How to use this website and Developing Positive Outcomes for Public Health Consumers

How to use this website

This entire website is evolving and in living draft form. It will be frequently updated and changed, much the way our understanding of gender will.   It is a start at bringing a variety of information to clinicians. This document cannot replace your own good clinical judgment. Feel free to point out errors, disagreement, confusions through the email address on the side. It can only improve the quality and usability of the website. Please tell me if links do not work.  Thanks.


Finding information

You can click on pages on the left hand side for topics,  or use the “search” function, for instance put in “depression” and each page with the word “depression” will be shown for you to choose from. You can click on webpages and wesites on the right side that are other sources of important information outside of the Transgender Health Services (THS) as well as the SFDPH wensite for Transgender Health Services (THS).

This is a start towards a comprehensive site. For some readers, the information they need is as minimal as “Guidelines in Brief,” and “Why would a surgeon need to know,..” For other people, they can find information about what questions they might consider in a gender assessment or the possible concerns regarding various diagnoses and recovery issues. A reader can simply click on a section they are interested in rather than going through these guidelines in any particular order. In the future, there should be highlighted words that are clickable links.

This website is dedicated to helping clinicians have the information they need in order to complete the necessary mental health assessments for people who require a referral letter to a surgeon associated with the SFDPH. Consumers in public health have distinct psychosocial experiences that increase the likelihood of negative outcomes from medical procedures in general. This will be detailed throughout this document. We all want the best possible outcome.

How do I do an assessment?
When asked about the details of how they do assessments, experienced clinicians had difficulty concretizing what it is that they do.   Their answers were vague; it is very patient-centered and specific; decades of experience informs what they know and what they do. That is not a helpful answer when trying to train less experienced providers. This manual is an attempt to provide some direction and concrete information. The American Counseling Association created a list of competencies[1] which is very helpful, but they do not tell a clinician how to think about the person in front of them and how to proceed with an assessment. The Vancouver guidelines are spectacular, but don’t focus on a public health population moving through our managed care system.

Some clinicians are concerned about the amount of information in the letter. We all want to protect a client’s privacy. Behavioral health information can be very important for a surgeon or an anesthesiologist to adequately care for a patient. Therapists may not realize the implications of various behavioral health issues for peri-operative care and post-operative outcomes. This is more carefully explained in the section Why would a surgeon need to know… and detailed in the Diagnostic section.

Informed consent as a model only works when clients have access to the information and have the ability to understand and respond to that information. Health providers and mental health providers currently have important knowledge to share as well as acknowledging how much we really do not know. We want to reduce the possibility of disappointment with post-operative outcomes and post-operative regret by ensuring that we provide individualized information.  Informed consumers are truly capable of self-determination and acting with autonomy. For details on the challenges and failures of informed consent, see the articles on Informed consent.

The information in this website and the ideas behind the guidelines came from speaking with community groups, transgender, transsexual, and gender non-conforming people, individual clinicians, my own experiences as a clinician and the help of many, many people. There is information that has come from other places and other people and care has been taken to cite all of these folks for the incredible work they have done.

Developing positive outcomes  (briefly covering what is in some of the other sections)

The goal of the Transgender Health Services is to provide holistic care that is not focused on just a single part of an individual. We recognize that the brain, the body and the mind are not separate, they interact and effect each other. For instance, a transgender person who was abused as a child for their gender non-conforming behavior may have mental health problems as well as physical health problems related to chronic cortisol sculpting the brain and changing brain and endocrine behaviors. They may be more likely to develop autoimmune diseases or other inflammatory diseases and have a poorer quality of life. Health affects mental health and lowering their stress and learning new coping skills may improve their quality of life and potentially extend the length of their life. Mental health affects physical health as well. Stress decreases immune functioning, for instance. (There will be a section up soon explain this but for now, look at the CDC Adverse Childhood Events studies.)

Holistic care means we are not reducing people to their gender identity. Just as gender-related care was ignored or dismissed, the psychosocial aspects of an individual’s life should not be minimized or ignored when preparing an individual for a stressful, irreversible, life-changing surgery. In public health we have known for a long time that poor people, isolated people, people mental health issues, homeless and marginally housed people have worse outcomes and tend to have health problems related to minority stress, discrimination, marginalization and abuse. A system of care with decreasing resources and few services is unlikely to create the best possible outcomes, no matter how well-intentioned providers are. Recognition of these contexts means we have to identify unaddressed needs and respond to the individual.

It is incredible and wonderful that transgender people finally have access to this component of medically necessary care. However, like everything else, “equal” access doesn’t guarantee equal outcomes. Well-resourced people with families, partners, homes, jobs that come with private health insurance will do better across the board than under-resourced people. Stress causes the body to under function. It can cause the body to fight itself. It is no wonder that under-resourced people generally have poorer outcomes in the health care system. People with mental health issues generally have poorer outcomes as well. Providers do not have to accept poorer outcomes as a fait accompli Instead publc health providers fight to ensure that poor people, people with mental health issues, and isolated people have outcomes that are acceptable to THEM.

While the issues about outcomes are true for general surgical interventions and our populations, it does not mean that any given individual will have a bad outcome. Public health providers cannot level the playing field. Hopefully, we can scaffold enough so that transgender, transsexual and gender-non-conforming patients have a reasonable shot at a positive outcome from a surgical intervention. We do this through accurate diagnosis, education and psychosocial support. We do this through genuine informed consent. Just as a person needs to know that a medical problem like poorly managed diabetes will effect their possible access to and outcome from surgery or that they need to attempt to stabilize their blood sugar and diet, people need to know about the implications of poorly controlled mental illness or the impact of their homelessness on access and outcomes.

Public health workers want to extend life, improve the quality of life and prevent bad outcomes, decrease the likelihood that an individual will experience overwhelming regret, and ensure that clients are genuinely informed with the research that we have and understand the limitations of that research. If people experience regret, we want them to stay in care and be supported.

Gender is critically important, and only part of an individual’s life. After transition, a person must have a fair chance at longevity and an authentic and happy life. Identifying and decreasing potential peri- and post-operative complications related to mental health or psychosocial needs should be identified, assessed and addressed prior to surgery to give people that opportunity.

THS is attempting to assist public health clients with gender dysphoria who are at higher risk for poor outcomes due to psychosocial issues to have positive post-operative outcomes and improve their overall quality of life. We want clinicians to have whatever information we can provide so they can assist patients to make genuinely informed decisions and to plan for pre, peri, and post-operative care with a focus on keeping the individual as stable as possible throughout. Well-resourced or under-resourced, we want everyone to have the best possible outcome. We are public health and it’s what we do.

2.4.14 last update.

[1] Burnes, T. R., Singh, A. A., Harper, A., Pickering, D. L., Moundas, S., Scofield, T., … & Reicherzer, S. Approved by ALGBTIC Board-September 18, 2009 Approved by American Counseling Association Governing Council-November 7, 2009.

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