Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Every Tuesday, we will be presenting blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).
That being said, we’re very happy to offer a platform where we can feature these individuals and the information they have to share. We’d like to make this an ongoing dialogue. If you have questions, remarks, or would like more information on a topic, please feel free to leave comments below or on our Facebook page, and we’ll pass them along to the author.
On December 8th, 2015, Dictionary.com announced that the Word of the Year was Identity, partly because of the expanding conversations about gender identity. The news stood out to me because 2015 was a year I learned a lot from working with transgender patients.
The year 2015 was indeed a big year for the transgender community and the gender identity conversation. In January, Transparent, an Amazon series about the patriarch of a family coming out as a transwoman (a biological male who identifies as a woman), won the Golden Globe for Best Television Series. In April, Bruce Jenner came out as transgender and made national news. In July, the Pentagon announced its decision to allow transgender Service members to serve openly in the military starting in 2016.
As the year 2015 came to an end, I couldn’t help but reflect on my own professional experiences dealing with gender and sexual identity issues. When I joined the Navy in February 2004 as a commissioned officer and Navy psychologist, I had to sign an informed consent about the Don’t Ask, Don’t Tell policy, essentially promising not to engage in homosexual behaviors. As a psychologist serving active duty military members, I struggled with how best to document cases when patients had same-sex relationship problems or issues having to do with homosexuality, because being identified as gay/lesbian could lead to a Service member’s discharge from the service. I, along with many of my colleagues, learned how to “code” such issues in a way that conveyed the message without spelling things out. Equally importantly I learned how to get relevant information from patients by asking the right questions and using inclusive language. I remember once doing an interview together with a psychology intern, who asked a patient if she was married or had a boyfriend. The patient said no, so the intern checked “no” for relationship status. Then I asked the patient if she was in a relationship, and the patient said yes. I asked where he or she was, and the patient replied, “She is in the Navy too”. The whole case changed from that point. I was reminded then how important it was to keep our own assumptions in check and to always use precise and inclusive language in a way that allows for all possibilities.
In 2010, Don’t Ask, Don’t Tell was officially repealed, allowing gay, lesbian and bisexual Service members to serve openly in the military. I remember clearly a fellow Navy Psychologist coming out as gay in one of our meetings days later and how proud I was to have witnessed history.
Shortly after, one of the Navy psychology interns I supervised had a patient who was biologically male, but identified as a female. The patient came to mental health because she felt trapped in her body as well as in the military. At the time, this patient would have been diagnosed with Gender Identity Disorder, but such a diagnosis would have ended her career in the Navy and she didn’t want that, so we called it an Adjustment Disorder. Neither the intern, nor I had any prior experience working with transgender patients so we tried to do as much research as possible because referring her out to civilian mental health services wasn’t an option. In the end, all our research efforts turned out to be more of an academic exercise, as the patient was stationed on a ship that often went out to sea and her attendance in therapy was very spotty. Before long she was transferred away and we never heard from her again. Her inability to receive mental health services on a consistent basis is a typical challenge faced by active duty Service members seeking or needing mental health care, especially those with conditions they do not wish to disclose to their commands.
In 2013, when the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders was published, Gender Identity Disorder ceased to exist and a new diagnosis, Gender Dysphoria, was added. This was a very important change, recognizing that a person doesn’t have a mental illness just because his/her gender identity does not match sex assigned at birth. Rather, the distress such a person experiences from the incongruence can cause clinical impairment, making it a diagnosable condition. Being transgender is not a mental health disorder. Not every transgender person has Gender Dysphoria, but those who do can benefit from both psychological and medical/surgical treatments.
In my current job as a clinical psychologist working in an Employee Assistance Program, my first encounter with a transgender patient happened at the beginning of 2015. M was a transwoman in her 40s and came to me stating she needed help to finally accept who she was. She talked about dressing as a girl at age 2, when she still lived in Mexico, and how she quickly learned that it was not acceptable. However, after 40 years, she could no longer hold that part of herself back. She was in her third marriage, and finally opened up to her wife about who she was. She came to therapy because she felt conflicted, guilty, and selfish for wanting to express her true gender identity. I remembered that in the first session, I asked her what name she wanted to be called and what pronoun I should use. That simple question brought tears to her eyes. She replied that she was overwhelmed by the question because of the acceptance it conveyed. I was reminded yet again how powerful words are and how important it is to use impeccable language. After meeting with M for a couple of sessions, I referred her to a psychologist on her insurance panel who listed LGBT issues as one of her specialties. I did so partly because I felt that I didn’t have expertise working with transgender patients, so M would be better served by someone with more experience in this field. Another reason I referred M out was because I work in a program that practices short-term treatments, and I felt that she needed longer-term treatment.
