Transgender Medicinemedicine

Home , Cisgender, Sex reassignment surgery, Transvestism

TransgenderTransgender MedicineMedicine

NickNick Gorton,Gorton, MD,MD, DABEMDABEM LyonLyon--MartinMartin HealthHealth ServicesServices nick@[email protected]  ElectiveElective inin TransgenderTransgender MedicineMedicine -- Sarah@[email protected]

 ResidentsResidents  Medical,Medical, NP,NP, PAPA studentsstudents OverviewOverview

 DefinitionsDefinitions andand HistoryHistory

 StateState ofof TransgenderTransgender CareCare TodayToday

 BasicBasic TreatmentTreatment OverviewOverview

 ResourcesResources

 TimingTiming andand questionsquestions DefinitionsDefinitions

 SexSex –– male, female,  GenderGender –– masculine,

intersex, transsexual feminine, androgynous

* Non Binary DefinitionsDefinitions

 GenderGender IdentityIdentity

 GenderGender ExpressionExpression DefinitionsDefinitions

 TransTransgendergender

 TransTranssexualsexual

 Cisgender/CissexualCisgender/Cissexual Cisgender Cissexual

Transgender Transsexu al DefinitionsDefinitions

 TransgenderTransgender woman,woman, MTF,MTF, transwomantranswoman,, womanwoman

 TransgenderTransgender man,man, FTM,FTM, transmantransman,, manman HistoricalHistorical ContextContext

 HarryHarry BenjaminBenjamin st ·· AlfredAlfred Kinsey,Kinsey, refersrefers toto himhim 11 patientpatient inin 19481948 ·· BenjaminBenjamin H.H. ““TranssexualismTranssexualism andand transvestismtransvestism asas psychosomaticpsychosomatic andand somatopsychicsomatopsychic syndromes.syndromes.”” AmAm JJ PsychotherPsychother.. 8(2):2198(2):219--30.30. 19541954 ·· ““TheThe TranssexualTranssexual PhenomenonPhenomenon”” -- 19661966 HistoricalHistorical ContextContext

 TransTrans carecare inin academiaacademia ·· 19531953 –– HamburgerHamburger C,C, etet al.al. ““Transvestism:Transvestism: hormonal,hormonal, psychiatric,psychiatric, andand surgicalsurgical treatment.treatment.”” JJ AmAm MedMed AssocAssoc.. 152(5):391152(5):391--6.6. ·· 19591959 –– RandellRandell JB.JB. ““TransvestitismTransvestitism andand transtrans-- sexualismsexualism:: AA studystudy ofof 5050 cases.cases.”” BritishBritish MedMed J.J. 2(5164):14482(5164):1448--52.52. HistoricalHistorical ContextContext -- USUS

 TransgenderTransgender carecare inin academiaacademia -- 1960s1960s

·· 19651965 –– John'sJohn's HopkinsHopkins programprogram opensopens ·· 19651965 –– FirstFirst SRSSRS isis performedperformed atat JHUJHU ·· 1960s1960s –– 70s70s –– gendergender programsprograms atat universityuniversity medicalmedical centerscenters:: Stanford,Stanford, NorthwesternNorthwestern,, UniversityUniversity ofof Minnesota,Minnesota, Hopkins,Hopkins, etc.etc. HistoricalHistorical ContextContext

 ProfessionalProfessional OrganizationOrganization && StandardsStandards -- 1970s1970s

·· 19711971 –– HBIGDAHBIGDA formedformed ·· 19791979 –– StandardsStandards ofof CareCare VersionVersion 11 HistoricalHistorical ContextContext

 IncreasingIncreasing RecognitionRecognition ·· 19801980 –– DiagnosticDiagnostic andand StatisticalStatistical ManualManual ofof rd MentalMental DisordersDisorders -- 33 EditionEdition HistoricalHistorical ContextContext

 IncreasingIncreasing RecognitionRecognition ·· InclusionInclusion inin DSMDSM--IIIIII legitimizedlegitimized carecare HistoricalHistorical ContextContext

 WhatWhat thethe #&*@!#&*@! happenedhappened inin thethe earlyearly 80s....?80s....? HopkinsHopkins ChangesChanges

 PaulPaul McHughMcHugh ·· DirectorDirector ofof thethe DepartmentDepartment ofof PsychiatryPsychiatry andand BehavioralBehavioral SciencesSciences atat JohnsJohns HopkinsHopkins UniversityUniversity SchoolSchool ofof Medicine,Medicine, andand PsychiatristPsychiatrist--inin--ChiefChief ofof thethe JohnsJohns HopkinsHopkins HospitalHospital,, 19751975--20012001 HopkinsHopkins ChangesChanges

 PaulPaul McHughMcHugh ·· CouncilCouncil Member,Member, thethe PresidentPresident Bush'sBush's CouncilCouncil onon BioethicsBioethics HopkinsHopkins ChangesChanges

 PaulPaul McHughMcHugh –– AcademicAcademic workwork

·· PraisedPraised byby NARTH:NARTH: ··http://http://www.narth.com/docs/desiresch.htmlwww.narth.com/docs/desiresch.html ·· TheThe DesireDesire forfor aa SexSex Change:Change: PsychiatristPsychiatrist sayssays sexsex--changechange surgerysurgery isis aa collaborationcollaboration withwith aa mentalmental disorder,disorder, notnot aa treatment.treatment. HopkinsHopkins ChangesChanges

