Presentation on theme: "The T in LGBT: Last but not Lost (Transgender Teenagers)"— Presentation transcript:
1The T in LGBT: Last but not Lost (Transgender Teenagers) 20th Annual Family Practice Reviewand ReunionFebruary 21, 2014Lee Ann E. Conard, RPh, DO, MPHDivision of Adolescent & Transition Medicine
2Disclosures and Conflicts of Interest Dr. Conard has no relevant financial relationships to disclose or conflicts of interest to resolve.
3Pre-Test Question #1Transgender 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
4Pre-Test Question #2What 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 femaledepending on how they are dressed.5. It does not matter what their gender is.
6Goals and Objectives Describe the assessment of a Trans* patient Determine a treatment plan for a Trans* patientIdentify local resources for Trans* patients and their familiesThe 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
7Although 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.
8As 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
9Trans* 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.
10Trans* 101: Terminology Trans* Transgender Gender Nonconforming TranssexualMTFFTMTo 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.
12Prevalence of Transgender Depends on definitionGender variant 1:500Transitioned 1:20,000DSM VNatal 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.
13Stability of Gender Identity Static and binary or FLUID over timeRates of persistenceNatal males – 2.2% to 30%Natal females – 12% to 50%Most children ages 5-12 years diagnosed with gender dysphoria do not persist as adolescentsDesistenceNatal males – 63 to 100% identify as gayNatal females – 32 to 50% identify as lesbianWallien, J Am Acad Child Adoles Psychiatry 2008; 47(12):
14Coming Out – Gender Variant / Transgender PatientsMean,(Age Range)BiologicalFemaleMaleAge of presentation14.8 (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, BostonSpack, Pediatrics, 2012
15Coming Out in Cincinnati – Gender Variant / Transgender PatientsMean,(Age Range)BiologicalFemaleMaleCurrent Age16.3 (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 CenterJuly, 2013 – September 2014
16Etiology – Multifactorial CultureGeneticFamily clustersBiologicalBrain differencesHormonalPrenatal androgen exposureEnvironmentalNo evidence that parenting style, abuse, or other events influence orientation/genderEtiology 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.
18As 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.
19Our 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?
21Ask 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
22The 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?”
23Environmental ScanWaiting rooms and common areas should reflect the patients we serve and be inclusiveNon-discrimination policyPosters, brochuresInformation and resourcesStickers for badges
27History-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
28Psychological Assessment Acknowledge presenting concernsThorough assessmentGender dysphoriaOther mental health concernsEmotional functioningPeer and social relationshipsIntellectual functioning / school achievementFamily functioning
29TrajectoryNot clearChild needs to be accepted and loved for who they areIdeally, parents adapt quickly, manage their own emotions and reactions, and create a safe home environmentSome parents need timeDenial, dismay, anger often move to acceptance
30DSM V Gender non-conformity is not a mental disorder Gender dysphoria – preferred termClinically significant distress and impairment for at least six months related to incongruenceDesire must be present and verbalized in youthGender Identity Disorder (GID) – no longer appropriate
31Developmental approach Avoids disease and pathologyFluid, flexible view of genderCognitive and developmental perspectiveDevelopment of identityExploration of cultural rolesSuccessful integration into adulthoodCareful screening of gender experiences
32Child DevelopmentMost 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.
33Younger Children Some are quite clear about their gender identity Some may not have the capacity to verbalize or conceptualizeBehavior, mood and social problems
34Consistent 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.
36Adolescents May start to identify at puberty Very difficult time Ask about gender identityHigh rates of self harm and suicidality (40%)
37Earlier Screening for Gender Development Systematic screening and counseling about genderIdentify and support sexual minority youthCreates a safe environmentHelps children articulate and express themselvesModeling support and acceptance
38What else could it be? Disorders that may produce gender confusion SchizophreniaPsychotic depressionManiaEmergence in the context of trauma
39Common Issues for Trans* patients Lack of access to careInsurance issuesSocioeconomic issuesHomelessnessFoster CareViolenceBullying & harassmentHate crimesCommon 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
40Thursday, June 27, 2014Tiffany 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.
41Negative Health Outcomes Higher levels of family rejection during adolescence have been linked to negative health outcomes for GLBTQ youth
42Common Mental Health Issues Depression/Suicide> 8 times as likely to attempt suicide6 times as likely to be depressedAnxietyEating and body image issuesSubstance abuse> 3 times as likely to use drugs2 times as likely to use tobaccoSexual 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
43Other Common Health Concerns Overweight and ObesitySexual Health IssuesViolence and abuse – 3 XEarly sexual debut – 3 XMultiple sex partners - > 2 XSexually Transmitted InfectionsHigher HIV rates – 4 XUnintended Pregnancy - > 2 XIn 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
44Don’t forget! They can still be normal teenagers!