Several months later, I met my second transgender patient, K, who was also a transwoman and a college student. She started secretly dressing as a girl around age 12. She came out to her family about her gender identity at age 19, while in college. In 2014, she entered into therapy, began living full time as a woman, and started hormone therapy. K had been seeing a therapist who specialized with transgender issues for more than a year and was getting both group therapy as well as monthly individual sessions. This therapist wrote a letter to support her effort to get gender reassignment surgery through her health insurance plan. However, the letter was considered insufficient by the plan, leading K to come to our office seeking another letter that would be acceptable.
While working with K, I found out that the therapist she had been seeing was in fact not a trained or licensed mental health professional and thus could not legally provide any kind of documentation. In addition, K had been getting hormone therapy through the black market in Los Angeles, even though hormone therapy should have been a covered service under her health insurance. K told me that she had been seeing an endocrinologist that was on her insurance panel. However, after meeting with this endocrinologist for months, he finally told her that he was not comfortable providing such services. K felt betrayed by this doctor, who saw her month after month, collected money, and did nothing. I was shocked to learn that as someone with good healthcare coverage, there were still considerable barriers for K to receive the services she needed.
Working together with her insurance company, K was referred to another endocrinologist who was willing to manage her hormone therapy, so she no longer had to pay for it on the black market and take unnecessary health risks. I had not had any experience writing support letters for gender reassignment surgery, so I researched the subject. I learned that a growing number of public and commercial health insurance plans in the United States now contain defined benefits covering gender reassignment-related procedures, usually including genital reconstruction surgery, chest reconstruction , breast augmentation, and hysterectomy.
The most significant event that shaped transgender health occurred in May 2014, when the ban on Medicare coverage for gender reassignment surgery was lifted. The ruling by a Department of Health and Human Services (HHS) board was in response to a lawsuit filed on behalf of Denee Mallon, then 74, a transgender woman and Army Veteran from Albuquerque. The Medicare ban was imposed in the 1980s, due to a lack of well controlled long-term studies demonstrating the safety and effectiveness of these surgical procedures. But since then, research has demonstrated that gender reassignment surgery is an effective therapy for some individuals suffering from Gender Dysphoria, with decades-long studies and clinical case reports showing positive results. Now there is agreement among professionals in the field that this is effective treatment. The American Medical Association, the World Professional Association for Transgender Health, the American Psychiatric Association, the American Psychological Association, and the National Association of Social Workers are among the professional medical groups that have endorsed gender reassignment surgery in the last decade. The independent board, whose decisions are binding on HHS, stated that medical studies published over the past three decades showed that the grounds for exclusion of coverage were “not reasonable” anymore and lifted the ban. Medicare never defended its policy, nor did it question the new evidence, which included medical studies provided by several experts in this field as part of the review.
Although Medicare coverage is only for people 65 and older, other insurance plans often take their cues from Medicare on what should be considered a medically necessary covered treatment. As a result, the ruling essentially and significantly expanded options for transgender individuals of all ages. Now gender reassignment surgery is covered by many private insurance plans, as well as Medicaid and the Affordable Care Act.
The health plan K has covers medical services to transgender people according to the guidelines provided by the World Professional Association for Transgender Health. In order for a transgender person to be considered for gender reassignment surgery, including genital reconstructive surgery, two letters from qualified mental health professionals must be submitted. Some of the requirements are:
Since K had met the requirements for gender reassignment surgery as stipulated by her health insurance plan, I was able to provide a letter attesting to this fact. However, since her original therapist was, in fact, not a licensed mental health professional, I referred her to another clinician on her insurance panel to obtain the second letter. While it seemed that this was yet another hurdle for her to clear, K remained optimistic and hopeful that she would be able to complete her transition in the next few months.
Near the end of 2015, months after I referred M out, she came back to see me. She asked that I be her therapist, because the “expert” I had referred her to “pushed” her to transition when she was not ready and she stopped going after a few sessions. She stated that she felt more supported by me because I listened to her experiences and helped her explore her feelings and choices without telling her what to do. I agreed to see her for a few sessions while looking for another therapist for her. After a couple of sessions, M stated that she was now ready to transition because the need to be her true self outweighed anything and everything she could potentially lose by transitioning, such as her spouse and her job. However, she only wanted to have hormone therapy, not gender reassignment surgery out of respect for her wife’s wish. M has been sexually attracted to women all her life, identifies as heterosexual, and has two children. She fears that after having hormone therapy, she will no longer be attracted to women, a fear shared by her wife.
