Gender
Identity Dysphoria, or Transgenderism
Some
men and women are born into bodies that do not reflect their truest,
most authentic gender. These men and women are not only widely
misunderstood the general population, but they are also often
misunderstood by professionals. Michele O'Mara has worked with
over a hundred men and women who are experiencing gender conflicts.
Michele
O'Mara, LCSW,
is a mental health professional, licensed in the state of Indiana.
She has been providing services to trasngender men and women for the
last decade, and she has assisted hundreds of men and women in their
search for gender peace. Typically your point of entry for
services with Transgender Indiana will be with Michele O'Mara, where an
initial assessment or plan of action will be developed in response to
your actual goals and concerns related to your gender. To schedule
an appointment for any of the following services, you can do so online here,
at any time.
- Individual and Family Counseling
- Gender clarification, diagnosis
(if applicable), and exploration of options for making peace with
your gender
- Letter of referral for Hormone
Replacement Therapy (HRT) and Sex Reassignment Surgery (SRS) also
known as Gender Reassignment Surgery (GRS)
- Support through Real Life
Experience (RLE) also known as Real Life Test (RLT)
- Emotional and psychological
support and assistance through the steps necessary for a
gender transition
- Bi-weekly Gender Support Group
Bethany
Schwartz is
a Life Transformation Coach (LT Coach) specializing in gender
transitions. As a coach, she provides a variety of very specific
services to assist in your PHYSICAL TRANSITION.
Bethany has been nurturing personal and professional change for
individuals and organizations for 22 years. She is also a post-op
MtF transsexual who has served the Transgender community as a
researcher, education planner, and presenter for the Chicago Be All, the
Chicago Gender Society, and the Rikki Swin Institute for Transgender
Studies.
The
Standards of Care (SOC) for Gender Identity Disorders -- Sixth Version,
clearly states the role of mental
health professional in the care of individuals with Gender Identity
Disorders (GID), and these are as follows:
III.
The Mental Health Professional
The Ten Tasks of the
Mental Health Professional.
Mental health professionals (MHP) who work with individuals with gender
identity disorders may be regularly called upon to carry out many of
these responsibilities:
-
to
accurately diagnose the individual's gender disorder;
-
to
accurately diagnose any co-morbid psychiatric conditions and see to
their appropriate treatment;
-
to
counsel the individual about the range of treatment options and
their implications;
-
to
engage in psychotherapy
-
to
ascertain eligibility and readiness for hormone and surgical
therapy;
-
to
make formal recommendations to medical and surgical colleagues;
-
to
document their patient's relevant history in a letter of
recommendation;
-
to
be a colleague on a team of professionals with interest in the
gender identity disorders;
-
to
educate family members, employers, and institutions about gender
identity disorders;
-
to
be available for follow-up of previously seen gender patients.
The
Training of Mental Health Professionals.
The
Adult-Specialist.
The
education of the mental health professional who specializes in adult
gender identity disorders rests upon basic general clinical competence
in diagnosis and treatment of mental or emotional disorders. The basic
clinical training may occur within any formally credentialing
discipline--for example, psychology, psychiatry, social work,
counseling, or nursing. The following are the recommended minimal
credentials for special competence with the gender identity disorders:
-
A master's degree or
its equivalent in a clinical behavioral science field. This or a
more advanced degree should be granted by an institution accredited
by a recognized national or regional accrediting board. The mental
health professional should have written credentials from a proper
training facility and a licensing board.
-
Specialized training
and competence in the assessment of the DSM-IV/ICD-10 Sexual
Disorders (not simply gender identity disorders).
-
Documented
supervised training and competence in psychotherapy.
-
Continuing education
in the treatment of gender identity disorders which may include
attendance at professional meetings, workshops, or seminars or
participating in research related to gender identity issues.
The
Child-Specialist.
The
professional who evaluates and offers therapy for a child or early
adolescent with GID should have been trained in childhood and adolescent
developmental psychopathology. The professional should be competent in
diagnosing and treating the ordinary problems of children and
adolescents.
The
Differences between Eligibility and Readiness.
