbox tryit\">\r\n<h3>Try It<\/h3>\r\nhttps:\/\/assess.lumenlearning.com\/practice\/f391e4d8-fb2f-4fda-8823-73cec5a1fd91\r\n\r\nhttps:\/\/assess.lumenlearning.com\/practice\/f529fbe5-a23e-4f9a-b555-42ae1b6f9c2c\r\n\r\n<\/div>\r\n<div class=\"textbox examples\">\r\n<h3>Watch It<\/h3>\r\nThis video tells the first-person account of Jamie's experience during his hormonal treatment and transition.\r\n\r\n[embed]https:\/\/www.youtube.com\/watch?v=RYuipbRGu5s[\/embed]\r\n\r\nYou can view the <a href=\"https:\/\/course-building.s3-us-west-2.amazonaws.com\/Abnormal+Psychology\/transcripts\/MyGenderTransitionFromFemaleToMale_transcript.txt\" target=\"_blank\" rel=\"noopener\">transcript for \"My Gender Transition From Female To Male \u2022 Dear BuzzFeed\" here (opens in new window)<\/a>.\r\n\r\n<\/div>\r\n<div class=\"textbox learning-objectives\">\r\n<h3>Glossary<\/h3>\r\n<strong>bottom surgery:<\/strong>\u00a0surgery to alter the genitalia\r\n\r\n<strong>conversion therapies:\u00a0<\/strong>the\u00a0pseudoscientific\u00a0practice of trying to change an individual\u2019s\u00a0sexual orientation\u00a0from\u00a0homosexual\u00a0or\u00a0bisexual\u00a0to\u00a0heterosexual\u00a0using psychological, physical, or spiritual interventions\r\n\r\n<strong>gender affirming surgery:<\/strong>\u00a0any form of surgical procedure performed on a\u00a0transgender\u00a0person in order to change their\u00a0sex characteristics\u00a0to better reflect their\u00a0gender identity\r\n\r\n<strong>gender performativity:<\/strong>\u00a0concept arguing that both sex and gender are constructed\r\n\r\n<strong>harm reduction model:<\/strong>\u00a0a set of practical strategies and ideas aimed at providing hormonal therapy based on assessment of individual patient\u2019s needs, history, and situation with an overriding goal of achieving the best outcome for patients rather than rigidly adhering to arbitrary rules\r\n\r\n<strong>identity:<\/strong>\u00a0the way one understands, describes and expresses oneself and the reflection of those entities to others\r\n\r\n<strong>interactionist\u00a0theory of gender identity:<\/strong>\u00a0a theory that suggests that, up to a certain age, gender identity is relatively fluid and subject to constant negotiation\r\n\r\n<strong>non-op:<\/strong>\u00a0those who do not wish to include surgery in their transition\r\n\r\n<strong>post-op:<\/strong>\u00a0those who have already had surgery\r\n\r\n<strong>pre-op:<\/strong>\u00a0those who plan to have surgery but not yet done so\r\n\r\n<strong>top surgery:<\/strong>\u00a0surgery to alter the chest and breast tissue\r\n\r\n<strong>transgender transition services:<\/strong>\u00a0the various medical treatments and procedures that alter an individual's primary and\/or secondary sexual characteristics\r\n\r\n<strong>transsexual:<\/strong>\u00a0a person who has undergone gender affirming hormone therapy and gender affirming surgery\r\n\r\n<strong>World Professional Association for Transgender Health\u00a0(WPATH)\u00a0Standards of Care:<\/strong>\u00a0international clinical protocols outlining the recommended assessment and treatment for gender non-conforming individuals across the lifespan or transgender or transsexual people who wish to undergo social, hormonal, or surgical transition to the other sex\r\n\r\n<\/div>","rendered":"<div class=\"textbox learning-objectives\">\n<h3>Learning Objectives<\/h3>\n<ul>\n<li style=\"font-weight: 400;\">Examine historical and current perspectives on gender dysphoria<\/li>\n<li style=\"font-weight: 400;\">Describe and evaluate treatments for gender dysphoria<\/li>\n<\/ul>\n<\/div>\n<h2>Historical and Modern Perspectives on Gender and Gender Identity<\/h2>\n<h3><span id=\"Early_medical_literature\" class=\"mw-headline\">Early Medical Literature<\/span><\/h3>\n<p>In late-19th-century medical literature, women who chose not to conform to their expected gender roles were called &#8220;inverts,&#8221; and they were portrayed as having an interest in knowledge and learning and a &#8220;dislike and sometimes incapacity for needlework.&#8221; During the mid-1900s, doctors pushed for corrective therapy on such women and children, which meant that gender behaviors that were not part of the norm would be punished and changed. The aim of this therapy was to push children back to their &#8220;correct&#8221; gender roles and thereby limit the number of children who became transgender.<\/p>\n<h3><span id=\"Freud_and_Jung's_views\" class=\"mw-headline\">Psychodynamic Perspectives: Freud and Jung&#8217;s Views<\/span><\/h3>\n<p>In 1905,\u00a0Sigmund Freud\u00a0presented his theory of\u00a0psychosexual development\u00a0in\u00a0<i>Three Essays on the Theory of Sexuality<\/i>, giving evidence that in the pregenital phase children do not distinguish between sexes, but assume both parents have the same genitalia and reproductive powers. On this basis, he argued that bisexuality was the original sexual orientation and that heterosexuality was resultant of repression during the\u00a0phallic stage, at which point gender identity became ascertainable. According to Freud, during this stage, children developed an\u00a0<strong>Oedipus complex<\/strong>\u00a0where they had sexual fantasies for the parent ascribed the opposite gender and hatred for the parent ascribed the same gender, and this hatred transformed into (unconscious) transference and (conscious) identification with the hated parent who both exemplified a model to appease sexual impulses and threatened to castrate the child&#8217;s power to appease sexual impulses.