Transcript A Dream too Far Transgendered Individuals and the Medical Community A Presentation to the OHSU Physicians Assistant Program July 27, 2005 11/7/2015 Sara Kristine Becker, MD.

A Dream too Far
Transgendered Individuals and the
Medical Community
A Presentation to the OHSU
Physicians Assistant Program
July 27, 2005
11/7/2015
Sara Kristine Becker, MD
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Metamorphosis

“The past is but the beginning of a beginning and all that
is and has been is but the twilight of the dawn”
H. G Wells
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Sara Becker, MD
Sara Kristine Becker is a board certified Family Physician who has practiced
Family Medicine and Obstetrics in Portland, Oregon for 24 years. She obtained
a Bachelors of Science in Computer Science at Michigan State University where
she taught for two years. She graduated from the University of Michigan
Medical School with her MD Degree in 1977. Her residency in Family Medicine
was completed in 1980. She started her practice in Milwaukie, Oregon in 1980.
She is a Diplomat of the American Board of Family Practice and an Associate
Clinical Professor of Family Practice at Oregon Health Sciences University in
Portland, Oregon. She is a licensed multiengine; instrument rated commercial
pilot and an Aviation Medical Examiner for the Federal Aviation Administration.
Her hobbies are flying, computers, piano, guitar, growing orchids, walking, and
teaching.
Her professional interests are general Family Medicine, Aviation Medicine, and
hormone replacement therapy. She is a member of the Harry S. Benjamin
International Gender Dysphoria Association, the Oregon Academy of Family
Medicine, the Oregon Medical Association, the American Academy of Family
Physicians, and the Civil Aviation Medical Association. She is on the Active Staff
of Providence Milwaukie Hospital an the Courtesy Staff of Portland Adventist
Medical Center.
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To Change Ones Gender
Oddity, perversion or fact of nature
 Frequency
 Why is it important for health professionals to
understand gender change or transsexualism in
Human Beings
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Jurassic Park
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Finding Nemo
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Sex and Gender
The genetics of sex
 The biochemical expression of sex
 The variability of nature
 The difference between sex and gender
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The Variability of Nature
Many different types of expression of sex.
 Over 17 known intersexed conditions in Humans.
 Some are genetic others biochemical
 Understanding this variation may form the basis
for transsexualism.
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The Genetics of Gender
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The Y Chromosome is the key
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The Genetic Expression of
Sex
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The biological pattern in humans is female
The Y chromosome triggers the release of chemicals
which inhibit the formation of female structures and
instead produces male structures 1/3 size of X
Arose after split between chimps and humans
60 genes produce the male testis and exist in multiple
copies of the gene. The SRY and ZFY direct chain of
masculinization.
Y chromosome only one that self corrects
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The Genetic Expression of
Sex
Prior to six weeks the rudimentary reproductive
systems in human fetuses appear identical.
 At 6-7 weeks the gonads differentiate into
testicles that produce testosterone in XY
individuals
 Absence of testosterone causes the Mullerian
ducts to develop into female genitalia
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The Genetic Expression of
Sex
Between six and twelve weeks of pregnancy in an
XY fetus, testosterone and its derivative
dyhydrotestosterone promotes masculinization of
the genitals and produce a penis and testicles
 Absence of the above produces the clitoris and
labia,
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The Biochemical Expression of
Sex
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The Genetic Expression of
Sex
Between 0.1% and 2.0% of individuals develop
atypical sexual differentiation.
 Some are intersexed. Others are developmental
anomalies
 There are genetic variations such as XXX, XXY,
XYY, XO as well
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The Biochemical Expression of
Sex
Effects on the Hypothalamus (behavior)
 Hoch 8 genes
 Estrogen plays no role in fetal development.
Females develop because of an absence of
testosterone not the presence of estrogen

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The Biochemical Expression of
Sex
The genes on the chromosomes produce enzymes
that moderate masculinization.
 Deficiencies of certain enzymes such as 5 areductase deficiency and 17b hydroxysteroid
dehydrogenase deficiency produce female like
genitalia in XY (male) infants because there is a
lack of dihydrotestosterone required for external
male genitalia
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The Biochemical Expression of
Sex
At puberty, these genetic males but in appearance
females often masculinize.
 In one study of 18 individuals with this defect
raised as girls, 17 rejected the female role and
adopted a male gender. This is a contradiction of
rearing producing gender behavior
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The Biochemical Expression of
Sex
Guevodoces
 “Penis at 12”
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The Biochemical Expression of
Sex
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Congenital adrenal hyperplasia makes genetic
females appear as males. This is often
associated with increased male behavior.
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The Biochemical Expression of
Sex
“A Sex Difference in the Human Brain and its
relationship to Transsexuality” 1998, Nature
378:68-70 Zhou J, et al.
 “Male-to-Female Transsexuals Have Female
Neuron Numbers in a Limbic Nucleus, 2000, J
Clinical Endocrine Metab 85(5):2034-41
 John and Joan
 Finger length
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The Biochemical Expression of
Sex
This suggests that gender identity may evolve
independent of genitals
 Transmen (F2M) and Transwomen (M2F)tend to
be left handed more than their age and gender
matched “normal” controls. (Green and Young,
2000) (Zucker 2001)
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The Variability of Nature

