Transcript Did You Hear About Cait? - Society for Adolescent Health and

SAHM 2015
Pr omoti ng Health Thr oughout#SAHM16
Adolescence and Young Adulthood
Youth
i n Context:
Annual
Meeting
SAHM 2016 Annual Meeti
ng
Embracing
Transitions:
Interactions Among Adolescents,
Environments, and Healthcare
Synaptiv (CME provider) asks all individuals involved in the development and
presentation of Continuing Medical Education (CME) activities to disclose all
relationships with commercial interests. This information is disclosed to CME activity
participants. Synaptiv has procedures to resolve apparent conflicts of interest. In
addition, presenters are asked to disclose when any discussion of unapproved use of
pharmaceuticals and devices is being discussed.
Dr. Steever, Dr. Oransky and Dr. Barangan have no
commercial relationships to disclose.
The use of the medications discussed in this talk are
considered off-label use.
™
Jointly sponsored by SynAptiv and the Society
for Adolescent Health and Medicine (SAHM)
SAHM 2016
“Did You Hear About Cait?:
A Primer for Adolescent
Transgender Care”
John B. Steever, MD
Matthew Oransky, PhD
(Veenod Chulani, MD, FSAHM)
Caroline J. Barangan, MD
Becoming Cait
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Video
http://mashable.com/2015/08/31/transgender-teensfuture/
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Concerns and Barriers
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Objectives
• Describe the initial evaluation of an adolescent seeking
transgender care, including medical and mental health care
•
Describe feminizing and masculinizing hormone therapy
protocols, including contraindications, initiation, and ongoing
monitoring and management
•
Discuss issues associated with the care of transgender
adolescents, including parental consent and involvement,
surgical body modification, and insurance/ reimbursement
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Background
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Sexual Orientation
Sexual Attraction
Sexual Behavior
Paradigm of
Sexuality
Biological Sex
Gender
Identity/Expressn
Definitions
•
Sex – classification made based on anatomic or biological markers.
• assumed to be binary, HOWEVER: 2% of infants born with intersex condition
•
Gender Identity - internal/personal sense of being male or female
•
Transgender – umbrella term referring to individual whose gender identity does
not match sex assigned at birth.
•
Cis-gender – someone whose gender identity matches assigned sex
•
Gender Expression – How one manifests or outwardly expresses their masculinity
or femininity (e.g., dress, hair, behaviors, mannerisms)
• Often conforms with gender identity, but NOT ALWAYS
Definitions
•
Trans-Male – a transgender person who was assigned female
at birth but whose gender identity is that of a man
•
Trans-Female – a transgender person who was assigned
female at birth but whose gender identity is that of a woman
Definitions
•
Non-Binary Gender – a gender identity that doesn’t fit w/in the gender
binary.
• I’m not a boy but not quite a girl. I’d feel more myself if I was
somewhat more feminine, but I like my dangadoo.
•
Gender Fluid – a gender identity which varies over time. A gender fluid
person may, at any time, identify as male, female or non-binary, or some
combination of identities
•
Genderqueer – a person who does not subscribe to conventional gender
distinctions but identifies with neither, both or a combination of male
and female genders
Awareness of Gender Identity
Between ages 1 and 2
—Conscious of physical differences
between sexes
At 3 years old
—Can label themselves as girl or boy
By age 4
—Gender identity stable
—Recognize gender constant
Gender Play
All pre-pubertal children play with gender expression
& roles
▫ Passing interest or trying out gender-typical behaviors
▫ Interests related to other/opposite sex
▫ Few days, weeks, months, years
Gender Nonconforming Youth
Persistent, consistent, insistent
•
•
•
Cross gender expression, role playing
Wanting other gender body/parts
Not liking one’s gender & body (gender
dysphoria)
Who to Screen?
•
All children
• Developmental stages
•
Non-conforming expression
•
Concerns/problems with
• Mood
• Behavior
• Social
Integrated Trans* Service
•
Primary/reproductive healthcare •
•
Health education
•
Psychological testing
•
Evaluation for medical
•
Legal Advocacy
intervention
•
Support Group
•
Hormone therapy
•
Individual therapy
•
Family therapy
Mental Health/ Psychiatry services
Mental Health
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Psychosocial Needs
Trans* youth have higher rates of
• Discrimination
•Homelessness
• Victimization
•Poor Access to Health Care
• Family Rejection
• Social Isolation
•School Problems related to
victimization
• Peer Harassment and Violence
•Commercial Sex Work
Mental Health Needs
Trans* youth have higher rates of
•
Depression
•
Low Self-Esteem
•
Anxiety
•
Non Suicidal Self-Harm
•
Trauma
•
Substance Use
•
Sexual Risk Behaviors
Research has found
that 30-50% of
transgender youth
report a past suicide
attempt
(e.g., MA Dept of Ed, 2006; Dean et al., 2000)
Why Support
for Trans*
Youth
Matters
Travers, Bauer,
Pyne, &
Bradley, 2012;
TSER
Kid Friendly Gender Screening
Gender Dysphoria DSM V
Gender Incongruence (in Adolescents or Adults)
1.
A marked incongruence between one’s experienced/expressed gender
and assigned gender, of at least 6 months duration, as manifested by 2:







