The new SOC acknowledge that “gender dysphoria” may exist, and may be classified as a mental disorder in order to facilitate access to health care. However, transgender, transsexual, and gender non-conforming individuals are not inherently disordered, and gender dysphoria is not necessarily a life-time diagnosis.

The new SOC clearly state that “reparative therapies” are unethical, affirm the value of harm reduction approaches, and call for health care providers to play a greater role in advocating for increased tolerance and equity, and the elimination of prejudice, discrimination, and stigma.

Another major shift is the tone of the new SOC. The new standards are focused on what health care providers can do to assist transgender individuals with affirming their gender identity, exploring different options for expression of that identity, and making decisions about treatments to alleviate gender dysphoria, rather than what “hoops” transgender individuals need to “jump through” to prove that they are eligible to access treatment. The dreaded term “real life test” or “experience” has been removed, although 12 continuous months of living in a gender role that is congruent with their gender identity is required for genital surgery.

The new SOC also contain key changes in the qualifications of mental health professionals. Assessment of individuals for hormone therapy can be done by a health professional that has appropriate training in behavioural health and is competent to assess gender dysphoria (including family physicians and nurse practitioners), especially when working as part of multi-disciplinary teams. Surgery requires independent assessment by two mental health professionals with a master’s degree or its equivalent in clinical behavioural science.

And in addition to hormonal and surgical treatments and mental health services, the new SOC also address issues related to primary care, gynecologic and urologic care, reproductive options, and voice and communication therapy for transgender people.

The two main objectives of the Bill C-389 are to provide:

1) explicit federal human rights protection on the grounds of gender identity and gender expression; and

2) the availability of greater moral and penal sanction for crimes committed against an individual because of the individual’s gender identity or gender expression.

Contrary to the allegations of some of the Bill’s detractors, the terms gender identity and gender expression are well defined in the medical, psychological, and social science literature, and they have been interpreted by Canadian courts and tribunals with ease and clarity. It is also important to recognize that the provisions of Bill C-389 will not create new or special rights for transgender individuals, and in particular, it will not change the law with respect to washroom use. Rather, its enactment will explicitly confirm the law’s protection of the safety and human dignity of everyone in Canada regardless of gender identity or gender expression. It will also ensure that gender variant people’s right to participate in, and contribute to, Canadian society and economic life are not hampered by ignorance, prejudice, hatred and violence.

WHY THE BILL IS NECESSARY – DISCRIMINATION, HARASSMENT & VIOLENCE BECAUSE OF GENDER IDENTITY & GENDER EXPRESSION

Three notable studies have recently released data/reports that help to quantify and qualify the nature and extent of discrimination, harassment and violence based on gender identity and gender expression: The National Transgender Discrimination Survey (NTDS) conducted by the U.S. National Centre for Transgender Equality, the Egale Canada Human Rights Trust National Climate Survey on Homophobia in Canadian Schools, and the TransPULSE project (a study of the Social Determinants of Health of trans people in Ontario). The data document shocking rates of discrimination and harassment in employment and housing, as well as tremendously high incidence of harassment and violence based on gender identity and gender expression in schools and in the community.

The following NTDS data was presented at our conference in Montreal on May 1st, 2010: A total of 47% of NTDS survey respondents reported that, because they were transgendered, they experienced at least one of the following negative job outcomes: were underemployed (44%), did not get a job they applied for (44%), were denied a promotion (23%), were moved from client contact (20%), or were fired (26%). Additionally, 97% reported negative job experiences, including: harassment (50%), breach of confidentiality (48%), deliberate improper pronoun use (45%), inappropriate questions (41%), forced gender presentation (32%), denial of appropriate bathroom access (22%), physical assault (7%) and sexual assault (6%). These numbers are even more disturbing given the survey respondents’ high rates of education (40% with some college, 27% with college degrees, and 20% with graduate degrees). Additionally, a high percentage of respondents reported having been assaulted or harassed in public places. In school, trans students reported being subjected to harassment, physical assault, or sexual assault not only by other students but, shockingly, by teachers as well. Finally, the negative impacts of discrimination, harassment and violence were reflected in abysmally low levels of income and housing stability.

The statement is as follows:

“The WPATH Board of Directors strongly urges the de-psychopathologisation of gender variance worldwide. The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon which should not be judged as inherently pathological or negative. The psychopathologlisation of gender characteristics and identities reinforces or can prompt stigma, making prejudice and discrimination more likely, rendering transgender and transsexual people more vulnerable to social and legal marginalisation and exclusion, and increasing risks to mental and physical well-being. WPATH urges governmental and medical professional organizations to review their policies and practices to eliminate stigma toward gender-variant people.”