The
SOC provides eligibility requirements for hormones and surgery. Without
first meeting eligibility requirements, the patient and the therapist
should not request hormones or surgery. An example of an eligibility
requirement is: a person must live full time in the preferred gender for
twelve months prior to genital reconstructive surgery. To meet this
criterion, the professional needs to document that the real life
experience has occurred for this duration. Meeting readiness
criteria--further consolidation of the evolving gender identity or
improving mental health in the new or confirmed gender role--is more
complicated because it rests upon the clinician's judgment. The
clinician might think that the person is not yet ready because his
behavior frequently contradicts his stated needs and goals.
The
Mental Health Professional's Relationship to the Endocrinologist and
Surgeon.
Mental
health professionals who recommend hormonal and surgical therapy share
the legal and ethical responsibility for that decision with the
physician who undertakes the treatment. Hormonal treatment can
often alleviate anxiety and depression in people without the use of
additional psychotropic medications. Some individuals, however, need
psychotropic medication prior to, or concurrent with, taking hormones or
having surgery. The mental health professional is expected to make these
decisions and see to it that the appropriate psychotropic medications
are offered to the patient. The presence of psychiatric co-morbidities
does not necessarily preclude hormonal or surgical treatment, but
some diagnoses pose difficult treatment dilemmas and may delay or
preclude the use of either treatment.
The
Mental Health Professional's Documentation Letters for Hormones or
Surgery Should Succinctly Specify:
-
The
patient's general identifying characteristics
-
The
initial and evolving gender, sexual, and other psychiatric diagnoses
-
The
duration of their professional relationship including the type of
psychotherapy or evaluation that the patient underwent
-
The
eligibility criteria that have been met and the MHP's rationale for
hormones or surgery
-
The
patient's ability to follow the Standards of Care to date and the
likelihood of future compliance
-
Whether
the author of the report is part of a gender team or is working
without benefit of an organized team approach
-
That
the sender welcomes a phone call to verify the fact that the mental
health professional actually wrote the letter as described in this
document.
The organization and
completeness of these letters provide the hormone-prescribing physician
and the surgeon an important degree of assurance that mental health
professional is knowledgeable about gender issues and is competent in
conducting the roles of the mental health professional.
One
Letter is Required for Instituting Hormone Therapy.
One
letter from a mental health professional, including the above seven
points, written to the medical professional who will be responsible for
the patient's endocrine treatment is sufficient.
Two-Letters
are Generally Required for Surgery.
It is ideal if mental health professionals conduct their tasks and
periodically report on these processes to a team of other mental health
professionals and nonpsychiatric physicians. Letters of recommendation
to physicians or surgeons written after discussion with a gender team
then reflect the influence of the entire team. One letter to the
physician performing surgery will generally suffice as long as it is
signed by two mental health professionals.
More commonly, however, letters of recommendation are from mental health
professionals who work alone without colleagues experienced with gender
identity disorders. Because professionals working independently may not
have the benefit of ongoing professional consultation on gender cases,
two letters of recommendation are required prior to endorsing surgery.
If the first letter is from a person with a master's degree, the second
letter should be from a psychiatrist or a clinical psychologist--those
with doctoral degrees who can be expected to adequately evaluate
co-morbid psychiatric conditions. If the first letter is from the
patient's psychotherapist, the second letter should be from a person who
has only played an evaluative role for the patient. Each letter writer,
however, is expected to cover the same topics. At least one of the
letters should be an extensive report. The second letter writer, having
read the first letter, may choose to offer a briefer summary and an
agreement with the recommendation.
Fees
Sessions are 50 minutes and cost
$90.
Michele does
request full payment from each client at the time of
service unless a special arrangement/agreement has been made
in advance. She will provide you with receipts
and related documentation (codes for service, diagnosis, and dates of
service as requested by insurance company) for your reimbursement.
Michele is a Licensed Clinical Social
Worker in the state of Indiana (License # 34003162A). These
credentials are recognized by most insurance companies and as a result I
am most often a reimbursable provider. (Meaning, if you see me, even if
I am out of your network, which I probably am, your insurance company is
still likely to cover me for out-of-network services).
Michele
does not submit insurance claims
on behalf of clients. She will provide receipt of services for you to
submit to your insurance company for reimbursement, for tax-deduction
purposes, or for use with your Flex Accounts.
