Health Editor’s Note: In June of 2011, the Veterans Health Administration (VHA) issued a Directive to establish a policy for delivery of healthcare to transgender and intersex veterans who were registered in the Department of Veterans Affairs (VA) healthcare system or was eligible for VA care. The main gist of this Directive was to set an example for providers in both the private and public healthcare sectors that would be respectful and would also secure equal access for transgender veterans

The new directive was to accomplish several things:

All VA staff was to provide care to transgender veterans without any discrimination

All personal information about transgender status and medical care would be kept confidential

States that under existing regulations, sex reassignment surgery cannot be performed or paid for by the VA

States that all other medically necessary healthcare for transgender veterans is covered, including sex-specific care such as pap smears, mammograms, mental health services, and transition related care, such as hormone therapy.

Since the Directive was issued by the Veterans Health Administration (VHA) which oversees mental and medical healthcare for military veterans, there was no authority to change policies for CHAMPVA or TRICARE programs. The Directive applies to military veterans, not active duty members or dependents of active duty, retired, or veteran service members. TRICARE and CHAMPVA have different sets of rules than the VHA. TRICARE, of course, is the healthcare program run by the DOD that serves retired and active duty members of the uniformed services and their dependents. CHAMPVA does the same for retired members of the military.

The existing sex reassignment surgery exclusion applies to actual surgical procedures, but does not bar VA facilities from giving pre- and post-operative care or evaluations. The VA will not pay for or perform sex reassignment surgery.

In the 2016 VA Impact Analysis, the VA was planning to continue it previous policy, to not cover sex reassignment surgery, because there was the assumption, on the part of the VA, that surgical treatments were not medically necessary. The VA also gave the excuse that surgical treatment for gender dysphoria could lead to suicide. Any sane person would understand that if one feels like a male person and is in female body or vice versa, that would lead to immense emotional issues that could cause someone to feel so out of control of his or her life that he or she thinks about ending his or her life. Feeling hopeless since you cannot have surgery. I believe there is another reason why the VA does not want to cover the expenses for sex reassignment surgery. The VA does not want to spend money on its veterans.

I did look at the approximate actual costs of sex reassignment surgeries. These surgeries on the average run about $140,450 from male to female and $124,400 from female to male. This involves surgery and alterations for the face, upper body, and bottom.

Gender dysphoria is a real medical issue whether the person is a veteran or not. Gender dysphoria is the distress a person has as a result of the gender he or she was given at birth, well actually at fertilization of the egg that made the embryo that became this person. The assigned sex does not match how the person identifies him or herself. He or she feels that his or her gender does not meet his or her biological makeup…male or female.

What the VA needed to say/explain/prevaricate about, in its various missives on sex reassignment for a veteran, is that it is too costly. The VA does not want to spend money on veterans. The VA will not address stem cell repairs for various body issues. These are done all the time outside the VA. You can be told by a VA doctor that stem cell treatments do not work, when there is clearly proof that they do. Again, the cost would be more than the VA would want to spend on a veteran. You can even by an older veteran….say 60 or so and the VA will not do dental implants for you since they deem that you will not live long enough to enjoy a mouth full of usable teeth.

Until the VA is willing to use its allotted monies to actually treat veterans for whatever illnesses or diseases veterans have, there will be the continual denial of various services to the veterans. Services that are readily available and commonly performed in the regular healthcare world. A veteran is supposed to be able to receive “free” healthcare, not unlike members of congress receive. Congress a health care package that comes with the “job.” Jumping through VA healthcare hoops at the VA, receiving poor care, such as inadequate physical therapy and pain management, the run around for receiving appointments and treatments, and often receiving the short end of the healthcare stick in the process, is enough to make any veteran contemplate the idea that the VA is just waiting for him or her to die. The VA does not think the veteran is worth the cost of healthcare, any and all healthcare that a veteran needs or requires to live a life worth living. Shame on them!……Carol

