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Source: http://www.doksinet Information for General Practitioners Working with Transgender People Including Children and Adolescents and Their Families Within Community Healthcare Organisation (CHO) Area 5 (Carlow, Kilkenny, South Tipperary, Waterford & Wexford) Source: http://www.doksinet Source: http://www.doksinet Information for General Practitioners Working with Transgender People Introduction Transgender people are individuals whose gender identity or gender expression is different from the sex assigned at birth. Gender identity is the internal sense of being male or female, neither or both We all have a gender identity. Some transgender people will medically transition and undergo hormone replacement therapy and/or surgery to align their bodies with their gender identity. Transgender people have a variety of needs relating to their healthcare including access to mental health, medical transition and primary care services that are sensitive to their identities and

experience. This pamphlet is intended to support GPs working with transgender people and their families to provide informed and sensitive care to their patients. The HSE are currently developing a standardised model of care for transgender people including children and adolescents. These guidelines will be subject to amendment once this model of care is finalised. What you will find in this pamphlet: 1. 2. 3. 4. 5. 6. 7. 8. 9. 1. Terminology Your Role as GP Mental Health Profile of Transgender People Suggestions for Working with Transgender Patients Treatment Options Transgender Specific Assessment & Care a. Services for children and adolescents b. Services for adults c. Services for families The Prevalence of Transgender People in Ireland Gender Dysphoria vs Gender Nonconformity Resources Terminology A transgender person is an individual whose gender identity and/or gender expression differs from the sex assigned to them at birth. This term can include diverse

gender identities such as: transsexual, transgender, crossdresser, androgynous, genderqueer, non-binary, gender variant or differently gendered people. Not all individuals with identities that are considered part of the transgender umbrella will refer to themselves as transgender. For some, this may be because they identify with a particular term (such as transsexual or genderqueer) which they feel more precisely describes their identity. Others may feel that their experience is a medical or temporary condition and not an identity (for example they feel they have gender dysphoria but are not transgender). A more detailed glossary of terms is available on page 9. 1 Source: http://www.doksinet Information for General Practitioners Working with Transgender People 2. Your Role as GP A key factor in engagement is an open, non-judgemental, understanding and supportive approach. It is important to remember that as a GP you may be the first person a patient talks to about their

gender identity. Patients’ views, especially if there is ambiguity regarding their gender identity, need to be taken seriously. Some people may have suffered in silence for a long time before seeking help and are clear about how they want to move forward. At this point, it may be unhelpful to ask them to further delay their request for treatment. 3. Mental Health Profile of Trans People There is a high incidence of suicide, self-harm and depression among transgender people. Delays in accessing essential health-related support to enable transitioning can exacerbate these risks. In 2013, TENI published Speaking from the Margins, the largest study of transgender people in Ireland (N=164), which found: • High levels of suicidal ideation with a lifetime prevalence of 78% thinking about ending their lives. Forty percent of those with suicidal ideation had made at least one attempt, with 8% of these attempts being in the previous year. • A substantial number of the participants

reported having self-harmed at some point in their lives (44%), with 6% currently self-harming. • Common experiences of stress (83%), depression (82%) and anxiety (73%) were reported. The report also found that transition had a positive impact on a transgender person’s mental health, with 75% of participants reporting they felt that their mental health had improved, compared to 6% who felt it was worse since transition. The positive impact was even more significant in terms of suicidal thoughts and behaviour; with the majority of respondents reporting that they thought about or attempted suicide less after transition. It was reported that 81% thought about or attempted suicide more before transition, and only 4% doing so after transition (McNeil et al, 2013). 4. Suggestions for Working with Transgender Patients GPs play a critical role in supporting transgender people by providing healthcare, information and referrals. Here are a few simple suggestions for working with

transgender patients: 1. This may be the first time a patient has acknowledged or discussed their gender identity therefore it is imperative that the client feels understood and not judged as a negative reaction may cause significant distress and hopelessness. 2. Ask the person what name and pronoun they would like you to use 3. Educate yourself about transgender issues by reading books, attending conferences, and consulting with transgender experts e.g Transgender Equality Network Ireland (TENI) 4. Reassuring transgender patients that confidentiality will be maintained by all staff within the service will ease anxiety and fears. 5. Gender identity and sexual orientation are not the same Transgender people can be heterosexual, gay, lesbian, bisexual, queer or asexual. 6. Questions regarding surgical status, if necessary as part of routine history-taking, should be approached sensitively. 2 Source: http://www.doksinet Information for General Practitioners Working with

