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Transgender Medicine for the Primary Care Provider October 19, 2017

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Transgender Medicine for the Primary Care Provider October 19, 2017 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 • IntroducDon, three vigneFes • Define gender dysphoria • Review approaches to paents with gender dysphoria • Outline pharmacologic therapies used in transgender medicine • Outline challenges and barriers to care, and future direcDons 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, oQen 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 acDviDes 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 “ScoF” 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when younger – Over Dme, has more clearly expressed a male idenDty – Social transiDon at age 12 – More socially withdrawn and depressed with new cung behavior – Extremely distraught about new breast development – Very concerned about the prospect of menstruang Case 2 Case 3 • John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, presenDng to the primary care office with abdominal pain – QuesDons to consider: • What organs does John have? • Is John sexually acDve with men, women, both? • How can we make John’s visit to the office a posiDve one? Terminology • Biologic sex – the geneDc, anatomic, and hormonal determinants that define male and female • gender idenDty – 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 idenDty 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 characterisDcs 2. Strong desire to be rid of primary/secondary sex characterisDcs or desire to prevent development of anDcipated secondary characterisDcs 3. Strong desire for the primary/secondary sex characterisDcs 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. ConvicDon that one has typical feelings of the other gender B. Clinically significant distress or impairment in social, occupaonal, or other areas of funcDoning hFp://transhealth.ucsf.edu/protocols Creang a Safe Clinical Environment • Cultural humility - individuals recognize that their own experiences my not project onto the experiences or idenDDes of others • Staff training – front line staff have “make-or-break” interacDons with trans paents • WaiDng areas – inclusive posters and art, pamphlets, sckers • Bathrooms – gender neutral opDon, or use based on preference • gender idenDty 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 AddiDonal idenDty (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 sDll present • Trans men less likely to be up to date on cervical screening; higher rates of inadequate sampling • Chest binding can cause skin breakdown • Tucking may increase risk for inguinal hernia Sex Differences in Testosterone Medical IntervenDons 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 ini7a7on 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 • ProgesDns • Spironolactone gnRH Analog • Pros: – Suppression of development of secondary sex characterisDcs • 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” • ProgesDns – Norethindrone, Depo-Provera • Suppresses menses in natal females • Blunts development of male sex characterisDcs in natal males • Spironolactone • Blocks acDon 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 leFer of support from mental health provider – Almost never covered by insurance • Phalloplasty/Metoidioplasty (F to M), Vaginoplasty (M to F) “boFom surgery – OQen restricted to > 18 years old Other common discussions • Breast binding • Packing and STPs • Tucking • Eang disorders • Pharmacotherapy for mental health concerns • Sexually transmiFed infecDons • ContracepDon and ferDlity • Substance use • Complicaons of hormones Transgender Medicine at UofM • Pediatric gender Program (at MoF) • Adult Hormone Providers – Family medicine – 3 physicians in OB/gYN – REI • Surgical – All gender-related surgeries • Voice therapy • CGSP PoliDcal and LogisDc Challenges • Percep7on 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 • ProhiBi7vely expensive costs and lack of insurance coverage Referecnes and Thank You! • American Psychiatric Associaon. (2013). Diagnos(c and Sta(s(cal Manual of Mental Disorders (5th ed.). Arlington, VA. • Delemarre-Van de Waal HA, Cohen-KeFenis PT. (2006). Clinical management of gender idenDty 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-KiFenis P, Delemarr-van de Waal HA, gooren LJ, Meyer WJ, Spack NP, Montori VM. (2009). Endocrine treatment of transsexual persons: an Endocrine Society clinical pracDce guideline. J of Clin Endo and Metab 94(9), 31232-54. • Hill DB, Menevielle E, Sica KM, Johnson A. (2010). An affirmave intervenDon 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 idenDty 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. • hFp://transhealth.ucsf.edu/trans?page=guidelines-home .
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