1. Substance Use in Transgender Individuals Myo Thwin Myint, M.D., F.A.A.P. Department of Psychiatry & Behavioral Sciences Department of Pediatrics Tulane University School of Medicine

2. Introduction Sex ◦ Biological indicators ◦ Males & females Gender ◦ Public lived roles ◦ Boy/man & girl/woman © Alcohol Medical Scholars Program2

3. When Mismatch Occurs Stigma Prejudice & discrimination Physical/sexual abuse/neglect Minority stress Psychological stress Mental health problems Alcohol & drug problems 3© Alcohol Medical Scholars Program

4. Outline Definitions Characteristics of transgender Psychiatric & substance use D/O Treatments 4© Alcohol Medical Scholars Program

5. Outline Definitions Characteristics of transgender Psychiatric & substance use D/O Treatments 5© Alcohol Medical Scholars Program

6. Gender Identity ♂ ♀ Alternative © Alcohol Medical Scholars Program6

7. Trans… Transgender: identity ≠ natal sex Transexual: undergone transition Transvestism: cross-dressing © Alcohol Medical Scholars Program7

8. Sexual Orientation Androphilia: to ♂ Gynephilia: to ♀ © Alcohol Medical Scholars Program8

9. Outline Definitions Characteristics of transgender Psychiatric & substance use D/O Treatments 9© Alcohol Medical Scholars Program

10. Gender Dysphoria (DSM-5) Children: 6+ for 6+ months ◦ Desire being other gender ◦ Cross-dressing ◦ Cross-gender roles in play ◦ Preference in toys of other gender ◦ Other gender playmates ◦ Rejection of typical natal gender toys ◦ Dislike of one’s sexual anatomy ◦ Desire for characteristics of other Must → distress/impairment 10© Alcohol Medical Scholars Program

11. Gender Dysphoria (DSM-5) Adol./Adults: 2+ for 6+ months ◦ Incongruence ◦ Desire to be rid of one’s sex characters ◦ Desire for other gender’s sex characters ◦ Desire to be other gender ◦ Desire to be treated as other gender ◦ Having feelings of other gender Must → distress/impairment 11© Alcohol Medical Scholars Program

12. Gender Noncomformity Not = gender dysphoria Gender conformity: Behavior/appearance as society expects Gender nonconformity: Acting gender atypical by society © Alcohol Medical Scholars Program12

13. Gender Noncomformity Not indicative of sexual orientation Can apply to people w/o distress Varies w/ time & place © Alcohol Medical Scholars Program13

14. Gender Dysphoria Only some transgender individual At times of significant distress Related to gender incongruence © Alcohol Medical Scholars Program14

15. Diversity, Not Pathology © Alcohol Medical Scholars Program15

16. Prevalence 0.01% natal ♂ 0.003% natal ♀ © Alcohol Medical Scholars Program16

17. Course: Persisters 30% natal ♂ 50% natal ♀ Predictors ◦ Intensity of early dysphoria ◦ Seen in adolescents © Alcohol Medical Scholars Program17

18. Course: Desisters Natal ♂ ◦ Androphilic attraction ◦ Self identify as gay/homosexual Natal ♀ ◦ Gynephilic attraction ◦ Self identify as lesbian © Alcohol Medical Scholars Program18

19. Course: Late Onset Natal ♂ ◦ Transvestic behavior ◦ Gynephilic attraction ◦ Self identify as lesbian post transition Natal ♀ ◦ No transvestic behavior ◦ Androphilic attraction ◦ Self identify as gay post transition © Alcohol Medical Scholars Program19

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21. Differential Diagnosis Gender roles noncomformity: ◦ Tomboyism ◦ Girly-boy Transvestic disorder (D/O) ◦ Cross dressing for sexual excitement ◦ Causes distress/impairment © Alcohol Medical Scholars Program21

22. Differential Diagnosis Body dysmorphic D/O ◦ Thinking body parts are not well-formed ◦ Focusing on alteration/removal Schizophrenic & other psychotic D/O ◦ Hearing voices/paranoia ◦ Rare to have gender delusion only © Alcohol Medical Scholars Program22

23. Outline Definitions Characteristics of transgender Psychiatric & substance use D/O Treatments 23© Alcohol Medical Scholars Program

