1. The T in LGBT: Last but not Lost (Transgender Teenagers)
20th Annual Family Practice Review
and Reunion
February 21, 2014
Lee Ann E. Conard, RPh, DO, MPH
Division of Adolescent & Transition Medicine

2. Disclosures and Conflicts of Interest
Dr. Conard has no relevant financial relationships to disclose or conflicts of interest to resolve.

3. Pre-Test Question #1
Transgender teens have higher rates of this than the general population? 1. Congenital Adrenal Hyperplasia 2. Irritable bowel syndrome 3. Personality disorders 4. Polycystic Ovary Syndrome 5. *Suicide attempts

4. Pre-Test Question #2
What is the most appropriate way to figure out someone’s gender?
1. Ask them if they are male or female.
2. Ask them if they are transgender.
*Ask them if they are male, female,
somewhere in between or not on the scale.
Assume that they are male or female
depending on how they are dressed.
5. It does not matter what their gender is.

6. Goals and Objectives Describe the assessment of a Trans* patient
Determine a treatment plan for a Trans* patient
Identify local resources for Trans* patients and their families
The goals and objectives for today are to:
Describe the assessment of a Trans* patient, including history-taking, affirming clinical interactions, and provision of a safe environment.
Determine a mental health treatment plan for a Trans* patient including potential treatment goals and interaction with the transgender treatment team.
Identify local resources for Trans* patients and their families

7. Although LBG (sexuality) and T (gender) are 2 separate entities, they tend to be lumped together, which makes sense to some degree for political lobbying. Although both groups have some similar health risks, Trans* people are often lost in and to the health care system.

8. As we see more and more children, adolescents and young adults identifying as trans*, we need a road map to keep them from getting lost, and to help us care for them.
Road Map

9. Trans* 101: Gender & Sexual Identity
This is the genderbread person, who represents the differences between gender and sexual identity. Most of us tend to ask about attractions: who are you attracted to? Males, females, both, neither, all, or are you unsure? Most of us tend to know what sex or gender is – at birth, when the OB says, “It’s a boy!” or, “It’s a girl!”. Gender identity is discussed less commonly. This is a sense of being, male, female, somewhere in between, or neither. Gender expression is how a person acts, dresses, speaks and behaves to show their gender.

10. Trans* 101: Terminology Trans* Transgender Gender Nonconforming
Transsexual
MTF
FTM
To make sure we are on the same page in our discussion, I would like review some terminology with you. A lot of people ask me what the asterisk stands for. Trans* is an umbrella term that refers to all the identities in the gender identity spectrum. It includes terms such as transgender, gender variant, gender creative, gender fluid, gender expansive, gender queer, two-spirit, and gender non-conforming. Transgender is when one’s gender identity is not the same as the assigned or natal gender. For example, a person who was born a male, with male genitalia, but who feels that they are really female, or somewhere in between male and female. Gender non-conforming denotes an expression of gender that is different from what is culturally expected, for example, a boy who likes to wear clothing that our society associates with femininity. A gender non-conforming person is not necessarily transgender. Transsexual is a subset of transgender people who have transitioned to another gender, often with hormones and/or reassignment surgery. I thought I was being helpful, and sent a note describing a patient as MTF, and the recipient of the note thought I was talking about Monday, Tuesday and Friday. MTF is shorthand for Male to Female or a Transwoman, while FTM is Female to Male, or a Transman.

11. Background

12. Prevalence of Transgender
Depends on definition
Gender variant 1:500
Transitioned 1:20,000
DSM V
Natal adult males 0.005% to 0.014%
Natal adult females 0.002% to 0.003%
Gay, Lesbian & Straight Education Network (GLSEN)
2011, 1.4%
Human Rights Campaign (HRC)
2012, 9%
Now I want to put gender variance into context for you. How common is it? This is a very good question that does not have a great answers. Prevalence depends on definition – is it the natal female who likes to play football? Is it the adult natal female who is taking testosterone and has had top surgery? Gender variance is thought to be 1 in 500, transitioned adults are thought to be 1 in 20,000.
The DSM V talks about natal adult males and natal adult females, but these rates are probably underestimates. HRC completed a survey in 2012 of 10,030 self-identified youth, ages 13-17, 925 or ~ 9% identified as gender variant.