“In sum, gender identity is, whether consistant or
inconsistant with other characteristics may be
understood to be “much less a matter of choice
and much more a matter of biology” (Coolidge
2000) The scientific evidence supports the
paradigm that transsexualism is strongly
associated with the neurodevelopment of the brain
(Zhou 1995)
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The Biochemical Expression of
Sex
For more info consult
http://www.gires.org.uk

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The Difference Between Sex and
Gender
Sex is the physical expression of genes.
 Gender is the concept of how one relates to
another in society (masculine vs feminine) and
self perception.
 The organic basis of gender identity may be a
reflection of hormonal effects in utero
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Gender Identity Dysphoria
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Considered to be a birth defect
Born with the body of one sex and the brain of another
The disparity between body and mind produces
depression which often becomes overwhelming
Most likely related to intrauterine hormone exposure but
true causes are unknown
Considered throughout the civilized world as a medical
condition not a psychiatric one
The German Prisoner
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Gender Identity Dysphoria
Transsexualism (Christine Jorgenson)
 History
 Incidence .2 to 1.0% (true incidence is unknown)
 Males to Females (M2F) or MTF
 Females to Males (F2M) or FTM
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Gender Identity Dysphoria
Who you are
 Who you love
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The Farthest Journey
A Journey too Far
 A Trip from one existence to another
 How long does it really take?
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Feelings and Memories
Of Mind and Thought
The Deep Feelings
The Bedtime Prayer
Living “The Lie”
The False Construct
Puberty the “Treason of the Body”
The Wakening Dream
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The Shell Cracks
The pain of not being--?relation to testosterone
 The emergence of Gender Identity Dysphoria
 The Ultimate Dilemma
 Addressing the mirror
 The spiral downward
 Facing the end of being or a new being in the end
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The Shell Cracks
Gender Identity Disphoria is a situational
depression.
 It cannot be cured with drugs, therapy, or prayer
 Dysphoria means difficult to bear in Greek
 Some patients become acutely suicidal when the
feelings cannot be contained and they face a loss
of all they hold dear knowing the stigma of
changing gender
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From “True Selves “ by Mildred
Brown
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Gender Identity Dysphoria
Since the mind cannot be changed, the body must
be changed
 In modern therapy, no attempt is made to cure the
transsexual. Rather, options are explored
 Some exist living part-time in the gender of their
mind. Most seek to transition
 Our society is not geared for us to live “In
Between”
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Symptoms of GID
A situational depression
 Drugs and Alcohol abuse
 Devotion to profession, military commitment
 To transition or not-endless rumination
 The price of truth
 Mildred Brown
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The Harry S. Benjamin International
Gender Dysphoria Association
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The Harry S. Benjamin International
Gender Dysphoria Association
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The Harry Benjamin International Gender Dysphoria
Association, Inc. (HBIGDA) is a professional organization
devoted to the understanding and treatment of gender identity
disorders. There are approximately 350 members from around the
world, in the fields such as psychiatry, endocrinology, surgery,
psychology, sexology, counseling, sociology, and law.
HBIGDA provides opportunities for scientific interchange among
professionals through its biennial conferences and publications. It
develops and publishes Standards of Care for the treatment of
gender identity disorders. These internationally accepted
guidelines are designed to promote the health and welfare of
persons with gender identity disorders.
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Treatment of Gender Identity
Dysphoria
The Harry S Benjamin International Gender Identity
Dysphoria Association provides:
 Certification and guidelines for counselors who treat
transsexuals
 Provide guidelines for cross gender hormone therapy
 Provide guidelines for gender reassignment surgery
(sex change surgery)
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The Harry S. Benjamin International
Gender Dysphoria Association
•Establishing Standards of Care for Gender Identity Disorders
•HBIGDA has established internationally accepted Standards of Care
(SOC) for the treatment of gender identity disorders.
These standards are updated and revised as new scientific information
becomes available.
The latest revision, SOC Version Six, was released February 20, 2001.
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“Transition”
To change ones body and mind image to the gender
Opposite to the cage one is born to.
To learn to relate in society as one of the opposite
Gender.
The process of “Becoming” or “Transitioning”
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Transition
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To actively transition requires skilled counseling,
emotional support, and intense planning.
This is an illness that does not favor the illiterate,
the impoverished, or the ignorant.
 It does favor the mind that can plan and write.