24. Prevalence: Any Psych. Dx 70% Lifetime 40% Current © Alcohol Medical Scholars Program24

25. Prevalence: Suicide © Alcohol Medical Scholars Program25 W/ MDD Trans- gender General population Ideation60%40% Attempt30%10%

26. Prevalence: Psych. Dx © Alcohol Medical Scholars Program26 D/O Trans- gender General population Social anxiety 7%

27. Prevalence: Psych. Dx © Alcohol Medical Scholars Program27 D/O Trans- gender General population Social anxiety 45%7%

28. Prevalence: Psych. Dx © Alcohol Medical Scholars Program28 D/O Trans- gender General population Social anxiety 45%7% Major depressive 7%

29. Prevalence: Psych. Dx © Alcohol Medical Scholars Program29 D/O Trans- gender General population Social anxiety 45%7% Major depressive 26%7%

30. Prevalence: Psych. Dx © Alcohol Medical Scholars Program30 D/O Trans- gender General population Social anxiety 45%7% Major depressive 26%7% PTSD9%

31. Prevalence: Psych. Dx © Alcohol Medical Scholars Program31 D/O Trans- gender General population Social anxiety 45%7% Major depressive 26%7% PTSD13%9%

32. Prevalence: Substance Use © Alcohol Medical Scholars Program32 Trans- gender General population Cocaine40%15%

33. Prevalence: Substance Use © Alcohol Medical Scholars Program33 Trans- gender General population Cocaine40%15% Meth> 40%5%

34. Prevalence: Substance Use © Alcohol Medical Scholars Program34 Trans- gender General population Cocaine40%15% Meth> 40%5% IV drugs40%25%

35. Prevalence: Substance Use © Alcohol Medical Scholars Program35 Trans- gender General population Cocaine40%15% Meth> 40%5% IV drugs40%25% Tobacco70%20%

36. Outline Definitions Characteristics of transgender Psychiatric & substance use D/O Treatments 36© Alcohol Medical Scholars Program

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38. Physical Rx: Hormones Estrogen for ♂ → ♀ Testosterone ♀ → ♂ Suppressors to block puberty High rate of use w/o supervision 38© Alcohol Medical Scholars Program

39. Physical Rx: Hormones Possible side effects ◦ Hypomania/mania ◦ Psychosis Interactions w/ substance use ◦ Smoking + estrogen → risk of clot ◦ Smoking + testosterone → risk of heart disease 39© Alcohol Medical Scholars Program

40. Physical Rx: Surgery Irreversible Only 1-2% regret Improves dysphoria sx & psych fxn 40© Alcohol Medical Scholars Program

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42. Psychotherapy Explore identity, role, expression Address negative impact Alleviate internalized hatred Enhance support Improve body image Promote resilience 42© Alcohol Medical Scholars Program

43. Psychosocial Rx Voice & communication therapy Hair removal Learn to dress as identified gender 43© Alcohol Medical Scholars Program

44. Rx Barriers Discrimination Hostility & insensitivity Strict binary gender segregation Lack of group acceptance 44© Alcohol Medical Scholars Program

45. Primary Care Pediatricians Family Medicine Internists Coordinating care 45© Alcohol Medical Scholars Program

46. Mental Health Assess comorbid diagnoses Monitor psychiatric sx 46© Alcohol Medical Scholars Program

47. Other Rx Specialists Endocrinologists Urologists Gynecologists Plastic surgeons © Alcohol Medical Scholars Program47

48. Rx Outcomes 80% w/o gender dysphoria 75% ↓ ↓ anxiety & depression 80%  quality of life 48© Alcohol Medical Scholars Program

49. Summary Be familiar w/ changing terms Being transgender not = pathology Dysphoria needs interventions Higher rates of psychiatric diagnosis Be mindful of Rx barriers 49© Alcohol Medical Scholars Program

50. Resources World Professional Association for Transgender Health (www.wpath.org)www.wpath.org Center of Excellence for Transgender Health (www.transhelath.ucsf.edu)www.transhelath.ucsf.edu American Psychiatric Association (www.psych.org)www.psych.org American Academy of Child & Adolescent Psychiatry (www.aacap.org)www.aacap.org American Academy of Pediatrics (www.aap.org)www.aap.org 50© Alcohol Medical Scholars Program

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