Transgender People 7. Not all transgender people medically transition (either hormonally or surgically) There is no one size fits all. 8. If a transgender person is seeking to medically transition or is looking for psychological support, refer to the services detailed below. 9. Be cognisant that co-existing health issues may not be linked to gender issues 10. Signpost to supports and further information is available at wwwhseie, Primary Care Unit and from at www.teniie Further details in the resource section 5. Treatment Options Some transgender people will seek to address their gender dysphoria by accessing psychological support and/or proceeding with a medical transition, which may include hormonal and/ or surgical interventions. In Ireland, the treatment pathway is evolving and individuals have varying experiences.  or adults, the most common forms of treatment options that transgender people seek F include: • Changes in gender expression and role (which may involve

living part time or full time in another gender role, consistent with one’s gender identity); • Hormone treatment therapy to feminise or masculinise the body; • Surgery to change primary and/or secondary sex characteristics (e.g breast/chest, external and/or internal genitalia, facial features, body contouring); • Psychotherapy or counselling (individual, couple, family, or group) for purposes such as exploring gender identity, role, and expression; addressing the negative impact of gender dysphoria and stigma on mental health; alleviating internalised transphobia; enhancing social and peer support; improving body image; or promoting resilience. In adolescents the treatment options that young people may seek include: • Reversible interventions: These involve the use of GnRH analogues to suppress oestrogen or testosterone production (‘puberty blockers’) and as a result delay the physical changes of puberty. • Partially reversible interventions: These

include hormone treatment to masculinise or feminise the body. • Psychotherapy or counselling (individual, family) for purposes such as exploring gender identity, role, and expression; addressing the negative impact of gender dysphoria and stigma on mental health; alleviating internalised transphobia; enhancing social and peer support; improving body image; or promoting resilience. For transgender children medical interventions, such as hormonal or surgical interventions, are not indicated. However with professional guidance a social transition can be considered along with psychological and family support. It is important to keep all options open for the future and approach with caution when facilitating social transition. 6. Transgender Specific Assessment & Care a. Services for children and adolescents If a family presents with their child or adolescent who is experiencing anxiety due to their gender identity there are a few steps can be taken: 3 Source:

http://www.doksinet Information for General Practitioners Working with Transgender People Pre-Pubertal Children: General Practitioner At present the existing care pathway in Ireland for pre-pubertal children generally begins with an approach by the child and the family to their GP. In some instances the GP may undertake some or all of the following: 1) A referral to the local CAMHS (Child and Adolescent Mental Health Service) team may be made. However, it has been reported that some CAMHS teams only accept referrals if significant comorbid mental health concerns are present. If they do not accept the referral, they may be able to signpost other local services that might be more appropriate in the first instance (there is evidence to indicate this does not always happen). 2) At this stage a social transition may be advised with careful management by family, GP and CAMHS. International evidence indicates that social transition should be approached with caution and in

consultation with professionals. Social transition may include a change of name, pronoun use, hairstyle and clothing in keeping with the child’s gender identity. If social transition in the school setting is planned, staff training is recommended to be carried out prior to the social transition, which can provided by TENI. 3) A referral to TransParenCI, a national transgender family support group may be made. 4) A referral to TENI, the national support group for transgender people may be made with regards to support in school. Pubertal: General Practitioner At present the existing care pathway in Ireland for pubertal children generally begins with an approach by the child and the family to their GP. In some instances the GP may undertake some or all of the following: 1) A referral may be made by the GP to the CAMHS (Child and Adolescent Mental Health Service) team. Some CAMHS teams only accept referrals if significant comorbid mental health concerns are present. If they do not

accept the referral, they may be able to signpost other local services which might be more appropriate in the first instance (there is evidence to indicate this does not always happen). 2) A referral may be made to TransParenCI, a national transgender family support group. 3) A referral may be made to TENI, the national support group for transgender people may be made with regards to support in school. 4) Undertake ongoing monitoring of the child’s situation. Child and Adolescent Mental Health Services (CAMHS) Once the adolescent has been accepted by a CAMHS service, an application can be made by the family of the young person to the Treatment Abroad Scheme (TAS), in conjunction with the CAMHS Consultant Child & Adolescent Psychiatrist for specialist input from the Gender Identity Development Service, Tavistock and Portman NHS Trust. There are huge variations and geographical disparities in waiting lists for CAMHS, the subsequent time required to process the TAS application