13. Stability of Gender Identity
Static and binary or FLUID over time
Rates of persistence
Natal males – 2.2% to 30%
Natal females – 12% to 50%
Most children ages 5-12 years diagnosed with gender dysphoria do not persist as adolescents
Desistence
Natal males – 63 to 100% identify as gay
Natal females – 32 to 50% identify as lesbian
Wallien, J Am Acad Child Adoles Psychiatry 2008; 47(12):

14. Coming Out – Gender Variant / Transgender
Patients
Mean,
(Age Range)
Biological
Female
Male
Age of presentation
14.8 (4-20)
15.2 (6-20)
14.3 (4-20)
Total n, (%)
97 (100)
54 (55.7)
43 (44.3)
Gender variant and transgender youth also come out at early ages. These are data from the Gender evaluation and Management Service at Children’s in Boston. Of 97 consecutive patients, the average age was 14 years, but they saw children as young a 4 years of age. Additionally, the biologic females were older at presentation than the biologic males, and this is probably because it is easier to be a tomboy in our society, than it is to be a boy who wears dresses.
GeMS Clinic, Children’s Hospital, Boston
Spack, Pediatrics, 2012

15. Coming Out in Cincinnati – Gender Variant / Transgender
Patients
Mean,
(Age Range)
Biological
Female
Male
Current Age
16.3 (6-23)
16.3 (7-22)
16.4 (6-23)
Total n, (%)
90 (100)
50 (55.6)
40 (44.4)
Over 15 months. Averaging 5 new patients per month.
Cincinnati Children’s Hospital Medical Center
July, 2013 – September 2014

16. Etiology – Multifactorial
Culture
Genetic
Family clusters
Biological
Brain differences
Hormonal
Prenatal androgen exposure
Environmental
No evidence that parenting style, abuse, or other events influence orientation/gender
Etiology of transgender is multifactorial. In different cultures, there are a wide range of beliefs about gender and definitions of masculine and feminine. There are LGB family clusters, which suggests a genetic component, but there is no clear pattern of inheritance. Identical twin concordance is thought to be 48-66%. One thing that parents of transgender children often ask, is don’t we need to do chromosomes? The answer is no, because child has normal genitalia and physical development associated with their natal gender.
There are brain differences noted in gender variant people. In MTF, two sex-dimorphic nuclei, the central portion of the bed nucleus of the stria terminalis (BSTc) and the interstitial nucleus of theanterior hypothalamus 3 (INAH3), located in the hypothalamus, appear to be female-sized and thus smaller when compared to men.
One hypothesis is that exposure to high levels of prenatal androgens can cause brain changes, but there is no variance in hormone levels post-natally.
There is no evidence that parenting style, abuse, or other events influence sexual orientation or gender identity.

17. Patient Assessment

18. As we start to work with the trans
As we start to work with the trans* patients and their families, it can feel a bit like Alice in Wonderland. It may seem strange to us at first, but as we increase our knowledge and aptitude, we become more comfortable. I have been taking care of trans* patients for almost 10 years, and I am very comfortable in this world. However, we need to remember that other people, including our support staff and families of our patients may feel like they have gone down the rabbit hole.

19. Our goal, as providers and in our clinics and in our hospital system is to provide a safe environment for our patients to self-identify. We are not the gender police.
Gender Police?

20. Safe environment

21. Ask preferred name and pronouns: Use them!
In addition to training ourselves, we need to make sure that our clinic staff – everyone from the front desk staff to the nurses to the providers understand how to provide an affirming environment. We are in the process of training ASRs and ancillary staff to make sure that we are providing culturally competent and respectful care. Please let us know if you would like training for your staff.
Asking preferred name and pronouns and using them!
Ask preferred name and pronouns: Use them!
NATIONAL LGBT HEALTH EDUCATION CENTER: A PROGRAM OF THE FENWAY INSTITUTE

22. The second thing to do is to find or designate gender neutral or family restrooms. Imagine being a spork trying to decide between the spoon restroom and the fork restroom. I spend a lot of my time writing bathroom letters to schools – not something I imagined doing when I was in medical school. I have to laugh about it, because if I didn’t, it would make me cry – everyone deserves a safe place to go to the restroom. Imagine instead that you are a spork, trying to decide if you should go in the spoon or fork locker room to change into your bathing suit for swimming in gym class. That is how I ended up caring for transgender patients. My first patient was unable to decide what to do in that situation, and attempted suicide, and I provided his medical care while he was hospitalized and from that point forward.
“What to do? What to do?”

