Organic. TransSEXualism has nothing to do with sex but everything with gender identity... (NATURE) Psychological (NURTURE)

Transcription

1 University Hospital Ghent (Belgium) TRANSGENDER CARE introduction TransSEXualism has nothing to do with sex but everything with gender identity... Stan Monstrey Gender dysphoria Gender Identity Disorder (GID) Dissatisfaction with how somebody experiences the sex of birth and the psychological, social and legal roles which apply to that sex TRANSSEXUALISM is the most extreme form of Gender Dysphoria (Gender Identity Disorder) Etiology Psychological (NURTURE) Organic (NATURE) NATURE... Brain (neonatal) vs. Internal gonads (W6) vs. External genitalia (W12) Intersex conditions Hormonal experiments in animals Joan-John case Hand preference Sex dimorphic nuclei in the brain Twin study 1

2 NURTURE... Psychoanalysis (Freud) -lack of seperation with the mother -competition with the father Wish of the mother Real nurture Dysfuntional family sex (penis-vagina) gender (male-female) sexuality (heterohomosexual) Male-Female emale DICHOTOMY versus Gender SPECTRUM Spectrum Gender No gender Male-female traits Cross-gender behaviour Homosexuality Transvestitism Transgenderism Transsexuality 2

3 Gender Incongruent Gender Queer DISEASE (transsexual patient) vs. VARIANCE (transgender client) DSM IV (V) Criteria Persistent discomfort about own sex Persistent preoccupation (>2 years) to change sex characteristics Post puberty No genetic or psychiatric disease Gender Dysphoria = SUFFERING! Treatment: Psychotherapy versus Gender Reasssignment 3

4 Gender reassignment STANDARDS OF CARE (WPATH) Diagnostic phase Hormonal therapy + living in the desired gender role ( Real Life Test ) Gender reassignment Surgery Two referrals for genital surgery? WPATH SOC 7: - ONE mental health professional for the breast surgery - TWO mental health professionals for the genital surgery Evidence??? - Balance between the paternalistic approach (protect patients from themselves) versus the patient-centered approach (patient and surgeon agree what is the best option for gender transition treatment) (Bouman 1014) - Differentiate between internal and external genital surgery?? (Philipsburg 2015) - Informed consent Informed Consent Dialogue-based consent (Roque 2015) Provide proper information about proposed intervention and consequences Respect the voluntary decision of the patient Insure that the patient is competent to make the informed decision Adequate preparation and assessment within a multi-disciplinary team is more important than just requiring 2 referrals 4

5 REGRET PATIENTS ACCREDITATION? REIMBURSEMENT? 0 / 1678 SRS Reimbursement General trends: 1. Overall budget restrictions 2. Legally: more 3. Financially: less 4. Reconstructive vs. Aesthetic 5. Reduction in hospital beds Prevalence in Belgium Transgender health care in Belgium State register 1/1/ /6/14 => N=730 (IGVM, 2013) Medical records 1: men; 1: women => N=443 (De Cuypere et al., 2007) Gender dysphoria 1:2.000 à men; 1:4.000 à women => N=3.125 (De Cuypere & Olyslager, 2009) Gender incongruence 0.7% men; 0.6% women => N= (Wierckx, Van Caenegem, Elaut et al., 2015) Gender ambivalence 2.2% men; 1.9% women => N= (Wierckx, Van Caenegem, Elaut et al., 2015) 5

6 Numbers of new clients on yearly basis Genderteam UZ Ghent ( ) adults minors Belgian genderteams Ghent Two genderteams INTER disciplinary Adult clinic from age 18 focus on allround assessment assistance to partners/families intake -> end process possibility ( obligation) of psychotherapy Pediatric clinic children/ado s up to 17 focus on healthy development in all areas of functioning Amsterdam protocol puberty suppression hormones from 16y surgery from 18y Gouvernment-supported initiative TIP (1) Lowering threshold towards health care through dissemination of up-to-date, evidence-based information on gender dysphoria and available health care providing approachable first contact ( /telephone) with free advice from a neutral position helping to close the gap between health care providers and individuals with gender dysphoria clinical position (2) Help build alliances with gouvernement bodies MTF Transformation Aesthetic procedures Breast augmentation Perineal transformation Voice operation 6

7 FFS Facial Femizing Surgery Courtesy Dr. Capitan & Dr. Simon) breast augmentation aesthetic cosmetic vs. functionial reconstructive breast augmentation 7

8 LIPOFILLING vaginoclitoroplasty anteriorly pedicled penile (scrotal) inversed skin flap technique 8

9 castration clitoris + hood 9

10 Intestinal flap Colon/ Colon/Sigmoid Sigmoid / Endoscopic 10