 NARTHNARTH ·· ProvidesProvides muchmuch ofof thethe 'professional'professional scientific'scientific' supportsupport forfor thethe ExEx--GayGay movement.movement. ·· HomosexualityHomosexuality isis simplysimply aa behaviorbehavior choice.choice. ·· 'Reparative'Reparative therapy'therapy' helpshelps peoplepeople 'make'make thethe rightright choice.'choice.' HopkinsHopkins ChangesChanges

 NARTHNARTH

Don't be gay, Sparky! Don't be gay! HopkinsHopkins ChangesChanges

 Member,Member, USUS CatholicCatholic ConferenceConference ofof Bishop'sBishop's blueblue--

ribbonribbon reviewreview boardboard ((estest 2002)2002) toto monitormonitor implementationimplementation ofof newnew clericalclerical sexsex abuseabuse policypolicy

 ““BombshellBombshell discoverydiscovery”” thatthat thethe abuseabuse crisiscrisis wasnwasn’’tt

aboutabout pedophiliapedophilia oror aboutabout repeatedrepeated systematicsystematic covercover--upup byby Bishops,Bishops, but...but... HopkinsHopkins ChangesChanges

 Member,Member, USUS CatholicCatholic ConferenceConference ofof Bishop'sBishop's blueblue--

ribbonribbon reviewreview boardboard ((estest 2002)2002) toto monitormonitor implementationimplementation ofof newnew clericalclerical sexsex abuseabuse policypolicy

 ““BombshellBombshell discoverydiscovery”” thatthat thethe abuseabuse crisiscrisis wasnwasn’’tt

aboutabout pedophiliapedophilia oror aboutabout repeatedrepeated systematicsystematic covercover--upup byby Bishops,Bishops, butbut ““homosexualhomosexual predationpredation onon AmericanAmerican CatholicCatholic youth.youth.”” HopkinsHopkins ChangesChanges

 PaulPaul McHughMcHugh

?????? HopkinsHopkins ChangesChanges

 “The post-surgical subjects struck me as caricatures of “The post-surgical subjects struck me as caricatures of women.women. TheyThey worewore highhigh heels,heels, copiouscopious makeup,makeup, andand flamboyantflamboyant clothing;clothing; theythey spokespoke aboutabout howhow theythey foundfound themselvesthemselves ableable toto givegive ventvent toto theirtheir naturalnatural inclinationsinclinations forfor peace,peace, domesticity,domesticity, andand gentlenessgentleness—— butbut theirtheir largelarge hands,hands, prominentprominent AdamAdam’’ss apples,apples, andand thickthick facialfacial featuresfeatures werewere incongruousincongruous (and(and wouldwould becomebecome moremore soso asas theythey aged).aged).””

Paul McHugh. "Surgical Sex." First Things: A Monthly Journal of Religion and Public Life 147 (November 2004): 34-38. HopkinsHopkins ChangesChanges

 PaulPaul McHughMcHugh

Paul McHugh. "Surgical Sex." First Things: A Monthly Journal of Religion and Public Life 147 (November 2004): 34-38. HopkinsHopkins ChangesChanges

 PaulPaul McHugh:McHugh: transwomentranswomen notnot 'real'real women'women'

·· ““First,First, theythey spentspent anan unusualunusual amountamount ofof timetime thinkingthinking andand talkingtalking aboutabout sexsex andand theirtheir sexualsexual experiences.experiences. ·· Second,Second, discussiondiscussion ofof babiesbabies oror childrenchildren provokedprovoked littlelittle interestinterest fromfrom them;them; indeed,indeed, theythey seemedseemed indifferentindifferent toto children.children. ·· ButBut third,third, andand mostmost remarkable,remarkable, manymany ofof thesethese menmen-- whowho--claimedclaimed--toto--bebe--womenwomen reportedreported thatthat theythey foundfound womenwomen sexuallysexually attractiveattractive andand thatthat theythey sawsaw themselvesthemselves asas 'lesbians.''lesbians.'””

Paul McHugh. "Surgical Sex." First Things: A Monthly Journal of Religion and Public Life 147 (November 2004): 34-38. HopkinsHopkins ChangesChanges

 PaulPaul McHughMcHugh –– becausebecause 'real women' 'real women' ··Don'tDon't thinkthink andand talktalk aboutabout sex.sex. ··AreAre universallyuniversally interestedinterested inin childrearing.childrearing. ··Aren'tAren't lesbians.lesbians. OK

Paul McHugh. "Surgical Sex." First Things: A Monthly Journal of Religion and Public Life 147 (November 2004): 34-38. HopkinsHopkins ChangesChanges

 ““[[O]nceO]nce II waswas givengiven authorityauthority overover allall thethe practicespractices

inin thethe [Johns[Johns Hopkins]Hopkins] psychiatrypsychiatry departmentdepartment II realizedrealized thatthat ifif II werewere papassivessive II wouldwould bebe tacitlytacitly coco-- optedopted inin encouragingencouraging sexsex--changechange surgerysurgery inin thethe veryvery departmentdepartment thatthat hadhad originallyoriginally proposedproposed andand stillstill defendeddefended it.it. II decideddecided toto challengechallenge whatwhat II consideredconsidered toto bebe aa misdirectionmisdirection ofof psychiatrypsychiatry andand toto demanddemand moremore informationinformation bothboth beforebefore andand afterafter theirtheir operations.operations.””

