Sex reassignment surgery

Sex reassignment surgery (SRS), also known as gender reassignment surgery (GRS) and several other names, is a surgical procedure (or procedures) by which a transgender person's physical appearance and function of their existing sexual characteristics are altered to resemble those socially associated with their identified gender. It is part of a treatment for gender dysphoria in transgender people.

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Professional medical organizations have established Standards of Care that apply before someone can apply for and receive reassignment surgery, including psychological evaluation, and a period of real-life experience living in the desired gender.

Feminization surgeries are surgeries that result in anatomy that is typically gendered female. These surgeries include vaginoplasty, feminizing augmentation mammoplasty, orchiectomy, facial feminization surgery, reduction thyrochondroplasty (tracheal shave), and voice feminization surgery among others.

Masculinization surgeries are surgeries that result in anatomy that is typically gendered male. These surgeries include chest masculinization surgery (top surgery), metoidioplasty, phalloplasty, scrotoplasty, and hysterectomy.

In addition to SRS, patients may need to follow a lifelong course of masculinizing or feminizing hormone replacement therapy.

Terminology

There are numerous other expressions that are used to refer to this type of surgery apart from sexual reassignment surgery and gender reassignment surgery. The American Society of Plastic Surgeons (ASPS) uses the term gender confirmation surgery or GCS.[1][2] Other terms include gender-affirming surgery, sex change operation, genital reconstruction surgery, sex realignment surgery,[3] and sex reconstruction surgery.

Some transgender people who desire medical assistance to transition from one sex to another identify as transsexual.[4][5] A trans woman assigned male at birth and seeking feminizing surgery may have one or more of the procedures used for trans women, which go by various names, such as feminizing genitoplasty, penectomy, orchiectomy, or vaginoplasty. A trans man assigned female at birth and seeking masculinizing surgery may undergo one or more procedures, which may include masculinizing genitoplasty, metoidioplasty or phalloplasty.

History

The goal of early transition surgeries was the removal of hormone-producing organs (such as the testicles and the ovaries) in order to reduce their masculinizing or feminizing effects. Later, as surgical technique became more complex, the goal became to produce functional sex organs from sex organs that are already present in the patient.

In the US in 1917, Dr. Alan L. Hart, an American tuberculosis specialist, becomes one of the first female-to-male transsexuals to undergo hysterectomy and gonadectomy for the relief of gender dysphoria.[6]

In Berlin in 1931, Dora Richter, became the first known transgender woman to undergo the vaginoplasty[7] surgical approach.

This was followed by Lili Elbe in Dresden during 1930–1931. She started with the removal of her original sex organs, the operation supervised by Dr. Magnus Hirschfeld. Lili went on to have four more subsequent operations that included an orchiectomy, an ovary transplant, a penectomy, and ultimately an unsuccessful uterine transplant, the rejection of which resulted in death. An earlier known recipient of this was Magnus Hirschfeld's housekeeper,[8] but their identity is unclear at this time.

In 1951, Dr. Harold Gillies, a plastic surgeon active in World War II, worked to develop the first technique for female-to-male SRS, producing a technique that has become a modern standard, called phalloplasty.[9] Phalloplasty is a cosmetic procedure that produces a visual penis out of grafted tissue from the patient.

Following phalloplasty, in 1999, the procedure for metoidioplasty was developed for female-to-male surgical transition by Drs. Lebovic and Laub.[10] Considered a variant of phalloplasty, metoidioplasty works to create a penis out of the patient's present clitoris. This allows the patient to have a sensation-perceiving penis head.[10] Metoidioplasty may be used in conjunction with phalloplasty to produce a larger, more "cis-appearing" penis in multiple stages.[10]

On 12 June 2003, the European Court of Human Rights ruled in favor of Van Kück, a German trans woman whose insurance company denied her reimbursement for sex reassignment surgery as well as hormone replacement therapy. The legal arguments related to the Article 6 of the European Convention on Human Rights as well as the Article 8. This affair is referred to as Van Kück vs Germany.[11]

In 2011, Christiane Völling won the first successful case brought by an intersex person against a surgeon for non-consensual surgical intervention described by the International Commission of Jurists as "an example of an individual who was subjected to sex reassignment surgery without full knowledge or consent".[12]

As of 2017, some European countries require forced sterilization for the legal recognition of sex reassignment.[13]