23. Environmental Scan
Waiting rooms and common areas should reflect the patients we serve and be inclusive
Non-discrimination policy
Posters, brochures
Information and resources
Stickers for badges

24. History-Taking

25. Presentation May present at various ages May be fluid
Prepubertal
Peripubertal
Adolescence
Adulthood
May be fluid
Increasing in number
Open recognition of gender minorities

26. Laverne Cox – Orange is the New Black

27. History-Taking History of gender dysphoria
How is the family doing? What is the family doing?
How is school? Where are they going to the restroom? Changing for gym?
Where else does the child interact with the community?
HEADS exam

28. Psychological Assessment
Acknowledge presenting concerns
Thorough assessment
Gender dysphoria
Other mental health concerns
Emotional functioning
Peer and social relationships
Intellectual functioning / school achievement
Family functioning

29. Trajectory
Not clear
Child needs to be accepted and loved for who they are
Ideally, parents adapt quickly, manage their own emotions and reactions, and create a safe home environment
Some parents need time
Denial, dismay, anger often move to acceptance

30. DSM V Gender non-conformity is not a mental disorder
Gender dysphoria – preferred term
Clinically significant distress and impairment for at least six months related to incongruence
Desire must be present and verbalized in youth
Gender Identity Disorder (GID) – no longer appropriate

31. Developmental approach
Avoids disease and pathology
Fluid, flexible view of gender
Cognitive and developmental perspective
Development of identity
Exploration of cultural roles
Successful integration into adulthood
Careful screening of gender experiences

32. Child Development
Most children can verbally describe their own and other’s genders between 18 and 24 months of age. Children as young as 2 start to demonstrate preference for toys, games and types of play. By the age of 4, children use gendered words – he/him, she/her. During the school-age years, children typically view gender and gender roles as static. One of my young MTF transgender patients would come home from school crying because she was always told she had to be the Daddy when they would play house at school.

33. Younger Children Some are quite clear about their gender identity
Some may not have the capacity to verbalize or conceptualize
Behavior, mood and social problems

34. Consistent persistent Insistent
Parents often think or want to know if this is a phase their child is going through. It may be, but the things we are looking for the child to be consistent, persistent and insistent on their gender identity.

35. Preexisting Psychiatric Diagnoses
Mood disorders (12-35%)
Anxiety (16-24%)
Suicidal ideation and self harm (9-22%)
Suicide attempts (9%)

36. Adolescents May start to identify at puberty Very difficult time
Ask about gender identity
High rates of self harm and suicidality (40%)

37. Earlier Screening for Gender Development
Systematic screening and counseling about gender
Identify and support sexual minority youth
Creates a safe environment
Helps children articulate and express themselves
Modeling support and acceptance

38. What else could it be? Disorders that may produce gender confusion
Schizophrenia
Psychotic depression
Mania
Emergence in the context of trauma

39. Common Issues for Trans* patients
Lack of access to care
Insurance issues
Socioeconomic issues
Homelessness
Foster Care
Violence
Bullying & harassment
Hate crimes
Common issues for trans* patients include lack of access to care – it can be hard to find Trans* friendly providers. Of LGBT adults, 19% have been refused care and 28% were harassed at the provider’s office or at the hospital. Adolescents may not have insurance or may be afraid to use it. When a teen comes out, there is a high risk for abuse and rejection % of homeless youth may be LGBTQ and a large number are in the foster care system, which often lacks training for foster parents. They may suffer violence related to gender identity, and are at extreme risk because gender identity is difficult to hide. Perpetrators of violence can be parents, teachers, police officers, health care providers and other students. Sexual minority youth are twice as likely to have been verbally harassed at school as non-LBGT youth. 15% of those who are transgender or gender non-conforming left school due to harassment.
Injustice at Every Turn: A Report of the National Transgender Discrimination Survey National Gay and Lesbian Task Force, February, 2011

40. Thursday, June 27, 2014
Tiffany Edwards — a 28-year-old transgender woman of color — was found shot to death in the middle of the street in Walnut Hills, Ohio, a suburb of Cincinnati.
Hate crimes happen here in Cincinnati. Although incidents may be random, they may feel targeted and can cause identity crisis, loss of trust, perception of personal vulnerability and mental health effects.