Paul McHugh. "Surgical Sex." First Things: A Monthly Journal of Religion and Public Life 147 (November 2004): 34-38. HopkinsHopkins ChangesChanges EverythingEverything

 PaulPaul McHughMcHugh

 EnlistsEnlists JHUJHU researcherresearcher JonJon MeyerMeyer toto undertakeundertake aa studystudy ofof postpost--operativeoperative transgendertransgender womenwomen

 MeyerMeyer J,J, andand ReterReter K.K. ““SexSex reassignment.reassignment. FollowFollow-- up.up.”” ArchArch GenGen Psychiatry.Psychiatry. 36(9):101036(9):1010--5.5. 19791979..  ComparedCompared 5050 patientspatients seekingseeking SRS,SRS, operatedoperated withwith nonnon--operatedoperated HopkinsHopkins ChangesChanges EverythingEverything

 PaulPaul McHughMcHugh

 EnlistsEnlists JHUJHU researcherresearcher JonJon MeyerMeyer toto undertakeundertake aa studystudy ofof postpost--operativeoperative transgendertransgender peoplepeople

 NonNon ValidatedValidated OutcomeOutcome ScaleScale ·· SESSES (Male(Male toto Female)Female) ·· LegalLegal ··ArrestedArrested --11 ··ArrestedArrested andand JailedJailed --22 ·· MentalMental HealthHealth

··PsychiatricPsychiatric contactcontact --11 ··OutpatientOutpatient treatmenttreatment --22 ··InpatientInpatient treatmenttreatment --33 Meyer'sMeyer's StudyStudy

 NonNon ValidatedValidated OutcomeOutcome ScaleScale ·· CohabitationCohabitation ··GenderGender AppropriateAppropriate +1+1 ··NonNon--GenderGender AppropriateAppropriate --11 ·· MarriageMarriage

··HeterosexualHeterosexual marriagemarriage +2+2 ··SameSame--SexSex MarriageMarriage --22 Meyer'sMeyer's StudyStudy

··HeterosexualHeterosexual marriagemarriage +2+2 ··SameSame--SexSex MarriageMarriage --22 - 4 Meyer'sMeyer's StudyStudy

 ResultsResults ·· DespiteDespite ratherrather creativecreative studystudy designdesign ·· InIn eacheach subgroupsubgroup operatedoperated eithereither diddid thethe samesame oror betterbetter thanthan thethe nonnon--operatedoperated ·· InIn overalloverall scorescore operatedoperated diddid slightlyslightly betterbetter thanthan nonnon operated,operated, butbut thisthis diddid notnot reachreach statisticalstatistical significancesignificance

 UnderpoweredUnderpowered –– TypeType IIII errorerror

 OverOver--hypedhyped Meyer'sMeyer's StudyStudy

 AtAt oddsodds withwith otherother researchresearch studiesstudies ofof outcomesoutcomes afterafter SRSSRS forfor transgendertransgender peoplepeople

WOW! Meyer'sMeyer's StudyStudy

 AtAt oddsodds withwith otherother researchresearch studiesstudies ofof outcomesoutcomes afterafter SRSSRS forfor transgendertransgender peoplepeople

WOW! CollapseCollapse ofof TransmedicineTransmedicine inin AmericanAmerican AcademicAcademic CentersCenters

 TransgenderTransgender healthhealth carecare perceivedperceived asas ·· Dangerous and ineffective ·· Bad science

 ClosureClosure ofof USUS academicacademic gendergender programs*programs* ·· Insurance exclusions instituted in United States ·· Almost all care funded by individuals

*Except for PHS at U of M TransgenderTransgender HealthHealth CareCare TodayToday

What you get in most western democracies

Ethical and evidence Based transgender care

Cuba, What you get Kazakhstan, in the US Iran PrimaryPrimary CareCare andand HormoneHormone TherapyTherapy

 YouYou alreadyalready knowknow 90%90% ofof whatwhat youyou needneed toto knowknow (or(or youyou willwill byby thethe endend ofof training)training)

 MostMost medicalmedical carecare ofof transgendertransgender patientspatients hashas nothingnothing toto dodo withwith beingbeing transgendertransgender

 100%100% ofof thethe medicalmedical treatmentstreatments andand mostmost ofof thethe surgeriessurgeries areare usedused inin cisgendercisgender patientspatients ButBut nownow II havehave aa patientpatient inin mymy office!office!

 AskAsk forfor helphelp  Experienced clinicians Experienced clinicians  TransMedicine yahoo group TransMedicine yahoo group  Your patient Your patient

 BuyBuy aa bookbook

 GoGo toto aa conferenceconference  WPATH WPATH SFDPH's Tom Waddell  GLMA, TransHealth SFDPH's Tom Waddell Clinic Protocols  Others Others

 ConsultConsult DrDr GoogleGoogle

HowHow doesdoes thisthis allall work?work?

 ConsultConsult withwith specialistspecialist forfor complexcomplex casescases

 WhenWhen youyou areare startingstarting youryour ownown practice,practice, itsits OKOK toto taketake easyeasy onesones whowho 'follow'follow thethe SOC'SOC'

www.wpath.orgwww.wpath.org TypicalTypical NarrativeNarrative ('following('following SOC')SOC')

 AcceptAccept youryour ownown transtrans identityidentity andand seekseek helphelp

 Internet,Internet, locallocal groups,groups, organizationsorganizations

 FindFind aa therapisttherapist andand receivereceive aa dxdx (and(and letter)letter)

 33 monthmonth 'Real'Real LifeLife Experience'Experience' OROR  PsychotherapyPsychotherapy (duration(duration TBD,TBD, usuallyusually 3+months)3+months)

 FindFind aa physicianphysician

 StartStart hormonehormone therapytherapy  NonNon--genitalgenital surgerysurgery (same(same timetime asas HRT)HRT)  11 yearyear successfulsuccessful –– genitalgenital surgerysurgery TypicalTypical NarrativeNarrative (following(following SOC)SOC)

 DoesDoes everyoneeveryone dodo itit thisthis way?way?

