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PROVIDING CARE TO ADOLESCENTS AND YOUNG ADULTS John Steever, MD Mount Sinai Adolescent Health Center

8/19/2020

Providing Care to Transgender Adolescents and Young Adults [video transcript]

00:08 Let's introduce our speaker for today, Dr. John Steever. Dr. Steever, currently he works at the Adolescent Health Center at Mount Sinai Medical Center in Manhattan, New York as an Associate Professor of Pediatrics. Dr. Steever has been providing puberty suppression and cross gender hormones to youth at the Mount Sinai Adolescent Health Center since 2013. His training is focused on providing medical services to high risk youth, including LGBTQ clients and those affected by HIV/AIDS. He has also written several articles on transgender medical care and is a member of the Mount Sinai Center for Transgender Medicine and Surgery. So thank you so much for taking the time to join us today, Dr. Steever. And now I'll let you take it away.

00:50 Great, thank you so much for having me. So again, I'm John Steever. I'm with the Mount Sinai Adolescent Health Center. And we're going to be talking about providing care for transgender adolescents and young adults. So disclosures I have none. Nothing to disclose. Our learning objectives today, we're going to recognize things like assigned sex at birth, gender identity, expression, and sexual orientation and discuss those a bit. We're going to discuss some primary and specialized care that may be needed by transgender adolescents. And we're going to work on explaining about how bias and stigma can create disparities and lead to risk. And we're also going to provide some initial management strategies for the appropriate and competent care for gender nonconforming youth. This talk really has things for, because I recognize there are a variety of disciplines that are watching this, so there'll be stuff for medical folks, for non medical folks, for social workers, for mental health people. And hopefully, this will raise some interest in learning more about some of these things, since by necessity we're only going to get a sort of relatively shallow dive into some of these topics. And as you can tell, many of them you can go a lot deeper on some of these topics.

02:17 So we'll start off with early childhood and pre-pubescent gender development. And we'll start with a case, a case of R, and we're going to talk about pre pubertal gender nonconformity here. So R is an eight year old assigned male at birth child. And during the visit with the physician, R's parents express concern that most of his friends are female, he hates sports, he was caught wearing his older sister's clothes and makeup last week, and he loves to paint his nails. So right off the bat, do you think R's parents should be concerned? And so our answers, our polling question is yes, no, maybe. And so our results are that most people say no, but that's evenly split with maybe. So I will say based so far and what we know right now, that really there's nothing to be concerned so far here. And we'll talk about some of the things that might potentially be concerning, but so far, no.

03:32 So let's take a quick detour into some terminologies, this is probably familiar with most people, but I just kind of want to make sure we're on the same page. So defining gender. So I use this little graphic here, on the right side of the screen, to kind of look at some of the components of

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gender and sexuality. And right now we're going to focus on the left side of that graphic, the gender side, and we have things like assigned sex at birth. So when a baby is born, the obstetrician looks down at the genitals and says, 'this child has a . This is a boy.' And so assigned sex at birth is basically based upon body parts, maybe hormones and biology depending upon if it's not clear from the body parts. And that's assigned sex at birth, sometimes referred to as Natal birth or biologic birth, but really probably the best term is assigned sex at birth. And then we have gender identity. And really, gender identity is the understanding of oneself as female, male, transgender, gender non conforming, gender queer, gender non binary, gender fluid, or cisgender. And this is really a brain thing. So this is how you see yourself in your own head. So if you're a Matrix fan, this is one sense of identity of who you are, how residual self image of how you see yourself. This is a brain thing. And then there's gender expression, and this is the ways in which a person may act, present themselves and communicate around gender within a given culture. So we often talk about individuals who may identify as male, but have as a gender expression, a more feminine expression. And so all of these things assigned sex at birth, gender identity, gender expression, come together and make up how you see yourself, what is your gender identity.

05:32 And then, on the other side, because this case is also going to talk a little bit about sexuality, we want to talk a little about what is sexuality. And so we think of sexual orientation, the sexual concept of oneself, how you see yourself, based on your feelings towards someone else, your attractions and your desires. And there are many terms for this. You know, we have heterosexual, homosexual, lesbian, gay, bisexual, transgender, questioning, queer, pansexual, and asexual, so a lot of these terms as one defines one's orientation are present. And then we also have sexual behaviors. So people who do not necessarily identify as gay or lesbian or bi, but may have certain behaviors that put them into kind of higher risk categories. We have young men who have sex with men, or MSM, and then young women who have sex with other women, WSWs. And so these kind of components, sexual behavior, sexual orientation, and then sexual attraction, which is sort of a catch all for things like crushes and sort of more transient things, these three items come together in sort of helping form and define one's sexuality.

