Jun. 20, 2012 - Issue #870: Food Trucks

Transgender surgery a requirement

Ontario clinic reveals more open counselling services

'You're fired!" These words will forever be linked to the name Donald Trump. But Trump got himself in trouble recently using his power to fire in another enterprise he owns—the Miss Universe Canada beauty pageant which recently disqualified Jenna Talackova from participating. She is a transsexual whose reassignment surgery was done in 2010. On Twitter, she wrote she had been "disqualified for being born." However, she has done more than post to social media sites. Her lawyer held a press conference on the matter, and Trump backtracked. Talackova trumped the Donald. The Talackova case is just one that highlights the issues facing those who have undergone gender reassignment surgery.

This past March, at the Rainbow Health Ontario conference in Ottawa one of the main topics was mental health assessments for transgender clients as they prepare for surgery. The presenters were from the Centre for Addiction and Mental Health's Gender Identity Clinic, which offers consultation and support to those exploring the idea of the surgery. The clinic is a small operation for a big province. Presenters psychiatrist Christopher McIntosh heads the clinic, and Nicola Brown, a psychologist, is the only full-time professional treatment staff. The clinic relies on graduate students and doctors in the community to meet the need more successfully.

In 2011 the clinic made some important changes in how assessments for surgeries are done. The age of eligibility for surgery has been reduced from 21 to 18. While in other jurisdictions candidates for surgery need to show financial stability, which usually involves engagement in employment or education, this clinic accepts people on provincial disability benefits and even those on regular welfare assistance. As Dr Brown explained, "We should not expect a higher level of productivity from trans people than for other people." 

Another difference in the clinic's approach relates to the requirement that the person live a "real life experience" as a person of the other sex prior to treatment. In the past, the requirement was for a 12-month "real life" experience before hormone treatment. 2011 saw that reduced to three months. Dr Brown said that the changes were made with various levels engaged. "Upper management have been supportive," explained Brown. "As well, the changes were made in consultation with the Ministry of Health and the Sherbourne Health Centre." The centre is the home of Rainbow Health Ontario. This inclusive approach in decision-making avoided conflict over the changes.  

During the conference presentation, McIntosh gave a couple scenarios to illustrate the clinic's selection process. As an example, client number one is treatment engaged, living quietly at home and caring for a family member requiring assistance. This client takes part in a group and attends the clinic. This person is offered the treatment.

Client number two is not engaged in the treatment process, rarely goes out of the house, and leaves all contacts with matters outside the home to another family member. This person was not seen as a good candidate.

The examples led one participant in the conference session to criticize "psychiatrization" of being transgender. Should the Diagnostic and Statistical Manual of Mental Disorders, the psychiatric bible, rule? The DSM terms the transgender condition as genital identity disorder or genital dysphoria. Many transgender people carry no other DSM diagnosis, reminding one of the past listing of homosexuality in the DSM. Considering the societal prejudices that trans persons can experience, it is not surprising that they might experience DSM diagnoses such as anxiety and depression. But, more attention, it was held, should be given to the role of the family physician and hormone replacement therapy, which more family physicians need information about. As Dr Brown noted, "The issue tends to arise at puberty." But, often much younger children experience the identity conflict. In Talackova's case, she began hormone therapy at age 14, but she identified as female as early as four years old.

According to Dr McIntosh, recent studies of quality of life of trans people are more positive than some of the much older ones. Dr Louis Gooren, writing in The New England Journal of Medicine, found that for the group of transgender people experiencing no other DSM diagnosis, "sex reassignment benefits this group." And the clinic is still in a process of change as Dr Brown commented during the conference—it is currently rethinking the real life experience requirement for hormone treatment. 

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