The early history of sex reassignment surgery in transgender people has been reviewed by various authors.[14][15]

Prior to surgery

Medical considerations

Some transgender persons present with health conditions including diabetes, asthma, and HIV, which can lead to complications with future therapy and pharmacologic management.[16] Typical SRS procedures involve complex medication regimens, including hormonal therapy, throughout and after surgery. Typically, a patient's treatment involves a healthcare team consisting of a variety of providers including endocrinologists, whom the surgeon may consult when determining if the patient is physically fit for surgery.[17][18] Health providers including pharmacists can play a role in maintaining safe and cost-effective regimens, providing patient education, and addressing other health issues including smoking cessation and weight loss.[19]

People with HIV or hepatitis C may have difficulty finding a surgeon able to perform successful surgery. Many surgeons operate in small private clinics that cannot treat potential complications in these populations. Some surgeons charge higher fees for HIV and hepatitis C-positive patients; other medical professionals assert that it is unethical to deny surgical or hormonal treatments to transgender people solely on the basis of their HIV or hepatitis status.[20]

Other health conditions such as diabetes, abnormal blood clotting, ostomies, and obesity do not usually present a problem to experienced surgeons. The conditions do increase the anesthetic risk and the rate of post-operative complications. Surgeons may require overweight patients to reduce their weight before surgery, any patients to refrain from hormone replacement before surgery, and smoking patients to refrain from smoking before and after surgery. Surgeons commonly stipulate the latter regardless of the type of operation.

Fertility is also a factor considered in SRS, as patients are typically informed that if an orchiectomy or oöphoro-hysterectomy is performed, it will make them irreversibly infertile.[17]

Ethical considerations

At birth
Main article: Sex assignment § Assignment in cases of infants with intersex traits, or cases of trauma

SRS does not refer to surgery performed on infants with differences in sex development (intersex).[21] Infants born with intersex conditions might undergo interventions at or close to birth.[22] This is controversial because of the human rights implications.[23][24]

Minors

Sex reassignment surgery performed on unconsenting minors (babies and children) may result in catastrophic outcomes (including PTSD and suicide—such as in the David Reimer case, following a botched circumcision) when the individual's sexual identity (determined by neuroanatomical brain wiring) is discrepant with the surgical reassignment previously imposed.[25][26][27] Milton Diamond at the John A. Burns School of Medicine, University of Hawaii recommended that physicians do not perform surgery on children until they are old enough to give informed consent and to assign such infants in the gender to which they will probably best adjust. Diamond believed introducing children to others with differences of sex development could help remove shame and stigma. Diamond considered the intersex condition as a difference of sex development, not as a disorder.[28][29]

Standards of care
See also: Transgender rights

Sex reassignment surgery can be difficult to obtain due to financial barriers, insurance coverage, and lack of providers. An increasing number of surgeons are now training to perform such surgeries. In many regions, an individual's pursuit of SRS is often governed, or at least guided, by documents called Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (SOC). The most widespread SOC in this field is published and frequently revised by the World Professional Association for Transgender Health (WPATH, formerly the Harry Benjamin International Gender Dysphoria Association or HBIGDA). Many jurisdictions and medical boards in the United States and other countries recognize the WPATH Standards of Care for the treatment of transgender individuals. Some treatment may require a minimum duration of psychological evaluation and living as a member of the target gender full-time, sometimes called the real life experience (RLE) (sometimes mistakenly referred to as the real life test (RLT)) before sex reassignment surgeries are covered by insurance.

Standards of Care usually give certain very specific "minimum" requirements as guidelines for progressing with treatment, causing them to be highly controversial and often maligned documents among transgender patients seeking surgery. Alternative local standards of care exist, such as in the Netherlands, Germany, and Italy. Much of the criticism surrounding the WPATH/HBIGDA-SOC applies to these as well, and some of these SOCs (mostly European SOC) are actually based on much older versions of the WPATH-SOC. Other SOCs are entirely independent of the WPATH. The criteria of many of those SOCs are stricter than the latest revision of the WPATH-SOC. Many qualified surgeons in North America and many in Europe adhere almost unswervingly to the WPATH-SOC or other SOCs. However, in the United States many experienced surgeons are able to apply the WPATH SOC in ways which respond to an individual's medical circumstances, as is consistent with the SOC.