06:55 So when we look at gender more specifically, and we wonder, well, when does somebody become conscious of this? And so Nelson's Textbook of Pediatrics will say that a person becomes aware of their gender very early, so between the ages of one and two, children are conscious of the physical differences between the sexes. By three they can typically label themselves as a boy or girl. And by four, they typically recognize that gender identity is a stable item within themselves, and they recognize that gender is constant. Now this is a little bit put to the test with kids who are transgender, many youth who are gender non conforming or transgender will have that awareness and at a very young age will say, 'I'm a boy or a girl,' despite what they're told by other people, because they understand how they feel. Other children will say, 'I said some of these things as a small kid, but I was so reinforced to base my gender upon my body, so it wasn't until much later that I really understood why that label never really fit myself.' So gender identity is very present very early on.

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08:21 How many adults in the United States identify as LGBT? So this is a slide from the adult literature. Now, I don't really have a very similar slide to small children, because of the developmental nature of children it's harder to do a study and figure out what percentage of five year olds will identify as lesbian, what percentage of five year olds identify as gay and trans. But from the adult world, you can see that about 3.4 to 3.6% of adults will identify as gay or lesbian, and about 0.3% of the population will identify as transgender, and these are from very large studies. So this was from a study when the Affordable Care Act rolled out in Massachusetts, and the study people actually called or attempted to call virtually every adult household in Massachusetts and asked about gender identity. And that's where we got the 0.3% for transgender individuals. One way we might screen for this especially in kids, it's kind of a fun graphic, the Genderbread person. And it really points out some of these things that we've been talking about. So that gender identity is a brain thing. It's how you see yourself. Gender expression is sort of a whole body thing, how you present yourself to the world. Sexuality is attractions, that's sort of a heart thing. And then sex here is sort of the old school version of that definition, but we're really talking about body parts when we talk about sex in this case, so what genitals do you have. And then you can see on the right side, that many of these items really are not a binary thing, male, female, you know, boy, girl, gay, straight, these things are really on a scale. And so you can have a little fun and plot out where you fit on, you know, in your gender identity from sort of non gendered to feminine, where do you fall on a scale of one to 10? Where do you fall on the masculine scale from non gendered to male? Same with gender identity, with biologic sex. And then with attraction, I think people are most familiar with the idea that attraction is not a binary, it's not that you're just attracted to men are just attracted to women, some people are attracted both, and in varying degrees, and some people are not really attracted to anybody. So that's kind of a fun graphic to use sometimes with small children, or kids, and with adults, so you can kind of see how that works.

11:13 So gender play. So again, back to our patient R, one of the concerns the parents had was around this kids play. And I think it really is important to note that all pre pubertal children play with gender roles and expression. And so this is a very normal thing that R does, with wanting to dress up in his sister's clothes, wanting to paint his nails, things like that. And these gender atypical play may be a passing interest, or maybe a more regular, more pervasive interest. And it can last a few days to a few years. And really, I want to emphasize this is a normal part of childhood. So we should not be worried that R is doing this sort of thing. That's one of reasons why the answer to that question of should you be worried is no. So really, I think we want to then come back to R and get a little more information. So talking to R directly, and also talking to his parents, you know, how does the child feel about their gender? And obviously, you have to use words that the family will understand and the patient will understand, but how do they feel about acting more masculine or feminine? You can even go so far as to say, do you sometimes use a different name for yourself? And how do you feel about these concerns? You can ask the kid, what do you think? Is this a problem? Would you want something different? And so when you do that, in this case, R reports that sometimes he wishes he was a girl, but he does prefer the pronouns he and him. And he's more sad that his mother's upset than anything that he feels is wrong with himself. And when pressed, he is a little unsure about what gender he could be, or

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what he would be if he could choose. And basically, he would like to be able to play with some girl things without feeling bad. And so I think these are all really normal reactions. And so what do you think about what are we going to do next? Is this a reassurance issue? Should we continue? I know this is sort of for the medical people, should we look for more lab work and imaging to look for a reason? Check hormone levels, things like that? Do we do nothing? Or do we go gung ho, and like let's encourage the social transition? Let's get him to change his name and all these things? So here's our quick poll, what would you recommend we do next? Right. And the thing that everyone chose for the most part was reassurance. Nothing is also sort of reassuring too. So that's a good close second. I don't think we necessarily need to encourage social transitioning yet, because we don't really know where this person is going. So I would say reassurance is our next thing. And so again, you're just going to explain that gender role and gender expression during childhood development is common. And really, what we are going to do is support R, we're going to let R take the lead and as his brain develops, and as he gets a little bit older, we will see where his gender identity goes. And basically, support from the family is really essential. You can of course offer yourself as a resource, but also be aware of some of the national and local resources things like the Center here in New York. PFLAG is another terrific national organization and there may be other support groups and therapists locally to where you are that you should have some of these numbers and contacts available.