There is a myth that all transgender people are gay, when, in fact, transgender people have the same variance in sexual orientation as cisgender people - people whose gender identify match their biological sex. They can be heterosexual, homosexual, bisexual, asexual, or fall into other non-binary categories. After the transition, some remain attracted to the gender they were attracted to prior to the transition, while others find that the gender they are sexually attracted to changes, as in the case of K. In addition to possibly losing her spouse, M also worries about losing her job. She wonders how her transition will be received by her coworkers, her supervisor, and those she serves at work. Nonetheless, despite her worries and fears, M is absolutely sure that she cannot live the rest of her life being a male when she identifies as a woman.
To help M with her transition via hormone therapy, I referred her to the same endocrinologist who manages K’s hormone therapy. M has only recently started accepting her gender identity and feels isolated from the transgender community, so with K’s consent, I introduced M to K, who is further along in her transition and is willing to share her experiences.
As of now, I continue to manage both K and M’s mental health care. These two patients have taught me a great deal about working with transgender patients. I remember when I was active duty, I didn’t have the luxury to say “This is not my area of expertise, so let me refer you to someone else,” as I may be the only psychologist responsible for thousands of active duty Service members in theater, on a ship or at a remote duty station. Now, while I am no longer in uniform, and theoretically could refer patients to a panel of mental health professionals, I have come to find out that it is not always feasible or in the patients’ best interest to refer them out right away. In short, to serve my patients to the best of my abilities, I had to increase my own competence working with this population.
I recognize my limits and my scope of practice, so I try to educate myself through research, reading, consultation with colleagues, and attending workshops. One thing I have read and heard repeatedly from transgender people is that being transgender is not a choice and the drive to be authentic with one’s self identity, including gender identity, is so strong that nothing they have tried can make it go away. This may be reflected in the higher than usual percentage of transgender people serving in the military. On the surface, it may seem counterintuitive for transgender people to serve in an environment that has little tolerance for deviance, but on the other hand, some transgender people may be drawn into the military to prove to themselves that they are “real men”, a phenomenon termed “flight into hypermasculinity”. This was seen in Kristin Beck’s story “Warrior Princess: A U.S. Navy SEAL’s Journey to Coming Out Transgender”. Kristin served as a SEAL for 20 years with 13 combat deployments and was the ultimate warrior and patriot. Her journey of becoming a transwoman is quite powerful and relevant to those who are currently serving or having served in the military. (For more information, on Kristen Beck, see Holly O’Reilly’s blog entry here (LINKTO: http://deploymentpsych.org/blog/staff-perspective-lady-valor-kristen-bec...))
Not every transgender person wants to transition biologically. Some are content with expressing themselves as the gender they desire without physiological changes while others would like their bodies to match their identified gender. Of those who do want to transition biologically, some may only want to have hormone therapy without surgical transition. While I realize that every transgender case is different, I have learned some general principles. These include: meet the patients where they are, help them be themselves, refer them to resources (including support groups and physicians who can help them), ask questions about their needs, and let them educate me about their experiences. My most important job is to listen for what they need and remind myself that it is never about my agenda. I believe that as long as I continue to do these things, I can be an advocate and an ally to my transgender patients and stay beside them during their long and sometimes difficult journey.
Dr. Hsuehmei Price earned her doctoral degree in clinical psychology from Long Island University. She joined the Navy as an active duty psychologist in 2004. After completing her tour, she worked for the Department of the Navy as a civilian psychologist. In this capacity she ran the mental health clinic at Marine Corps Recruit Depot San Diego. Dr. Price subsequently worked for the Center for Deployment Psychology for about 18 months before becoming the Assistant Training Director for Navy Psychology at Naval Medical Center Portsmouth, supervising Navy psychology interns and postdoctoral fellows.
Dr. Price relocated to California in 2013 and since that time has been employed by the County of Riverside as a clinical psychologist. Her areas of expertise include: relationship issues, crisis intervention, coping with trauma, working with veterans, navigating life transitions and treating mood and anxiety disorders. She utilizes an integrative approach that tailors interventions to the patient's needs.