a marked incongruence between one’s experienced/expressed gender and primary and/or
secondary sex characteristics (or, in young adolescents, the anticipated secondary sex
characteristics)
a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked
incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to
prevent the development of the anticipated secondary sex characteristics)
a strong desire for the primary and/or secondary sex characteristics of the other gender
a strong desire to be of the other gender (or some alternative gender different from one’s assigned
gender)
a strong desire to be treated as the other gender (or some alternative gender different from one’s
assigned gender)
a strong conviction that one has the typical feelings and reactions of the other gender (or some
alternative gender different from one’s assigned gender)
Gender Dysphoria DSM V
2. The condition is associated with clinically significant distress or impairment in social, school, or
other important areas of functioning.
3. Subtypes
1. With a disorder of sex development
2. Without a disorder of sex development
4. Specifier: Posttransition (If the individual has transitioned to full-time living in desired gender
(with or without legalization of gender change) and has undergone (or is preparing to have) at
least one cross-sex medical procedure or treatment regimen - namely regular cross-sex hormone
treatment or gender reassignment surgery confirming the desired gender (e.g.,
penectomy, vaginoplasty in a natal male, mastectomy or phalloplasty in a natal female).
5. DSM NOTES that adolescent or adult-onset gender dysphoria exists
Addressing Parents’ Questions
Behaviors & expression may non-conform,
but children can still feel that they are in right body
Family acceptance, love, support critical
All children are at risk for crisis when their true sense of identity is
discouraged &/or punished
Will they change their mind?
6-39% of children with gender dysphoria persist until
adolescence/adulthood
• Factors associated with persistence:
•
•
•
•
Intensity and consistency of gender dysphoria
Having gender dysphoria in childhood
Attempts to socially transition
Being assigned female at birth
Factors Associated with Persistence:
•
THINK and FEEL you are the other gender VERSUS
WISHING you are the other gender
•
Puberty and the anticipation of body changes
generates distress and increasing dysphoria
•
May see increased depression/anxiety/social
withdrawal, etc. around puberty
Gender Dysphoria Through Development
• Study on 70 gender dysphoric adolescents w/ gender
dysphoria at 12 and started cross-hormone therapy at
16. (de Vries, 2010)
• Surveyed them after age 18.
• Behavioral and emotional symptoms decreased
• General functioning improved
• No adolescents withdrew from cross-gender medical
treatments or said they regretted it
Therapeutic Approaches
• Historical Approach
• Pathologizing and reparative: CBT therapy directed at
reducing GNC behaviors and blaming parents.
• Outcomes: did not show much influence on gender
identity or sexual orientation. Did not alleviate
distress. Was harmful
• Therapist in gatekeeper role: GNC individuals used to
have to align themselves with the gender binary and
prove that they wanted to be at the other end of the
spectrum to receive treatment.
Current Approaches
• Evidenced Based Affirmative Approach (EBAA) and the
Multi-Dimensional Family Approach (Malpas, 2011)
• Research indicates that affirming one’s gender identity in
combination with medical transition reduces psych distress
• Some medical providers are using the informed consent
model along with WPATH guidelines, but mostly for > 18
• At AHC we see individuals as young as 10 years old so we
feel we need more than just informed consent
Gender Evaluation
1. Meet criteria for diagnosis of Gender Dysphoria?
2. Understand insistence, persistence, consistency of gender
identification
• Utrecht Gender Dysphoria Scale
• Body Image Scale
• Recalled Childhood Gender Identity Scale
• AHC’s Gender Assessment Interview Tool
• Assess ability to give informed consent
AHC’s Gender Assessment Interview
•
Semi-Structured interview assessing:
•
Current Gender Identification and Expression
•
Early Awareness and Family Context
•
School and Work Context
•
Sexual Development
•
Current Intimate Relationship(s)
•
Future Plans⁄ Expectations
Informed Consent
•
Can the individual give informed consent to hormones?
• Full understanding of medical risks and benefits
• Review consent forms with pt.
• Realistic expectations regarding changes that will occur w/ hormones
• Review outline of physical changes
• Note that we cannot control how each individual will react to
hormones
• Realistic expectations regarding social/emotional consequences
• Hormones may not be a “magic fix”
• Contraindications to this understanding?
• Intellectual disability, psychosis, autism
Components of Ongoing Individual Therapy
•
Help navigating medical and social transition
• Pacing and problem solving around social transition
• Managing expectations
• Dealing with social issues/consequences
• Intervening in youth’s various contexts if necessary (e.g.,
school)
•
Address ongoing comorbid mental health issues and
psychosocial stressors
Social Transition
Different for every individual, but may include:
•
•
Change dress
Change pronouns
•
Name Change (social and legal)
•
Changing voice (with or without voice therapy)
•
•
Using different bathrooms
Coming out/disclosure to friends, family, romantic partners, school personnel and/or
strangers
Passing or going stealth vs. being read or being clocked
•
Binder - packer
•
Bodyshaper – corset – gaff
Can be the first step in transitioning (although some wait to physically
transition)
Challenges
Family Context!!
• Whose on board? Parents? Siblings? School?
• Parents often have their own grieving process and anxiety about the
future
• Managing desired pace of child vs. parents
• Parental dilemmas
• How to support my child’s authentic self while also making sure
he/she is socially accepted and safe?
• How I can I affirm current embodiment while remaining flexile
about the future?
• What does it mean for me as a parent or a person?
• Is it my fault??
• Who around me will be supportive or will judge? (Malpas, 2011)
Challenges
•
Individuals that have always felt gender dysphoria (since age 2-3)
vs. individuals that start feeling dysphoria during puberty or much
later
•
Binary versus non-binary identities
•
Internet Use: Source of support and information but also need to
exercise precaution (loneliness can make people more vulnerable)
Challenges – Family Rejection
Patient is 18yo Bengali trans female who faced serious rejection upon
coming out to family. Therapeutic interventions aimed to promote
acceptance among family were unsuccessful. Patient is extremely
depressed.