Brownley leads 83 bipartisan members of Congress to Call on VA to End Ban on Medically Necessary Treatments for Transgender Veterans

Washington, D.C. – Today, 83 bipartisan Members of Congress, led by Congresswoman Julia Brownley (D-CA), called on the U.S. Department of Veterans Affairs (VA) to end its ban on medically necessary treatments for our country’s transgender veterans. Currently, the VA bans certain medically prescribed procedures to treat gender dysphoria. The VA, through a recent request for comment, is seeking to justify this ban based on antiquated and discriminatory claims that these treatments can lead to suicidal thoughts. In fact, peer-reviewed evidence shows that denying patients access to these procedures can actually increase the risk of suicide.

“More than 160,000 transgender servicemembers have put their lives on the line in order to protect our constitutionally protected freedoms, including the right to live free from discrimination,” said Congresswoman Brownley, Ranking Member of the House Veterans’ Affairs Health Subcommittee. “It is simply unacceptable that we would ask our veterans to risk their lives to protect our rights but we would refuse to defend theirs in return. The VA must put an end to this discriminatory and outdated ban on treatments for gender dysphoria and ensure that all our nation’s veterans have access to the healthcare they have earned.”

“VA’s prohibition on surgical treatment for veterans experiencing gender dysphoria is not only discriminatory on its face, it also puts the health and well-being of transgender veterans at risk. Let me be clear: denying any veteran the medical treatment they need to live healthy and productive lives is antithetical to VA’s core mission, and to do so based on a prejudiced world-view that disregards scientific consensus is disgraceful. VA should immediately reverse course and provide these veterans the care they deserve. It is the right thing to do,” said Congressman Tim Walz, Ranking Member of the House Veterans’ Affairs Committee.

“One of our government’s most sacred obligations is to support those who have served their country, regardless of their gender identity,” said Charlotte Clymer, the Human Rights Campaign’s Press Secretary for Rapid Response. “The Department of Veterans Affairs’ exclusion of many forms of transition-related health care flies in the face of every major medical authority and undermines the health and wellbeing of transgender patriots who have laid their lives on the line for this country and their families. We are grateful to Representative Brownley for her leadership on this critical issue, and thank all the Members of Congress who signed onto this letter to support transgender veterans like myself.”

“We thank Representative Brownley and Members of Congress who are calling on the VA to do the right thing by veterans. No eligible veteran should be denied the health care they have earned and that medical professionals say they need. Standing between veterans and their care would be nothing less than a moral failure,” said Mara Keisling, Executive Director of the National Center for Transgender Equality.