Many surgeons require two letters of recommendation for sex reassignment surgery. At least one of these letters must be from a mental health professional experienced in diagnosing gender identity disorder (now recognized as gender dysphoria), who has known the patient for over a year. Letters must state that sex reassignment surgery is the correct course of treatment for the patient.[30][31]

Many medical professionals and numerous professional associations have stated that surgical interventions should not be required in order for transsexual individuals to change sex designation on identity documents.[32] However, depending on the legal requirements of many jurisdictions, transsexual and transgender people are often unable to change the listing of their sex in public records unless they can furnish a physician's letter attesting that sex reassignment surgery has been performed. In some jurisdictions legal gender change is prohibited in any circumstances, even after genital or other surgery or treatment.

Insurance

A growing number of public and commercial health insurance plans in the United States now contain defined benefits covering sex reassignment-related procedures, usually including genital reconstruction surgery (MTF and FTM), chest reconstruction (FTM), breast augmentation (MTF), and hysterectomy (FTM).[33] In order for patients to qualify for insurance coverage, certain insurance plans may require proof of the following:

  • a written initial assessment by a qualified licensed mental health professional
  • persistent, well-documented gender dysphoria
  • months of prior physician-supervised hormone therapy

In June 2008, the American Medical Association (AMA) House of Delegates stated that the denial to patients with gender dysphoria or otherwise covered benefits represents discrimination, and that the AMA supports "public and private health insurance coverage for treatment for gender dysphoria as recommended by the patient's physician."[34] Other organizations have issued similar statements, including WPATH,[35] the American Psychological Association,[36] and the National Association of Social Workers.[37]

In 2017, the United States Defense Health Agency for the first time approved payment for sex reassignment surgery for an active-duty U.S. military service member. The patient, an infantry soldier who identifies as a woman, had already begun a course of treatment for gender reassignment. The procedure, which the treating doctor deemed medically necessary, was performed on November 14 at a private hospital, since U.S. military hospitals lack the requisite surgical expertise.[38]

Surgical procedures
Main articles: Sex reassignment surgery (male-to-female) and Sex reassignment surgery (female-to-male)

Bottom surgery

The array of medically indicated surgeries differs between trans women (male to female) and trans men (female to male). For trans women, genital reconstruction usually involves the surgical construction of a vagina, by means of penile inversion or the sigmoid colon neovagina technique; or, more recently, non-penile inversion techniques that make use of scrotal tissue to construct the vaginal canal. For trans men, genital reconstruction may involve construction of a penis through either phalloplasty or metoidioplasty. For both trans women and trans men, genital surgery may also involve other medically necessary ancillary procedures, such as orchiectomy, penectomy, mastectomy or vaginectomy. Complications of penile inversion vaginoplasty are mostly minor; however, rectoneovaginal fistulas (abnormal connections between the neovagina and the rectum) can occur in about 1–3% of patients. These require additional surgery to correct and are often fixed by colorectal surgeons.[39]

As underscored by WPATH, a medically assisted transition from one sex to another may entail any of a variety of non-genital surgical procedures, any of which are considered "sex reassignment surgery" when performed as part of treatment for gender dysphoria. For trans men, these may include mastectomy (removal of the breasts) and chest reconstruction (the shaping of a male-contoured chest), or hysterectomy and bilateral salpingo-oophorectomy (removal of ovaries and Fallopian tubes). For some trans women, facial feminization surgery, hair implants, and breast augmentation are also aesthetic components of their surgical treatment.[40]

Scope and procedures

The best known of these surgeries are those that reshape the genitals, which are also known as genital reassignment surgery or genital reconstruction surgery (GRS)- or bottom surgery (the latter is named in contrast to top surgery, which is surgery to the breasts; bottom surgery does not refer to surgery on the buttocks in this context). However, the meaning of "sex reassignment surgery" has been clarified by the medical subspecialty organization, the World Professional Association for Transgender Health (WPATH), to include any of a larger number of surgical procedures performed as part of a medical treatment for "gender dysphoria" or "transsexualism". According to WPATH, medically necessary sex reassignment surgeries include "complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation ... including breast prostheses if necessary, genital reconstruction (by various techniques which must be appropriate to each patient ...)... and certain facial plastic reconstruction."[41] In addition, other non-surgical procedures are also considered medically necessary treatments by WPATH, including facial hair electrolysis.[41]