Therapist helps connect patient to other supports (e.g., support group at AHC;
community resources that are supportive of trans youth)

Phases of transition are considered in context of family support and potential
consequences (e.g., getting kicked out)

Benefits of “being oneself” are weighed in relation to dangers of physical changes
Medical Care
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Treatment Goals
Improve quality of life by
•
Facilitating transition to physical state that more closely
represents the individual’s sense of self
•
Experience puberty congruent with gender
•
Prevent unwanted secondary sex characteristics
• Reduce need for future medical , surgical interventions
•
Avoid depression, risk taking
•
Establish early, strong social support
Phases of Transitioning
Reversible
• clothes, hair, shoes, toys,
GnRH analogues
Partially
reversible
• masculinizing & feminizing
hormone therapy
Irreversible
• gender reassignment surgery
(GRS)
Benefits of “Blockers”
•
Gonadotropin Releasing Hormone (GnRH) analogues block puberty
• Leuprolide
• Histrelin
•
Delay irreversible 2
ndary
sex characteristics
• Allow time for teen to mature & make decision
• Allow time for parent & social support to develop
• Prevent unwanted secondary sex characteristics
• Reduces needs for future medical interventions
GnRH Analogues
•
Continuous GnRH secretion
• Suppress FSH, LH
• Initial ↑ LH, FSH followed by desensitized pituitary
• LH FSH secretion suppressed
•
Leuprorelin, Triptorelin, & Goserelin
• Monthly & 3-monthly depot preparations
Histrelin implant
• 12 month
• Typically not covered by insurance
•
Dosing GnRH Analogues
Select dosing schedule
• Monthly depot SQ or IM
• Range 3.75, 7.5, 11.5 mg
• 3-monthly long-acting 11.25 mg IM
Counseling & Consent
• Few side effects aside from injection pain,
withdrawal bleed if menarchal
• Expect to see some “ effects” in 2-4 week range
Phases of Transitioning
Reversible
• clothes, hair, shoes, toys, GnRH
analogues
Partially
reversible
• masculinizing & feminizing
hormone therapy
Irreversible
• gender confirmation/affirmation
surgery (GCS/GAS)
Beginning Hormonal Treatment
•
Establish commitment to next steps
•
•
•
•
Gender incongruency
Readiness for transition
Expectations, goals
Management plan
•
Obtain informed consent
•
Order baseline labs
•
Establish follow up
Letter from
mental health
professional
Feminizing Hormones
• Estrogens - induce development female
ndary
2
sexual characteristics
• Anti-androgen treatment reduce effect of
endogenous male sex hormones
• Spironolactone
• Use if no contraindications (renal disease, ↑ K)
Estrogen
•
Estradiol
• Oral or Sublingual 2–8 mg/day
• Patch 0.1–0.4 mg twice weekly
•
Estradiol cypionate or valerate inj
• 5–20 mg IM q 2 wks
•
Premarin not recommended
Estrogen
Effect
redistribution of body fat