15:10 So one of the things that we're going to kind of keep an eye out with R is when we're talking about somebody who's sort of gender non conforming, is we're going to kind of look at how persistent, consistent, and insistent this is. Does the cross gender expression or role playing continue? Does R start to talk about wanting other gendered body parts to be other genders? Does he started talking about not liking his own body, his own body parts? And maybe he's going to begin to feel that he's somewhere in the middle, he's agendered or non binary, and may begin to sort of refuse to ascribe typical male or female assignments. And these are all things that we're going to keep an eye out for so that we can help him a little bit in the future.

16:02 When you look at, sort of from a pathology based perspective, you're thinking about this diagnosis of gender dysphoria, which is really the marked difference between expressed and experienced gender and the gender that you were assigned. So basically feeling like you're in the wrong body. And the DSM says that this must continue for at least six months. And it must cause clinically significant distress or impairment in social, occupational, or other important functions. So problems in school, problems at work, problems at home. And in children, the desire to be the other gender must be present and verbalized. And that's all in the DSM. Now, that's a pretty heavy duty clinical diagnosis that you have to be upset by this to make this diagnosis. And I sort of prefer a more developmental perspective, and think about gender diversity. So when we think about sexual orientation, or we think about height, we think about weight, we think about skin color, all these things, there is a diversity to it. It's not one or the other. And so this, if you apply this to gender, it makes you realize that gender diversity is normal. Gender is universal, variance is expected. And diversity does not necessarily mean deviance. And if you take it from this developmental perspective, you're going to help improve care, you're going to decrease the impact of minority stress on this patient, you're going to help

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advocate for him, which is sort of another form of reproductive justice. And you're going to advocate, empower basically vulnerable populations. So being patient developmentally centered really does allow for some flexibility in clinical judgment. You don't have to go right to the pathology. And you know, why do I say this? Yes, there is data to support that. So often trans youth are underrepresented in LGBT studies. But the SHINE study of transgender female youth from the Bay Area in 2014, really looked at social supports. And it was noted that with support, family acceptance was associated with protective factors against things like depression, substance abuse, risky sexual behavior, and suicidal attempts and ideation. So even with somebody as young as R, it is very possible to say to the child, 'I love you, I accept you, even if I don't always understand, but let's do this journey together.' And to be protected like that and to be supportive does provide some resilience to our young people.

18:52 All right, so I'd like to shift gears a little bit and get into a little bit about phases of transitioning. So we talked, one of the options earlier in the poll was social transition. And so that is sort of often the first phase of transitioning. And those phases are developed into three parts reversible, partially reversible, and irreversible. You don't have to necessarily go in any particular order, but this is probably one of the more common ways of doing it. So the reversible phases of transition should somebody want to do this of course, it's things like clothing, hair, shoes, toys, and medicines called the GnRH analogs. Lupron is one of the most common of that, it is probably the first of its class though there are several and we'll discuss some specifics later. And then partially reversible items, the masculinizing and feminizing hormone therapy. And then of course, the irreversible things like surgical interventions.

19:53 So, gender and adolescence. So our next case is K, who on first visit was noted to be a 12 year old assigned female at birth brought in by parents for mood and behavior concerns. So again, this kid has come to you from that for those attention issues. And as you explore those concerns, you learn that K does identify as male, and gender expression is very masculine. I think the picture, you know, says 1000 words right there. And K is distressed by puberty, he'd been doing just fine and then all of a sudden at age 12, man, puberty starts to start to creep into his body. And he is really upset by that. And he's not sure what to do. This is a very common story. And then over time K does continue to socially transition. So he's wearing boy clothes bought from the boy sections of the stores, he cuts his hair very short. He uses a masculine name and not the feminine name that he was assigned at birth. But really, when he comes back to you he's now 13 and he's very interested in not having periods, he wants those to go away, because that's probably the biggest source of distress to him. And his parents are very supportive. They want their child to be healthy and happy. But they're also a little, you know, cautious, and don't want to do anything irreversible. And so they want to know what are the options available. So of course, in young adolescence, we're going to start to begin an initial assessment. So establishing privacy is important, you may ask the mom to step out of the room for a little bit, perhaps not necessarily in the first visit. But you also want to start working with the child directly themselves in the context of the family. And then you will have a chance to explain what is and is not confidential. You want to establish trust and rapport, maybe double checking about name and pronouns, asking about the goals that this person has, we already know this for

