The Transgender Handbook: A Guide for Transgender People, Their Families and Professionals

Contents
In Memoriam
List of Contributors
Introduction
Language and Terminology
Overview
Introduction
Gender
Gender Role
Description of the Various Terms
Learning Points
Further Reading
References
The Prevalence of Being Transgender: Estimating the Size of the Transgender Population
Overview
Introduction
The Complexities of Finding Out about Prevalence Rates
Some Numbers
Clinical Studies
Prevalence According to Age and Gender
Population Surveys
Other Prevalent Studies
Conclusion
Learning Points
References
Historical Background and Theories Regarding the Causes of Being Transgender
Overview
Introduction
Historical Background
Transgender People in History
Psychological Theories
Medical Treatment over the Years
Why Do Some People Identify as Transgender?
Biological Theories
Family Studies
Brain Studies
Differences in Transgender People
Hormonal Studies
Gene Studies
Psychosocial and Cultural Factors
Learning Points
Further Reading
References
Diagnostic Classification for Gender Identity-Related Phenomena Over the Years
Overview
Introduction
Overview of Gender Identity Diagnoses in DSM and
Rationale for Changes
Core Criteria
DSM-III – Introduction of Diagnostic Criteria for Transsexualism
From DSM-III to DSM-III-R
From DSM-III-R to DSM-IV
From DSM-IV-R to DSM-5
Specifiers
Conclusion
Learning Points
Further Reading
References
Gender Dysphoria and Gender Incongruence in Children
Overview
Introduction
Gender Dysphoria and Gender Incongruence in Childhood
Prevalence of Gender Incongruence and Gender Dysphoria in Childhood
Psychological Functioning and Social Acceptance
What Causes the Poor Psychological Functioning in Gender Incongruent Children, and Why Is There This Great Variability in Psychological Functioning?
Development of Children With Gender Dysphoria or Gender Incongruence
Is It Possible to Predict the Persistence or Desistence of Childhood GD and What May Be the Factors and Processes Involved?
Clinical Management of Children with Gender Dysphoria and Gender Incongruence
Learning Points
Further Reading
References
Transgender Youth
Overview
Introduction
Clinical Presentations
Vignette - Max/Maxine
Gender Identity Development and Relevance of Sexual Orientation in Adolescents
Vignette – Lisa
Causal Pathways of Gender Dysphoria in Young People
Co-Occurring Psychological Challenges and Mental Health Conditions
Vignette – Tom
Care for Transgender Youth
Primary Care Setting
Specialized Transgender Care
Mental Health Interventions
Reversible Physical Interventions
Partially Reversible Interventions
Irreversible Surgical Interventions
Conclusion
Learning Points
Further Reading
References
Transgender Families
Overview
Introduction
Transgender Families
Clinical Implications and the Role of Peer Support
Learning Points
Further Reading
References
Aging in Transgender and Gender Nonconforming Communities
Overview
Introduction
Key Definitions, Terms, and Identities within TGNC Aging Communities
Intersectionality
Providing a Welcoming Environment for TGNC Older Adults
Common Concerns of TGNC Older Adults
TGNC Older Adults and Access to Healthcare
Mental Health Factors Influencing TGNC Older Adults
Sociocultural Considerations
TGNC Older Adult Practice Interventions
Addressing Issues Related to Generational Cohorts
Exploring Issues Related to Grief
Healthcare Provider Advocacy
Learning Points
Further Reading
Further Resources
References
Transgender and Sexual Orientation
Overview
Introduction
Sex and Gender Concepts
The Role of Sexual Orientation in the Past
Gender Nonconformity in Childhood and Adolescent/Adult Psychosexual Outcome
The Role of Sexual Orientation in the Present
The Role of Sexual Orientation: What’s Next?