\u00a0In 1913,\u00a0Carl Jung\u00a0proposed the\u00a0<strong>Electra complex<\/strong>\u00a0as he both believed that bisexuality did not lie at the origin of psychic life and that Freud did not give adequate description to the female child (Freud rejected this suggestion).<\/p>\n<h3><span id=\"1950s_and_1960s\" class=\"mw-headline\">1950s and Beyond<\/span><\/h3>\n<p>During the 1950s and &#8217;60s, psychologists began studying gender development in young children, partially in an effort to understand the origins of\u00a0homosexuality\u00a0(which was viewed as a\u00a0mental disorder\u00a0at the time). In 1958, the Gender Identity Research Project was established at the\u00a0UCLA Medical Center\u00a0for the study of\u00a0intersex\u00a0and transsexual individuals. Psychoanalyst\u00a0Robert Stoller\u00a0generalized many of the findings of the project in his book\u00a0<i>Sex and Gender: On the Development of Masculinity and Femininity<\/i>\u00a0(1968). He is also credited with introducing the term\u00a0<i>gender identity<\/i>\u00a0to the International Psychoanalytic Congress in\u00a0Stockholm, Sweden, in 1963. Behavioral psychologist\u00a0John Money\u00a0was also instrumental in the development of early theories of gender identity. His work at\u00a0Johns Hopkins Medical School&#8217;s Gender Identity Clinic (established in 1965) popularized an\u00a0<strong>interactionist\u00a0theory of gender identity<\/strong>, suggesting that, up to a certain age, gender identity is relatively fluid and subject to constant negotiation. His book\u00a0<i>Man and Woman, Boy and Girl<\/i>\u00a0(1972) became widely used as a\u00a0college textbook, although many of Money&#8217;s ideas have since been challenged.<sup id=\"cite_ref-83\" class=\"reference\"><\/sup><\/p>\n<h3><span id=\"Butler.27s_views\"><\/span><span class=\"mw-headline\">Butler&#8217;s views<\/span><\/h3>\n<div id=\"attachment_4051\" style=\"width: 199px\" class=\"wp-caption alignright\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4051\" class=\"wp-image-4051\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/09\/03043257\/1024px-Judith-butler-frankfurt-2012-212x300.jpg\" alt=\"A portrait of Judith Butler looking to the right of the camera.\" width=\"189\" height=\"267\" \/><\/p>\n<p id=\"caption-attachment-4051\" class=\"wp-caption-text\"><strong>Figure 1.<\/strong> Judith Butler is an American philosopher and gender theorist.<\/p>\n<\/div>\n<p>In the late 1980s,\u00a0Judith Butler\u00a0began lecturing regularly on the topic of gender identity. In 1990, they published\u00a0<i>Gender Trouble: Feminism and the Subversion of Identity<\/i>, introducing the concept of<strong>\u00a0gender<\/strong> <strong>performativity,<\/strong>\u00a0arguing that both sex and gender are constructed.<\/p>\n<h2><span id=\"Present_views\" class=\"mw-headline\">Present views<\/span><\/h2>\n<p>Gender dysphoria (GD) exists when a person suffers discontent due to gender identity, causing them emotional distress. Researchers disagree about the nature of distress and impairment in people with gender dysphoria. Some authors have suggested that people with gender dysphoria suffer because they are stigmatized and victimized by society; if the society was more accepting of transgender identities and non-binary expressions of gender, they would suffer less and\/or may not experience dysphoria at all. Other research into genetic variation, hormones, and differences in brain functioning and brain structures suggest evidence for the biological etiology of the symptoms associated with gender dysphoria; however, much of this research is preliminary and still controversial.<\/p>\n<p>As you have read, in the past, gender identity development was mostly viewed through cognitive and behaviorist lens\u2014arguing that struggles with gender identity developed from the environment or cognitive schemas. More recent research has been done to understand biological and influences on gender variances and how early social experiences may create lasting epigenetic changes related to sex differences. Research suggests that, for example, early social experiences may act as such epigenetic influence that they ultimately shape lasting sex differences in brain and behavior,\u00a0but a lot more research is needed in this field to obtain solid knowledge relevant for understanding GD.<\/p>\n<p>For example, early postmortem studies of transsexual neurological differentiation was focused on the hypothalamic and amygdala regions of the brain. Using magnetic resonance imaging (MRI), some transgender women were found to have female-typical putamina that were larger in size than those of cisgender males.