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this person, they would like to stop their menstrual period. And getting to know the person is important. So a general adolescent health assessment, like the heads exam, is very important. And this may lead into a more detailed and sensitive history.

22:35 What not to do? I think everybody should have a little alone time with the doctor or the health care provider. So never allowing that is is not recommended, we really want to have the kids to have a little bit of private time. Don't assume a name or pronoun. My clinic is very lucky, our intake forms have at the very top, what is the name you use? And what are your pronouns? So we know right away what somebody has requested. And for the kids who are not transgender, the kids often going to understand this. And frankly, you know, people with the name of Joseph who always go by Joe, really appreciate that you've asked what name they would prefer to be used. So they don't find that weird at all. Don't disclose information about the child to the parent without the patient's consent, especially some of the more personal stuff. But obviously, there are limits of confidentiality. And do not dismiss the parents as a source of support. Many families really want the best for their kids, and are just really seeking help for that. And then, of course, the last thing is do not refer to reparative therapy. And for those of you who don't know, reparative therapy is counseling thats goal is to change a person's sexual orientation or gender identity. This is not an acceptable form of counseling or therapy. I think everybody probably knows this, and is in fact illegal to do in minors in several states, including New Jersey, right across the border from us here in New York. So you may have a parent who says, 'Can you can you do something and change them, their life will be so much easier if they're not transgender?' And the answer's no, there is no counseling or therapy that will do that sort of thing.

24:36 You want to review this kid's experience. Tell me your own story in your own words. These are not super short visits. This is going to take a little time. Ask about specific feelings, thoughts, behaviors, preferences. There may be some great stories that the parents can give about early childhood saying, like when was the last time you could get K to actually wear a dress? What happened at that wedding? You know, things like that. What happened with haircuts and things like that? There's some great stories that are out there. You may want to document prior efforts to adopt the desired gender, kids will talk about clothing, makeup, maybe binding their chest to flatten the chest, if they're a little farther along in puberty. And review a patient's goals. So you want to make sure that what we're doing, where we're going, is a reasonable thing. We obviously, of course, before we start any sort of hormonal treatment, we want to talk about establishment of next steps, right? Readiness for transition, goals, expectations, a management plan. So know who your resources are both medical and mental health wise. Informed consent is really important here. Baseline labs, I order baseline labs, most people do. But there are definitely some providers who say that this is not a necessary thing. And so that's something that you can decide, there is no rule that you have to do that. And of course, establishing follow up is always important.

26:10 So, next question. At this point with K, do we need an evaluation? Do we need an evaluation from a mental health expert to establish a gender a diagnosis of gender dysphoria? Whoo,