decresed muscle mass
softening of skin
decreased libido
decreased spontaneous erections
breast growth
decreased testicular volume
decreased sperm production
decreased terminal hair growth
Onset (months) Maximum (years)
3 to 6
3 to 6
3 to 6
1 to 3
1 to 3
3 to 6
3 to 6
unknown
6 to 12
2 to 3
1 to 2
unknown
3 to 6
3 to 6
2 to 3
2 to 3
>3
>3
Effects of Feminizing Hormones
•
Varies from patient to patient
•
Noticeable changes within 4 weeks
•
Reversible effects prior to 6 months
•
Effects continue at decreasing rate for < 2 years
•
Post orchiectomy “spurt” of breast growth & feminization
• Decrease estrogen dose needed
Risks of Feminizing Hormones
• Complete risks are unknown
• Most studies performed in biological women
• Limited research regarding risks
• Mortality not necessarily increased
• FDA all administration off-label
• More research in the pipeline
Risks of Feminizing Hormones
•
Vasc thrombotic events
•
•
Increased Weight
•
•
Decreased Libido
•
Erectile dysfunction
•
Liver dysfunction
•
TG ↑ (pancreatitis)
•
HDL ↑ LDL ↓
•
Increased BP
•
•
Glucose intolerance
Gall bladder disease
Pituitary adenoma
Breast cancer (3 cases)
Anti-androgens
↑K
↓ BP
Progesterone
•
No good data in transgender
women
•
Induced an “inflammatory” state
in male bodied persons when
tried as male birth control
•
Weight gain, “tubular breasts”
Other Feminizing Adjuncts
• Anti-androgens
• Spironolactone 50–100 mg PO BID
• Finasteride 2–5 mg PO QD
• Cosmetics
• Eflornithine (Vaniqua), laser, electrolysis
Baseline Labs
Feminizing Hormone Therapy




CBC
LFTs
Lipids
Chem 10
 Estrogen
 Testosterone
 Prolactin
If before or using
estradiol
•AST
•Prolactin
•? T or E
If spironolactone
•Potassium
Lab Follow-Up
for Feminizing Hormone Therapy
Q 3 months 1-2 years
• Test according to need
• Testosterone level at 1 yr
•
Goal < 55 ng/dl
• Estradiol
• If concerns re overuse
• Goal ‘average female levels”
• K (Cr)
• If spironolactone
Goals
Dosing & labs by
Generate desired
effects
Avoid side effects
Average natal levels
Testosterone
•
Multiple dosing regimens
•
Oil based testosterone for injection
• Cypionate or enanthate
• SQ 50–100 mg SQ weekly
• Decreased peaks/troughs, side effects
• IM 50-100 mg weekly or 100-200 mg every other week
Masculinizing Hormones
• Other forms
• Transdermal androderm 2.5–10 mg daily
• Androgel 2.5–5 mg packets with dosing
50–100 mg daily
• Topical testosterone to clitoris will not increase size
• Progestins may be used short term to stop menses
Testosterone
Effect
skin/ acne
facial/ body hair
scalp hair loss
increased muscle mass
fat redistribution
cessation of menses
clitoral enlargement
vaginal atrophy
deepening of voice
Onset (months) Maximum (years)
1 to 6
6 to 12
6 to 12
6 to 12
1 to 6
2 to 6
3 to 6
3 to 6
6 to 12
1 to 2
4 to 5
2 to 5
2 to 5
1 to 2
1 to 2
1 to 2
Risks of Masculinizing Hormones

