CAPT Lisa Cartwright Megan M Weis Chair BUMED Transgender Working Group Special Counsel to the General Counsel Lisacartwrightusuhsedu ID: 686263
Download Presentation The PPT/PDF document "Emerging Transgender Issues and the Law:..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Emerging Transgender Issues and the Law: Medical and Legal Update
CAPT Lisa Cartwright
Megan
M.
Weis
Chair, BUMED Transgender Working
Group
Special
Counsel to the General
Counsel
Lisa.cartwright@usuhs.edu
Army
Office of the General Counsel
202-560-3759Slide2
Emerging Transgender Issues and the Law:
Medical Management
for Gender Transition for Transgender IndividualsSlide3
Overview
Definitions
Gender
Dysphoria
Standards of Care
Gender Transition
TimelineSlide4
Definitions
Gender Identity
A person’s intrinsic sense of being male, female, or alternative genderSlide5
Definitions
Natal Gender
Gender assigned at birthSlide6
Definitions
Transgender
1
Diverse
group of individuals who cross or transcend culturally defined categories of gender
Gender identity
differs to varying degrees from
natal genderSlide7
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 roleSlide8
Definitions
Gender Dysphoria
Discomfort or
distress
caused by discrepancy between Gender Identity and Natal Gender
1Slide9
Definitions
Gender Dysphoria in Adolescents and Adults
(DSM 5)
2
M
arked
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 functioningSlide10
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 genderSlide11
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
. Slide12
Definitions
Gender nonconforming
Individual whose gender identity, role or expression differs from cultural norms prescribed for people of a particular sex
1
Differs from gender dysphoria due to absence of strong desire to be of another gender
2Slide13
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 conditionSlide14
Definitions
Disorder of Sexual Development (DSD)
Congenital conditions where development of chromosomal, gonadal, or anatomic sex is atypical
A.
k
. a. “intersex”Slide15
Definition
Transvestism
(cross dressing)
1
Wearing clothing and adopting a gender role presentation that, in a given culture, is more typical of the other sex
1Slide16
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 dressingSlide17
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 durationSlide18
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 individualsSlide19
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 resourcesSlide20
Transgender Prevalence
???
Mostly derived from clinics where patient meet criteria for severe gender
dysphoria
Reported prevalence
1
1:11,900-45,000
MtF
1:30,400-200,000
FtM
True
prevalance
is likely much higherSlide21
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
PsychotherapySlide22
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 documentsSlide23
Psychotherapy (WPATH SOC)1
Mental health screening
REQUIRED for hormonal or surgical treatment
Psychotherapy
Highly recommended
NOT requiredSlide24
Hormone Therapy (WPATH SOC)1
Medically necessary
for
many
individuals with Gender
Dysphoria
Recommended prior to some, not all, surgical treatmentSlide25
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 concernsSlide26
Hormone Therapy Informed Consent (WPATH SOC)
1
May result in irreversible physical changes
Document
Comprehensive information provided
Possible benefits
Risks
Impact on reproductive capacitySlide27
Hormone Therapy Effects
Occur over course of 2 years
Variable timeline
Variable effectsSlide28
Hormone Therapy EffectsFtM
Deep voice
Variable clitoral enlargement
Facial/body hair
Cessation menses
Breast atrophy
Decreased body fat %
Reduction in fertilitySlide29
Hormone Therapy EffectsMtF
Breast growth
Erectile dysfunction
Decreased testicular size
Increased body fat %
Reduction in fertilitySlide30
Hormone Therapy Risks1
Risk level
MtF
FtM
Likely increased
Venous
thromboembolism
Gallstones
Elevated
Liver Enzymes
Hypertriglyceridemia
Polycythemia
Weight gain
Acne
Balding
Sleep apnea
Likely
increased in the presence of risk factors
Cardiovascular disease
Possible increased
Hypertension
Hyperprolactinemia
/
prolactinoma
Elevated liver enzyme
Hyperlipidemia
Possible increased in presence of risk factors
Type 2 Diabetes
Destabilization of psychiatric disorders
Cardiovascular disease
Hypertension
Type 2 Diabetes
Not
increased or inconclusive
Breast Cancer
Bone density loss
Breast cancer
Cervical cancer
Ovarian cancer
Uterine cancerSlide31
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
initiatationSlide32
Sex Reassignment Surgery(WPATH SOC)
1
MtF
FtM
Breast/chest
Breast
augmentation
mastectomy
Genital
Penectomy
Orchiectomy
Vaginoplasty
Clitoroplasty
Vulvoplasty
Hysterectomy/
salpingectomy
Oophorectomy
Metoidioplasty
Phalloplasty
Vaginectomy
Srotoplasty
Penile prosthesis
Testicular
prosthesis
Non-genital/ non-breast
Facial feminization
Liposuction/
Lipofilling
Voice surgery
Thyroid cartilage reduction
Gluteal
augmentation
Voice surgery (rare)
Liposuction/
lipofilling
Pectoral implantsSlide33
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 prerequisiteSlide34
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 augmentSlide35
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 therapySlide36
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”)Slide37
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 yearSlide38
Transition TimelineSlide39
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 individualsSlide40
References
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
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
Edited by American Psychiatric Association, 2013.
American Psychiatric Association (APA) statement
,
Gender Dysphoria in the DSM-5
.
www.psychiatry.org
, 2013.
Slide41
Emerging Transgender Issues and the
Law: Legal UpdateSlide42
Agenda
Corrections
Civilian
Other Countries
U.S. Military
42Slide43
Corrections
8
th
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
43Slide44
Corrections-BOP
BOP Transgender Resource Guide,
November 2014
Prison Rape Elimination Act (
PREA
)
44Slide45
Corrections-Military
Manning
Has sued for medical
care for
gender dysphoria under 8
th
Amendment.
Army
Court of Criminal Appeals
:
"Reference to
appellant . . .either
be
neutral . . . or
employ a feminine pronoun."
45Slide46
Civilian- Legal Developments
Title VII of the Civil Rights Act of 1964
Executive Order 11478 (Amended July 2014)
Agency Guidance
DOJ Positions
46Slide47
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
” theory
47Slide48
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. Slide49
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.”Slide50
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
50Slide51
DOJ Positions
Attorney General
Memorandum- Title VII
discrimination
based on gender identity constitutes sex
discrimination
Statements of Interest
Title IX and Equal Protection Clause
51Slide52
Other Countries
52Slide53
Veterans
VA: providing care to transgender patients
DoD: name change on DD 214s
53Slide54
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
).
54Slide55
Questions?
55