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50/50 split. Wow, I love this. This is great. That's phenomenal. I would have said that the answer is no. We are not doing anything permanent yet to this kid. And so I don't feel that we have to have a mental health expert weigh in quite yet. Would I like them to start thinking about and making sure they've got mental health expert people to connect to? Absolutely. Because transitioning brings forth its own set of issues that come up. But at the moment, I would have said no, you don't need a mental health expert. That may change, hint, hint later. So right now we're really talking about just the reversible stuff. And one of the big medicines that I think we're going to talk about with this family is the GnRH analogs. And so we're going to try and suppress hormones, FSH and LH, which will suppress estrogen and testosterone production, which will basically stop puberty in its tracks. This is a pause button. And it really is an amazing medicine or set of medicines, really, because there's several variations. Lupron is the most common one that is a brand name, I apologize but it's easy for me to say the one. But for the whole GnRH group, they all work really well and with minimal side effects, and they are all not permanent. They're temporary things. And you can see the Leuprorelin, Triptorelin, Goserelin, are all most commonly used, and there's also an implant. So like for those of you who are aware, there's a birth control implant, a little rod of medicine that goes under the skin. The same thing for this GnRH analog, Histrelin, and small surgical procedure puts it into the skin and provides medicine to block puberty for 24 to 36 months, it works amazingly well. And what are the benefits of doing this? Well, you know, in this case, we're doing something not permanent, okay? And we're also buying some time, I think the parents and the patient, or the parents have also wanted the patient to explore their gender a little bit more to get a better idea about what's going on. So this buys us some time, we're going to block the delay the formation, we're going to block the formation of irreversible secondary sexual characteristics, which will allow time for the teen to mature and help better make the decisions. We will allow time for the parents and social supports to develop and will allow the provider, gives me a little space because I don't want to provide irreversible effects to a minor. Because, you know, the younger the child, potentially the less certain they are. And there's definitely data, though it may not be great data I will give you that, that a certain percentage of younger children who may meet criteria for gender dysphoria will outgrow that. They will desist in their thinking about that. So doing a blocker helps me feel better that I know that we haven't done anything irreversible at a super young age, and it gives time to develop a plan here. What are the risks of the blockers, of course, everything has a risk. There are very few, but of course you having medical visits, and in this time of COVID, a lot of people do not want to go to the doctor. Injections, a little pain, problems at the site. Lab work again, pain, complications from lab draws. An exam, many of these trans kids are very hyper aware about their physical bodies and doing an exam is tough. And you have to be very gentle about how you approach that. Height considerations, you could change a person's height eventually. So that's an important thing to think about. It does not stop height, but it's the ultimate height achieved that may be changed by continuous use of the GnRH analogues. Expense. These are wickedly expensive medicines, $20,000 per year if you're to pay retail for this, so very expensive, sometimes hard to get. There is also a little bit of weight and anxiety issue. So you're blocking puberty, but you haven't really helped them move forward with their gender journey. And so that itself can cause some anxiety. And then of course, bone mineral density may be reduced if these medicines are used for too long. So we're sort of limited to a four year window for that. And then of course, here's a child who's going to lack the secondary sexual characteristics compared to their peers. So this will be the kid who looks like he hasn't hit

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puberty yet, sitting in that eighth grade classroom where everyone is developing. So you know, you have to be aware of that. So I think overall, the relief is greater than the harms or risks. But of course, it should be discussed with the family.

32:07 Dosing, everything from one month injections to three month injections. That's what I use a lot of for these things. And then of course, the implant is once every two to almost two and a half years. They can have some immediate side effects, like withdrawal bleeding, if they're about to start their menarchy. Possibility of hot flashes and mood changes, I really rarely see that. And you expect to see effects. And I put that in quotes because really, what's interesting is the ideal thing is that nothing happens, right? There's no changes, they come back in six months or whatever and you're like, how's it going? And they're like, nothing's going on, I'm like perfect! No more hair, no increased growth or, you know, increased hair, increased vocal changes, no chest development. And those are fantastic things.

33:08 So I want to shift gears and talk about our next patient a little bit. Patient B, and so B comes to you and is a 16 year old MTF, who is kicked out by her mother's boyfriend for being "gay." B presents as female, B is new to you, and presents really with a chief complaint of a genital rash. So a few things about this slide. One is some terminology, you'll see MTF or FTM often kicked around in the literature, I find this terminology to be a little on the clunky side, because by the time I've actually translated that into my head I've missed what the question was. So I prefer terms like trans man, trans woman. So the woman or the man part of that name tells me where this person would like to be headed, how they see themselves. And the trans tells me that's not how they were assigned at birth. So in this case, I will say that this is a 16 year old trans woman kicked out by her mother's boyfriend. And the second thing important to this slide is that not everybody who's trans comes in specifically for the trans stuff, they're going to come to you for other things. In this case, this person came in with a genital rash. So what's next? Do you, here's our next polling question, so are we going to dive right into an evaluation of gender identity? Are we going to deal with just the rash? Are we going to do a huge psychosocial screening? Do we all of the above? What do y'all think?

34:50 Interesting. So about half felt like we should deal with the rash by itself and then half said deal with all of it. And I agree, I think that starting to deal with all of it is pretty important. This person is brand new to your clinic, it's hard to ignore some of these things. But why the psychosocial screening? We'll come back to that in a second. So I definitely, with this person, I'm going to do a little gender work. So what name and pronouns should I use, they most likely registered under their birth name. So asking if your claim isn't already set up for that, what name or pronouns should I use? Put that in your medical record. Now this says gender, but really, it should say what are the body parts of your partners? Because it's interesting that many trans individuals will date other trans individuals. So when somebody says, 'well, I date men,' I don't really necessarily know what that means. So I ask what kind of person are your sexual partners, and I'll rattle off cisgendered male, cisgendered female, trans male, trans female, and things like that. And so you have a better sense of what's going on. And so you want to also ask about the

