Transgender Medicine for the Primary Care Provider October 19, 2017

Daniel Shumer, MD Assistant Professor in Pediatrics Division of Pediatric Endocrinology University of Michigan Disclosures

I have no financial relationships to disclose

Objecves • Introducon, three vignees • Define • Review approaches to paents with gender dysphoria • Outline pharmacologic therapies used in transgender medicine • Outline challenges and barriers to care, and future direcons for the field.

Case 1

• Timmy is presents to the pediatrician at age 8 years… – Since age 4 he has very much wished he were a girl, oen stang emphacally, “I’m not a boy, I’m a girl!” – He has been secretly playing dress-up in his older sister’s clothes – He loves to play with dolls and pretends that he is a mother feeding and changing their diapers – At school he likes to play with girls, and avoids rough-and- tumble acvies with boys – Throws tantrums when redirected away from feminine behaviors – Recently stated that “I just want to chop it off!” in reference to his penis – Parents are distressed and don’t know how to proceed Case 1 Case 2

• Sarah “Sco” is a 14 year-old natal girl who presents year-old girl presents to endocrine clinic with his parents, referred by pediatrician – Described by parents as a “tomboy” when younger – Over me, has more clearly expressed a male identy – Social transion at age 12 – More socially withdrawn and depressed with new cung behavior – Extremely distraught about new development – Very concerned about the prospect of menstruang Case 2 Case 3

• John is a 36 year old transman who has been treated with testosterone for 10 years, presenng to the primary care office with abdominal pain – Quesons to consider: • What organs does John have? • Is John sexually acve with men, women, both? • How can we make John’s visit to the office a posive one? Terminology

• Biologic sex – the genec, anatomic, and hormonal determinants that define male and female • Gender identy – a person’s own classificaon of self as male or female • Gender expression – how you demonstrate your gender through the way you dress, act, behave and interact • Sexual orientaon – the sex of the persons that one finds sexually desirable

DEFINITIONS

• Gender identy disorder (DSM IV) • Gender dysphoria (DSM V) Gender Dysphoria in Adolescents and Adults (DSM V) A. Marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duraon, as manifest by at least two of the following 1. Marked incongruence between expressed gender and primary/ secondary sex characteriscs 2. Strong desire to be rid of primary/secondary sex characteriscs or desire to prevent development of ancipated secondary characteriscs 3. Strong desire for the primary/secondary sex characteriscs of the other gender 4. Strong desire to be the other gender (or some alternave gender) 5. Strong desire to be treated as the other gender (or alternave gender) 6. Convicon that one has typical feelings of the other gender B. Clinically significant distress or impairment in social, occupaonal, or other areas of funconing hp://transhealth.ucsf.edu/protocols Creang a Safe Clinical Environment • Cultural humility - individuals recognize that their own experiences my not project onto the experiences or idenes of others • Staff training – front line staff have “make-or-break” interacons with trans paents • Waing areas – inclusive posters and art, pamphlets, sckers • Bathrooms – gender neutral opon, or use based on preference • Gender identy data on medical record Creang a Safe Clinical Environment • Gender identy (two-step): • What is your gender identy? ☐ Male ☐ Female ☐ Transgender man / Transman ☐ Transgender woman / Transwoman ☐ Genderqueer / Gender nonconforming Addional identy (fill in) ______☐ Decline to state • What sex were you assigned at birth? ☐ Male ☐ Female ☐ Decline to state Physical Exam

• Exam can be source of anxiety for paents • Gender affirming approach – Use of correct name, pronouns – Terminology for body parts – OK to ask – Screening for anatomy sll present • Trans men less likely to be up to date on cervical screening; higher rates of inadequate sampling • Chest binding can cause skin breakdown • may increase risk for inguinal hernia Sex Differences in Testosterone Medical Intervenons

Trans youth suffer from two condions commonly treated by pediatric endocrinologists…

• Precocious puberty: precocity of an undesired puberty • Pubertal delay: delay of the desired puberty

The Amsterdam Experience

Treatment of adolescents with GD diagnosed by a mental health professional at Tanner 2-3 (males 11-13; females 10-12) using GnRHa analogues to:

1) Suppress spontaneous pubertal development 2) Allow for balanced decision regarding sex reassignment

Followed by iniaon of cross-sex hormone therapy at age ~16

Followed by gender reassignment surgery at age ~18 Adult Assessment

• Requirement for mental health support?