Post-surgical considerations

Quality of life and physical health

Patients of sex reassignment surgery may experience changes in their physical health and quality of life, the side effects of sex steroid treatment. Hence, transgender people should be well informed of these risks before choosing to undergo SRS.[42]

Several studies tried to measure the quality of life and self-perceive physical health using different scales. Overall, transsexual people have rated their self-perceived quality of life as ‘normal’ or ‘quite good’, however, their overall score was still lower than the control group.[43] Another study showed a similar level of quality of life in transsexual individuals and the control group.[44] Nonetheless, a study with long-term data suggested that albeit quality of life of patients 15 years after sex reassignment surgery is similar to controls, their scores in the domains of physical and personal limitations were significantly lower.[42][45] On the other hand, research has found that quality of life of transsexual patients could be enhanced by other variables. For instance, trans men obtained a higher self-perceived health score than women because they had a higher level of testosterone than them. Trans women who had undergone face feminization surgery have reported higher satisfaction in different aspects of their quality of life, including their general physical health.[46]

Psychological and social consequences

After sex reassignment surgery, transsexuals (people who underwent cross-sex hormone therapy and sex reassignment surgery) tend to be less gender dysphoric. They also normally function well both socially and psychologically. Anxiety, depression and hostility levels were lower after sex reassignment surgery.[47] They also tend to score well for self-perceived mental health, which is independent from sexual satisfaction.[48] Many studies have been carried out to investigate satisfaction levels of patients after sex reassignment surgery. In these studies, most of the patients have reported being very happy with the results and very few of the patients have expressed regret for undergoing sex reassignment surgery.[49]

Although studies have suggested that the positive consequences of sex reassignment surgery outweigh the negative consequences,[50] it has been suggested that most studies investigating the outcomes of sex reassignment surgery are flawed as they have only included a small percentage of sex reassignment surgery patients in their studies.[51] These methodological limitations such as lack of double-blind randomized controls, small number of participants due to the rarity of transsexualism, high drop-out rates and low follow-up rates,[52] which would indicate need for continued study.

Persistent regret can occur after sex reassignment surgery. Regret may be due to unresolved gender dysphoria, or a weak and fluctuating sense of identity, and may even lead to suicide.[53] Risk categories for post-operative regret include being older, having characterised personality disorders with personal and social instability, lacking family support, lacking sexual activity, and expressing dissatisfaction with the results of surgery.[54] During the process of sex reassignment surgery, transsexuals may become victims of different social obstacles such as discrimination, prejudice and stigmatising behaviours.[55] The rejection faced by transsexuals is much more severe than what is experienced by LGB individuals.[56] The hostile environment may trigger or worsen internalized transphobia, depression, anxiety and post-traumatic stress.[57]

Many patients perceive the outcome of the surgery as not only medically but also psychologically important. Social support can help them to relate to their minority identity, ascertain their trans identity and reduce minority stress.[55] Therefore, it is suggested that psychological support is crucial for patients after sex reassignment surgery, which helps them feel accepted and have confidence in the outcome of the surgery; also, psychological support will become increasingly important for patients with lengthier sex reassignment surgery process.[55]

Sexuality

Looking specifically at transsexual people's genital sensitivities, trans men and trans women are capable of maintaining their genital sensitivities after SRS. However, these are counted upon the procedures and surgical tricks which are used to preserve the sensitivity. Considering the importance of genital sensitivity in helping transsexual individuals to avoid unnecessary harm or injuries to the genitals, allowing trans men to obtain an erection by inserting a penile implant after phalloplasty,[58] the ability for transsexual to experience erogenous and tactile sensitivity in their reconstructed genitals is one of the essential objectives surgeons want to achieve in SRS.[58][59] Moreover, studies have also found that the critical procedure for genital sensitivity maintenance and achieving orgasms after phalloplasty is to preserve both the clitoris hood and the clitoris underneath the reconstructed phallus.[58][59]

Erogenous sensitivity is measured by the capabilities to reach orgasms in genital sexual activities, like masturbation and intercourse.[58] Many studies reviewed that both trans men and trans women have reported an increase of orgasms in both sexual activities,[48][42] implying the possibilities to maintain or even enhance genital sensitivity after SRS.

