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
Objec ves • Introduc on, three vigne es • Define gender dysphoria • Review approaches to pa ents with gender dysphoria • Outline pharmacologic therapies used in transgender medicine • Outline challenges and barriers to care, and future direc ons 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, o en sta ng empha cally, “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 ac vi es 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“tomboy” when younger – Over me, has more clearly expressed a male iden ty – Social transi on at age 12 – More socially withdrawn and depressed with new cu ng behavior – Extremely distraught about new breast development – Very concerned about the prospect of menstrua ng Case 2 Case 3
• John is a 36 year old transman who has been treated with testosterone for 10 years, presen ng to the primary care office with abdominal pain – Ques ons to consider: • What organs does John have? • Is John sexually ac ve with men, women, both? • How can we make John’s visit to the office a posi ve one? Terminology
• Biologic sex – the gene c, anatomic, and hormonal determinants that define male and female • Gender iden ty – a person’s own classifica on of self as male or female • Gender expression – how you demonstrate your gender through the way you dress, act, behave and interact • Sexual orienta on – the sex of the persons that one finds sexually desirable
DEFINITIONS
• Gender iden ty 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’ dura on, as manifest by at least two of the following 1. Marked incongruence between expressed gender and primary/ secondary sex characteris cs 2. Strong desire to be rid of primary/secondary sex characteris cs or desire to prevent development of an cipated secondary characteris cs 3. Strong desire for the primary/secondary sex characteris cs of the other gender 4. Strong desire to be the other gender (or some alterna ve gender) 5. Strong desire to be treated as the other gender (or alterna ve gender) 6. Convic on that one has typical feelings of the other gender B. Clinically significant distress or impairment in social, occupa onal, or other areas of func oning h p://transhealth.ucsf.edu/protocols Crea ng a Safe Clinical Environment • Cultural humility - individuals recognize that their own experiences my not project onto the experiences or iden es of others • Staff training – front line staff have “make-or-break” interac ons with trans pa ents • Wai ng areas – inclusive posters and art, pamphlets, s ckers • Bathrooms – gender neutral op on, or use based on preference • Gender iden ty data on medical record Crea ng a Safe Clinical Environment • Gender iden ty (two-step): • What is your gender iden ty? ☐ Male ☐ Female ☐ Transgender man / Transman ☐ Transgender woman / Transwoman ☐ Genderqueer / Gender nonconforming Addi onal iden ty (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 pa ents • Gender affirming approach – Use of correct name, pronouns – Terminology for body parts – OK to ask – Screening for anatomy s ll 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 Interven ons
Trans youth suffer from two condi ons 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 ini a on 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? Medica ons to suppress pubertal development or pubertal symptoms
“Blockers” • GnRH analogs • Proges ns • Spironolactone GnRH Analog • Pros: – Suppression of development of secondary sex characteris cs • 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”
• Proges ns – Norethindrone, Depo-Provera • Suppresses menses in natal females • Blunts development of male sex characteris cs in natal males • Spironolactone • Blocks ac on 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 pa ents 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 Augmenta on (M to F) “top surgery” – Can be performed under age 18 – Requires le er of support from mental health provider – Almost never covered by insurance • Phalloplasty/Metoidioplasty (F to M), Vaginoplasty (M to F) “bo om surgery – O en restricted to > 18 years old Other common discussions • Breast binding • Packing and STPs • Tucking • Ea ng disorders • Pharmacotherapy for mental health concerns • Sexually transmi ed infec ons • Contracep on and fer lity • Substance use • Complica ons 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 Poli cal and Logis c Challenges
• Percep on that GD is a psychiatric (DSM-IV), not medical, condi on • Lack of mental health personnel skilled in assessing gender dysphoric children • Unfamiliarity and anxiety in the primary community concerning medical treatment of transgender pa ents • Prohibi vely expensive costs and lack of insurance coverage Referecnes and Thank You!
• American Psychiatric Associa on. (2013). Diagnos c and Sta s cal Manual of Mental Disorders (5th ed.). Arlington, VA. • Delemarre-Van de Waal HA, Cohen-Ke enis PT. (2006). Clinical management of gender iden ty 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 a er puberty suppression and gender reassignment. Pediatrics 134(4), 1-9 • Edwards-Leeper L, Spack NP. (2012). Psychological evalua on 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-Ki enis P, Delemarr-van de Waal HA, Gooren LJ, Meyer WJ, Spack NP, Montori VM. (2009). Endocrine treatment of transsexual persons: an Endocrine Society clinical prac ce guideline. J of Clin Endo and Metab 94(9), 31232-54. • Hill DB, Menevielle E, Sica KM, Johnson A. (2010). An affirma ve interven on for families with gender variant children: parental ra ngs 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 iden ty 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. • h p://transhealth.ucsf.edu/trans?page=guidelines-home