<a class=\"footnote\" title=\"Saleem F, Rizvi SW (December 2017). &quot;Transgender Associations and Possible Etiology: A Literature Review&quot;. Cureus. 9 (12): e1984. doi:10.7759\/cureus.1984\" id=\"return-footnote-1793-1\" href=\"#footnote-1793-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a> Some trans women have also shown a female-typical central part of the bed nucleus of the stria terminalis (BSTc) and interstitial nucleus of the anterior hypothalamus number 3 (INAH-3), looking at the number of neurons found within each.<a class=\"footnote\" title=\"Guillamon A, Junque C, G\u00f3mez-Gil E (October 2016). &quot;A Review of the Status of Brain Structure Research in Transsexualism&quot;. Archives of Sexual Behavior. 45 (7): 1615\u201348. doi:10.1007\/s10508-016-0768-5\" id=\"return-footnote-1793-2\" href=\"#footnote-1793-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a><\/p>\n<div class=\"textbox exercises\">\n<h3>Changing the Stigma<\/h3>\n<p>Today, most medical professionals who provide transgender transition services to adults now reject <strong>conversion therapies <\/strong>(the\u00a0pseudoscientific\u00a0practice of trying to change an individual\u2019s\u00a0sexual orientation\u00a0from\u00a0homosexual\u00a0or\u00a0bisexual\u00a0to\u00a0heterosexual\u00a0using psychological, physical, or spiritual interventions)\u00a0as abusive and dangerous, believing instead what many transgender people have been convinced of: that when able to live out their daily lives with both a physical embodiment and a social expression that most closely matches their internal sense of self, transgender and transsexual individuals live successful, productive lives virtually indistinguishable from anyone else.<\/p>\n<p>The\u00a0APA\u2019s guidelines for psychotherapy with lesbian, gay, and bisexual clients (American Psychological Association, 2000,\u00a02012) serve as a main reference for clinicians and highlight, among several issues, the need for clinicians to recognize that their own attitudes and knowledge about the experiences of sexual minorities are relevant to the therapeutic process with these clients and that, therefore, mental health care providers must look for appropriate literature, training, and supervision.<\/p>\n<\/div>\n<h2>Treatment for Gender Dysphoria<\/h2>\n<p>The\u00a0<strong>World Professional Association for Transgender Health<\/strong>\u00a0(WPATH)\u00a0<strong>Standards of Care<\/strong>\u00a0(Version 7 from 2011) are considered by some as definitive treatment guidelines for providers. The\u00a0Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People\u00a0are international clinical protocols outlining the recommended assessment and treatment for gender non-conforming individuals across the lifespan or transgender or transsexual people who wish to undergo social, hormonal, or\u00a0surgical\u00a0transition to the other sex. Clinicians&#8217; decisions regarding patients&#8217; treatment are often influenced by this standard of care (SOC). They are most widespread standard of care (SOC) used by professionals working with transsexual, transgender, or\u00a0gender variant\u00a0people.<\/p>\n<p>Other standards of care (SOC) exist, including the guidelines outlines in Gianna Israel and Donald Tarver&#8217;s classic 1997 book <em>Transgender Care<\/em>. Several health clinics in the United States (e.g., Tom Waddell Health Center\u00a0in San Francisco,\u00a0Callen-Lorde Community Health Center\u00a0in New York City, and Mazzoni Center\u00a0in Philadelphia) have developed protocols for transgender hormone therapy following a <strong>harm reduction model<\/strong> that is starting to be embraced by increasing numbers of providers.\u00a0Willingness to provide hormonal therapy based on assessment of individual patients needs, history, and situation with an overriding goal of achieving the best outcome for patients rather than rigidly adhering to arbitrary rules has been successful.<\/p>\n<p><strong>Transgender transition services<\/strong>, the various medical treatments and procedures that alter an individual&#8217;s primary and\/or secondary sexual characteristics, are thus now considered highly successful, medically necessary interventions for many transgender persons, including but not limited to transsexuals, especially those who experience the deep distress of body dysphoria.<\/p>\n<p>Achieving basic human rights for all transgender persons undoubtedly requires increased social acceptance of each individual&#8217;s own expression of their identity, regardless of their biological gender or social role expectations. However, for those transgender individuals who experience the internal distress of body dysphoria, social acceptance of variation, while vastly important, will not be sufficient. For this segment of the transgender community, some medical services and procedures will also be required in order for these individuals to feel aligned with their bodies and for the distress of body dysphoria to be fully alleviated.