The letter, which is supported by the Human Rights Campaign, the National Center for Transgender Equality, Equality California, and the Palm Center, was signed by Reps. Julia Brownley (D-CA), Tim Walz (D-MN), Salud O. Carbajal (D-CA), Mark Takano (D-CA), Andre Carson (D-IN), Yvette D. Clarke (D-NY), Mark DeSaulnier (D-CA), Mike Quigley (D-IL), Nanette Barragán (D-CA), Raúl M. Grijalva (D-AZ), Eleanor Holmes Norton (D-DC-AL), Pramila Jayapal (D-WA), Joseph P. Kennedy III (D-MA), Alan Lowenthal (D-CA), Michelle Lujan Grisham (D-NM), Sean Patrick Maloney (D-NY), Chellie Pingree (D-ME), Jackie Speier (D-CA), Peter Welch (D-VT), Barbara Lee (D-CA), Nydia M. Velázquez (D-NY), Anthony G. Brown (D-MD), Daniel T. Kildee (D-MI), Alcee L. Hastings (D-FL), Dina Titus (D-NV), Niki Tsongas (D-MA), Jared Polis (D-CO), Susan Davis (D-CA), Danny K. Davis (D-IL), Earl Blumenauer (D-OR), Scott H. Peters (D-CA), Tim Ryan (D-OH), Kathleen M. Rice (D-NY), Elizabeth H. Esty (D-CT), Zoe Lofgren (D-CA), Jan Schakowsky (D-IL), Bill Foster (D-IL), Ted W. Lieu (D-CA), Lucille Roybal-Allard (D-CA), Jerrold Nadler (D-NY), Bonnie Watson-Coleman (D-NJ), A. Donald McEachin (D-VA), J. Lou Correa (D-CA), Debbie Wasserman Schultz (D-FL), Gwen Moore (D-WI), Robert A. Brady (D-PA), Darren Soto (D-FL), Colleen Hanabusa (D-HI), Adriano Espaillat (D-NY), Mark Pocan (D-WI), Jamie Raskin (D-MD), Judy Chu (D-CA), Ann McLane Kuster (D-NH), Adam B. Schiff (D-CA), José E. Serrano (D-NY), Diana DeGette (D-CO), Jimmy Panetta (D-CA), David Cicilline (D-RI), Suzan DelBene (D-WA), Frederica S. Wilson (D-FL), Donald M. Payne, Jr. (D-NJ), Jared Huffman (D-CA), Albio Sires (D-NJ), Peter A. DeFazio (D-OR), Keith Ellison (D-MN), Charlie Crist (D-FL), David E. Price (D-NC), John Yarmuth (D-KY), Karen Bass (D-CA), Suzanne Bonamici (D-OR), Ileana Ros-Lehtinen (R-FL), William R. Keating (D-MA), Paul D. Tonko (D-NY), Donald Norcross (D-NJ), Henry C. “Hank” Johnson, Jr. (D-GA), Frank Pallone, Jr. (D-NJ), Eliot L. Engel (D-NY), Ruben Kihuen (D-NV), Grace Meng (D-NY), Lois Frankel (D-FL), Eric Swalwell (D-CA), Ruben Gallego (D-AZ), and Katherine Clark (D-MA).