• Informed consent model? Medicaons to suppress pubertal development or pubertal symptoms

“Blockers” • GnRH analogs • Progesns • Spironolactone GnRH Analog • Pros: – Suppression of development of secondary sex characteriscs • Improves future ability to pass as the affirmed gender • Minimizes dysphoria associated with unwanted pubertal changes • “Reversible” • Cons: – Concern about social difficulty remaining pre- pubertal – Concern about bone density accrual GnRH Analog

• Leuprolide (Lupron Depo-Ped) – 15mg IM monthly ($2,314/kit, $27,768/year) – 30mg IM every 3 months ($6,942/kit, $27,768/year) • Histrelin – Supprelin LA (50mg) 65mcg/day • Approved for precocious puberty in children, manufacturer recommends annual replacement • $19,298 – Vantas (50mg) 50mcg/day • Approved for prostate cancer treatment in adult men, manufacturer recommends annual replacement • $3,840 Other “Blockers”

• Progesns – Norethindrone, Depo-Provera • Suppresses menses in natal females • Blunts development of male sex characteriscs in natal males • Spironolactone • Blocks acon of androgens at their receptor • Used primarily to decrease development of facial and body hair in transwomen Cross sex hormones

• Testosterone (F to M) – Testosterone enanthate or cypionoate • 50mg SC weekly • Some paents may prefer gels or patches • Estrogen (M to F) – 17β-estradiol (estrace) • 2-8 mg PO daily • Estrogen patches: 0.1-0.3 mg/24hr patches Surgery

• Mastectomy (F to M), Breast Augmentaon (M to F) “top surgery” – Can be performed under age 18 – Requires leer of support from mental health provider – Almost never covered by insurance • Phalloplasty/Metoidioplasty (F to M), Vaginoplasty (M to F) “boom surgery – Oen restricted to > 18 years old Other common discussions • Breast binding • and STPs • Tucking • Eang disorders • Pharmacotherapy for mental health concerns • Sexually transmied infecons • Contracepon and ferlity • Substance use • Complicaons of hormones

Transgender Medicine at UofM

• Pediatric Gender Program (at Mo) • Adult Hormone Providers – Family medicine – 3 physicians in OB/GYN – REI • Surgical – All gender-related surgeries • Voice therapy • CGSP Polical and Logisc Challenges

• Percepon that GD is a psychiatric (DSM-IV), not medical, condion • Lack of mental health personnel skilled in assessing gender dysphoric children • Unfamiliarity and anxiety in the primary community concerning medical treatment of transgender paents • Prohibively expensive costs and lack of insurance coverage Referecnes and Thank You!

• American Psychiatric Associaon. (2013). Diagnosc and Stascal Manual of Mental Disorders (5th ed.). Arlington, VA. • Delemarre-Van de Waal HA, Cohen-Keenis PT. (2006). Clinical management of gender identy disorder in adolescents: a protocol on psycological and paediatric endocrinology aspects. Eur J Endo 155(Suppl 1):S131-S137. • De Vries et al. (2014). Young adult psychological outcome aer puberty suppression and gender reassignment. Pediatrics 134(4), 1-9 • Edwards-Leeper L, Spack NP. (2012). Psychological evaluaon and medical treatment of transgender youth in an interdisciplanary “Gender Management Service” (GeMS) in a major pediatric center. J of Homosexuality 59(3), 321-36. • Hembree WC, Cohen-Kienis P, Delemarr-van de Waal HA, Gooren LJ, Meyer WJ, Spack NP, Montori VM. (2009). Endocrine treatment of transsexual persons: an Endocrine Society clinical pracce guideline. J of Clin Endo and Metab 94(9), 31232-54. • Hill DB, Menevielle E, Sica KM, Johnson A. (2010). An affirmave intervenon for families with gender variant children: parental rangs of child mental health and gender. J of Sex and Marital Ther 36(1), 6-23. • Shumer DE, Spack NP. (2013). Current management of gender identy disorder in childhood and adolescence: guidelines, barriers and areas of controversy. Curr Opin in Endo, Diab, Obesity 20(1), 69-73. • Spack NP, Edwards-Leeper L, Feldman HA, Leibowitz S, Mandel F, Diamond DA, Vance SR. (2012). Children and adolescents with gender dysphoria referred to a pediatric medical center. Pediatrics 129(3), 418-25. • hp://transhealth.ucsf.edu/trans?page=guidelines-home