<\/p>\n<h2>Treatment<\/h2>\n<div id=\"attachment_4037\" style=\"width: 322px\" class=\"wp-caption alignright\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-4037\" class=\"wp-image-4037\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/09\/02221145\/A-genderqueer-person-sitting-in-a-hospital-gown-sitting-in-an-exam-room-300x200.jpg\" alt=\"A genderqueer person sitting in an exam room and wearing a hospital gown.\" width=\"312\" height=\"208\" \/><\/p>\n<p id=\"caption-attachment-4037\" class=\"wp-caption-text\"><strong>Figure\u00a0 2.<\/strong>\u00a0Some transgender individuals will undergo top or bottom surgeries, while others may choose not to have any surgery at all.<\/p>\n<\/div>\n<p>Today, gender affirming surgery\u00a0is performed on people who choose to have this change so that their anatomical sex will match their gender identity. Transgender\u00a0individuals sometimes wish to undergo this type of surgery to refashion their\u00a0primary sexual characteristics, secondary characteristics, or both, because they feel they will be more comfortable with different genitalia. This may involve removal of penis, testicles or breasts, or the fashioning of a penis, vagina, or breasts. In the past, sex assignment surgery has been performed on infants who are born with ambiguous genitalia. However, current medical opinion is strongly against this procedure on infants since many adults have regretted that these decisions were made for them at birth.<\/p>\n<p><b>Gender confirmation surgery<\/b>\u00a0(or gender affirming surgery) refers to any form of surgical procedure performed on a\u00a0transgender\u00a0person in order to change their\u00a0sex characteristics\u00a0to better reflect their\u00a0gender identity. Surgical procedures are usually preceded by\u00a0hormone replacement therapy.<\/p>\n<p>Some forms of gender confirmation surgery include<\/p>\n<ul>\n<li><strong>bottom surgery<\/strong>, or surgery to alter the genitalia.<\/li>\n<li><strong>top surgery<\/strong>, or surgery to alter the chest and breast tissue.<\/li>\n<li>facial reconstruction surgery, to alter the appearance of the face.<\/li>\n<\/ul>\n<p>Those who plan to have surgery but not yet done so are often referred to as\u00a0<strong>pre-op<\/strong>\u00a0while those who have already had surgery are referred to as\u00a0<strong>post-op<\/strong>. Those who do not wish to include surgery in their transition are referred to as\u00a0<strong>non-op<\/strong>.<\/p>\n<p>Sex reassignment surgery performed on nonconsenting minors (babies and children) may result in catastrophic outcomes (including\u00a0PTSD\u00a0and suicide\u2014such as in the\u00a0<em>David Reimer\u00a0<\/em>case following a botched circumcision) when the individual&#8217;s sexual identity (determined by neuroanatomical brain wiring) is discrepant with the surgical reassignment previously imposed. Milton Diamond\u00a0at the John A. Burns School of Medicine of the University of Hawaii\u00a0recommended that physicians do not perform surgery on children until they are old enough to give informed consent and to assign such infants in the gender to which they will probably best adjust. Diamond believed introducing children to others with differences of sex development could help remove shame and stigma. Diamond considered the intersex condition as a difference of sex development, not as a\u00a0disorder.<\/p>\n<div class=\"textbox exercises\">\n<h3>The History of Transition SurgerY<\/h3>\n<p>The goal of early transition surgeries was the removal of hormone-producing organs (such as the testicles and the ovaries) in order to reduce their masculinizing or feminizing effects. Later, as surgical technique became more complex, the goal became to produce functional sex organs from sex organs that are already present in the patient.<\/p>\n<p>In the United States in 1917, Dr.\u00a0Alan L. Hart, an American tuberculosis specialist, became one of the first female-to-male transsexuals to undergo\u00a0hysterectomy\u00a0and\u00a0gonadectomy\u00a0for the relief of gender dysphoria.<sup id=\"cite_ref-6\" class=\"reference\"><\/sup><\/p>\n<p>In Berlin in 1931,\u00a0Dora Richter, became the first known transgender woman to undergo the\u00a0vaginoplasty\u00a0<sup id=\"cite_ref-7\" class=\"reference\"><\/sup>surgical approach.<\/p>\n<p>This surgery was followed by\u00a0Lili Elbe\u00a0in Dresden during 1930\u20131931. She started with the removal of her original sex organs, the operation supervised by Dr.\u00a0Magnus Hirschfeld. Lili went on to have four more subsequent operations that included an\u00a0orchiectomy, an\u00a0ovary\u00a0transplant, a\u00a0penectomy, and ultimately an unsuccessful\u00a0uterine transplant, the rejection of which resulted in death. An earlier known recipient of this was Magnus Hirschfeld&#8217;s\u00a0housekeeper,\u00a0<sup id=\"cite_ref-8\" class=\"reference\"><\/sup>but their identity is unclear at this time.<\/p>\n<p>In 1951, Dr.