Conclusion
Learning Points
References
Sexuality and Relationships of Transgender People
Overview
Introduction
Potential Effects of Genderconfirming Treatment on Sexual Life
Sexual Effects of Hormone Treatment
Sexual Effects of Genderconfirming Surgery
1. Effects of Genderconfirming Treatment on Sexual Desire
2. Effects of Genderconfirming Treatment on Sexual Arousal
3. Effects of Genderconfirming Treatment on Orgasm
4. Sexual Pain and Genderconfirming Treatment
Transgender People and Sexual Orientation
Gender Identity versus Sexual Orientation
Genderconfirming Treatment and ‘Changes’ in Sexual Orientation
Transgender People and Intimate Partner Relationships
Learning Points
References
Fertility Options in Transgender People
Overview
Introduction
The Effect of Hormone Treatment and Gender Confirming Surgery on Fertility
Genital Reconstructive Surgery in Transgender Women
Cross-Sex Hormone Treatment in Transgender Women
Genital Reconstructive Surgery in Transgender Men
Cross-Sex Hormone Treatment in Transgender Men
Current Fertility Preservation Options for Transgender Men
Embryo Cryopreservation
Oocyte Cryopreservation
Ovarian Tissue Cryopreservation
Current Fertility Preservation Options for Transgender Women
Sperm Cryopreservation
Surgical Sperm Extraction
Testicular Tissue Cryopreservation
Future Fertility Prerservation Options for Transgender Patients
Transgender Gestation
Transgender Parenting and Children
Discussion and Conclusion
Learning Points
Further Reading
References
Genderqueer and Non-Binary Genders
Overview
Introduction
Population and Recognition
Mental Health
Clinical Work
Physical Interventions
Hormones
Surgeries
Reproductive Matters
Conclusion
Learning Points
Further Reading
References
Transgender and Autism Spectrum Disorder
Overview
Introduction
Autism Spectrum Disorder
ASD and Transgender Feelings
Vignette – Susan
How Often Do Feelings of Gender Dysphoria and ASD co-Occur?
Co-Occurrence Rates of Feelings of Gender Dysphoria and ASD
Why Are There Higher Numbers of People with ASD among Transgender People?
The Extreme Male Brain Theory
Other Hypotheses
Vignette- Danny
Diagnosis and Treatment
Implications and Challenges for Assessing Suitability for Gender Affirmative Medical Intervention in People with ASD
Assessment of Pre-Pubescent Children with Transgender Feelings and ASD
Vignette – Jamie
Assessment of Adolescents with Transgender Feelings and ASD
Gender Affirmative Treatment in Adolescents with Transgender Feelings and ASD
Assessment of Adults with Transgender Feelings and ASD
Conclusion
Learning Points
Further Reading
References
Mental Health Problems in the Transgender Population: What Is the Evidence?
Overview
Introduction
Assessing the Available Literature Critically
Cross Sectional Studies: How Common Are Mental Health Problems at One Specific Point in Time?
Overview of the Studies
Type of Study
Population
Measurements
Controls
Outcome Definition
Studies Investigating Mental Health or Psychiatric Disorders
Studies Investigating Symptoms of Mental Health Problems or Psychiatric Disorders
Studies Investigating Suicidality and Non Suicidal Self Injury (NSSI) Behaviour
Longitudinal Studies: The Effect of GCMI on Mental Health Problems
Overview of the Studies
Type of the Studies
Population
Measurements
Method
Outcome Definition
Studies Investigating Mental Health Disorders, Symptoms and Behaviours at Follow-up
Protective and Risk Factors of Mental Health Problems among Transgender People: How to Prepare Transgender People for a Positive Life Ahead, the Role of the Professional, Family (of Choice) and the Transgender Person
Protective Factors
Risk Factors
Conclusion
Learning Points
Further Reading
References
Access to Clinical Services and the Role of Primary Care
Overview
Introduction
Brief History
Diagnostic Issues
Standards of Care and Best Clinical Practice
Accessing Specialist Transgender Health Services
The Role of Primary Care
General Issues
Treatment of Mental Health Issues
Self-Prescribed Hormones
Health Promotion
Sexual Health and Fertility
Screening in Primary Care for Transgender People
Breast Cancer Screening
Cervical Screening
Ovarian and Uterine Screening
Prostate Screening
Cardiovascular Screening
Bone Density
Prolactin
Polycythaemia
Conclusion
Learning Points
Further Reading
References
The WPATH Standards of Care
Overview
Introduction
What Are Standards of Care and Why Are They Needed?