Weight increase

Mood changes

Liver dysfunction

TG ↑ HDL ↓ LDL ↑

Insulin resistance

Increased homocysteine

Polycythemia

Male pattern baldness

Possible pelvic pain
Management of Side Effects of Masculinizing Hormones
• Rogaine to treat pattern baldness
• Estrogen vaginal cream for atrophy
• Retinoids for acne
• Progestin for menses
• Spotting may occur for several months followed
by amenorrhea
Initial Lab Testing for Masculinizing Hormone Therapy





CBC
LFTs
Lipids
Cr, Glucose
Testosterone
If using T
•AST
•Hb
•Testosterone total
•Lipids
Lab Follow-Up
for Masculinizing Hormone Therapy
•
Q 3 months 1-2 years
•
Test according to need
Goals
Dosing & labs by
•
Testosterone level at 1 yr
• Goal 300-750 ng/dl
Generate desired
effects
•
•
•
CBC
Liver function tests
Lipids
Avoid side effects
Average natal levels
Phases of Transitioning
Reversible
• clothes, hair, shoes, toys, GnRH
analogues
Partially
reversible
• masculinizing & feminizing
hormone therapy
Irreversible
• gender confirmation/affirmation
surgery (GCS/GAS)
Surgical Options for Trans-men
• Male chest construction
• Different technique than mastectomy or implants
• Hysteroopherectomy
• Phalloplasty /metoidioplasty
• No function without pump
• Rarely covered by health insurance
• Performed by specialized surgeons
Surgical Options for Trans-women
•
Breast implants
•
Orchiectomy/penectomy
•
Vaginoplasty
•
Facial feminizing
•
Vocal cord surgery
•
Plastic surgery (waist, hip, buttocks)
•
Rib removal (11–12)
Health Care for Trans-men
• Emotional well being
•
• Instructions in self breast
exam
• STI testing
• Including HIV
• PCOS
• Mammography
•
• Glucose testing
• Fertility
• Contraception
Breast cancer screening
Pap cancer screening
• Atrophy looks like dysplasia
•
? Dexa scans
• Testosterone > 5 yrs
• Age > 50
Health Care for Trans-women
• Emotional well-being
•
• Self breast exam
• STI testing, prevention
• Mammography 10+
years or age 50
• Including HIV testing
• Fertility considerations
• Sperm/embryo banking
• Contraception
Breast cancer screening
•
Additional screenings,
limited evidence
• ?Prostate screening for
older patients
• ?”pap” – screen HPV
Contraception
•
Trans-men have some pregnancy risk
• Testosterone not fail-safe contraceptive
• May continue to ovulate while on testosterone
• Testosterone may adversely affect development of fetus
• Consider DMPA, LARC, & barrier methods
•
Avoid assumptions about future children
• Do you want to be pregnant or have genetic children?
Challenges
•
Insurance/ Reimbursement
•
Medicaid to start paying for surgeries
•
Medicaid covering cross gender hormones
•
Poor universal coverage for GnRH analogs
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Take Home Points
•
Screening for gender issues, like sexual health concerns,
important throughout life span
•
Mental health & support important
•
Promoting family support is essential
•
Medical management of treatment, including
hormones, is safer than self prescribing
•
STI & other health care maintenance continue
Summary
Transgender youth are a unique population to work with and
deserve the same high quality medical care that all teens
deserve. They are just like every other adolescent, but with a
twist.
Tool Box
•
PPT
•
Reasons to Support Trans Youth
•
Genderbread Person
•
General Mental Health Clearance Letter
•
Short Mental Health Clearance Letter
•
Informed Consent - Testosterone
•
Informed Consent – Estrogen
•
Physicians for Reproductive Health
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Contact Information
[email protected]
[email protected]
[email protected]
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