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rash, so it's in the genitals, so you're going to do a little bit of sexual history evaluation. So have they ever had anal, genital, oral sex. Do they give, receive, both? How many partners have they had? Do you use condoms, sometimes always, mostly, never? Any other symptoms of maybe an infection, discharge, stuff like that. And then a little peripherally, this kid has been kicked out of her home, so any sex and having to exchange sex for shelter, food, drugs, other things, any forced sex or sexual assault, ? You want to definitely establish safety, trust, rapport, that you are there for them, that you are listening to them. You want to make sure also though, that you evaluate any problem the patient has. I find that sometimes students want to dive into the thing that interests them the most. 'Oh trans person, let's talk about that.' But don't forget to deal with the issue that they actually came in with, so don't forget to deal with the rash. If there's time, begin a heads assessment. And as most of you probably know, heads is a great way that a physician or medical provider can do a very brief biopsychosocial biopsy, basically. And heads stands for home, education, activity, drugs, sex, suicide, and I'm happy to share more about that at another time. But in this case, questions about the heads shows definitely some victimization at home and at school, we know this kid had been kicked out. That there has been some sex work with consistent, unprotected receptive anal and oral sex. There's been some depression and patient considered suicide in the past, there's been some substance use, meth is used in this case, I more often see things like marijuana, but alcohol and nicotine products are very common. And then street hormones. This patient's been getting hormones off the street, buying them from friends, and also injecting silicone in herself. So you can see a fairly high risky medical history. And so why is it important to ask about these things? Well, because we know from various surveys, even in young people, 9th to 11th graders, the risk behaviors are significantly higher among trans youth than cisgendered youth. Emotional bullying, distress, are definitely more common among trans women than the males. And of course, some protective factors that we talked about are things like family connectedness, a close student teacher relationship, and feeling safe in one's own community. And before I forget, I wanted to make sure I touch on the term trans versus cis. So obviously, trans is where somebody's body and mind don't necessarily match. And in a cisgendered person, mind and body do match. And these are terms actually sort of come from chemistry. So you have molecules that are trans molecules, and you have molecules where if you just change the conformation of the molecule, it becomes a cis molecule, same activity, same function, but just slightly different conformation. And so the term cis is often used in opposition to trans because you certainly don't want to say, well, what's the opposite of trans? Oh, that's normal? No, no, you can't use normal because then that implies the trans is not normal. So trans and cis, that's where that comes from. And so in our kid, given this kid's sexual and drug history, we're obviously going to be following the MMWR guidelines and trying to obtain an HIV serology, syphilis serology, nucleic acid amplification on the urine for gonorrhea and chlamydia, we're going to offer to do a rectal swab for gonorrhea and chlamydia, and pharyngeal swab for gonorrhea. And we also may ask about Hepatitis C, doing some evaluations for Hepatitis C serology. And then you know, because we're also trying to be holistic, let's see what we can prevent. So asking about immunizations on Hepatitis A, B, and HPV. So those are definitely some of the things we want to provide for our kid. We want to talk about harm reduction. So safer sex, planning for future condom use, and maybe family planning, talking about PEP and PrEP, close follow up, we need to do some psychosocial support and survival things. So looking for housing, vocational assistance, maybe substance use counseling and screening, and mental health counseling and screening.

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Obviously, these are some of the barriers to care. This person has a lack of parental and familial support, they may have some issues around lack of health care and the ability to pay and access to providers. And then they may have concerns regarding confidentially and their rights to care, these often leads to a delay in care and making it much more harder to control chronic medical conditions like diabetes and asthma, things like that. And then of course, social stigma can lead to mental health sequelae.

41:52 This is a busy slide, but basically tries to demonstrate the impact of homophobia and transphobia on these individuals. How they internalize that, and that becomes shame, stigma, isolation. These lead to poor health outcomes, poor psychological outcomes. And then the asterisks you can see there are where a culturally competent medical and mental health team can be a mitigating factor. So being more supportive of youth helps improve their screening rates and helps improve their health care access and utilization. Having a welcoming office is really important, having inclusive intake forms, welcoming signage, and then working to train your staff and provide education for the frontline staff who are often the very first face of your care. So I've worked with my staff, instead of saying, How may I help you, sir? or How can I help you miss? Get rid of the gender, genderisation of the of the questions and say, Hello there. How can I help you today? And when somebody says, where are the bathrooms, don't say, well, the men's bathroom is, no just say the bathrooms are and you point in the right direction. So working with your staff in providing education can be really, really important. And early access to gender affirming hormones and care really does provide an improved quality of life. These are just some of the items there that we have noted that can be improved with an early access to do affirming hormones.

