Transgender identity or dysphoria?; Treatment Tips; Sex

SAVVY: The difference between gender identity issues and gender dysphoria. Transgender Terminology

SKILLS: Treatment issues for transgender people in addiction treatment

SOUL: Sex

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Last week, I had lunch with Laura and some of her care management team. Laura is a 46-year-old transgender person (not her real name nor age) who from a very early age was aware that she was not in sync with her assigned gender identity. While born with male sex characteristics and assigned a male identity as Larry (not his real name), Laura, for most of her life, assumed the outside presentation as a male gender. She sometimes felt like she was acting as a male identity for her work and public persona, however was not really stressed or impaired by those gender identity issues.

What Laura was more interested in talking about was how she was doing well with her substance use disorder and recovery while also doing well as a transgender woman – a transgender individual who identifies as a woman.

Before I met Laura, I was not sure she really was as untroubled by the combination of her addiction and her gender identity issues as was reported to me by the care management team. After hearing her story of addiction and recovery, I was persuaded she indeed did not suffer from Gender Dysphoria as presented in DSM-5 (2013). The previous relevant diagnosis in DSM-IV-TR was Gender Identity Disorder. But not all people who assume a gender opposite to what was assigned at birth are distressed.  So in DSM-5 the focus of the new diagnosis, Gender Dysphoria, is on people who are impaired and in pain over their gender identity. This dysphoria is what creates the designation as a disorder, rather than the identity issues themselves.

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Distinguish between gender dysphoria and gender identity issues

Gender Dsyphoria in adolescents and adults is a diagnosis characterized by “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least 2 of six criteria.”(DSM-5, 2013, page 452). The diagnostic criteria revolve around a strong desire to assume a gender identity, expression or behavior different from those of the opposite gender assigned at birth.

What makes the difference between the current diagnosis (Gender Dsyphoria) and the previous Gender Identity Disorder? The current diagnosis points to the presence of: “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” Laura certainly has a strong desire to be “of the other gender” and “to be treated as the other gender.” She has very understanding and supportive parents. Her personality style is one that’s engaging and she radiates resilience. In addition, she lives in a more accepting environment. Due to these factors, Laura has rarely been distressed or impaired in any way by gender identity clashes.

Even with supportive parents, it is understandable how Gender Dysphoria develops. Listen to the compelling story of “A Mother Comes To Terms With Her Transgender Child” in a March 16, 2015 segment of National Public Radio’s Here & Now program. You will hear how the dysphoria develops and then is resolved, as Mimi Lemay struggled with the journey of her daughter Mia towards becoming her son, Jacob.

http://hereandnow.wbur.org/2015/03/16/trans-son-letter

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Become familiar with current Transgender Terminology

The National Center for Transgender Equality updated terminology in their January 2014 glossary of terms.

http://transequality.org/issues/resources/transgender-terminology

Here are a few highlights to note:

• “Transgender is correctly used as an adjective, not a noun.” e.g., “transgender people” is appropriate but “transgenders” is often viewed as disrespectful.”
• “Trans” is shorthand for “transgender”.
• “Transgender Man: A term for a transgender individual who currently identifies as a man (see also “FTM”).”
• “Transgender Woman: A term for a transgender individual who currently identifies as a woman (see also “MTF”).”
• “Gender Identity: An individual’s internal sense of being male, female, or something else. Since gender identity is internal, one’s gender identity is not necessarily visible to others.”
• “Transsexual: An older term for people whose gender identity is different from their assigned sex at birth who seeks to transition from male to female or female to male. Many do not prefer this term because it is thought to sound overly clinical.”
• “Cross-dresser: A term for people who dress in clothing traditionally or stereotypically worn by the other sex, but who generally have no intent to live full-time as the other gender. The older term “transvestite” is considered derogatory by many in the United States.”

References:

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Arlington, VA, American Psychiatric Association, 2013.

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) Washington, DC, American Psychiatric Association.

Gee, Beck: “Treating Trans” Addiction Professional, March 2, 105

Access at: http://www.addictionpro.com/blogs/nalgap/treating-trans

Transgender Terminology, National Center for Transgender Equality. Up dated January 2014.

Access at: http://transequality.org/issues/resources/transgender-terminology

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Have you noticed how there is more in the media about transgender individuals -whether that be the journey of Chaz Bono, the only child of American entertainers Sonny and Cher. She was born Chastity Bono and is now a transgender man. Or more recently Bruce Jenner, the former U.S. track and field athlete and current television figure, as he transitions to be a transgender woman.

Transparent is an American comedy-drama television series produced for Amazon Studios that debuted on February 6, 2014. The story revolves around a Los Angeles family and their lives following the discovery that the person they knew as their father, Mort, is a transgender individual. (Wikipedia).

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When treating transgender people in addiction treatment, are your policies and procedures designed with “understanding the humanity of Trans individuals”?