Letter to the Secretary of U.S. Department of Affairs The Honorable Robert Wilkie Secretary U.S. Department of Veterans Affairs 810 Vermont Avenue SE Washington, DC 20420 RE: Notice of Petition for Rulemaking and Request for Comments – Exclusion of Gender Alterations from the Medical Benefits Package Dear Secretary Wilkie: Our country has made a sacred commitment to care for those who have borne the battle, and that includes the more than 163,000 transgender veterans[1] who have served their country in uniform. We urge the U.S. Department of Veterans Affairs (VA) to provide our nation’s transgender veterans, all medically necessary treatments prescribed by a veterans’ physician, including medically necessary procedures to treat gender dysphoria. The VA itself explained in a 2016 Impact Analysis that the exclusion for “gender alterations” was originally based on an assumption that surgical treatments were not medically necessary, but it agreed that “surgical procedures are now widely accepted in the medical community as medically necessary treatment for gender dysphoria.”[2] Indeed, there is an overwhelming international consensus that medical treatments, including surgical treatments, are safe, effective, and medically necessary when clinically indicated to alleviate gender dysphoria. Leading medical associations agree that such treatment should be a covered benefit in programs such as the VA.[3] America’s leading medical and mental health organizations, including the American Medical Association, the American Academy of Nursing, the American College of Physicians, the American Medical Student Association, and the American Nurses Association, have argued against the VA’s current ban on covering surgical treatment for gender dysphoria. They maintain that proper treatment of gender dysphoria, as determined between a patient and physician on a case-by-case basis, can include surgical treatment. These experts warned that by prohibiting VA physicians from recommending and providing this medically necessary care, the VA was contradicting established standards of care and placing transgender veterans at “substantially greater risk of serious physical and emotional trauma.”[4] The VA, in its request for comment, is attempting to justify a continued ban on surgical treatment for gender dysphoria because it could lead to suicide and suicidal ideation among veterans. In particular, the VA cites the February 2018 Department of Defense report on “Military Service by Transgender Individuals” to suggest that there is “considerable scientific uncertainty” on the efficacy of medical treatments for gender dysphoria. This report was widely refuted by medical experts, who criticized its mischaracterization of the scientific consensus on the effectiveness of medical treatments for gender dysphoria.[5] In fact, evidence shows that denying patients access to this medically-recommended procedure can increase risk of suicide. As the medical community notes in their brief: “When not properly treated, gender dysphoria can result in clinically significant psychological distress, dysfunction, debilitating depression, and, for some people, self-mutilation, thoughts of and attempts at suicide, and death.” [6] This broad medical consensus on the treatment of gender dysphoria is based on decades of peer-reviewed studies and clinical observation—including studies of veterans—that demonstrate its efficacy and substantial health benefits. Studies have found that access to medical treatment, including surgical treatments when clinically indicated, substantially contribute to decreasing rates of suicidal ideation and behavior,[7] including among transgender veterans.[8] Additionally, numerous studies have found that access to these treatments is associated with substantial improvements in other measures of mental health closely tied to suicidality, including anxiety and depression.[9] Our nation’s veterans have put their lives on the line to defend our freedoms, including the right to equality and to protection from discrimination. That our nation would ask our veterans to protect rights that we would not afford them in return is unacceptable. It is wrong to single out any group of veterans to deny access to medically necessary care. While transgender veterans represent a small percentage of the overall veteran population, transgender Americans are twice as likely to be veterans than the general US population.