\u00a0Harold Gillies, a plastic surgeon active in World War II, worked to develop the first technique for\u00a0female-to-male gender affirming surgery, producing a technique that has become a modern standard, called\u00a0phalloplasty.\u00a0<sup id=\"cite_ref-9\" class=\"reference\"><\/sup>Phalloplasty is a cosmetic procedure that produces a visual penis out of grafted tissue from the patient.<\/p>\n<p>Following phalloplasty, in 1999, the procedure for\u00a0metoidioplasty\u00a0was developed for female-to-male surgical transition by Drs. Lebovic and Laub.\u00a0Considered a variant of phalloplasty, metoidioplasty works to create a penis out of the patient&#8217;s present clitoris. This allows the patient to have a sensation-perceiving penis head.\u00a0Metoidioplasty may be used in conjunction with phalloplasty to produce a larger, more &#8220;cis-appearing&#8221; penis in multiple stages.<\/p>\n<p>On 12 June 2003, the\u00a0European Court of Human Rights\u00a0ruled in favor of Van K\u00fcck, a German trans woman whose insurance company denied her reimbursement for gender affirming surgery as well as\u00a0hormone replacement therapy. The legal arguments related to the\u00a0Article 6 of the European Convention on Human Rights\u00a0as well as the\u00a0Article 8. This affair is referred to as\u00a0<i>Van K\u00fcck vs Germany<\/i>.<\/p>\n<p>In 2011,\u00a0Christiane V\u00f6lling\u00a0won the first successful case brought by an\u00a0intersex\u00a0person against a surgeon for non-consensual surgical intervention described by the\u00a0International Commission of Jurists\u00a0as &#8220;an example of an individual who was subjected to sex reassignment surgery without full knowledge or consent.&#8221;<\/p>\n<\/div>\n<h3>Psychological Treatments<\/h3>\n<p>Treatment for a person diagnosed with GD may include psychotherapy or to support the individual&#8217;s preferred gender through hormone therapy, gender expression and role, or surgery.\u00a0<span style=\"font-size: 1em;\">Psychotherapy is any therapeutic interaction that aims to treat a psychological problem.\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">This may include psychological counseling, resulting in lifestyle changes or physical changes resulting from medical interventions such as hormonal treatment, genital surgery, electrolysis or laser hair removal, chest\/breast surgery, or other reconstructive surgeries.\u00a0<\/span><span style=\"font-size: 1em;\">Psychotherapeutic treatment of GD involves helping the patient to adapt.\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">The goal of treatment may simply be to reduce problems resulting from the person&#8217;s transgender status, for example, counseling the patient in order to reduce guilt associated with cross-dressing or counseling a spouse to help them adjust to the patient&#8217;s situation.<\/span><\/p>\n<p>Until the 1970s, psychotherapy was the primary treatment for gender dysphoria and generally was directed to helping the person adjust to the gender of the physical characteristics present at birth. Though some clinicians still use only psychotherapy to treat gender dysphoria, it may now be used in addition to biological interventions. Attempts to alleviate GD by changing the patient&#8217;s gender identity to reflect birth characteristics have been ineffective.<\/p>\n<h3>Biological Treatments<\/h3>\n<p>Biological treatments physically alter primary and secondary sex characteristics to reduce the discrepancy between an individual&#8217;s physical body and gender identity. Biological treatments for GD without any form of psychotherapy is quite uncommon. Researchers have found that if individuals bypass psychotherapy in their GD treatment, they often feel lost and confused when their biological treatments are complete.<a class=\"footnote\" title=\"Hakeem, Az (2008). &quot;Changing Sex or Changing Minds: Specialist Psychotherapy and Transsexuality&quot;. Group Analysis. 41 (2): 182\u2013196. doi:10.1177\/0533316408089883. S2CID 143359476.\" id=\"return-footnote-1793-3\" href=\"#footnote-1793-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a><\/p>\n<h3>Prepubescent Children<\/h3>\n<p>The question of whether to counsel young children to be happy with their sex assigned at birth or to encourage them to continue to exhibit behaviors that do not match their sex assigned at birth\u2014or to explore a transgender transition\u2014is controversial. The follow-up studies of children with gender dysphoria consistently show that the majority cease to feel transgender during puberty and identify instead as gay or lesbian.<a class=\"footnote\" title=\"Wallien, M. S. C., &amp; Cohen-Kettenis, P. T. (2008). Psychosexual outcome of gender-dysphoric children. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1413\u20131423.\" id=\"return-footnote-1793-4\" href=\"#footnote-1793-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a><a class=\"footnote\" title=\"Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., &amp; Cohen-Kettenis, P. T. (2013). Factors associated with desistence and persistence of childhood gender dysphoria: A quantitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 582\u2013590.