 IfIf theythey don'tdon't shouldshould youyou stillstill treattreat them?them? HarmHarm ReductionReduction

 WPATHWPATH--SOCSOC explicitlyexplicitly endorseendorse harmharm reductionreduction especiallyespecially withwith experiencedexperienced cliniciansclinicians MedicalMedical Treatments:Treatments: FundamentalsFundamentals

 SetSet realisticrealistic goalsgoals  WhatWhat will,will, might,might, andand won'twon't happenhappen

 EmphasizeEmphasize primaryprimary andand preventativepreventative carecare

 UseUse thethe simplestsimplest hormonalhormonal programprogram thatthat willwill achieveachieve goalsgoals

 EveryEvery optionoption doesn'tdoesn't workwork forfor everyevery patientpatient  Cost,Cost, easeease ofof use,use, safetysafety MedicalMedical Treatments:Treatments: FundamentalsFundamentals

 PatiencePatience isis aa virtuevirtue   PubertyPuberty comparisoncomparison  Take a long term outlook – safety and efficacy Take a long term outlook – safety and efficacy

 SideSide effectseffects areare inin thethe eyeeye ofof thethe beholderbeholder   BaldnessBaldness

 Screening:Screening: MedicalMedical Treatments:Treatments: FundamentalsFundamentals

 PatiencePatience isis aa virtuevirtue   PubertyPuberty comparisoncomparison  Take a long term outlook – safety and efficacy Take a long term outlook – safety and efficacy

 SideSide effectseffects areare inin thethe eyeeye ofof thethe beholderbeholder   BaldnessBaldness

 Screening:Screening: MedicalMedical Treatments:Treatments: FundamentalsFundamentals

 HormoneHormone treatmentstreatments areare oneone ofof thethe easiesteasiest partsparts

 FTMFTM –– TestosteroneTestosterone upup toto normalnormal malemale dosedose

 Dose that masculinizes and stops menses is enough Dose that masculinizes and stops menses is enough  MTFMTF –– MoreMore difficultdifficult becausebecause mustmust suppresssuppress

testosteronetestosterone productionproduction toto getget bestbest resultsresults  Anti-androgen(s) – Spironolactone most common in US Anti-androgen(s) – Spironolactone most common in US   EstrogensEstrogens titratedtitrated toto higherhigher thanthan normalnormal replacementreplacement dosesdoses forfor womenwomen (usually(usually 33--5x5x higher)higher) MedicalMedical Treatments:Treatments: MTFMTF

 EstrogensEstrogens atat highhigh dosedose   33--5x5x normalnormal femalefemale replacementreplacement dosesdoses   PartiallyPartially toto feminizefeminize   PartiallyPartially toto betterbetter suppresssuppress testosteronetestosterone productionproduction

 AntiAnti--AndrogenAndrogen  Spironolactone and others Spironolactone and others   OrchiectomyOrchiectomy

 ResultsResults variablevariable   AgeAge atat startingstarting isis importantimportant   GeneticsGenetics playsplays aa bigbig partpart Hormones:Hormones: MTFMTF -- EstrogensEstrogens

 OralOral -- $$

 Premarin 1.25 – 10mg/d (usual 5-6.25) $$

 Estradiol 1-5mg/d (usual 2-4)

 IMIM –– DelestrogenDelestrogen $$$$

 10-40mg q2weeks (usual 20)

 Can't easily 'stop' in an emergency when patient immobilized

 TransdermalTransdermal –– EstradiolEstradiol patchpatch $$$$$$

 0.1-0.3mg/day (1-3 patches/week – overlapped)

 Probably the safest for transwomen predisposed to thrombo-

embolic and CVD dz (age>40, smoking, FH, etc.)

Hormones:Hormones: MTFMTF -- EstrogensEstrogens

 BeneficialBeneficial effectseffects   BreastBreast growthgrowth   SuppressSuppress androgenandrogen productionproduction  Change of body habitus (muscle and fat) Change of body habitus (muscle and fat)   SofteningSoftening ofof skinskin

 Contraindications/PrecautionsContraindications/Precautions  Same as in cisgender women Same as in cisgender women  Individual risk/benefits (MTF get greater benefits r/t Individual risk/benefits (MTF get greater benefits r/t mentalmental healthhealth thanthan menopausalmenopausal cisgendercisgender women.)women.)  In transwomen with absolute CI – at least suppress In transwomen with absolute CI – at least suppress testosteronetestosterone fullyfully Hormones:Hormones: EstrogensEstrogens AdverseAdverse EffectsEffects

 THROMBOEMBOLIC DISEASE

 Hepatotoxicity (especially ORAL) – incr TA, adenomas

 Prolactinoma (if dose is too high)