46Defining Gender Expansive Do you consider yourself male, female, transgender or other gender (e.g., genderqueer or androgynous)?MaleFemaleTransgenderI prefer to identify as: (Specify) ________________________Decline to answer66%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
47Gender-related questions CDCNatal GenderCurrent GenderTeen Health Center MethodDo 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.
48What to do if someone comes out Be cautious in offering guidance which may be construed as encouragement to come outYouth are the best judges of how their families may reactOffer general support, make referrals and be available for future advice or assistance
54Evidence - and Consensus - Based Practices Endocrine Society’s Clinical GuidelinesEndocrine Treatment of Transsexual Persons2009World Professional Association for Transgender Health (WPATH)Standards of Care for the Health of Transsexual, Transgender & Gender-Nonconforming People2012American Psychiatric Association (APA)Report of the APA Task Force on Treatment of Gender Identity Disorder2011
55Children Optimal approach is controversial No randomized controlled trials (RCTs)Highest level of evidence is expert opinionOutcome – without treatment – a minority will identify as transgender in adulthoodUnable to differentiate at a young ageNo follow-up data have demonstrated that any modality of treatment has a statistically significant effect on later gender identity
56Overarching Goal of Treatment Optimize psychological adjustment and wellbeing of the childWhat does this mean?Minimize gender atypical behaviorPrevention of adult transsexualism
57Approaches 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
59Consensus Recommendations for Children Accurate diagnosisDiagnosis and treatment of coexisting psychiatric conditionsIdentification of mental health concerns in caregiversProvision of psychoeducation and counseling about the full range of treatment optionsProvision of age-appropriate information to the childAssessment of safety – family, school, community
60Adolescents 2 Groups Recommendation for staged gender transition Persistence from childhoodOnset in adolescence – more psychopathologyRecommendation for staged gender transitionSocial transition – real life experience (RLE)Puberty blockersGender Affirming hormonesNo RCTs, case reports and studies without control groups
61Adolescents Long-term trajectory is more predictable For adolescents who underwent pubertal suppression, all have continued on to gender-affirming hormones and/or surgeryRare for adolescents to regret gender transition
62Consensus Recommendations for Adolescents Accurate diagnosisDiagnosis and treatment of coexisting psychiatric conditionsPsychotherapy and provision of support prior to and during transitionAssessment of readiness for puberty blockers and/or gender affirming hormonesProvision of psychoeducation to familiesAssessment of safety – family, school, community
63Psychological and Social Interventions Help families be supportive of their childFocus on reduction of distress related to gender dysphoria and other psychosocial difficultiesFormal evaluations of different psychotherapeutic approaches have not been publishedReparative therapy is not effective, not ethical
64Psychological and Social Interventions Help families manage uncertaintyDo not impose a binary view of genderSupport families in making difficult decisionsExtent the child is allowed to express their gender roleWhen to inform othersWho to inform
66What Are We Doing? Patient and family support & resources Interacting with schools and communitySAFE letterMenstrual suppressionPuberty blockersGender-affirming hormonesAssisting with transition
67What Do We Need From You? Assessment of gender dysphoria Family counseling and supportive psychotherapy to alleviate distress related to gender dysphoriaAssess and treat any coexisting mental health issuesRefer to us for physical interventions, resources and supportWPATH Standards of Care, Version 7, 2012
68What Do We Need From You? Letter of support Diagnosis of gender dysphoriaPatient is psychologically stable
70Transgender Clinic Division of Adolescent & Transition Medicine Ages 5 to 24LocationsMain CampusLibertyNorthern KentuckyMultidisciplinary Clinic - QuarterlyPediatric EndocrinologyPediatric & Adolescent Gynecology
71Resources for Families Family Acceptance Project - familyproject.sfsu.eduTrans Youth Family Allies -Human Rights Campaign –PFLAG –GLSEN –Advocates for Youth –
72Resources for Providers Human Rights Campaign –LGBT Cultural CompetenceGLMA: Health Professionals Advancing LGBT Equality –Cultural Competence WebinarsAdvocates for Youth -Publications for working with LGBT youthPhysicians for Reproductive Health – prh.org
73Post-Test Question #1Transgender 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
74Post-Test Question #2What 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 femaledepending on how they are dressed.5. It does not matter what their gender is.