\" id=\"return-footnote-1793-5\" href=\"#footnote-1793-5\" aria-label=\"Footnote 5\"><sup class=\"footnote\">[5]<\/sup><\/a> Other clinicians also report that a significant proportion of young children diagnosed with gender dysphoria later do not exhibit any dysphoria.<a class=\"footnote\" title=\"Spiegel, Alix (May 8, 2008). &quot;Q&amp;A: Therapists on Gender Identity Issues in Kids&quot;. NPR. Retrieved September 16, 2008.\" id=\"return-footnote-1793-6\" href=\"#footnote-1793-6\" aria-label=\"Footnote 6\"><sup class=\"footnote\">[6]<\/sup><\/a><\/p>\n<p>Professionals who treat gender dysphoria in children have begun to refer and prescribe hormones, known as puberty blockers, to delay the onset of puberty until a child is believed to be old enough to make an informed decision on whether hormonal gender affirmation leading to gender affirming surgery will be in that person&#8217;s best interest.<\/p>\n<h3>Psychological and Social Consequences<\/h3>\n<p style=\"margin-top: 0px;\">Overall, psychotherapy, hormone replacement therapy, and gender affirming surgery together can be effective treating GD when the WPATH standards of care are followed. The overall level of patient satisfaction with both psychological and biological treatments is very high.<\/p>\n<p>After gender affirming surgery, <strong>transsexual <\/strong>individuals\u00a0(people who underwent gender affirming hormone therapy and gender affirming surgery) tend to be less\u00a0gender dysphoric. They also normally function well both socially and psychologically. Anxiety, depression, and hostility levels were lower after gender affirming surgery. They also tend to score well for self-perceived mental health, which is independent from sexual satisfaction. Many studies have been carried out to investigate satisfaction levels of patients after gender affirming surgery. In these studies, most of the patients have reported being very happy with the results and very few of the patients have expressed regret for undergoing gender affirming surgery.<\/p>\n<p>Although studies have suggested that the positive consequences of gender affirming surgery outweigh the negative consequences, it has been suggested that most studies investigating the outcomes of gender affirming surgery are flawed as they have only included a small percentage of gender affirming surgery patients in their studies. These methodological limitations such as lack of double-blind randomized controls, small number of participants due to the rarity of transsexualism, high drop-out rates, and low follow-up rates, which would indicate need for continued study.<\/p>\n<p>Persistent regret can occur after gender affirming surgery. Regret may be due to unresolved gender dysphoria, or a weak and fluctuating sense of identity, and may even lead to suicide. Risk categories for post-operative regret include being older, having characterized personality disorders with personal and social instability, lacking family support, lacking sexual activity, and expressing dissatisfaction with the results of surgery. During the process of gender affirming surgery, transsexuals may become victims of different social obstacles such as discrimination, prejudice, and stigmatizing behaviors. The rejection faced by transsexuals is much more severe than what is experienced by LGB individuals. The hostile environment may trigger or worsen internalized transphobia, depression, anxiety, and post-traumatic stress.<\/p>\n<p>Many patients perceive the outcome of the surgery as not only medically but also psychologically important. Social support can help them to relate to their minority identity, ascertain their trans identity, and reduce minority stress. Therefore, it is suggested that psychological support is crucial for patients after gender affirming surgery, which helps them feel accepted and to have confidence in the outcome of the surgery; also, psychological support will become increasingly important for patients with lengthier gender affirming surgery processes.<\/p>\n<div class=\"textbox tryit\">\n<h3>Try It<\/h3>\n<p>\t<iframe id=\"assessment_practice_f391e4d8-fb2f-4fda-8823-73cec5a1fd91\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/f391e4d8-fb2f-4fda-8823-73cec5a1fd91?iframe_resize_id=assessment_practice_id_f391e4d8-fb2f-4fda-8823-73cec5a1fd91\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<p>\t<iframe id=\"assessment_practice_f529fbe5-a23e-4f9a-b555-42ae1b6f9c2c\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/f529fbe5-a23e-4f9a-b555-42ae1b6f9c2c?iframe_resize_id=assessment_practice_id_f529fbe5-a23e-4f9a-b555-42ae1b6f9c2c\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<\/div>\n<div class=\"textbox examples\">\n<h3>Watch It<\/h3>\n<p>This video tells the first-person account of Jamie&#8217;s experience during his hormonal treatment and transition.