Brief History and Evolution of the Standards of Care
The First SOC
Changes in Approach
SOC 7 Process
SOC 7 Chapter-by-Chapter Summary
Purpose and Use
Global Applicability
Difference between Gender Dysphoria and Gender Non Conforming
Epidemiology
Overview of Therapeutic Approaches
Assessment and Treatment of Children and Adolescents
Mental Health
Hormone Therapy
Reproductive Health
Voice and Communication Therapy
Surgery
Postoperative Care and Follow-Up
Lifelong Preventive and Primary Care
Applicability of the Standards of Care to People Living in Institutional Environment
Applicability of the Standards of Care to People with Disorders of Sex Development (DSD)
Major Changes in SOC7
Myths, Challenges and Controversies Associated with These Guidelines over Time
Future Direction and Next Steps
Learning Points
Further Reading
References
Hormone Treatment for Transgender Children and Adolescents: Puberty, Blockers, Sex-Hormones and Helping Me Fit My True Gender Identity
Overview
Introduction
What Is Puberty?
What Happens in Puberty?
What Are Hormones?
What Happens to a Girl in Puberty?
What Happens to a Boy in Puberty?
How Long Does It Take to Go Through Puberty?
How Do You Know Where You Are in the Puberty Process?
When Can a Girl Become Pregnant?
When Can a Boy Get a Girl Pregnant?
Hormone Blockers
What Is the ‘blocker’?
How Does It Work?
How Is the Blocker Given?
Is it Harmful?
If I Come Off It, Will It Have Harmed My Body?
If I Come Off It, Will It Have Harmed My Mind and Feelings?
Does the Blocker Weaken My Bones?
Does the Blocker Stop the Puberty Hormones Completely?
Does the Blocker Make the Changes of Puberty Go Away?
Does the Blocker Stop Me Growing?
What Happens When I Stop Going Through Puberty?
What Happens to My Sex Glands?
Sex Hormones
What Are Sex Hormones?
What Are the Treatment Sex Hormones?
Are Sex Hormones Drugs?
How Are Sex Hormones Given?
Do Cross-Sex Hormones Make Natural Changes of Puberty Happen?
Do Cross-Sex Hormones Have Any Side Effects?
If I Am Non-Binary, Do I Have Other Choices than the Blocker and Cross-Sex Hormones?
Can a Partial Transition Happen without Having to Get All the Changes Brought about by Sex Hormones?
Can I Have Gender Affirming Surgery without Having to Take Hormone Blockers or Sex Hormones?
