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

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Presentation on theme: "The T in LGBT: Last but not Lost (Transgender Teenagers) 20 th Annual Family Practice Review and Reunion February 21, 2014 Lee Ann E. Conard, RPh, DO,"— Presentation transcript:

1 The T in LGBT: Last but not Lost (Transgender Teenagers) 20 th 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. 3.*Ask them if they are male, female, somewhere in between or not on the scale. 4.Assume that they are male or female depending on how they are dressed. 5. It does not matter what their gender is.

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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

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8 Road Map

9 Trans* 101: Gender & Sexual Identity

10 Trans* 101: Terminology Trans* Transgender Gender Nonconforming Transsexual MTF FTM

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%

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 Biological Male Age of presentation14.8 (4-20)15.2 (6-20)14.3 (4-20) Total n, (%)97 (100)54 (55.7)43 (44.3) GeMS Clinic, Children’s Hospital, Boston Spack, Pediatrics, 2012

15 Coming Out in Cincinnati – Gender Variant / Transgender Patients Mean, (Age Range) Biological Female Biological Male Current Age16.3 (6-23)16.3 (7-22)16.4 (6-23) Total n, (%)90 (100)50 (55.6)40 (44.4) 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

17 PATIENT ASSESSMENT

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19 Gender Police?

20 SAFE ENVIRONMENT

21 NATIONAL LGBT HEALTH EDUCATION CENTER: A PROGRAM OF THE FENWAY INSTITUTE Ask preferred name and pronouns: Use them!

22 “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 –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

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

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 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.

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 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 Kann, MMWR Surveill Summ (7):1-133

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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 HRC Youth Survey, %

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?

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

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 –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. 3.*Ask them if they are male, female, somewhere in between or not on the scale. 4.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


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