Hello, my name is Dr. Hansel Arroyo. I prefer he/him pronouns and I'm the Director of Psychiatry at the Center for Transgender Medicine and Surgery, and the Institute for Advanced Medicine at Mount Sinai Hospital. Today in this module, I would like to explore the basic components of transgender medicine and ultimately to help everybody understand how to make the determination. To start, my objectives will be to educate all medical providers to familiarize themselves with the diagnostic criteria, and to teach key points on how to engage in conversation with transgender individuals during an evaluation. To do this, I'm going to look into briefly the history of transgender medicine, look into the language used around describing the transgender experience, and then give an example of how to engage in a conversation with a transgender individual. First, let's explore what is gender. Gender and sex are broad categories of terms used to describe biological characteristics, behaviors, and self-identification. To further break that down, let's look at its components. First, we have gender identity. Gender identity is how you view yourself, your internal sense of who you are, and this is in relation to being a man, a woman, or some variation in between which is what we call gender queer. Another component is gender expression. Gender expression is simply how you express or demonstrate your identity, which is how you view yourself internally. This can go from being stereo typically feminine to stereo typically masculine, to having a combination of the two as it is in androgyny, or not having any qualities of either of these poles. Support and to also mention what is sex recorded at birth? So sex recorded at birth is an objective measure based on external genitalia. It could be male if one has a penis, female, one has a vagina or intersex, one has a combination of the two. Often confuse but unrelated to gender, it is important to define what is sexual orientation. Sexual orientation is simply who you're attracted to. It can be physically, emotionally, spiritually and it could come in different forms. It could be defined as heterosexual, it's being attracted to the opposite sex. Homosexual, being attracted to the same sex. Bisexual, being attracted to both sexes. Pansexual, which is being attracted to all sexes or perhaps you're not attracted to anybody as we define as asexual. Although unrelated to gender, sexual orientation and gender come into play in forming who we are and there is really no one way of how to define this, it could be linear or it could go in different directions. So generally speaking, the sex recorded at birth and the gender are congruent. So what if the sex recorded at birth and the gender are not congruent or align? This is what we call gender incongruence which is a term used to define the transgender experience. So essentially, transgender is an umbrella term used for individuals whose gender and sex recorded at birth or not aligned. The history of transgender or gender incongruence has been evolving over many years and so it has been our understanding of it. It was originally introduced in the Diagnostic Statistical Manual or DSM as third edition in 1975 under the term transsexualism. At this point, there was very little distinction between intersex, transsexualism, or even homosexuality. Further understanding of these experiences helped us to move it away from the psychosexual disorders where it originally lived into gender identity disorder. But this was in itself problematic because it implied that there was a disorder in identity. Further understanding of gender evolved that into a being a disorder of identity into us calling it gender dysphoria. The goal with this was to depathologize it and to imply that there was a distress or a dysphoria when it comes to a misalignment in one's gender and one's sex recorded at birth. By no means do we believe that being transgender is a mental health disorder, but calling it something could be useful because we would like to provide care where there are medical care, mental health or even surgical care. The process of depthologizing has already started and we don't know where it might land. Will we be use a diagnosis like gender incongruence as we're using right now or would eventually live outside of the medical field? So before we make the determination, it is important to point out that the goal of this is to be able to provide compassionate and comprehensive care. Like any individual, transgender or not, this requires a multidisciplinary team effort which can include primary care, mental health care, hormone treatment, surgical interventions. But ultimately, when we're making the determination this is important if treatment is necessary. To make the determination of gender incongruence, a qualified medical professional should have competency in its diagnostic criteria, to be able to differentiate gender incongruence from other conditions that may present similarly. By that I mean, that gender incongruence is not a product of substance abuse, external pressures, or existing psychiatric conditions. It's important to mention that their presence of gender incongruence in itself is not a mental health disorder. But those with the transgender experience may struggle with psychiatric conditions such as depression, anxiety, and post-traumatic stress disorder. There are specific vulnerabilities in this population due to minority stress, trauma, rejection, discrimination which can lead to higher suicide rates like we see which is around the 40 percent, which is eight times higher than the general population. For these reasons, it is important to have mental health services readily available. Some may experience an incongruence between their gender and their secondary sexual characteristics and there will be a strong desire to want to get rid of those sexual characteristics. So how do we talk to patients about gender? First, we should always introduce ourselves like I did at the beginning of this module with our names and our preferred pronouns. Second, ask the patients their name and their preferred pronouns and how they would like to be referred throughout the interview. Always have the patient tell you their narrative and don't make assumptions of what this might be. So as you better understand this, let's give a case presentation. So patient TG is 25 years old, male assigned at birth, and comes into your office to initiate ongoing primary care, but also to start hormone therapy as she is transgender. After you introduce yourself by name and preferred pronoun, TG states her name and says that she prefers to be referred as "she and her." At this point, you explain that for you to help her obtain hormone therapy, you must first ask her a couple of questions about her history. Okay. So, here are some examples of how to move forward. First you can ask, help me understand how you identify when it comes to your gender. You may also ask, do you think that your sex recorded at birth is the same or different from how you identify now? After hearing these questions, TG starts telling you that she has always known she was a woman, even as early as five years old. She was always confused why she was "assigned male" at birth and that she did not understand why others could not see her as a woman she is. She adds that this has been a feeling difficult to describe that has not changed at any point throughout her life. So at this point, you want to explore some of the developmental experiences that TG has mentioned. One way to ask about this is, when you were younger, do you remember feeling different, as if people could not see you the way you saw yourself? You could also ask, what gender do most people see you as? What is that experience like to you? Were you are uncomfortable with the clothing you were asked to wear early on? So after asking a little bit about her history, TG continues saying, "Before puberty started, I would experience a lot of distress. I couldn't sleep or eat and wanted to never go back to school." She feared that her body would change into something that wasn't who she was. Some questions you may ask around puberty which is often a very difficult time during the transgender experience, because the body is changing into a way that the individual does not relate to, would be, how do you respond to changes in your body during puberty? How do you feel with regards to your body now? Or how do you imagine yourself to be? TG describes that after puberty, she developed male characteristics, that to this day, have been a source of much stress and depression. She says that she has felt lost and a times would rather die than keep going. She finds hope in identifying a doctor that can help her start hormones that allow her to transition into the woman that she is. So our goal here with TG is to help her achieve lasting personal comfort with her gender self and to maximize overall health, psychological, and physical well-being. After formal evaluation, you make the determination that TG indeed experiences gender incongruence and that in her case, she experiences distress associated with this. You start her on hormone treatment and connect her to mental health services to further help her process her feelings and distress. So some takeaway points from this module. One, that gender and sex recorded at birth are not always aligned and this is what we call gender incongruence. When making the determination, it is important to remember that gender incongruence is not a mental health disorder but may require assistance for medical health professionals to achieve lasting personal comfort. Lastly, there is no one way to be transgender. Be compassionate and have an open ear to listen to their experience and to their medical needs. Thank you for joining me in this module and I hope that everybody has learned something about making the determination.