[10] By excluding medically necessary treatments from its medical benefits package, the VA hurts transgender veterans who have served their country, harming their health and in some cases putting their lives at risk. Simply put, the VA has an obligation to provide the necessary care that is prescribed to enrolled veterans by their health care practitioners. It is unconscionable to deny veterans the same access to health care services that civilians receive in the private sector, and that is available to Medicare beneficiaries and federal workers, simply because of outdated and unscientific prejudice against their gender identity. As Members of Congress, we have repeatedly declared our commitment to caring for our veterans who have risked their lives to protect our essential freedoms. In providing this coverage through the Veterans Health Administration we affirm this commitment, ensuring our veterans will not have to face insurmountable debts and continued distress to realize their gender identity. Thank you for your attention to this important matter. Sincerely, [1] Janelle Downing, Conron, Herman, and Blosnich, Transgender and Cisgender US Veterans Have Few Health Differences, (July 2018) https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.0027 2 VHA Chief Financial Officer, Impact Analysis for RIN 2900-AP69, Removing Gender Alterations Restriction from the Medical Benefits Package. (July 24, 2016) 3 World Prof. Ass’n for Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. (7th ed.2011) https://www.wpath.org/publications/soc; Wylie C. Hembree, Endocrine Treatment of Gender- Dysphoric/ Gender- Incongruent Persons: An Endocrine Society Clinical Practice Guideline. (2017) 102 The Journal of Clinical Endocrinology and Metabolism 3869; Am. Medical Association, AMA Policies on GLBT Issues, Patient Centered Policy H-185.950, Removing Financial Barriers to Care for Transgender Patients. (2008) http://www.tgender.net/taw/ama_resolutions.pdf; Am. Psychiatric Association, Position Statement on Discrimination Against Transgender and Gender Variant Individuals. (2012) http://www.dhcs.ca.gov/services/MH/Documents/2013_04_AC_06d_APA_ps2012_Transgen_Disc.pdf;Am. Psychological Association, Policy on Transgender, Gender Identity and Gender Expression Non-Discrimination. (2008) http://www.apa.org/about/policy/transgender.aspx; Am. College of Physicians, Lesbian, Gay, Bisexual and Transgender Health Disparities: A Policy Position Paper from the American College of Physicians. (2012). https://www.aafp.org/dam/AAFP/documents/about_us/special_constituencies/2012RCAR_Advocacy.pdf;American College of Obstetricians and Gynecologists, Committee Opinion No. 512: Health Care for Transgender Individuals. (2011) https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Health-Care-for-Transgender-Individuals; 4 Brief for Medical and Mental Health Professionals. et al. as Amici Curiae Supporting Petitioners, Dee Fulcher, Giuliano Silva, and the Transgender American Veterans Associations vs. Secretary of Veterans Affairs 5 American Medical Association, Letter to Secretary Mattis. (April 3 2018) https://www.politico.com/f/?id=00000162-927c-d2e5-ade3-d37e69760000; American Psychiatric Association, APA Reiterates Its Strong Opposition to Ban of Transgender Americans from Serving in U.S. Military. (March 24 2018)https://www.psychiatry.org/newsroom/news-releases/apa-reiterates-its-strong-opposition-to-ban-of-transgender-americans-from-serving-in-u-s-military; American Psychological Association, APA Statement Regarding Transgender Individuals Serving in Military. (March 26 2018) http://www.apa.org/news/press/releases/2018/03/transgender-military.aspx; Palm Center, Six Former Surgeons General Rebut Pentagon Assertions About Medical Fitness of Transgender Troops. (April 25 2018) https://www.palmcenter.org/six-former-surgeons-general-%E2%80%8Brebut-pentagon-assertions-about-medical-fitness-of-transgender-troops 6 Brief for Medical and Mental Health Professionals. et al. as Amici Curiae Supporting Petitioners, Dee Fulcher, Giuliano Silva, and the Transgender American Veterans Associations vs. Secretary of Veterans Affairs, Pursuant to 38 U.S.C. § 502 (2017)(No. 17-1460). The Public Policy Research Portal Cornell University, What does the scholarly research say about the effect of gender transition on transgender wellbeing? (2018) https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people;G Bauer, J. Pyne, M. Francino, T, R. Hammond, Suicidality among trans people in Ontario: Implications for social work and social justice. (2013) Service social (59)1, 35-62; L Bailey, S Ellis, J McNeil, Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt. (2014) The Mental Health Review, 19(4)209-220; G De Cuypere, E Elaut, G Heylens, G Maele, V Selvaggi, Long term follow- up: Psychosocial outcome of Belgain transsexuals after sex reassignment surgery. (2006) Sexologies 