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| HBIGDA STANDARDS OF CARE - 1998 (version 5) |
SECTIONS |
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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:
1. to
accurately diagnose the individual's gender disorder;
2. to
accurately diagnose any co-morbid psychiatric conditions and see to
their appropriate treatment;
3. to
counsel the individual about the range of treatment options and their
implications;
4. to
engage in psychotherapy
5. to
ascertain eligibility and readiness for hormone and surgical therapy;
6. to
make formal recommendations to medical and surgical colleagues;
7. to
document their patient's relevant history in a letter of recommendation;
8. to be
a colleague on a team of professionals with interest in the gender
identity disorders;
9. to
educate family members, employers, and institutions about gender
identity disorders;
10. 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:
1. 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.
2.
Specialized training and competence in the assessment of the
DSM-IV/ICD-10 Sexual Disorders (not simply gender identity disorders).
3.
Documented supervised training and competence in psychotherapy.
4.
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.
| Some
of the resources in this section contain differing viewpoints comprising
a variety of authors, committees, and interest groups. Additionally,
some of these materials are delivered in an advisory context, covering
legal, ethical, medical and social issues. These materials do not
necessarily represent the guidelines of TransGenderCare or
the philosophies of our staff. |
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