 Decreased glucose tolerance

 Lipid profile

 Gallbladder Disease

 Worsening migraine/seizure control

 Acne

 Breast Cancer

 Mood

 Decreased libido

Hormones:Hormones: MTFMTF -- AntiAnti--AndrogensAndrogens

 AntiandrogensAntiandrogens -- AllAll

 Decrease T production or activity

 Slow/stop MPB, and decrease unwanted hair growth

 Decrease erections/libido

 Improve BPH

 SpironolactoneSpironolactone 5050--300300 mg/dmg/d divideddivided bidbid

 Cheap, reasonably safe

 Hyper-K+, diuresis, changes in BP

 Decreased H/H (T erythropoetin)

 CyproteroneCyproterone Hormones:Hormones: MTFMTF -- AntiAnti--AndrogensAndrogens

 55--αα--reductasereductase inhibitorsinhibitors  Finasteride, dutasteride, etc Finasteride, dutasteride, etc  FinasterideFinasteride ((Proscar/PropeciaProscar/Propecia))

 Stops conversion of T DHT Stops conversion of T DHT  5mg tabs ~ $1 generic 5mg tabs ~ $1 generic  GnRHGnRH AgonistsAgonists

 $$$$$$ $$$$$$  Great for both gender adolescents because can fully Great for both gender adolescents because can fully suppress production of sex hormones Hormones:Hormones: MTFMTF -- Surgery?Surgery?

 StopStop EE twotwo weeksweeks beforebefore anyany immobilizingimmobilizing eventevent ((inclincl SRS)SRS) resumeresume aa weekweek afterafter ambulatingambulating regularlyregularly

 ContinueContinue (maybe(maybe increaseincrease dose)dose) antianti--androgenandrogen Hormones:Hormones: MTFMTF -- MonitoringMonitoring

 EveryEvery VisitVisit

 BP, Weight, BMI BP, Weight, BMI  Safety Safety  Mental health Mental health  General screening based on age, organ, gender, General screening based on age, organ, gender, andand sexsex appropriateappropriate normsnorms

 PatientPatient educationeducation

 S/S/SxSx ofof TEDzTEDz

 HealthyHealthy HabitsHabits

 VisionVision changeschanges oror lactationlactation

Hormones:Hormones: MTFMTF -- MonitoringMonitoring

 ClinicalClinical monitoringmonitoring mostmost importantimportant

 SameSame adverseadverse eventsevents inin cisgendercisgender ptspts

w/w/ samesame medsmeds (use(use whatwhat youyou know!)know!)

 LabsLabs

 0,0, 2,2, && 66 momo initiallyinitially thenthen ((semi)annualsemi)annual oror pp changeschanges  CBC,CBC, CMPCMP,, LipidsLipids  PLPL andand TT Glucose PL K+ Cr AST/ALT Hormones:Hormones: MTFMTF -- MonitoringMonitoring

st   PituitaryPituitary AdenomaAdenoma 11 PassPass MetabolismMetabolism

PL AST/AST Hormones:Hormones: MTFMTF –– AdverseAdverse effectseffects

 ElevatedElevated PL:PL: StopStop EstrogensEstrogens (not(not antianti--androgen)androgen)

 IfIf levelslevels normalize,normalize, resumeresume EE atat lowerlower dosedose  IfIf levelslevels remainremain highhigh MRIMRI toto r/or/o PLPL--omaoma  ElevatedElevated LFTsLFTs  LookLook forfor otherother cause!cause!  IfIf duedue toto E,E, lowerlower dosedose oror stopstop untiluntil LFTLFT normalnormal Hormones:Hormones: MTFMTF -- EfficacyEfficacy

 WhatWhat isis adequateadequate treatment?treatment?

 PtPt outcomesoutcomes –– breastbreast growthgrowth (peak(peak 22--33 yrs),yrs), changeschanges inin skin,skin, hair,hair, fat/muscle,fat/muscle, libidolibido  female range)  TheThe floorfloor –– testosteronetestosterone levelslevels ((female range)  TheThe roofroof –– prolactinprolactin levellevel  >20>20 possiblypossibly tootoo muchmuch (ask(ask @@ 'extra''extra' EE useuse oror otherother meds)meds)

 >25>25 probablyprobably tootoo muchmuch  >30>30 definitelydefinitely tootoo muchmuch MedicalMedical Treatments:Treatments: FTMFTM Hormones:Hormones: FTMFTM

 TestosteroneTestosterone InjectedInjected EstersEsters (cheapest)(cheapest)

 CypionateCypionate  CheapestCheapest -- $60$60 forfor 10ml10ml (~4mos(~4mos supply)supply)

 EnanthateEnanthate  Slightly more expensive Slightly more expensive  OtherOther formsforms (Soon(Soon inin US!)US!)  IntramuscularIntramuscular testosteronetestosterone undecanoateundecanoate ((NebidoNebido))

Hormones:Hormones: FTMFTM

Therapeutic Range

200 mg 2 weeks

100 mg week Hormones:Hormones: FTMFTM

 TransdermalTransdermal

 Expensive:Expensive: $7$7 dayday retail,retail, $1/day$1/day compoundedcompounded  LessLess variablevariable levelslevels  DailyDaily administrationadministration  RiskRisk ofof inadvertentinadvertent transfertransfer toto othersothers

1%, 5g QD 5%, 1g QD Hormones:Hormones: FTMFTM -- MonitoringMonitoring

 EveryEvery VisitVisit

 PatientPatient educationeducation

 VaginalVaginal bleedingbleeding

 HealthyHealthy habitshabits

 TxTx availableavailable forfor acne,acne, MPBMPB

MedicalMedical Treatments:Treatments: FundamentalsFundamentals

 ClinicalClinical monitoringmonitoring mostmost importantimportant

 SameSame adverseadverse eventsevents inin cisgendercisgender ptspts

w/w/ samesame medsmeds (use(use whatwhat youyou know!)know!)