43:38 Pre transition evaluation, we're going to discuss for this patient, for B, what are the risks and benefits of hormones? What are her expectations about what the hormones will do? Does she have any surgical goals and could we help with that? Let's talk about fertility. She is only 16, but maybe she has a real idea about wanting to be a biologic parent in the future. So how might we help her with that? Talking about the unknown future, what is on the horizon for these kids? Are there new medicines coming down the pike? Routine physical versus focused one depends upon the time you've got. I am a big fan of making sure that everybody has a routine full physical at some point, baseline labs, mental health assessment. So this is where I really think that the mental health assessment is important. You want to make sure that this person really does meet criteria for gender dysphoria, that there are no other significant psychiatric problems. There is a big difference obviously between 'I want to be a woman because I feel that I am a woman in my head. I've always been a woman. That's who I am.' Versus 'I want to be a woman because the voices up there are telling me I should be a woman.' Those are two different very things and my estrogen is not going to affect a psychotic disorder.

45:03 So estrogen for B, these are some of the effects that you see next to Miss Cox, who is on the cover of Time magazine from Orange is the New Black, Laverne Cox. And you'll see that many of these things, a redistribution of the normal body fat, a decrease in muscle mass, softening of

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the skin, decreased libido, decreased erections, breast growth, testicular volume shrinkage, decreased sperm production, and decreased terminal hair growth. These are all some of the effects of estrogen. And you can see that many of them take a while to start, several months, and may take many years for a full transition to happen. So this is not a fast process, it's pretty slow. Estrogen comes as a variety of things, sublingual, patches, shots. Shots are the most commonly used one. And you can you know, figure out what your patient would like based on that. And estrogen is usually paired with an antiestrogen, also known sometimes confusingly, as a blocker. The most common ones are things like spironolactone or finasteride. And then sometimes people want to use progesterone. There's very little data to support routine use of progesterone for the development of breast tissue. Some studies say yes, some say no. And then some show definite side effects. So I'm not a huge fan until somebody comes up with a more definitive study about using it on a routine basis. And then, of course, some of the trans women need other help with other things like laser, electrolysis, Vaniqua for hair removal. Some of these are expensive, but often helping remove unwanted facial hair, body hair may be very, very affirming for these individuals.

46:54 Some of the risks, there are risks of course. The biggest one is the VTE, the vascular thrombotic events, so clots, but weight, libido, erectile dysfunction, some trans women like using their penis, some do not. So having erectile dysfunction can be not a good thing, but for some they find it to be a very good thing. There can be liver dysfunction, changes to cholesterol level, blood pressure, glucose, all these things. Pituitary adenoma can be provoked by the use of estrogen. So you monitor for that. And we follow these kids and check labs on a regular basis. I usually do labs every three months or so, in the beginning. And then once somebody is doing well, and you can see there are some of my goals there, testosterone less than 70, estradiol in the 100 to 350 range. But really, I'm mostly looking for clinical effects. And if they're getting the clinical effects at the initial dosing, then I'm not too worried and we keep going with that. Other things that trans women need to be monitored for, emotional well being. There's a lot of depression, sadness, and suicide thoughts. STI testing and prevention, PEP and PrEP. These individuals are at high risk for the acquisition of HIV. Fertility considerations, sperm banking. Maybe breast cancer and other screenings as they get older. Luckily, this is usually when they've graduated from my program. So I'll let the adults deal with things like breast cancer screening and screening and stuff like that.

48:34 And then finally, I want to talk in the last few minutes about our last case, patient C. C is a 21 year old, asserted male, so sees himself as male, new to your practice. He's been getting testosterone from the internet for several years, he has just relocated and wants to start a new job as his identity as a male. So what's interesting to me is that when you talk to these kids, many of them reject an identity as trans male or trans female. They're simply I'm a male, I'm a female. So that's an important thing to know. So even though medically I think of them as a trans person, that's not necessarily how they see themselves and that in this case, clearly, is how C sees himself. And so, this gives me an opportunity about testosterone. There's three basic formulations, injectables, gel, and patch. Injections are what's used the most. And you can see these effects. This is Chaz Bono, the son of Sonny and Cher, who transitioned and you