<\/p>\n<p><iframe loading=\"lazy\" id=\"oembed-1\" title=\"My Gender Transition From Female To Male \u2022 Dear BuzzFeed\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/RYuipbRGu5s?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>You can view the <a href=\"https:\/\/course-building.s3-us-west-2.amazonaws.com\/Abnormal+Psychology\/transcripts\/MyGenderTransitionFromFemaleToMale_transcript.txt\" target=\"_blank\" rel=\"noopener\">transcript for &#8220;My Gender Transition From Female To Male \u2022 Dear BuzzFeed&#8221; here (opens in new window)<\/a>.<\/p>\n<\/div>\n<div class=\"textbox learning-objectives\">\n<h3>Glossary<\/h3>\n<p><strong>bottom surgery:<\/strong>\u00a0surgery to alter the genitalia<\/p>\n<p><strong>conversion therapies:\u00a0<\/strong>the\u00a0pseudoscientific\u00a0practice of trying to change an individual\u2019s\u00a0sexual orientation\u00a0from\u00a0homosexual\u00a0or\u00a0bisexual\u00a0to\u00a0heterosexual\u00a0using psychological, physical, or spiritual interventions<\/p>\n<p><strong>gender affirming surgery:<\/strong>\u00a0any form of surgical procedure performed on a\u00a0transgender\u00a0person in order to change their\u00a0sex characteristics\u00a0to better reflect their\u00a0gender identity<\/p>\n<p><strong>gender performativity:<\/strong>\u00a0concept arguing that both sex and gender are constructed<\/p>\n<p><strong>harm reduction model:<\/strong>\u00a0a set of practical strategies and ideas aimed at providing hormonal therapy based on assessment of individual patient\u2019s needs, history, and situation with an overriding goal of achieving the best outcome for patients rather than rigidly adhering to arbitrary rules<\/p>\n<p><strong>identity:<\/strong>\u00a0the way one understands, describes and expresses oneself and the reflection of those entities to others<\/p>\n<p><strong>interactionist\u00a0theory of gender identity:<\/strong>\u00a0a theory that suggests that, up to a certain age, gender identity is relatively fluid and subject to constant negotiation<\/p>\n<p><strong>non-op:<\/strong>\u00a0those who do not wish to include surgery in their transition<\/p>\n<p><strong>post-op:<\/strong>\u00a0those who have already had surgery<\/p>\n<p><strong>pre-op:<\/strong>\u00a0those who plan to have surgery but not yet done so<\/p>\n<p><strong>top surgery:<\/strong>\u00a0surgery to alter the chest and breast tissue<\/p>\n<p><strong>transgender transition services:<\/strong>\u00a0the various medical treatments and procedures that alter an individual&#8217;s primary and\/or secondary sexual characteristics<\/p>\n<p><strong>transsexual:<\/strong>\u00a0a person who has undergone gender affirming hormone therapy and gender affirming surgery<\/p>\n<p><strong>World Professional Association for Transgender Health\u00a0(WPATH)\u00a0Standards of Care:<\/strong>\u00a0international clinical protocols outlining the recommended assessment and treatment for gender non-conforming individuals across the lifespan or transgender or transsexual people who wish to undergo social, hormonal, or surgical transition to the other sex<\/p>\n<\/div>\n\n\t\t\t <section class=\"citations-section\" role=\"contentinfo\">\n\t\t\t <h3>Candela Citations<\/h3>\n\t\t\t\t\t <div>\n\t\t\t\t\t\t <div id=\"citation-list-1793\">\n\t\t\t\t\t\t\t <div class=\"licensing\"><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Original<\/div><ul class=\"citation-list\"><li>Modification, adaptation, and original content. <strong>Authored by<\/strong>: Sonja Ann Miller for Lumen Learning. <strong>Provided by<\/strong>: Lumen Learning. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><\/ul><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Shared previously<\/div><ul class=\"citation-list\"><li>Gender Dysphoria. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Gender_dysphoria#:~:text=Gender%20dysphoria%20(GD)%20is%20the,gender%20dysphoria%20are%20typically%20transgender.\">https:\/\/en.wikipedia.org\/wiki\/Gender_dysphoria#:~:text=Gender%20dysphoria%20(GD)%20is%20the,gender%20dysphoria%20are%20typically%20transgender.<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Sex reassignment surgery. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Sex_reassignment_surgery\">https:\/\/en.wikipedia.org\/wiki\/Sex_reassignment_surgery<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Gender confirmation surgery. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/gender.wikia.org\/wiki\/Gender_Confirmation_Surgery\">https:\/\/gender.wikia.org\/wiki\/Gender_Confirmation_Surgery<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Standards_of_Care_for_the_Health_of_Transsexual,_Transgender,_and_Gender_Nonconforming_People\">https:\/\/en.wikipedia.org\/wiki\/Standards_of_Care_for_the_Health_of_Transsexual,_Transgender,_and_Gender_Nonconforming_People<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Judith Butler. <strong>Authored by<\/strong>: Dontworry, modified by Emma7stern. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Judith-butler-frankfurt-2012.jpg\">https:\/\/commons.wikimedia.org\/wiki\/File:Judith-butler-frankfurt-2012.jpg<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Exam room. <strong>Authored by<\/strong>: Zackary Drucker. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/genderphotos.vice.com\/\">https:\/\/genderphotos.vice.com\/<\/a>. <strong>Project<\/strong>: The Gender Spectrum Collection. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/\">CC BY-NC-ND: Attribution-NonCommercial-NoDerivatives <\/a><\/em><\/li><li>Gender Dsyphoria. <strong>Provided by<\/strong>: Boundless. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/courses.lumenlearning.com\/boundless-psychology\/chapter\/gender-dysphoria\/\">https:\/\/courses.lumenlearning.com\/boundless-psychology\/chapter\/gender-dysphoria\/<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\">CC BY: Attribution<\/a><\/em><\/li><li>Conversion Therapy. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Conversion_therapy\">https:\/\/en.wikipedia.org\/wiki\/Conversion_therapy<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Gender Dysphoria. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.susans.org\/wiki\/Gender_dysphoria#Treatment%20\">https:\/\/www.susans.org\/wiki\/Gender_dysphoria#Treatment%20<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Sexual orientation and gender identity: review of concepts, controversies and their relation to psychopathology classification systems. <strong>Authored by<\/strong>: Carla Moleiro and Nuno Pinto. <strong>Provided by<\/strong>:  Instituto Universitu00e1rio de Lisboa ISCTE-IUL, CIS, Lisboa, Portugal. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyg.2015.01511\/full\">https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyg.2015.01511\/full<\/a>. <strong>Project<\/strong>: Frontiers in Psychology. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\">CC BY: Attribution<\/a><\/em><\/li><\/ul><div class=\"license-attribution-dropdown-subheading\">All rights reserved content<\/div><ul class=\"citation-list\"><li>My Gender Transition From Female To Male. <strong>Provided by<\/strong>: BuzzFeedVideo. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.youtube.com\/watch?v=RYuipbRGu5s&#038;feature=emb_logo\">https:\/\/www.youtube.com\/watch?v=RYuipbRGu5s&#038;feature=emb_logo<\/a>. <strong>License<\/strong>: <em>Other<\/em>. <strong>License Terms<\/strong>: Standard YouTube License<\/li><\/ul><\/div>\n\t\t\t\t\t\t <\/div>\n\t\t\t\t\t <\/div>\n\t\t\t <\/section><hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-1793-1\">Saleem F, Rizvi SW (December 2017). \"Transgender Associations and Possible Etiology: A Literature Review\". Cureus. 9 (12): e1984. doi:10.7759\/cureus.1984 <a href=\"#return-footnote-1793-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-1793-2\">Guillamon A, Junque C, G\u00f3mez-Gil E (October 2016). \"A Review of the Status of Brain Structure Research in Transsexualism\". Archives of Sexual Behavior. 45 (7): 1615\u201348. doi:10.1007\/s10508-016-0768-5 <a href=\"#return-footnote-1793-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-1793-3\">Hakeem, Az (2008). \"Changing Sex or Changing Minds: Specialist Psychotherapy and Transsexuality\". Group Analysis. 41 (2): 182\u2013196. doi:10.1177\/0533316408089883. S2CID 143359476. <a href=\"#return-footnote-1793-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-1793-4\">Wallien, M. S. C., &amp; Cohen-Kettenis, P. T. (2008). Psychosexual outcome of gender-dysphoric children. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1413\u20131423. <a href=\"#return-footnote-1793-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><li id=\"footnote-1793-5\">Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., &amp; Cohen-Kettenis, P. T. (2013). Factors associated with desistence and persistence of childhood gender dysphoria: A quantitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 582\u2013590. <a href=\"#return-footnote-1793-5\" class=\"return-footnote\" aria-label=\"Return to footnote 5\">&crarr;<\/a><\/li><li id=\"footnote-1793-6\">Spiegel, Alix (May 8, 2008). \"Q&amp;A: Therapists on Gender Identity Issues in Kids\". NPR. Retrieved September 16, 2008. <a href=\"#return-footnote-1793-6\" class=\"return-footnote\" aria-label=\"Return to footnote 6\">&crarr;<\/a><\/li><\/ol><\/div>","protected":false},"author":29,"menu_order":6,"template":"","meta":{"_candela_citation":"[{\"type\":\"cc\",\"description\":\"Gender Dysphoria\",\"author\":\"\",\"organization\":\"Wikipedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Gender_dysphoria#:~:text=Gender%20dysphoria%20(GD)%20is%20the,gender%20dysphoria%20are%20typically%20transgender.\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"Sex reassignment surgery\",\"author\":\"\",\"organization\":\"Wikipedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Sex_reassignment_surgery\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"original\",\"description\":\"Modification, adaptation, and original content\",\"author\":\"Sonja Ann Miller for Lumen Learning\",\"organization\":\"Lumen 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