 LabsLabs

 0,0, 2,2, && 66 momo initiallyinitially thenthen ((semi)annualsemi)annual oror pp changeschanges  CBC,CBC, CMPCMP,, LipidsLipids  TT (trough)(trough) inin FTMFTM Glucose Cr ALT T Hgb Hct BeneficialBeneficial EffectsEffects (any(any delivery...)delivery...)

 VoiceVoice deepeningdeepening

 ChangeChange ofof bodybody habitushabitus

 MaleMale patternpattern hairhair growthgrowth

 ClitoromegalyClitoromegaly

 AmenorrheaAmenorrhea

 EmotionalEmotional benefitsbenefits

 EnhancedEnhanced libidolibido Hormones:Hormones: FTMFTM –– AdverseAdverse effectseffects

 AcneAcne –– MCMC sideside effecteffect (chest/back)(chest/back)

 CVCV -- worseningworsening ofof surrogatesurrogate endpointsendpoints -- lipids,lipids,

glucoseglucose metabolism,metabolism, BPBP

 WeightWeight gaingain

 PolycythemiaPolycythemia ((normalsnormals forfor malesmales))

 UnmaskUnmask oror worsenworsen OSAOSA

 EnhancedEnhanced LibidoLibido

 MaleMale patternpattern hairhair growthgrowth andand lossloss HormonalHormonal Treatments:Treatments: IsIs thisthis safe?safe?

 VanVan KesterenKesteren P,P, etet al.al. ““MortalityMortality andand morbiditymorbidity

inin TSTS subjectssubjects treatedtreated withwith crosscross--sexsex hormones.hormones.”” ClinClin EndoEndo ((OxfOxf).). 47(3):33747(3):337--42.1997.42.1997.   DESIGN:DESIGN: Retrospective,Retrospective, descriptivedescriptive studystudy @@ universityuniversity teachingteaching hospitalhospital thatthat isis thethe nationalnational referralreferral centercenter forfor thethe NetherlandsNetherlands (serving(serving 1616 millionmillion people)people)   SUBJECTS:SUBJECTS: 816816 MTFMTF && 293293 FTMFTM onon HRTHRT forfor totaltotal ofof 10,15210,152 ptpt--yearsyears  OUTCOMES: Mortality and mobidity incidence ratios OUTCOMES: Mortality and mobidity incidence ratios calculatedcalculated fromfrom thethe generalgeneral DutchDutch populationpopulation (age(age andand gendergender--adjusted)adjusted) HormonalHormonal Treatments:Treatments: IsIs thisthis safe?safe?

 VanVan KesterenKesteren P,P, etet al.al. ““MortalityMortality andand morbiditymorbidity

inin TSTS subjectssubjects treatedtreated withwith crosscross--sexsex hormones.hormones.”” ClinClin EndoEndo ((OxfOxf).). 47(3):33747(3):337--42.1997.42.1997.

293 FTMs c/w ♀ ????

10,152 pt years

816 MTFs c/w ♂ ???? HormonalHormonal Treatments:Treatments: IsIs thisthis safe?safe?

 VanVan KesterenKesteren P,P, etet al.al. ““MortalityMortality andand morbiditymorbidity

inin TSTS subjectssubjects treatedtreated withwith crosscross--sexsex hormones.hormones.”” ClinClin EndoEndo ((OxfOxf).). 47(3):33747(3):337--42.1997.42.1997.  MTF/FTM total mortality no higher than general popl'n MTF/FTM total mortality no higher than general popl'n  Largely, observed mortality not r/t hormone treatment Largely, observed mortality not r/t hormone treatment   VTEVTE waswas thethe majormajor complicationcomplication inin MTFsMTFs.. FewerFewer casescases afterafter thethe introductionintroduction ofof transdermaltransdermal EE inin MTFsMTFs overover 4040  In MTFs increased morbidity from VTE and HIV and In MTFs increased morbidity from VTE and HIV and increasedincreased proportionproportion ofof mortalitymortality duedue toto HIVHIV

HIV VTE HormonalHormonal Treatments:Treatments: IsIs thisthis safe?safe?

 VanVan KesterenKesteren P,P, etet al.al. ““MortalityMortality andand morbiditymorbidity

inin TSTS subjectssubjects treatedtreated withwith crosscross--sexsex hormones.hormones.”” ClinClin EndoEndo ((OxfOxf).). 47(3):33747(3):337--42.1997.42.1997.

No Increase Morbidity 293 FTMs c/w ♀ or Mortality 10,152 pt years No Increase Mortality 816 MTFs c/w ♂ Increase morbidity r/t HIV/VTE HormonalHormonal Treatments:Treatments: IsIs thisthis safe?safe?

 GoorenGooren L,L, etet al.al. ““LongLong termterm treatmenttreatment ofof TSsTSs

withwith hormones:hormones: ExtensiveExtensive personalpersonal experience.experience.”” JJ ClinClin EndoEndo && MetabMetab.. 93(1):1993(1):19--25.25. 2008.2008.  Same clinic group as 1997 paper – now 2236 MTF, 876 Same clinic group as 1997 paper – now 2236 MTF, 876 FTMFTM (1975(1975--2006)2006)   Outcomes:Outcomes: M&MM&M Data,Data, surrogatesurrogate markersmarkers assessingassessing risksrisks ofof osteoporosisosteoporosis andand cardiovascularcardiovascular disease,disease, casescases ofof hormonehormone sensitivesensitive tumorstumors andand otherother potentialpotential risksrisks HormonalHormonal Treatments:Treatments: IsIs thisthis safe?safe?

