Emerging Transgender Issues and the Law: Medical and Legal

Update

CAPT Lisa Cartwright Megan M. WeisChair, BUMED Transgender Working Group Special Counsel to the General Counsel Lisa.cartwright@usuhs.edu

Army Office of the General Counsel202-560-3759

Emerging Transgender Issues and the Law: Medical

Managementfor Gender Transition for Transgender Individuals

Overview

• Definitions• Gender Dysphoria• Standards of Care• Gender Transition• Timeline

Definitions

• Gender Identity– A person’s intrinsic sense of being male, female, or

alternative gender

Definitions

• Natal Gender– Gender assigned at birth

Definitions

• Transgender1

– Diverse group of individuals who cross or transcend culturally defined categories of gender

– Gender identity differs to varying degrees from natal gender

Definitions1

• Female-to-male (FtM) – Natal female who has changed or is changing

body and/or gender role to a more masculine body or role

• Male-to-female (MtF)– Natal male who has changed or is changing body

and/or gender role to a more feminine body or role

Definitions

• Gender Dysphoria– Discomfort or distress caused by discrepancy

between Gender Identity and Natal Gender 1

Definitions

• Gender Dysphoria in Adolescents and Adults (DSM 5) 2

– Marked incongruence between one’s experienced/expressed gender and assigned gender, (at least 6 months)

– Associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning

Definitions

• Gender Dysphoria in Adolescents and Adults (DSM 5) 2

– incongruence between one’s experienced/expressed gender and assigned gender, manifested by at least two of the following:

• incongruence between one’s experienced/expressed gender and sex characteristics

• desire to be rid of one’s sex characteristics because of incongruence

• desire for the sex characteristics of the other gender• desire to be of other gender • desire to be treated as the other gender • conviction that one has typical feelings/reactions of other gender

Gender Dysphoria 2

• Often, but not always, accompanied by a desire to be rid of sex characteristics and/or a desire to acquire sex characteristics of the other gender

• May adopt the behavior, clothing, and mannerisms of the experienced gender

• Uncomfortable regarded by others, or functioning, as assigned gender

• May have a strong desire to be of a different gender and treated as such without seeking medical treatment to alter body characteristics.

Definitions

• Gender nonconforming – Individual whose gender identity, role or

expression differs from cultural norms prescribed for people of a particular sex1

– Differs from gender dysphoria due to absence of strong desire to be of another gender2

Gender Dysphoria 3

• Replaces “gender identify disorder”• Gender nonconformity is not itself a mental

disorder– Only some gender non-conforming people

experience gender dysphoria at some point in their lives

• CRITICAL ELEMENT is clinically significant distress associated with the condition

Definitions

• Disorder of Sexual Development (DSD)– Congenital conditions where development of

chromosomal, gonadal, or anatomic sex is atypical– A. k. a. “intersex”

Definition

• Transvestism (cross dressing) 1

– Wearing clothing and adopting a gender role presentation that, in a given culture, is more typical of the other sex1

Paraphillic disorders 2

• Voyeuristic disorder – Spying on others in private activities

• Exhibitionistist disorder– Exposing genitals

• Frotteuristic disorder– Touching or rubbing against non-consenting individual

• Sexual Masochism disorder– Undergoing humiliation, bondage, or suffering

• Sexual Sadism disorder– Inflicting humiliation, bondage or suffering

• Pedophillic disorder– Sexual focus on children

• Fetishistic disorder– Focus on nongenital body parts

• Transvestic disorder– Engaging in sexually arousing cross dressing

Definitions

• Transition 1

– Period of time when individuals change from natal gender to different gender role

– May include• Learning to live socially in another gender role• Finding most comfortable gender role and expression• Feminization or masculinization of the body through

hormones or medical procedures

– VARIABLE and INDIVIDIUALIZED nature and duration

WPATH (World Professional Association for Transgender Health)

• International multidisciplinary professional association to promote evidence-based care, education, research advocacy, public policy , and respect in transsexual and transgender health. 1

• Articulates Standards of Care (SOC) for Transgender, Transsexual and Gender-Nonconforming individuals

WPATH Standards of Care (SOC) 1

• Flexible • Clinical guidelines which may be modified by

individual health professionals and programs– Unique patient situation– Professional’s evolving practice– Research protocol– Lack of resources