41. Negative Health Outcomes
Higher levels of family rejection during adolescence have been linked to negative health outcomes for GLBTQ youth

42. Common Mental Health Issues
Depression/Suicide
> 8 times as likely to attempt suicide
6 times as likely to be depressed
Anxiety
Eating and body image issues
Substance abuse
> 3 times as likely to use drugs
2 times as likely to use tobacco
Sexual minority youth may have mental health issues. They are more than 8 times as likely than non-LBGT youth to attempt suicide and 6 times as likely to be depressed. They may have anxiety or eating disorders. They are more than 3 times as likely to use drugs and twice as likely to smoke. Another concern is that they may be forced into reparative therapy, to try to make them “straight” or revert back to their birth gender.
Ryan, Family Acceptance Project, 2009

43. Other Common Health Concerns
Overweight and Obesity
Sexual Health Issues
Violence and abuse – 3 X
Early sexual debut – 3 X
Multiple sex partners - > 2 X
Sexually Transmitted Infections
Higher HIV rates – 4 X
Unintended Pregnancy - > 2 X
In addition to mental health issues, sexual minority youth may also have other health concerns, including obesity. They are 3 times as likely as non-LGBT youth to experience dating violence and forced sexual encounters. They are 3 times more likely to have had their first sexual intercourse before age 13, and are more than twice as likely to have had 4 or more lifetime sexual partners. Because of these risks, they are more likely to have had a sexually transmitted infection, and are 4 times as likely as non-LGBT youth to have HIV. Also, teens who identify as lesbian and bisexual are twice as likely to report an unplanned pregnancy.
Kann, MMWR Surveill Summ (7):1-133

44. Don’t forget! They can still be normal teenagers!

45. Affirming Clinical interactions

46. Defining Gender Expansive
Do you consider yourself male, female, transgender or other gender (e.g., genderqueer or androgynous)?
Male
Female
Transgender
I prefer to identify as: (Specify) ________________________
Decline to answer
66%
10,030 LGBT youth, ages identified as transgender or other gender. If we are asking people if they are transgender, we may be missing a large number of patients.
HRC Youth Survey, 2012

47. Gender-related questions
CDC
Natal Gender
Current Gender
Teen Health Center Method
Do you consider yourself male, female, both, somewhere in between or other?
One question that we do not ask enough is about gender identity. This is a 2-step question asked by the CDC in their HIV surveillance surveys. It provides more detailed & accurate demographic information and minimizes confusion among non-transgender people, who may be unfamiliar with the concept of gender identity.

48. What to do if someone comes out
Be cautious in offering guidance which may be construed as encouragement to come out
Youth are the best judges of how their families may react
Offer general support, make referrals and be available for future advice or assistance

49. What to do if someone identifies as Trans*

50. Mental health treatment plan

51. What our patients want

52. What our families want

53. What we all want

54. Evidence - and Consensus - Based Practices
Endocrine Society’s Clinical Guidelines
Endocrine Treatment of Transsexual Persons
2009
World Professional Association for Transgender Health (WPATH)
Standards of Care for the Health of Transsexual, Transgender & Gender-Nonconforming People
2012
American Psychiatric Association (APA)
Report of the APA Task Force on Treatment of Gender Identity Disorder
2011

55. Children Optimal approach is controversial
No randomized controlled trials (RCTs)
Highest level of evidence is expert opinion
Outcome – without treatment – a minority will identify as transgender in adulthood
Unable to differentiate at a young age
No follow-up data have demonstrated that any modality of treatment has a statistically significant effect on later gender identity

56. Overarching Goal of Treatment
Optimize psychological adjustment and wellbeing of the child
What does this mean?
Minimize gender atypical behavior
Prevention of adult transsexualism