Learning Points
Further Reading
Hormone Treatment for Transgender Adults
Overview
Introduction
Biological Theory of Gender Identity Development
The Aim of Hormone Treatment
Physical Effects of Hormone Regimens
Initiation of Treatment
Transgender Women
Physical Effects
Breast Development
Skin and Hair
Body Shape
Genital Changes and Fertility
Mood and Cognition (Thinking)
Negative Effects of Hormone Treatment (Side-Effects)
The Effects of Oestrogen Therapy on Blood Clotting
High Prolactin (Hyperprolactinaemia)
Liver Function
Cholesterol
Osteoporosis (Thin Bones)
Cancer Risks
Additional Treatments
Hormone Protocols
Transgender Women
Transgender Men
Physical Effects
Facial and Body Hair
Body Shape
Genital Changes
Mood and Cognition (Thinking)
Voice
Negative Effects of Hormone Treatment (Side-Effects)
Cholesterol and Lipids
Thick Blood (Polycythaemia)
Liver Function
Cancer Risk
Osteoporosis (Thin Bones)
Hormone Protocols
Transgender Men
Long- Term Studies
Learning Points
Further Reading
References
Chest Surgery and Breast Augmentation Surgery
Overview
Introduction
Anatomy of the Breast and Chest
Development
Skin
Breast Content
Blood Supply
Underlying Muscles
Nerve Supply of the Nipple
Assessment Process
Physical (Clinical) Examination
Body Mass Index (BMI)
Cross-Sex Hormone Treatment
Family History
Breast Augmentation Surgery
Introduction
Hormone Therapy
Discussing the Options
Types of Implants
Textured and Smooth Implants
Procedure
Implant Placement
Location of the Incision
Stitches and Support Bra
Surgical Drains
Recovering from Surgical Care
Swelling and Tenderness
Exercise, Return to Activity
Risks and Complications
Effect on Cancer Detection Screening
Nipple Sensation
Lymphoma
Capsular Contracture
Leakage or Rupture of the Implant
Mastectomy and Chest Reconstructive Surgery
Double Incision Technique
Periareolar (or Keyhole) Technique
Other Surgical Techniques
Liposuction
Nipple-Areolar Procedures
Complications from Surgery
Inadequate or Excessive Resection
Seroma
Dog Ears
Scarring
Infections
Venous Thromboembolism
Further Complications
Long-Term Results
Learning Points
References
Genital Reconstructive Surgery for Transgender Women
Overview
Introduction
History
Criteria for Surgery
Preparation for Surgery
Genital Surgery
The Vagina
Complications
The Clitoris
The Labia
The Urinary Tract
Management after Surgery and Outcomes
Dilation Regimen
Appearance
Sexual Function and Genital Screening
Learning Points
References
Genital Reconstructive Surgery for Transgender Men
Overview
Introduction
Getting Referred to a Surgeon
Preparing for the First Surgery Consultation
Types of Genital Surgery
How to Decide Which Operation to Have
Surgical Staging for Phalloplasty
Stage 1 – Making the Phallus
Radial Artery Free Flap Phalloplasty
Pubic Phalloplasty (PP)
Antero-Lateral Thigh Flap Phalloplasty (ALT)
Radial Artery Free Flap Urethroplasty (RAU)
Other Types of Phalloplasty
Summary of Stage 1 surgery
Stage 2 - Connecting the Urethra, Glans Sculpting, Scrotoplasty and Rearranging Female Parts
Join-up Urethroplasty (Urethral Hook-up)
Perineal Urethra
Scrotoplasty
Glans Sculpting
Burying the Clitoris
Laparoscopic hysterectomy and bilateral ovary removal
Ablation Vaginectomy
Summary of Stage 2 Surgery
Stage 3 – Erectile and Testis Prostheses
Summary of Stage 3 Surgery
Outcome for Phalloplasty
Surgical Staging for Metoidioplasty
Typical Sequence for Metoidioplasty with Urethra
Stage 1. First Stage Buccal Mucosa Graft (BMG) Urethroplasty
Stage 2. Formation of Mini-Phallus, Scrotum, Urethra
Typical Sequence for Metoidioplasty without Urethra
How Does the UK Metoidioplasty Compare to Other Centres?
Outcome for Metoidioplasty
Learning Points
Further Reading
References
Facial Feminization Surgery
Overview
Introduction
General Considerations
Surgical Procedures
Forehead Reduction and Hairline Advance
Brow Lift
Complications and Aftercare
Rhinoplasty
Complications and Aftercare
Cheek Implants
Complications
Lip Lift and Dermis Graft
Complications and Aftercare
Mandible (Lower Jaw) Angle Shave and Taper
Complications and Aftercare
Genioplasty (Chin Reduction)
Complications and Aftercare
Thyroid Shave (Chondrolaryngoplasty)
Complications and Aftercare
Discussion
Learning Points
References
Voice, Speech and Language Therapy
Overview
Introduction
SLT Training and Regulation
Voice Specialist SLTs
Practice Guidelines
The Referral Process
Timing of SLT Treatment
Is Voice and Communication Change Important?