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know, it's things like acne, body hair, facial hair, you can have male pattern baldness with estrogen. I once met a guy who said, 'I paid a lot of money to lose my hair.' And so it really does happen. Increased muscle mass, fat redistribution. So from the hips and the thighs to the beer gut belly that cis men get. Cessation of the menstrual period, often the desired thing. Clitoral enlargement, about four to five centimeters after a few years. Vaginal atropy and a deepening of the voice. Common risks, there can be some mood changes, some weight gain is pretty common, acne, male pattern baldness, pelvic pain possible, and increase in hemoglobin hematocrit that has to be watched, especially if you also are overweight. Because those two things together can lead to very high hemoglobins and hematocrits, which could lead to an increase in clots. Not very common at all I will have to admit, but it is something I watch for. Rare effects but things you got to look out for are liver dysfunction, changes in your lipid profile, insulin resistance, and the polycythemia which is the increase in the hematocrit. Just to note, topical testosterone to the does not change the size of the clitoris. And progesterones may be used in the short term to help stop the menstrual period. So Depo provera has been used and it does not interfere with the testosterone. This sometimes is a hard sell for the trans boy because progesterones are a "female hormone" and just psychologically taking that can be a challenge for them. Again, lab follow up every three months. And then after that, you know after a year or two, every six to 12 months. I try to get a goal of 350 to about 1000 for the testosterone. But again, if they're having good physiologic response, I worry less about the goals. You can manage some of the side effects, you can use finasteride to treat male pattern baldness, sometimes you can use vaginal cream, a little estrogen vaginal cream for any atrophy or pain in the . You can pitch it as this is just like a little bit of lubricant, and that may be helpful. Things for acne, and then again things to stop the menstrual period, which is often a big thing for dysphoria.

52:21 So, C also had male chest reconstruction, also known as top surgery a few years ago, he's considering hysterectomy and oophorectomy, so removal of the uterus and ovaries in the next few years, and then what other health care needs might he have? So again, you're looking at the emotional well being of this person. Again, there's a lot of depression and sadness there. STI testing, never assume that somebody is not at risk for an STD. HIV testing, pap smears should be done on everybody who's sexually active at the age of 21. Again, this can be a little bit of a challenge. It's not something I go charging right into because many of these kids have a lot of dysphoria about their genitals, and so it's not something I rush right into. And of course, maybe breast cancer screening, especially since top surgery is not radical mastectomy, they leave some of the breast tissue in to help sculpt a more masculine shaped chest. So pap smears, yes, should be done. It's a question about what happens if they're never ever sexually active, should you do a pap smear? I don't think the data is out on that quite yet. And then last but not least, you know, last question is this patient occasionally has penile vaginal sex with cisgendered men. And so what are the contraception options available to this person that are not going to mess up his testosterone profile? So we've got an IUD, Depo provera which is the DMPA, the hormone the implant things like the Nexplanon, all the above? None of the above? What do you all think? Yes, D. Really, all of those are useful and have been used and are just fine. I've got several trans boys who have IUDs, several who use Depo, a few who use the implant. And none of the above is an interesting thought, but I think we really want to protect

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somebody from an unintended pregnancy who's on testosterone. So you gotta find something there. Next screen. All the above? Yes. All right. So yes, you have to talk about contraception for these patients. Testosterone is not a failsafe contraception, it does decrease one's fertility, but it's not considered contraception. And so, you know, you've got to think about things like Nexplanon, progesterone, IUD, Depo and other stuff. And this may be another person who you know may want to be pregnant and have their own genetic children. So, don't assume that a trans man does not want to be a father, they may really want to be a father.

55:29 Common surgical treatments we touched on some of these for the female to male patients. You can do which is the penile scrotal construction, mastectomy or top surgery, hysterectomy and oophorectomy are very common. Sometimes phalloplasty is also known as bottom surgery. So top and bottom surgery. And then for the trans women, things like a vaginoplasty, creating a vagina out of the skin of their penis, creation of a clitoris and labia, removal of the penis, removal of the testes, breast augmentation is a pretty popular surgical treatment, facial feminization, tracheal shave and vocal cord procedures. So I'm going to stop there. Sorry, I'm two minutes over. These are some resources around transgender care. That'll be in the PDF for you. And I say thank you all for listening. And I'm happy to hang out and take any questions. So Tara, give this back to you.

56:43 Thanks, Dr. Steever, for that presentation.

[End]

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