15(2)126-133; C Imbimbo, P Verze, A Palmieri, N Longo, F Fusco, D Arcaniolo, V Mirone, A report from a single institute’s 14 year experience in treatment of male to female transsexuals. (2009) The Journal of Sexual Medicine, 6(10) 2736-2745; G Bauer, R Scheim, A I Pyne, J Travers, R Hammond, Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada (2015) BMC Public Health 15(1)1-15 8 Tucker, R. P., Testa, R. J., Simpson, T. L., Shipherd, J. C., Blosnich, J., & Lehavot, K. Hormone therapy, gender affirmation surgery, and their association with recent suicidal ideation and depressive symptoms in transgender veterans. (2018) https://doi.org/10.1017/S0033291717003853 9 C Dhejne, R Van Vlerken, G Heylens, J Arceleus, Mental health and gender dysphoria: a review of the literature. (2016) International Review of Psychiatric; HM Murad, BM Elamin, ZM Garcia, JR Mullan, A Murad, PJ Erwin, VM Montori, Homronal therapy and sex reassignment: A systematic review and meta-analysis of the quality of life and psychosocial outcomes. (2010) Clinical Endocrinology https://www.ncbi.nlm.nih.gov/pubmed/19473181; A de Vries, J McGuire, T. Steensma, E Wagenaar, T Doreleijers, P Cohen- Kettenis, Young adult psychological outcome after puberty suppression and gender reassignment. (2014). http://pediatrics.aappublications.org/content/early/2014/09/02/peds.2013-2958; S Davis, S Colton-Meier, Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female to male transgender people. (2014) https://www.tandfonline.com/doi/abs/10.1080/19317611.2013.833152; R Weigert, E Frison, Q Sessiecq, K Al Mutairi, V Casoli, Patient satisfaction with breasts and psychosocial, sexual and physical wellbeing after breast augmentation in male to female transsexuals. (2013) Plastic and Reconstructive Surgery, 132(6), 1421–1429; L. Schmidt and R Levine, Psychological outcomes and reproductive issues among gender dysphoric individuals (2015). Endocrinology and Metabolism Clinics of North America 44(4), 773-785. 10 Sandy E. James, The Report of the 2015 U.S. Transgender Survey 167. (2016), www.ustranssurvey.org/report. [1] Janelle Downing, Conron, Herman, and Blosnich, Transgender and Cisgender US Veterans Have Few Health Differences, (July 2018) https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.0027 [2] VHA Chief Financial Officer, Impact Analysis for RIN 2900-AP69, Removing Gender Alterations Restriction from the Medical Benefits Package. (July 24, 2016) [3] World Prof. Ass’n for Transgender Health, Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. (7th ed.2011) https://www.wpath.org/publications/soc; Wylie C. Hembree, Endocrine Treatment of Gender- Dysphoric/ Gender- Incongruent Persons: An Endocrine Society Clinical Practice Guideline. (2017) 102 The Journal of Clinical Endocrinology and Metabolism 3869; Am. Medical Association, AMA Policies on GLBT Issues, Patient Centered Policy H-185.950, Removing Financial Barriers to Care for Transgender Patients. (2008) http://www.tgender.net/taw/ama_resolutions.pdf; Am. Psychiatric Association, Position Statement on Discrimination Against Transgender and Gender Variant Individuals. (2012) http://www.dhcs.ca.gov/services/MH/Documents/2013_04_AC_06d_APA_ps2012_Transgen_Disc.pdf;Am. Psychological Association, Policy on Transgender, Gender Identity and Gender Expression Non-Discrimination. (2008) http://www.apa.org/about/policy/transgender.aspx; Am. College of Physicians, Lesbian, Gay, Bisexual and Transgender Health Disparities: A Policy Position Paper from the American College of Physicians. (2012). https://www.aafp.org/dam/AAFP/documents/about_us/special_constituencies/2012RCAR_Advocacy.pdf;American College of Obstetricians and Gynecologists, Committee Opinion No. 512: Health Care for Transgender Individuals. (2011) https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Health-Care-for-Transgender-Individuals; [4] Brief for Medical and Mental Health Professionals. et al. as Amici Curiae Supporting Petitioners, Dee Fulcher, Giuliano Silva, and the Transgender American Veterans Associations vs. Secretary of Veterans Affairs [5] American Medical Association, Letter to Secretary Mattis. (April 3 2018) https://www.politico.com/f/?id=00000162-927c-d2e5-ade3-d37e69760000; American Psychiatric Association, APA Reiterates Its Strong Opposition to Ban of Transgender Americans from Serving in U.S. Military. (March 24 2018)https://www.psychiatry.org/newsroom/news-releases/apa-reiterates-its-strong-opposition-to-ban-of-transgender-americans-from-serving-in-u-s-military; American Psychological Association, APA Statement Regarding Transgender Individuals Serving in Military. (March 26 