 GoorenGooren L,L, etet al.al. CardiovascularCardiovascular RisksRisks

 Analyzed studies of surrogate markers for CVDz in Analyzed studies of surrogate markers for CVDz in MTF/FTM:MTF/FTM: BodyBody composition,composition, lipids,lipids, insulininsulin sensitivity,sensitivity, vascvasc function,function, hemostasis/fibrinolysishemostasis/fibrinolysis,, othersothers (HC(HC CRP)CRP)   SomeSome worsen,worsen, somesome improve,improve, somesome areare unchangedunchanged (overall(overall worse)worse)   MTFMTF dodo worseworse thanthan FTMFTM   HardHard clinicalclinical endpointsendpoints showshow nono differencedifference   CounselCounsel patientspatients aboutabout modifyingmodifying CVCV riskrisk HormonalHormonal Treatments:Treatments: IsIs thisthis safe?safe?

 GoorenGooren L,L, etet al.al. HormoneHormone DependentDependent TumorsTumors

 Lactotroph Adenoma Lactotroph Adenoma   ExtremelyExtremely rarerare   CheckCheck PL!PL!   ProstateProstate CancerCancer   ProstatectomyProstatectomy isis notnot aa partpart ofof SRSSRS   ScreenScreen basedbased onon thethe organsorgans presentpresent   ScreenScreen basedbased onon individualindividual riskrisk factorsfactors   WithdrawalWithdrawal ofof testosteronetestosterone maymay decreasedecrease butbut doesn'tdoesn't eliminateeliminate thethe riskrisk ofof BPHBPH andand malignancymalignancy HormonalHormonal Treatments:Treatments: IsIs thisthis safe?safe?

 DREDRE isis aa littlelittle differentdifferent

HormonalHormonal Treatments:Treatments: IsIs thisthis safe?safe?

 GoorenGooren L,L, etet al.al. HormoneHormone DependentDependent TumorsTumors

  BreastBreast cancercancer  MTF - Estrogen exposure: dose and duration MTF - Estrogen exposure: dose and duration  Conservative: screen as cisgender women of same age/risk Conservative: screen as cisgender women of same age/risk  Progesterone increases risk Progesterone increases risk   FTMFTM  Reported in 1 case 10 years after mastectomy Reported in 1 case 10 years after mastectomy  Mastectomy reduces but doesn't eliminate risk Mastectomy reduces but doesn't eliminate risk  Some injected testosterone is aromatized to estrogen Some injected testosterone is aromatized to estrogen  Family history Family history HormonalHormonal Treatments:Treatments: IsIs thisthis safe?safe?

 GoorenGooren L,L, etet al.al. GynecologicGynecologic TumorsTumors

 Gynecologic Tumors Gynecologic Tumors   CervicalCervical   OvarianOvarian   EndometrialEndometrial GynecologicGynecologic CancerCancer risksrisks inin FTMsFTMs

5 + ??? ??? GynecologicGynecologic CancerCancer risksrisks inin FTMsFTMs

Normal F T ??? M Hyperplasia P If C infrequent O periods Dysplasia S

Cancer

ENDOMETRIAL CANCER (slight) GynecologicGynecologic CancerCancer risksrisks inin FTMsFTMs GynecologicGynecologic CancerCancer risksrisks inin FTMsFTMs Cervical Cancer Risk Reduction from Pap Smears

100

0 Never Every 10 yr Every 5 yr Every 3 yr Every 2 yr Every year

IARC Working Group on Evaluation of Cervical Cancer Screening Programmes. Screening for squamous cervical cancer: duration of low risk after negative results of cervical cytology and its implication for screening policies. Br Med J. 1986;293:659-664. GynecologicGynecologic CancerCancer risksrisks inin FTMsFTMs GynecologicGynecologic CancerCancer risksrisks inin FTMsFTMs IsIs itit effective?effective?

 SuicidalitySuicidality decreaseddecreased fromfrom 2020--30%30% prepre--

treatmenttreatment toto 3%3% postpost treatmenttreatment

 DecreasedDecreased depressivedepressive symptoms,symptoms, improvedimproved socialsocial functioning,functioning, regretsregrets rarerare TheThe HardHard Stuff:Stuff: AdvocacyAdvocacy Insurance:Insurance: DenialDenial ofof CareCare

 ExclusionsExclusions

 IndividualIndividual andand smallsmall groupgroup  LargerLarger groupsgroups  DeDe factofacto exclusionsexclusions -- MedicaidMedicaid

 TitleTitle XIX:XIX: MedicaidMedicaid agenciesagencies ““maymay notnot arbitrarilyarbitrarily denydeny oror reducereduce thethe amount,amount, duration,duration, oror scopescope ofof aa requiredrequired serviceservice underunder §§§§440.210440.210 andand 440.220440.220 toto anan otherwiseotherwise eligibleeligible recipientrecipient solelysolely becausebecause ofof thethe diagnosis,diagnosis, typetype ofof illness,illness, oror conditioncondition”” ((§§440.230(c))440.230(c)) Insurance:Insurance: DenialDenial ofof CareCare