and the time it may take to be accepted onto the Tavistock Assessment Programme. This can range from a minimum of one year up to at least two years at which time pubertal development has been completed. This inevitably compounds the psychological distress experienced by the young person and their family, increases the risk of psychiatric comorbidities and increases the need for avoidable surgical interventions, if desired. 4 Source: http://www.doksinet Information for General Practitioners Working with Transgender People Gender Identity Development Service, Tavistock and Portman NHS Trust This service is currently provided on a quarterly basis in Our Lady’s Children’s Hospital Crumlin Dublin by visiting psychologists from the Tavistock and Portman NHS Trust. A detailed assessment is a pre-requisite prior to commencing hormone suppressants in Ireland, in keeping with best practice internationally known as the Dutch Protocol. This is to ensure the correct path is being taken

for an individual and to ensure any comorbid issues are identified and addressed. This process can take approximately one and half years or more to complete, depending on individual circumstances. Paediatric Endocrinology Service in Our Lady’s Children’s Hospital Crumlin (OLCHC) For young people under the age of 16 years once the psychological assessments are complete a referral can be made to the Paediatric Endocrinology Service in Our Lady’s Children’s Hospital Crumlin (OLCHC) in Dublin for hormonal treatment if appropriate. Ongoing monitoring and support of the adolescent from CAMHS is required at this time. The adolescent may be prescribed a pubertal suppressant by Paediatric Endocrinology Team in OLCHC. This treatment is reversible. The adolescent may remain on this treatment for up to 4 years It is recommended that GP’s would provide on-going support to the adolescent and family during this time. Young people aged between 16-17 years Young people aged 16 and 17

years are currently referred to Professor Donal O’Shea, Consultant Endocrinologist at St Colmcille’s Hospital, Loughinstown, Co. Dublin This age cohort does not have access to the specialist assessment provided through Tavistock therefore access to ongoing psychological support will be problematic if the young person is not linked in with CAMHS. Speech and Language Therapy Speech and language therapy can be accessed through some CAMHS teams, where the specialist therapist is available. A referral to a generic speech and language therapist, may be made by a GP at the request of the family. b. Services for Adults Individuals who are looking to explore their gender identity or gender expression or who are experiencing anxiety or depression related to their gender identity, should be referred to mental health specialists with experience in this field. Not all transgender people want to medically transition either hormonally or surgically. The following options should be considered

if a person states their wish to transition: 1. Referral to the local Community Mental Health Team for support and a diagnosis of Gender Dysphoria (GD) or Gender Identity Disorder (GID) by psychiatrist or a clinical psychologist. A thorough assessment is a pre-requisite to commencing hormone suppressants in Ireland, in line with international best practice. This is to ensure that the correct path is being taken for the individual and to ensure comorbid issues are identified and addressed. 2. Referral to Professor Donal O’ Shea, Consultant Endocrinologist at St Colmcille’s Hospital, Loughlinstown, Co Dublin. A robust diagnosis of Gender Dysphoria is currently required by the 5 Source: http://www.doksinet Information for General Practitioners Working with Transgender People Endocrine services in order to commence hormone treatment so it is advisable that: • Referrals to both the Community Mental Health Services and the Endocrinology services are made concurrently.

• Confirmation of this diagnosis by a colleague in Community Mental Health Services further enhances the process. • Referral to the local hospital for DEXA scans for baseline bone density scan prior to the first endocrinology appointment. This report should accompany the patient when they attend their first endocrinology appointment. • A full blood check (including FSH/LSH) should accompany the patient when they attend their first endocrinology appointment. Bloods can be taken 7-14 days prior to the first appointment. 3. Psychotherapy or counselling may be considered at this time as the person might be experiencing anxiety due to reactions from family and friends to their transition. 4. HSE Counselling in Primary Care (CIPC) may be considered if the patient has a medical card and over 16 years of age. Referral can be made through the patients GP or Primary Care Team Member eg. Public Health Nurse (PHN) 5. HSE Counselling in the form of Self Harm Intervention