The majority of the transsexual individuals have reported enjoying better sex lives and improved sexual satisfaction after sex reassignment surgery.[42] The enhancement of sexual satisfaction was positively related to the satisfaction of new primary sex characteristics.[42] Before undergoing SRS, transsexual patients possessed unwanted sex organs which they were eager to remove. Hence, they were frigid and not enthusiastic about engaging in sexual activity. In consequence, transsexuals individuals who have undergone SRS are more satisfied with their bodies and experienced less stress when participating in sexual activity.[42]

Most of the individuals have reported that they have experienced sexual excitement during sexual activity, including masturbation.[42] The ability to obtain orgasms is positively associated with sexual satisfaction.[48] Frequency and intensity of orgasms are substantially different among transsexual men and transsexual women. Almost all female-to-male individuals have revealed an increase in sexual excitement and are capable of achieving orgasms through sexual activity with a partner or via masturbation,[42][60] whereas only 85% of the male-to-female individuals are able to achieve orgasms after SRS.[61] A study found that both trans men and trans women reported qualitative change in their experience of orgasm. The female-to-male transgender individuals reported that they had been experiencing intensified and stronger excitements while male-to-female individuals have been encountering longer and more gentle feelings.[42]

The rates of masturbation have also changed after sex reassignment surgery for both trans women and trans men. A study reported an overall increase of masturbation frequencies exhibited in most transsexual individuals and 78% of them were able to reach orgasm by masturbation after SRS.[48][42][62] A study showed that there were differences in masturbation frequencies between trans men and trans women, in which female-to-male individuals masturbated more often than male to female[42] The possible reasons for the differences in masturbation frequency could be associated with the surge of libido, which was caused by the testosterone therapies, or the withdrawal of gender dysphoria.[48]

Concerning transsexuals’ expectations for different aspects of their life, the sexual aspects have the lowest level of satisfaction among all other elements (physical, emotional and social levels).[62] When comparing transsexuals with biological individuals of the same gender, trans women had a similar sexual satisfaction to non-trans women, but trans men had a lower level of sexual satisfaction to non-trans men. Moreover, trans men also had a lower sexual satisfaction with their sexual life than trans women.[48]

International

Africa

Morocco: Casablanca, Morocco is notable for being the home of Clinique de Parc, Dr. Georges Burou's clinic for transgender women. Burou is considered one of the pioneers of SRS.[63] A French gynecologist, Burou created the anteriorly pedicled penile skin flap inversion vaginoplasty, still considered the "gold standard" of skin-lined vaginoplasty.[64] He is credited with having performed over 3000 MtF surgeries.[65]

Asia

India: India is offering affordable sex reassignment surgery to a growing number of medical tourists[66] and to the general population.[67]

Iran: The Iranian government's response to homosexuality is to endorse, and fully pay for, sex reassignment surgery.[68][69] The leader of Iran's Islamic Revolution, Ayatollah Ruhollah Khomeini, issued a fatwa declaring sex reassignment surgery permissible for "diagnosed transsexuals".[68] Eshaghian's documentary, Be Like Others, chronicles a number of stories of Iranian gay men who feel transitioning is the only way to avoid further persecution, jail, or execution.[68] The head of Iran's main transsexual organization, Maryam Khatoon Molkara—who convinced Khomeini to issue the fatwa on transsexuality—confirmed that some people who undergo operations are gay rather than transsexual.[70]

Pakistan: In Pakistan, the Council of Islamic Ideology has ruled that SRS contravenes Islamic law as construed by the council.[71] This Pakistani law prevents Hijras from receiving feminizing surgery.

Thailand: Thailand is the country that performs the most sex reassignment surgeries, followed by Iran.[70]

Europe

France: Since 2016, France no longer requires SRS as a condition for a gender change on legal documents.[72][73] In 2017, a case brought earlier by three transgender French people was decided. France was found in violation of the European Convention on Human Rights for requiring the forced sterilization of transgender people seeking to change their gender on legal documents.[74]

Malta: As late as 2010, transgender people that have undergone SRS can change their sex on legal documents.[75]

Spain: Despite a resolution from the European Parliament in 1989 suggesting advanced rights for all European Union citizens, as of 2002 only Andalusia's public health system covers sex reassignment surgery.[76]

Switzerland: In 2010, the Swiss Federal Supreme Court struck down two laws that limited access to SRS. These included requirements of at least 2 years of psychotherapy before health insurance was obligated to cover the cost of SRS[77][78] and inability to procreate.[79]

Ukraine: In 2015, the Administrative District Court of Kiev ruled that forced sterilization was unlawful and no longer required for legal gender change.[80]

North America

Canada: Laws regarding legal recognition of gender identity vary from province to province in Canada with most provinces requiring reassignment surgery for a sex change on legal identification.

