Transcript Document

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
Disclosures and Conflicts of Interest
• Dr. Conard has no relevant financial
relationships to disclose or conflicts of
interest to resolve.
Pre-Test Question #1
Transgender teens have higher rates of this
than the general population?
1.
2.
3.
4.
5.
Congenital Adrenal Hyperplasia
Irritable bowel syndrome
Personality disorders
Polycystic Ovary Syndrome
*Suicide attempts
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.
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
Road Map
Trans* 101:
Gender & Sexual Identity
http://itspronouncedmetrosexual.com/
Trans* 101: Terminology
• Trans*
• Transgender
• Gender
Nonconforming
• Transsexual
• MTF
• FTM
BACKGROUND
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%
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):1413-23
Coming Out –
Gender Variant / Transgender
Mean,
(Age Range)
Biological
Female
Biological
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)
Patients
GeMS Clinic, Children’s Hospital, Boston
Spack, Pediatrics, 2012
Coming Out in Cincinnati –
Gender Variant / Transgender
Mean,
(Age Range)
Biological
Female
Biological
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)
Patients
Cincinnati Children’s Hospital Medical Center
July, 2013 – September 2014
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
PATIENT ASSESSMENT
Gender Police?
SAFE ENVIRONMENT
Ask preferred name and pronouns: Use them!
NATIONAL LGBT HEALTH EDUCATION CENTER:
A PROGRAM OF THE FENWAY INSTITUTE
“What to do? What to do?”
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
HISTORY-TAKING
Presentation
• May present at various ages
– Prepubertal
– Peripubertal
– Adolescence
– Adulthood
• May be fluid
• Increasing in number
– Open recognition of gender minorities
Laverne Cox – Orange is the New Black
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
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
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
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
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
Child Development
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
CONSISTENT
PERSISTENT
INSISTENT
Preexisting Psychiatric Diagnoses
• Mood disorders (12-35%)
• Anxiety (16-24%)
• Suicidal ideation and
self harm (9-22%)
• Suicide attempts (9%)
Adolescents
•
•
•
•
May start to identify at puberty
Very difficult time
Ask about gender identity
High rates of self harm and suicidality
(40%)
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
What else could it be?
• Disorders that may produce gender
confusion
– Schizophrenia
– Psychotic depression
– Mania
– Emergence in the context
of trauma
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
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.
Negative Health Outcomes
• Higher levels of family rejection during
adolescence have been linked to
negative health outcomes for GLBTQ
youth
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
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 2011 60(7):1-133
AFFIRMING CLINICAL
INTERACTIONS
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, 2012
Gender Expression
33%
Transgender
Other
66%
Gender-related questions
• CDC
– Natal Gender
– Current Gender
• Teen Health Center Method
– Do you consider yourself male, female,
both, somewhere in between or other?
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
What to do if someone identifies
as Trans*
MENTAL HEALTH
TREATMENT PLAN
What our patients want
What our families want
What we all want
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
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
Overarching Goal of Treatment
• Optimize psychological adjustment and
wellbeing of the child
• What does this mean?
– Minimize gender
atypical behavior
– Prevention of adult
transsexualism
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
Social Transitioning
• Externally presenting in one’s authentic
gender
• Entirely reversible
• No long-term outcome
studies
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
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
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
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
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
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
WORKING WITH THE
TRANSGENDER TREATMENT
TEAM
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
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
What Do We Need From You?
• Letter of support
– Diagnosis of gender dysphoria
– Patient is psychologically stable
LOCAL AND NATIONAL
RESOURCES
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
Resources for Families
• Family Acceptance Project familyproject.sfsu.edu
• Trans Youth Family Allies www.imatyfa.org
• Human Rights Campaign – www.hrc.org
• PFLAG – www.pflag.org
• GLSEN – www.glsen.org
• Advocates for Youth –
www.advocatesforyouth.org
Resources for Providers
• Human Rights Campaign – www.hrc.org
– LGBT Cultural Competence
• GLMA: Health Professionals Advancing
LGBT Equality – www.glma.org
– Cultural Competence Webinars
• Advocates for Youth www.advocatesforyouth.org
– Publications for working with LGBT youth
• Physicians for Reproductive Health – prh.org
Post-Test Question #1
Transgender teens have higher rates of this
than the general population?
1.
2.
3.
4.
5.
Congenital Adrenal Hyperplasia
Irritable bowel syndrome
Personality disorders
Polycystic Ovary Syndrome
*Suicide attempts
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.
Questions?
October 13 - 17, 2014