Programme (SHIP) may be considered and does not require a medical card. Referral can be made through the patients GP or Primary Care Team Member eg. Public Health Nurse (PHN) 6. A referral to local HSE Speech and Language services may be considered if requested by the patient. 7. Family support should be discussed with the patient and information can be provided to the patient in regard to TransParenCI, the national support group for families. Family members may also be referred for psychotherapy and counselling for support. 8. Information in regard to local transgender peer support groups can be provided to patients through TENI (see resource section). If the patient is unsure about transitioning or does not want to transition but is looking for support: 1. Referral for psychotherapy or counselling to explore gender identity or expression 2. Referral to a local transgender support group 3. Ongoing monitoring of the patient’s situation c. Family Support “ Cognitively,

families need to mourn and reconcile changes to the family identity. Therapists can help families to validate emotions, increase social support and provide accurate information on Transgenderism.” (Zamboni, 2006) It is very important that family members receive support. If families can receive the proper support and information at this time the outlook is positive. If the family member is interested to receiving support there are a number of suggestions: 1. Referral to TransParenCI This group holds monthly meetings and residential weekends They can also link families with other family members who have had similar experiences for a phone conversation and support (See resource section). 2. Psychotherapy or counselling List of healthcare providers with experience and knowledge in this area is available from www.teniie 6 Source: http://www.doksinet Information for General Practitioners Working with Transgender People 7.  The Prevalence of Transgender People in Ireland The

prevalence of transgender people in Ireland is difficult to estimate as there is no official collection of this data. GIRES, a UK-based organisation, estimates that 1% of individuals may experience some degree of gender variance or non-conformity and approximately 0.2% may undergo transition (Reed, 2011). In a recent study, researchers from the Department of Endocrinology in St. Columcille’s Hospital (SCH), Loughlinstown, Dublin reviewed the medical records of 218 patients and estimated prevalence of gender dysphoria at 1:10,154 male-to-female (MTF) and 1:27,668 female-to-male (FTM) individuals in the Irish population (Judge et al, 2014). However, these figures only include individuals seeking medical services from SCH and exclude those who are seeking treatment elsewhere or who do not medically transition. Nonetheless, the researchers suggest that the number of patients accessing services is steadily rising. This is particularly true for children and adolescents. Specialist gender

identity services internationally have observed increases in referral rates of adolescents in recent years (Aitken et al, 2015, Kaltiala-Heino et al, 2015). There also appears to be shift in sex ratio, with a preponderance of natal females referred (Aitken et al, 2015, Kaltiala-Heino et al, 2015 & Holt et al, 2014). 8. Gender Dysphoria Vs Gender Non-Conformity “The expression of gender characteristics, including identities that are not stereotypically associated with one’s assigned sex at birth is a common and culturally diverse human phenomenon [that] should not be judged as inherently pathological or negative.” - World Professional Association of Transgender Health (WPATH)  ender nonconformity refers to the extent to which a person’s gender identity, role, or G expression differs from the cultural norms prescribed for people of a particular sex.  ender dysphoria refers to discomfort or distress that is caused by a discrepancy between a G person’s gender

identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). Only some gender non-conforming people experience gender dysphoria at some point in their lives (Knudson et al, 2010). Some individuals may experience gender dysphoria at such a high level that the distress meets criteria for a formal diagnosis that might be classified as a mental disorder. According to the Diagnostic and Statistical Manual of Mental Disorders people who experience intense, persistent gender conflict can be given the diagnosis of gender dysphoria (American Psychiatric Association (5th ed), 2013). However, a diagnosis of gender dysphoria should not be confused with transgender identity. Transgender individuals are not inherently disordered. A disorder is a description of something with which a person might struggle, not a description of the person or the person’s identity. 7 Source: http://www.doksinet Information for General

Practitioners Working with Transgender People 9. Resources  ealth Services H www.hseie Primary Care Unit, Lacken, Dublin Road, Kilkenny. Phone (056) 77 84100 National Groups BeLong To Youth Services Phone: 01 670 6223 Website: www.belongtoorg Address: Parliament House, 13 Parliament Street, Dublin 2, Ireland Provides support for LGBT youth 13-24. Transgender Equality Network Ireland (TENI) Phone: 01 873 3575 Email: info@teni.ie Website: wwwteniie Address: Unit 2, 4 Ellis Quay, Dublin 7, Ireland Support Groups Transgender peer support groups exist across Ireland. See wwwteniie for more information Family Support TransParenCI- National family support group for transgender people Email: transparencigroup@gmail.com International Gender Identity Research and Education Society (GIRES) Phone: 01372 801554 Email: info@gires.orguk website: wwwgiresorguk World Professional Assocaition for Transgender Health (WPATH) Email: wpath@wpath.org Website: http://wwwwpathorg/ 8 Source:

http://www.doksinet Information for General Practitioners Working with Transgender People Glossary of Terms Sex: The designation of a person at birth as male or female based on their anatomy (genitalia and/ or reproductive organs) or biology (chromosomes and/or hormones). Gender Identity: Refers to a person’s deeply-felt identification as male, female, or some other gender. This may or may not correspond to the sex they were assigned at birth Gender Expression: The external manifestation of a person’s gender identity. Gender can be expressed through mannerisms, grooming, physical characteristics, social interactions and speech patterns. Gender Fluid: Is a non-binary gender identity. Gender fluid individuals experience different gender identities at different times. A gender fluid person’s gender identity can be multiple genders at once, then switch to none at all, or move between single gender identities. Some gender fluid people regularly move between only a few specific

genders, perhaps as few as two. Gender variant: People whose gender identity and/or gender expression is different from traditional or stereotypical expectations of how a man or woman ‘should’ appear or behave. Non-binary: Refers to gender identities that fall outside the gender binary of male or female. This includes individuals whose gender identity is neither exclusively male nor female, a combination of male and female or between or beyond genders. Similar to the usage of transgender, people under the non-binary umbrella may describe themselves using one or more of a wide variety of terms such as: gender fluid, genderqueer, etc. Transgender: Refers to a person whose gender identity and/or gender expression differs from the sex assigned to them at birth. This term can include diverse gender identities such as: transsexual, transgender, transvestite, non-binary, gender variant or differently gendered people. Transphobia: The fear, dislike or hatred of people who are trans or are

perceived to challenge conventional gender categories or ‘norms’ of male or female. Transphobia can result in individual and institutional discrimination, prejudice and violence against trans or gender variant people. 9 Source: http://www.doksinet Information for General Practitioners Working with Transgender People Acknowledgements TENI and HSE would like to thank the following contributors to this leaflet: - Dr. Derval Howley, Head of Service for Health and Wellbeing CHO5 HSE - Tara Hunt, Transformational Development Officer, Carlow, Kilkenny and South - - Broden Giambrone, CEO, TENI Tipperary CHO5 HSE Vanessa Lacey, Health and Education Manager, TENI Jeanne Hendrick, General Manager, HSE Social Inclusion CHO 5 Angela Joy, Regional Community Participation Coordinator, HSE Social Inclusion CHO5 Dr Pascal O’Dea, G.P Bagenalstown Co Carlow Dr Molly Owens, G.P Fethard Co Tipperary - Dr. Aileen Murtagh, Consultant Child and Adolescent Psychiatrist, St Patricks Mental

Health Services Dublin. - Susan Murphy, Primary Care Lead, Waterford CHO5 HSE - Leanne Leahy, HSE Social Inclusion CHO 5 HSE - Liz Kinsella, Primary Care Lead, Wexford CHO5 HSE 10 Source: http://www.doksinet Information for General Practitioners Working with Transgender People References Aitken, M., Steensma, TD, Blanchard R, et al (2015) Evidence for an altered sex ratio in clinicreferred adolescents with gender dysphoria J Sex Med, 12, 756-763 American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC: Author de Vries, A.L, Steensma, TD, Doreleijers, TA, Cohen-Kettenis, PT (2011) Puberty suppression in adolescents with gender identity disorder: A prospective follow-up study. Journal of Sexual Medicine, 8, 2276–2283. Holt, V., Skagerberg, E, Dunsford, M (2014) Young people with features of gender dysphoria: Demographics and associated difficulties. Clin Child Psychol Psychiatry, 21(1),108-18 Judge, C.,

O’Donovan, C, Callaghan, G, Gaoatswe, G, O’Shea, D (2014) Gender dysphoria prevalence and co-morbidities in an irish adult population Front Endocrinol (Lausanne),13(5), 87 Kaltiala-Heino, R., Sumia, M, Tyolajarvi, M, Lindberg, N (2015) Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child Adolesc Psychiatry Ment Health, 9:9. Knudson, G., De Cuypere, G, & Bockting, W (2010) Recommendations for revision of the DSM diagnoses of gender identity disorders: Consensus statement of The World Professional Association for Transgender Health. International Journal of Transgenderism, 12(2), 115–118 McNeil, J., Bailey, L, Ellis, S, & Regan, M (2013) Speaking from the Margins Trans Mental Health and Wellbeing in Ireland. Transgender Equality Network Ireland (TENI) Reed, B. (2011) The Number of Gender Variant People in the UK - Update 2011GIRES WPATH. (2011) World Professional Association for Transgender

Health: Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People. Zamboni, B.D (2006) Therapeutic Considerations in Working With the Family, Friends, and Partners of Transgendered Individuals. The Family Journal: Counselling and Therapy For Couples and Families, 14(2), 174-9. 11 Source: http://www.doksinet Source: http://www.doksinet