57. Approaches to Gender Dysphoria in Children
#1 – Work to lessen gender dysphoria and decrease cross-gender behaviors and identification
#2 – No direct effort to lessen gender dysphoria or gender atypical behaviors or remain neutral and have no therapeutic target for gender identity outcome
#3 – Affirmation of gender identity with support of transition to a different role
#1 May decrease the chance of persistence, for some persistence may be an undesirable outcome. #2
#3 Option for pubertal suppression

58. Social Transitioning Externally presenting in one’s authentic gender
Entirely reversible
No long-term outcome studies

59. Consensus Recommendations for Children
Accurate diagnosis
Diagnosis and treatment of coexisting psychiatric conditions
Identification of mental health concerns in caregivers
Provision of psychoeducation and counseling about the full range of treatment options
Provision of age-appropriate information to the child
Assessment of safety – family, school, community

60. Adolescents 2 Groups Recommendation for staged gender transition
Persistence from childhood
Onset in adolescence – more psychopathology
Recommendation for staged gender transition
Social transition – real life experience (RLE)
Puberty blockers
Gender Affirming hormones
No RCTs, case reports and studies without control groups

61. Adolescents Long-term trajectory is more predictable
For adolescents who underwent pubertal suppression, all have continued on to gender-affirming hormones and/or surgery
Rare for adolescents to regret gender transition

62. Consensus Recommendations for Adolescents
Accurate diagnosis
Diagnosis and treatment of coexisting psychiatric conditions
Psychotherapy and provision of support prior to and during transition
Assessment of readiness for puberty blockers and/or gender affirming hormones
Provision of psychoeducation to families
Assessment of safety – family, school, community

63. Psychological and Social Interventions
Help families be supportive of their child
Focus on reduction of distress related to gender dysphoria and other psychosocial difficulties
Formal evaluations of different psychotherapeutic approaches have not been published
Reparative therapy is not effective, not ethical

64. Psychological and Social Interventions
Help families manage uncertainty
Do not impose a binary view of gender
Support families in making difficult decisions
Extent the child is allowed to express their gender role
When to inform others
Who to inform

65. Working with the transgender treatment team

66. What Are We Doing? Patient and family support & resources
Interacting with schools and community
SAFE letter
Menstrual suppression
Puberty blockers
Gender-affirming hormones
Assisting with transition

67. What Do We Need From You? Assessment of gender dysphoria
Family counseling and supportive psychotherapy to alleviate distress related to gender dysphoria
Assess and treat any coexisting mental health issues
Refer to us for physical interventions, resources and support
WPATH Standards of Care, Version 7, 2012

68. What Do We Need From You? Letter of support
Diagnosis of gender dysphoria
Patient is psychologically stable

69. Local and National resources

70. Transgender Clinic Division of Adolescent & Transition Medicine
Ages 5 to 24
Locations
Main Campus
Liberty
Northern Kentucky
Multidisciplinary Clinic - Quarterly
Pediatric Endocrinology
Pediatric & Adolescent Gynecology

71. Resources for Families
Family Acceptance Project - familyproject.sfsu.edu
Trans Youth Family Allies -
Human Rights Campaign –
PFLAG –
GLSEN –
Advocates for Youth –

72. Resources for Providers
Human Rights Campaign –
LGBT Cultural Competence
GLMA: Health Professionals Advancing LGBT Equality –
Cultural Competence Webinars
Advocates for Youth -
Publications for working with LGBT youth
Physicians for Reproductive Health – prh.org

73. Post-Test Question #1
Transgender teens have higher rates of this than the general population? 1. Congenital Adrenal Hyperplasia 2. Irritable bowel syndrome 3. Personality disorders 4. Polycystic Ovary Syndrome 5. *Suicide attempts

74. Post-Test Question #2
What is the most appropriate way to figure out someone’s gender?
1. Ask them if they are male or female.
2. Ask them if they are transgender.
*Ask them if they are male, female,
somewhere in between or not on the scale.
Assume that they are male or female
depending on how they are dressed.
5. It does not matter what their gender is.

75. Questions?
October , 2014