2018) http://www.apa.org/news/press/releases/2018/03/transgender-military.aspx; Palm Center, Six Former Surgeons General Rebut Pentagon Assertions About Medical Fitness of Transgender Troops. (April 25 2018) https://www.palmcenter.org/six-former-surgeons-general-%E2%80%8Brebut-pentagon-assertions-about-medical-fitness-of-transgender-troops [6] Brief for Medical and Mental Health Professionals. et al. as Amici Curiae Supporting Petitioners, Dee Fulcher, Giuliano Silva, and the Transgender American Veterans Associations vs. Secretary of Veterans Affairs, Pursuant to 38 U.S.C. § 502 (2017)(No. 17-1460). [7]. The Public Policy Research Portal Cornell University, What does the scholarly research say about the effect of gender transition on transgender wellbeing? (2018) https://whatweknow.inequality.cornell.edu/topics/lgbt-equality/what-does-the-scholarly-research-say-about-the-well-being-of-transgender-people;G Bauer, J. Pyne, M. Francino, T, R. Hammond, Suicidality among trans people in Ontario: Implications for social work and social justice. (2013) Service social (59)1, 35-62; L Bailey, S Ellis, J McNeil, Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt. (2014) The Mental Health Review, 19(4)209-220; G De Cuypere, E Elaut, G Heylens, G Maele, V Selvaggi, Long term follow- up: Psychosocial outcome of Belgain transsexuals after sex reassignment surgery. (2006) Sexologies 15(2)126-133; C Imbimbo, P Verze, A Palmieri, N Longo, F Fusco, D Arcaniolo, V Mirone, A report from a single institute’s 14 year experience in treatment of male to female transsexuals. (2009) The Journal of Sexual Medicine, 6(10) 2736-2745; G Bauer, R Scheim, A I Pyne, J Travers, R Hammond, Intervenable factors associated with suicide risk in transgender persons: a respondent driven sampling study in Ontario, Canada (2015) BMC Public Health 15(1)1-15 [8] Tucker, R. P., Testa, R. J., Simpson, T. L., Shipherd, J. C., Blosnich, J., & Lehavot, K. Hormone therapy, gender affirmation surgery, and their association with recent suicidal ideation and depressive symptoms in transgender veterans. (2018) https://doi.org/10.1017/S0033291717003853 [9] C Dhejne, R Van Vlerken, G Heylens, J Arceleus, Mental health and gender dysphoria: a review of the literature. (2016) International Review of Psychiatric; HM Murad, BM Elamin, ZM Garcia, JR Mullan, A Murad, PJ Erwin, VM Montori, Homronal therapy and sex reassignment: A systematic review and meta-analysis of the quality of life and psychosocial outcomes. (2010) Clinical Endocrinology https://www.ncbi.nlm.nih.gov/pubmed/19473181; A de Vries, J McGuire, T. Steensma, E Wagenaar, T Doreleijers, P Cohen- Kettenis, Young adult psychological outcome after puberty suppression and gender reassignment. (2014). http://pediatrics.aappublications.org/content/early/2014/09/02/peds.2013-2958; S Davis, S Colton-Meier, Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female to male transgender people. (2014) https://www.tandfonline.com/doi/abs/10.1080/19317611.2013.833152; R Weigert, E Frison, Q Sessiecq, K Al Mutairi, V Casoli, Patient satisfaction with breasts and psychosocial, sexual and physical wellbeing after breast augmentation in male to female transsexuals. (2013) Plastic and Reconstructive Surgery, 132(6), 1421–1429; L. Schmidt and R Levine, Psychological outcomes and reproductive issues among gender dysphoric individuals (2015). Endocrinology and Metabolism Clinics of North America 44(4), 773-785. [10] Sandy E. James, The Report of the 2015 U.S. Transgender Survey 167. (2016), www.ustranssurvey.org/report.

Biography Biography Carol Duff, MSN, BA, RN



She has traveled extensively, is a photographer, and writes on medical issues. Carol has three children RJ, Katherine, and Stephen – two daughters-in-law; Suzy and Katie – two granddaughters; Isabella Marianna and Zoe Olivia – and one grandson, Alexander Paul. She also shares her life with husband Gordon Duff, many cats, and two rescue pups.



Carol’s Archives 2009-2013 Carol graduated from Riverside White Cross School of Nursing in Columbus, Ohio and received her diploma as a registered nurse. She attended Bowling Green State University where she received a Bachelor of Arts Degree in History and Literature. She attended the University of Toledo, College of Nursing, and received a Master’s of Nursing Science Degree as an Educator.She has traveled extensively, is a photographer, and writes on medical issues. Carol has three children RJ, Katherine, and Stephen – two daughters-in-law; Suzy and Katie – two granddaughters; Isabella Marianna and Zoe Olivia – and one grandson, Alexander Paul. She also shares her life with husband Gordon Duff, many cats, and two rescue pups.