Transgender Prevalence

• ???– Mostly derived from clinics where patient meet

criteria for severe gender dysphoria– Reported prevalence1

• 1:11,900-45,000 MtF• 1:30,400-200,000 FtM

• True prevalance is likely much higher

Gender Dysphoria Psychological and Medical Treatment

• Highly individualized– Change gender expression and role– Hormone therapy– Surgery– Both hormone therapy and surgery– Neither hormones or surgery– Psychotherapy

Gender Dysphoria Social Support and Gender Expression

Changes• Peer support• Support for family/friends• Voice/communication therapy• Hair removal• Breast binding/padding; genital tucking• Name change and gender change on identity

documents

Psychotherapy (WPATH SOC)1

• Mental health screening REQUIRED for hormonal or surgical treatment

• Psychotherapy– Highly recommended– NOT required

Hormone Therapy (WPATH SOC)1

• Medically necessary for many individuals with Gender Dysphoria

• Recommended prior to some, not all, surgical treatment

Hormone Therapy Criteria (WPATH SOC)1

• Referral from one mental health provider• Persistent, well documented Gender

Dysphoria• Informed consent capacity• Age of majority• Reasonably well controlled medical and

mental health concerns

Hormone Therapy Informed Consent (WPATH SOC)1

• May result in irreversible physical changes• Document

– Comprehensive information provided– Possible benefits– Risks– Impact on reproductive capacity

Hormone Therapy Effects

• Occur over course of 2 years• Variable timeline• Variable effects

Hormone Therapy EffectsFtM

• Deep voice• Variable clitoral enlargement• Facial/body hair• Cessation menses• Breast atrophy• Decreased body fat %• Reduction in fertility

Hormone Therapy EffectsMtF

• Breast growth• Erectile dysfunction• Decreased testicular size• Increased body fat %• Reduction in fertility

Hormone Therapy Risks1

Risk level MtF FtM

Likely increased Venous thromboembolismGallstonesElevated Liver EnzymesHypertriglyceridemia

PolycythemiaWeight gainAcneBaldingSleep apnea

Likely increased in the presence of risk factors

Cardiovascular disease

Possible increased HypertensionHyperprolactinemia / prolactinoma

Elevated liver enzymeHyperlipidemia

Possible increased in presence of risk factors

Type 2 Diabetes Destabilization of psychiatric disordersCardiovascular diseaseHypertensionType 2 Diabetes

Not increased or inconclusive

Breast Cancer Bone density lossBreast cancerCervical cancerOvarian cancerUterine cancer

Hormone Therapyfollow-up

• 2-3 months initially to stabilize on dose• Every 2-3 months for first year• Annual consultation with endocrine after first

year• Potential 1 year non-deployable form

initiatation

Sex Reassignment Surgery(WPATH SOC)1

MtF FtM

Breast/chest Breast augmentation mastectomy

Genital PenectomyOrchiectomyVaginoplastyClitoroplastyVulvoplasty

Hysterectomy/salpingectomyOophorectomyMetoidioplastyPhalloplastyVaginectomySrotoplastyPenile prosthesisTesticular prosthesis

Non-genital/ non-breast

Facial feminizationLiposuction/LipofillingVoice surgeryThyroid cartilage reductionGluteal augmentation

Voice surgery (rare)Liposuction/lipofilling Pectoral implants

Sex Reassignment Surgery Criteria(WPATH SOC)1

• Breast/chest surgery FtM– Single referral– Persistent, well-documented gender dysphoria– Informed consent capacity– Age of majority– Well controlled mental and medical health

concerns– Hormone therapy NOT prerequisite

Sex Reassignment Surgery Criteria(WPATH SOC)1

• Breast/chest surgery MtF– Single referral– Persistent, well-documented gender dysphoria– Informed consent capacity– Age of majority– Well controlled mental and medical health concerns– Hormone therapy NOT prerequisite

• RECOMMEND at least 12 months prior to breast augment

Sex Reassignment Surgery Criteria(WPATH SOC)1

• Genital (gonadectomy / hysterectomy)– Two referrals– Persistent, well-documented gender dysphoria– Informed consent capacity– Age of majority– Well controlled mental/medical health concerns– 12 continuous months of hormone therapy