In his article, Beck Gee emphasizes the need to see Trans people as “individuals who struggle with addiction just as any other person.”

http://www.addictionpro.com/blogs/nalgap/treating-trans

Here are some of the points his article raises:

• Does your paperwork assume that the sex the client was assigned at birth equals their gender? Does the gender box indicate male or female? Or is there room for a person to define their own identity?
• When deciding where to place a person – in the male or female section of the program, could you let the transgender person decide where they feel most comfortable?
• How safe do Trans people feel in your services? Do all clients feel safe and accepted, including Trans people? “Do you have gender-neutral bathrooms…Is your staff trained properly, from facility maintenance to Nurses to Techs to CEOs?”

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The ASAM Criteria’s multidimensional assessment provides a good “review of systems” to include all relevant clinical factors in treating transgender individuals.

In finding the balance between the focus on addiction recovery and transgender considerations, clinical issues in each Dimension include, but are not limited to:

Dimension 1: Acute intoxication and/or withdrawal potential

• Does the Trans individual use alcohol and other drugs to cope with any dysphoria over transgender issues and/or is the client’s use simply addiction in a person who happens to be a transgender individual? (Laura said clearly that her addiction was causally unrelated to her transgender issues and I discovered that I agreed with her.)

Dimension 2: Biomedical conditions and complications

• Is the person contemplating or undergoing Sex Reassignment Surgery or hormonal therapy to develop sex characteristics of the gender to which they are transitioning?
• If hormonal therapy, is it affecting other physical health areas? (Laura joked about how initially the hormonal therapy she was taking gave her an intimate understanding of “PMS – premenstrual syndrome”.)

Dimension 3: Emotional/behavioral/cognitive conditions and complications

• Distinguish between gender identity issues and gender dysphoria. Not everyone who faces the incongruence between their assigned gender at birth and the gender they feel most drawn to be, are distressed to the degree of meeting diagnostic criteria for a disorder.
• Review the following with the transgender person: What needs and problems are arising due their gender identity issues? What strengths, skills and resources might a client have which protects them from dysphoria? (Laura had temperament and resilience along with supportive parents and an accepting environment which explained her non-distress in her transgender journey.)

Dimension 4: Readiness to Change

• At what stage of change is the transgender individual at regarding their addiction versus their gender identity issues?
• How much are they able to focus on addiction recovery versus their stage of transgender transition?
• How does the treatment team balance a focus on transgender issues versus addiction recovery? (Laura was ready to focus on addiction recovery after some initial ambivalence; she was not feeling a need to focus on transgender issues. It is easy for treatment teams to get distracted by the transgender issues.)

Dimension 5: Relapse/Continued Use/Continued Problem potential

• To what degree does gender dysphoria contribute to relapse or continued use or problem potential?
• As with any co-occurring disorder, can the individual and team treat both disorders as primary disorders needing ongoing monitoring to reduce flare-ups?

Dimension 6: Recovery Environment

• Are there any family members or significant others who are helpful to the transgender individual in their addiction recovery? Are family or significant others problematic to the transgender person?
• Are there any school, work and other social concerns related to transgender issues? (Before Laura openly declared her female identity, she said that dressing as Larry  in men’s suits and ties at work felt incongruous and like she was “acting” for many years.)
• How understanding are self-help/mutual help groups to transgender individuals in addiction recovery?

Whether you use The ASAM Criteria or not, these dimensions structure a holistic perspective of all people, including transgender individuals.

References:

Gee, Beck: “Treating Trans” Addiction Professional, March 2, 105

Access at: http://www.addictionpro.com/blogs/nalgap/treating-trans

Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.

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I’ll have to check the Archives of 12 years of Tips & Topics (TNT) editions to see if I have ever written a SOUL section on Sex before. I don’t think I have. Some readers tell me that when they receive TNT in their inbox, the first section they skip to is SOUL. (With “Sex” in the Subject line of this month’s email, I expect a lot more skipping!)

It’s satisfying that readers enjoy this section, because SOUL is probably the part I enjoy writing the most…..I can just let it flow, without the requirement to be too academic, checking author references, articles, papers and the scientific literature.

But back to sex. Having talked to Laura about her transgender journey, I began thinking how sex, gender identity, gay rights, same-sex marriage, transgender, cross-dressing and on and on are so much in the media all the time.

Sex in advertising has been a long-held tradition that still keeps on working to capture most people’s attention. A skimpily-clad woman has nothing to do with gas mileage and engine capacity of an automobile, but somehow they always seem to be present (or draped around) cars at the auto show or in car advertisements.

Like religion and politics, sex is one of those topics tricky to maneuver in social intercourse….that’s “social” intercourse, not “sexual” intercourse. Everyone has had experience and knows what you are referring to. Yet it is a topic we all tiptoe around with everyone, except your most trusted friend, lover or ally.

Some male politicians have been known to denounce the evils of homosexuality, only to be caught being intimate with a male staff member. Or after declaring their support for family values and faithfulness, it is discovered they are having a baby with their journalist lover. Governors have lost face and their positions over sex. Presidents have damaged relationships and trust over sex, not to mention millions of marriages languishing in barrenness or ending in divorce over sex.

I haven’t talked about the wonders of sex and the joys and ecstasy of sex. I wonder if you’ll have to wait another 12 years for that edition of SOUL.

Enjoy.