What Effects Do Hormones Have on the Voice?
The Process of Voice Change
The Initial Assessment
The Initial Stage of Treatment
Indirect Therapy
Intermediate Stage of Treatment
Advanced Stages of Treatment
Group Work
Larynx and Vocal Surgeries
Larynx and Vocal Surgeries for Transgender Women
Thyroid Chondroplasty (Adam’s Apple Reduction)
Pitch Elevation Surgery: Crico-Thyroid Approximation Surgery
Vocal Surgery for Transgender Men
Singing Voice
Learning Points
Further Reading
Further Resources
References
Transgender Identities in Education
Overview
Introduction
Young Trans and Gender Variant People in School Settings
Transphobic Bullying in Schools
Mental Distress
Conclusion
Learning Points
Further Reading
Further Resources
Organisations
Gendered Intelligence
Mermaids
GIRES (Gender Identity Research and Education Society)
Scottish Transgender Alliance
UK Trans Info
Trans Media Watch
Schools Out
Educate and Celebrate
Diversity Role Models
Stonewall
Guidance and Teaching Tools
Cornwall Schools Transgender Guidance
Trans Inclusion Schools Toolkit
Classroom Project
Schools Project Homophobic and Transphobic Bullying and Hate Crime
It’s Pronounced Metrosexual
Guidance for Schools on Preventing and Responding to Sexist, Sexual and Transphobic Bullying
No Place for Bullying
Technical Guidance for Schools in England
Trans Staff and Students in HE and Colleges: Improving Experiences
References
Employment Issues: A Personal View
Overview
Introduction
My Story
Employment Issues
Conclusion
Learning Points
Further Reading
Further Resources
US
UK
Canada
Australia
Employment Issues for Transgender and Gender Variant People: A Legal Perspective
Overview
Introduction
The Trans Experience of the British Workplace
The Value of Work to Trans People
The Equality Act 2010 and Trans People
The Equality Act 2010 and Non-Binary or Non-Gendered People
The Workplace, Gender Roles, and Dress Codes
Employer’s Obligations under the Equality Act 2010
The Equality Act 2010: Defined Types of Discrimination
Section 13, Direct Discrimination
Association
Perception
Section 19, Indirect Discrimination
Section 26, Harassment
Section 27, Victimisation
Section 16, Absences from Work due to Gender Reassignment
Section 60, Pre-Employment Medical Questionnaires or Assessments
The Public Sector General Equality Duty
Public Sector Employers and the Human Rights Act 1998
Learning Points
References
Physical Activity and Sport Engagement in the Transgender Population
Overview
Introduction
The Challenges and Barriers Reported by Transgender People When Being Physically Active
External or Environmental Barriers to Sport and Physical Activity
Changing Facilities
The Difficulties of Binding or Tucking While Exercising
Sport-Specific Clothing
Transphobia in Physical Activity and Sport
Team Sport
Competitive Sport Policy for Transgender People
Individual or Internal Barriers to Physical Activity and Sport
Gender Incongruence
Discomfort with the Body
Anxiety About Negative Evaluation and Transphobia
How Physical Activity and Sport Can Be Made More Accessible to Transgender People
Changing Facilities
Sport-Related Clothing
Wipe out Transphobia
Team Sports
Trans-Specific Groups
Sport Policy
Body Positive Environments
Conclusion
Learning Points
Further Reading
References
My Journey through Transition
Overview
Introduction
Self-Acceptance
Coming-Out
Medical Transition
Social Transition
GRS (Gender Realignment Surgery)
Post GRS
Learning Points
Further reading
Helpful Websites
Much Ado About Sebastian
Overview
Childhood and Pre-Teenage Years
Aged 14/15 - Questioning My Gender Identity
Aged 16-17 - Early Social Transition and ‘Finding the Right Name’
‘Coming Out’ Publically
Aged 18 - Starting University
Attending the Transgender Health Service - Gender Affirming Surgery and ‘The Future’
Learning Points
About the Editors
Index
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