Sex Reassignment Surgery Criteria(WPATH SOC)1

• Genital (FtM metoidioplasty/phalloplasty; MtF vaginoplasty)– Two referrals– Persistent, well-documented gender dysphoria– Informed consent capacity– Age of majority– Well controlled mental/medical health concerns– 12 continuous months of hormone therapy– 12 continuous months living in desired gender role

(“real life experience”)

Real Life Experience

• Present consistently on day-today basis, across all settings of life in their desired gender role

• 12 months allows full range of life experiences throughout the year

Transition Timeline

Summary

• Transgender people may develop Gender Dysphoria

• Treatment for Gender Dysphoria may require hormonal or surgical treatment for gender transition

• Gender transition is highly variable among individuals

References1. Standards of Care for the Health of Transsexual, Transgender, and Gender-

Nonconforming People, Version 7. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J.,Fraser, L., Green, J., Knudson, G., Meyer, W. J., Monstrey, S., Adler, R. K., Brown, G. R.,Devor, A. H., Ehrbar, R., Ettner, R., Eyler, E., Garofalo, R., Karasic, D. H., Lev, A. I.,Mayer, G., Meyer-Bahlburg, H., Hall, B. P., Pfaefflin, F., Rachlin, K., Robinson, B., Schechter, L. S., Tangpricha, V., van Trotsenburg, M., Vitale, A., Winter, S., Whittle, S.,Wylie, K. R., & Zucker, K. International Journal of Transgenderism, 13:165–232, 2011

2. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Edited by American Psychiatric Association, 2013.

3. American Psychiatric Association (APA) statement , Gender Dysphoria in the DSM-5. www.psychiatry.org , 2013.

Office of the General Counsel

Emerging Transgender Issues and the Law: Legal

Update

Agenda

1. Corrections2. Civilian3. Other Countries4. U.S. Military

42

Corrections

• 8th Amendment- deliberate indifference to a prisoner’s serious medical need

- serious or significant physical or emotional injury, or substantial risk of

- reckless disregard• Gender Dysphoria as a serious

medical need• Prison security needs 43

Corrections-BOP

• BOP Transgender Resource Guide, November 2014

• Prison Rape Elimination Act (PREA)

44

Corrections-Military

• Manning – Has sued for medical care for gender

dysphoria under 8th Amendment.– Army Court of Criminal Appeals :

"Reference to appellant . . .either be neutral . . . or employ a feminine pronoun."

45

Civilian- Legal Developments

• Title VII of the Civil Rights Act of 1964

• Executive Order 11478 (Amended July 2014)

• Agency Guidance

• DOJ Positions

46

Title VII

• Unlawful for employers to discriminate in the employment of an individual “because of such individual’s . . . sex.” • Does not contain an explicit

prohibition of discrimination on the basis of sexual orientation or gender identity or expression.

• “Sex-sterotyping” theory47

Title VII

48

• Macy v. Holder (EEOC April 20, 2012)• EEOC ruled that discrimination on the

basis of gender identity is discrimination based on sex.

Executive Order 11478 (amended)

49

• “It is the policy of the Government of the United States to provide equal opportunity in Federal employment for all persons, to prohibit discrimination in employment because of race, color, religion, sex, national origin, handicap, or age, sexual orientation, gender identity, or status as a parent.”

Agency Guidance

• OPM: Federal government’s policy of providing a workplace free from discrimination based on sex includes discrimination based on gender identity

• OSHA: Restroom access• HHS: Proposed Rule addressing

nondiscrimination in federal health care programs

50

DOJ Positions

• Attorney General Memorandum- Title VII– discrimination based on gender identity

constitutes sex discrimination

• Statements of Interest– Title IX and Equal Protection Clause

51

Other Countries

52

Veterans

• VA: providing care to transgender patients• DoD: name change on DD 214s

53

U.S. Military• Working Group established- 28 July 2015• Start with the presumption that transgender

persons can serve openly without adverse impact on military effectiveness and readiness.

• No service member shall be involuntarily separated or denied reenlistment or continuation of active or reserve service on the basis of their gender identity without the personal approval of the USD(P&R).

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Questions?

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