We are aware of significant limitations to their application in Canada which vary from province to province. We do recognize that some clinical practices at CAMH are not in line with current WPATH standards, as is true at other centers across the country. As such, we are looking to develop a national consensus on both the interpretation and approach to local implementation of the WPATH standards.  As we continue our consultation with providers, transgender persons, and community based support agencies across the country, more formal position statements will be forthcoming. Our first CPATH position statement, which addresses the use of diagnoses in the context of gender variance, will be available shortly on our website.

CPATH does not endorse specific hormone or surgical protocols, however we do recommend that clinical providers use the best evidence available when adopting one. See the guidelines available in our resource section.

In Vancouver, Dr. Cameron Bowman works out of a private clinic and day hospital offering a variety of soft tissue procedures including blepharoplasty (eyelid surgery) and facial contouring with injectables (silicone, botx, etc.).  He works with Dr. Donald Fitzpatrick.

In Montreal, Dr. Eric Bensimon who is trained in both plastic and craniofacial surgery provides a wide variety of both bone and soft tissue procedures.  He  works with Dr. Pierre Brassard at the Centre Métropolitain de Chirurgie Plastique where they offer combined FFS and GRS options.

Although these procedures are not covered under any provincial health care plan (that is, patients must pay for both the hospital, anaesthitic, and surgical fees), the total cost is significantly less than many US centres. Both surgeons are  professors at major teaching centres, and their cosmetic work is highly regarded.

The proposed diagnostic criteria will be available on the Website www.dsm5.org, for public comment until April 20, 2010. APA is inviting health professionals, consumers of mental health services, and family members to visit the site to review and comment on the draft criteria.

Jack Drescher: Queer Diagnoses: Parallels and Contrasts in the History of Homosexuality, Gender Variance, and the Diagnostic and Statistical Manual

Heino F. L. Meyer-Bahlburg: From Mental Disorder to Iatrogenic Hypogonadism: Dilemmas in Conceptualizing Gender Identity Variants as Psychiatric Conditions

Peggy T. Cohen-Kettenis (Chair), Friedemann Pfafflin:  The DSM Diagnostic Criteria for Gender Identity Disorder in Adolescents and Adults

Kenneth J. Zucker: The DSM Diagnostic Criteria for Gender Identity Disorder in Children

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Photo: S. Holman

Social worker Catherine White Holman was a pioneer in Vancouver’s Downtown neighbourhoods, bringing health services to the most marginalized people in the city, according to long-time colleague Trevor Corneil. “Catherine was a remarkable person,” said Corneil, a physician at Three Bridges Community Health Centre where Holman was a founding staff member. “I have worked with Catherine for 15 years, since I started out as a resident, and I have seen her help thousands of people.” Holman was among the six people killed when their seaplane crashed soon after takeoff near Saturna Island Sunday November 29th.

Holman was a strong advocate for her clients at the clinic and an activist for the Gay Lesbian Bisexual Transgender community and was openly lesbian. She is survived by her spouse Shaira Holman. “Her marriage was a great celebratory moment for her,” said Corneil. “It was the one time she enjoyed what she always insisted on for her clients, equality.”

Holman was a founding staff member at the Three Bridges clinic and worked on the frontlines of the HIV epidemic when the disease began to spread among IV drug users in the 90s. The clinic employs several physicians, social workers, counsellors and advocates working on a model that combines medical services with a entire suite of mental health and community support services, from counselling to finding a place to live or securing disability benefits and finding childcare. She wrote the book, literally, on best practices in the care of GLBT patients, when she penned Guidelines for Transgender Care and Care of Transgender Adolescents, which describe standards and practices for care used by medical professionals all over the world.

“I wouldn’t use the word driven to describe her,” Three Bridges mental health counsellor Margaret Drewlo. “She was more joyous high energy.” Working with her was great, a privilege,” Drewlo said. “When she was at work she was totally at work and when she was off work she was having huge fun in the other part of her life.” “She lived big and she loved big,” said Drewlo. “She was always so expressive of her love for her partner, Shaira,” she said.

Holman was an instructor at the University of British Columbia, teaching medical students social work practices. Wednesday would have been her last class of the term.

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Catherine White Holman will be greatly missed by CPATH: Letter from Board