Additional
helpful Information
As
a professional member of The Harry Benjamin International Gender
Dysphoria Association, Michele does follow the Standards of Care (SOC's)
in her practice. These guidelines outline the eligibility and
readiness criteria for transgender adults seeking hormone therapy:
Eligibility
-
Demonstrable
knowledge of what hormones can and cannot medically do and hormone
benefit and risks
-
Either real-life
experience of at least 3 months living in the desired role OR a
period of psychotherapy (usually at least 3 months) specified by a
mental health professional)
-
Legal
age of majority (age 18 in the United States)
Readiness
-
Real-life experience
or psychotherapy has further consolidated gender identity
-
Patient is deemed
likely to take hormones responsibly
-
patient
has made progress in improving or continuing stable mental health
(implies control of sociopathy, substance abuse, psychosis, and
suicidal tendencies)
Effects
of Feminizing Hormones
Breast development -
This will vary greatly, as it does
with the genetic female population. The breast tissue growth
typically takes at least two years to reach maximum size, and it is rare
for breast development among MtF's to exceed a B cup size.
Within the first couple months of
hormone therapy ,a nodule-like formation behind the nipple develops and
along with this is significant tenderness/sensitivity in the area. These
changes are induced by an increase in the ductal system behind the
nipple which is a part of the transition process that will typically
normalize in a matter of months.
Body Hair -
Depending on the amount of body hair to
begin with, there is a significant decrease in hair over the course of
time and after several years and may diminish entirely over a period of
several years. Arm and leg hair as well as hair on the abdomen,
chest, and shoulders will greatly lessen and in some instances disappear
completely. Hair growth in specific regions including that around
the areola, armpits and pubic area will not lessen to the same extent.
Whatever beard hair is present at the start of HRT, will remain.
Electrolysis or laser hair removal will expedite the removal of this
hair and it makes sense to begin with this facial hair that will not go
away on it's own, and save hair removal treatments for chest and
shoulders until later to see if HRT does reduce or eliminate it.
Skin
- This will change greatly, becoming softer and less coarse.
Fat Distribution
- Over a period of time (1 to 2 years time), a change in the
subcutaneous fat (located just beneath the skin) will occur. The
hips, thighs and buttocks will collect the majority of this
distribution, and the tendency to collect fat in the stomach will
diminish somewhat. The resulting redistribution will result in a smaller
waistline and larger hips.
Muscle Mass
- Through the process of feminization much
of the upper body bulk will disappear over depending on the amount of
muscle mass an individual starts with.
Genitals - Testes
will lessen quite significantly in size. The production of
testosterone and sperm is also greatly reduced. Penile
size will also likely diminish. Sexual function will decrease, but
the extent to which performance is affected is unpredictable. Erections
may still continue, but will probably be less frequent, and not last as
long, and in some cases may not be possible. Ejaculate will lessen,
probably to the point of only producing a very small, clear discharge as
a result of the prostate and the associated structures responsible for
semen production being impeded.
Prostate Gland
- The prostate will diminish in size
due to the effects of estrogen and finasteride (Proscar), the latter
being administered as an anti-androgen. Beside from the feminizing
effect of these medications, both drugs are helpful in the treatment of
benign prostatic enlargement. This condition is often responsible
for the difficulty with urination experienced by many older individuals.
Through the course of hormone therapy, this urinary complaint will
likely be relieved.
Cardiovascular
- Coronary heart disease is the leading
cause of death in the United States. Due to various lifestyle and
hereditary factors, cardiovascular conditions may pose additional risks
to those undertaking elective medical therapies, such as the variety of
drug treatments engaged in the feminization process. However, the
effects of hormonal therapy may be similarly beneficial to the
male-to-female transgender patient with respect to arteriosclerotic
plaque disease and cardiovascular conditions, as it demonstrates itself
in the genetic female population.
Infertility/Impotence -
Long term use of estrogens may likely result in infertility, with
permanent infertility being a distinct possibility. Sexual
responsiveness will likely diminish over the course of hormonal therapy,
potentially resulting in the inability to achieve or maintain an
erection. These effects are the basis for feminizing hormone
therapy being termed chemical castration.
* Sperm-Banking
- If the transgender individual has any concern or desire to
"father" children in the future, it is imperative that the
male-to-female transgender individual choose the option of sperm
banking – having samples of their sperm frozen and stored for
later use – prior to beginning hormone therapy.
Voice is UNCHANGED by
hormone therapy.
However, inflection and manner of speech are very well suited to change.
Additionally, pitch can be raised through persistent vocal practice.
Given the importance of a gender congruent voice, surgical options have
been explored in an attempt to alter pitch, but this most delicate of
instruments is not likely to be properly retuned through surgery.