 MedicaidMedicaid DenialsDenials

 NotNot medicallymedically necessarynecessary  ExperimentalExperimental

 AMAAMA PolicyPolicy StatementStatement 20082008 AMAAMA ResRes 122122

 Whereas, Gender Identity Disorder (GID) is a serious medical condition Whereas, Gender Identity Disorder (GID) is a serious medical condition recognized as such in both the DSM-IV-TR and ICD-10  Whereas, GID, if left untreated, can result in clinically significant Whereas, GID, if left untreated, can result in clinically significant psychological distress, dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death  Whereas, An established body of medical research demonstrates the Whereas, An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID  RESOLVED, That the AMA support public and private health insurance RESOLVED, That the AMA support public and private health insurance coverage for treatment of gender identity disorder; and be it further  RESOLVED, That the AMA oppose categorical exclusions of coverage RESOLVED, That the AMA oppose categorical exclusions of coverage for treatment of gender identity disorder when prescribed by a physician Insurance:Insurance: NationalNational HealthHealth Care??Care??

 Medicaid???Medicaid???

 ExclusionsExclusions likelike thethe StupidStupid StupakStupak Amendment?Amendment? 504504 261261 83798379 nick@[email protected] IdentityIdentity DocumentsDocuments

 IdentityIdentity documentationdocumentation changechange isis oneone partpart ofof thethe medicalmedical treatmenttreatment forfor GIDGID

 LackLack ofof appropriateappropriate IDID

 VulnerabilityVulnerability toto interpersonalinterpersonal violenceviolence  InabilityInability toto  Get a job

 Make a purchase with a credit card

 Board a plane

 Enter a federal building

 VoluntaryVoluntary withdrawalwithdrawal fromfrom activitiesactivities SupportiveSupportive LettersLetters

 ThereThere areare nono gendergender copscops

 ItsIts notnot youryour jobjob toto enforceenforce badbad policypolicy

 YourYour jobjob

 AdvocateAdvocate forfor youryour patientspatients needsneeds  Don'tDon't lielie  GiveGive youryour truetrue medicalmedical opinionopinion  Don'tDon't writewrite somethingsomething ifif youyou don'tdon't havehave experienceexperience SupportiveSupportive Letters:Letters: aa thoughtthought experimentexperiment

 You are a doctor in NC in 1950. An 18 year old young You are a doctor in NC in 1950. An 18 year old young manman whowho isis youryour patientpatient asksasks youyou forfor help.help. HeHe isis white,white, butbut hishis greatgreat grandfathergrandfather waswas AfricanAfrican American.American. HeHe waswas acceptedaccepted toto attendattend UNCUNC--CH,CH, butbut anan anonymousanonymous letterletter toto thethe schoolschool revealedrevealed hishis heritage.heritage. HeHe waswas toldtold hehe mustmust provideprovide aa letterletter fromfrom aa teacher,teacher, doctor,doctor, oror ministerminister verifyingverifying hehe isis whitewhite toto bebe allowedallowed toto enterenter UNC.UNC. SupportiveSupportive Letters:Letters: aa thoughtthought experimentexperiment

 You're pretty advanced for the 50's and understand race as You're pretty advanced for the 50's and understand race as aa socialsocial constructconstruct andand believebelieve hehe reallyreally isis white....white.... butbut knowknow thatthat UNCsUNCs policiespolicies andand understandingunderstanding ofof racerace wouldwould excludeexclude him.him. SupportiveSupportive Letters:Letters: aa thoughtthought experimentexperiment

 Do you write the letter? Do you write the letter? SupportiveSupportive LettersLetters

 ThereThere areare nono gendergender copscops

 ItsIts notnot youryour jobjob toto enforceenforce badbad policypolicy

 YourYour jobjob

 I am a physician licensed to practice medicine and surgery I am a physician licensed to practice medicine and surgery inin thethe statestate ofof California.California.

 John Smith is a patient in my care at LMHS John Smith is a patient in my care at LMHS

 In my medical opinion Mr Smith is a transsexual man. In my medical opinion Mr Smith is a transsexual man.

 I have determined that his male gender predominates and I have determined that his male gender predominates and havehave providedprovided himhim withwith appropriateappropriate andand irreversibleirreversible sexsex reassignmentreassignment treatmentstreatments..

 (In addition, he has undergone irreversible sex (In addition, he has undergone irreversible sex reassignmentreassignment surgerysurgery thatthat II havehave verifiedverified byby mymy ownown examination.)examination.) SupportiveSupportive LettersLetters

 As a result Mr Smith has completed all necessary medical As a result Mr Smith has completed all necessary medical (and(and surgical)surgical) proceduresprocedures toto fullyfully transitiontransition fromfrom femalefemale toto malemale..

 HeHe shouldshould bebe consideredconsidered malemale forfor allall legallegal andand

documentationdocumentation purposespurposes –– includingincluding driversdrivers license,license, birthbirth certificate,certificate, passport,passport, andand socialsocial securitysecurity records.records.

 Indicating his gender as male is accurate and will eliminate Indicating his gender as male is accurate and will eliminate thethe considerableconsiderable confusionconfusion aandnd biasbias MrMr SmithSmith encountersencounters whenwhen usingusing identificationidentification thatthat doesdoes notnot reflectreflect hishis currentcurrent truetrue gender.gender. 504504 261261 83798379 nick@[email protected]