The United States of America: Many of the surgeries mentioned in the History section of this article were developed in the United States. Before the legalization of same-sex marriage in the United States, there were several notable Supreme Court cases that did not legally recognize individuals who underwent SRS by invalidating marriages of trans people.[81] Today, many states require SRS as a prerequisite for recognition of a legal sex change on official documents such as passports, birth certificates, or IDs.

Mexico: As of a 2014 law,[82] Mexico City no longer requires SRS for changes of sex on birth certificates, and several states have followed suit.[83]

South America

Argentina: In 2012, Argentina began offering government subsidized total or partial SRS to all persons 18 years of age or older.[84][85][69] Private insurance companies are prohibited from increasing the cost of SRS for their clients. At the same time, the Argentinian government repealed a law that banned SRS without authorization from a judge.[86] Furthermore, it is not required to undergo SRS to change sex on legal documents.[87]

Chile: In 2012, a bill was introduced that stated SRS was no longer a requirement for legal name and sex change.[88]

In 2013, Chile's public health plan was required to cover sex reassignment surgery.[88] The cost is subsidized by the government based on a patient's income.[88]

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See also

References
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  2. "About ASPS". American Society of Plastic Surgeons. Retrieved 2017-08-07.
  3. Harrington, Lee (1 May 2016). Traversing Gender: Understanding Transgender Realities. Mystic Productions Press. p. 287. ISBN 978-1-942733-83-6. OCLC 947837700. Retrieved 15 October 2018.
  4. Thomas E. Bevan, The Psychobiology of Transsexualism and Transgenderism (2014, ISBN 1-4408-3127-0), page 42: "The term transsexual was introduced by Cauldwell (1949) and popularized by Harry Benjamin (1966) [...]. The term transgender was coined by John Oliven (1965) and popularized by various transgender people who pioneered the concept and practice of transgenderism. It is sometimes said that Virginia Prince (1976) popularized the term, but history shows that many transgender people advocated the use of this term much more than Prince."
  5. R Polly, J Nicole, Understanding the transsexual patient: culturally sensitive care in emergency nursing practice, in the Advanced Emergency Nursing Journal (2011): "The use of terminology by transsexual individuals to self-identify varies. As aforementioned, many transsexual individuals prefer the term transgender, or simply trans, as it is more inclusive and carries fewer stigmas. There are some transsexual individuals, however, who reject the term transgender; these individuals view transsexualism as a treatable congenital condition. Following medical and/or surgical transition, they live within the binary as either a man or a woman and may not disclose their transition history."
  6. Munro, Donald. "Trans Media Watch". Retrieved 1 November 2018.
  7. Munro, Donald. "Trans Media Watch". Retrieved 13 June 2016.
  8. Magnus Hirschfeld, Zeitschrift für Sexualwissenschaft, 1908
  9. Roach, Mary (2007-03-18). "The First Man-Made Man - Pagan Kennedy - Books - Review". The New York Times. ISSN 0362-4331. Retrieved 2019-05-05.
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  13. M.H. (1 September 2017). "Why transgender people are being sterilized in some European countries". The Economist. Retrieved 2 September 2017.
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  34. AMA Resolution 122 "Removing Financial Barriers to Care for Transgender Patients". see: http://www.ama-assn.org/ama1/pub/upload/mm/15/digest_of_actions.pdf Archived 2009-03-27 at the Wayback Machine
  35. See WPATH Clarification Statement
  36. APA Policy Statement Transgender, Gender Identity, and Gender Expression Non-Discrimination. See online at: http://www.apa.org/pi/lgbc/policy/transgender.pdf Archived 2009-02-11 at the Wayback Machine
  37. NASW Policy Statement on Transgender and Gender Identity Issues, revised August 2008. See www.socialworkers.org
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