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Steps in Transition
Counseling
 Electrolysis or Laser to remove the beard
 Hormone Therapy to change the body
 The Real Life Test
 Surgery
 Beyond
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To Find a Chiron
The importance of the therapist who is skilled in
treating transsexualism
 What am I?
 How do I adjust to what I am?
 How do I make myself understood?
 How do I forgive myself to not being “fixable”
 How do I deal with so many others
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Counseling
It is critical to find a therapist that will work with
to provide the feedback and support to succeed.
 Must be familiar with the Harry S. Benjamin
International Gender Dysphoria Association
 Finding the right one
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Issues of Transition Dealt with in
Counseling
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Timing of transitioning
Hormone therapy
Informing spouses
Informing children
Informing friends
Informing relatives
Job preservation
Survival
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The Role of the Therapist
Weighing the options
Timing
No attempt to cure
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First Visit
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Patient fear
Shame
Guilt
Depression
Loss—”Be prepared to lose everything and anything you
keep is a gift”
The friend
The professional
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The First Believer
A close friend– one who will be accepting and can
act as a mirror for the new being
 Trust
 Availability
 Sharing the burden.
 Jesus started with only 12
 The “Mole”
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Educating Others
Being a transsexual means that one wishs to
change how one relates to others in society as a
member of the other gender. It does not mean one
is gay, trying to deceive others or that this is a
“life choice” Rather it is the way one has always
been.
 Mildred Browns book “True Selves”
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Educating
Dozens of people—dozens of feelings
 People basefeelings on their own life experiences,
moral and religious beliefs
 Not beneficial to out to large groups
 The advocate
 Education of the masses
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Issues of Transition
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Electrolysis
Hormone therapy
Preserving hair –Rogaine, Finasteride, Avodart
Voice
Walking
Mannerisms and clothing
Physical changes
Legal changes
Work
Surgery
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Issues of Transition
Economics
 Male to female $20,000-$100,000
 Female to male $10,000 (top) to $100,000
 Loss of job (70% of professional Ts in San
Francisco are unemployed)
 Physicians most likely to be fired
 Divorce
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Hormones
It is the human sex hormones which shape the
clay that becomes the being.
 Human beings are not fixed permanently into one
gender or another.
 To a great degree, feminization and
masculinization can occur in the same body at
different stages of life.
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Hormone Therapy
Estrogen to change the body to a feminine form
and soften the skin in M2F
 Antiandrogens to block testosterone so the
estrogen can work in M2F
 Testosterone injections to change female forms to
male
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Hormones
We all go through this process once.
 It is called puberty.
 It takes five to seven years the first time.
 It is not any faster the second time.
 To transition one must reverse the effects of the
first puberty as well as let the second occur.
 Higher hormone doses do not speed the process
but do increase risks and side effects.
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The Harry S Benjamin Standards
of Care
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Reasons for hormone therapy. Cross-sex hormonal treatments play
an important role in the anatomical and psychological gender
transition process for properly selected adults with gender identity
disorders.
Hormones are often medically necessary for successful living in
the new gender. They improve the quality of life and limit
psychiatric co-morbidity, which often accompanies lack of
treatment. When physicians administer androgens to biologic
females and estrogens, progesterone, and testosterone-blocking
agents to biologic males, patients feel and appear more like
members of their preferred gender.
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The Harry S Benjamin Standards
of Care
The individual must be known to a clinical
behavioral scientist for at least three months and
that provider should endorse the patients request
for hormone therapy with a letter.
 Clinical departures from these guidelines may
come about because of a persons unique
anatomic, social, or psychological situation.
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Effect of Hormones
Physical changes
 Mental changes
 Emotional changes
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Estrogen in M2F
Conjugated estrogens (Premarin, Ogen) 0.625 to
7.5 mg.
 Ethiny Estradiol (Estinyl) .02 to2.0.
 Estradiol (Estrace) 0.5 to 6.0mg.
 Estradiol Transdermal (Fempatch, Alora, Climara,
Estraderm) .1 to .2.
 Delestrogen () 40 mg q 2 weeks.
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Antiandrogens
in M2F
Block the production and effects of testosterone.
 Use allows a lower dose of estrogen to produce
the same feminization but reduce the risks of
estrogen.
 Many different kinds but many are expensive.
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Antiandrogens
in M2F
Spironolactone (Aldactone) 100-400 mg.
 Very effective at blocking testosterone, both
synthesis and at a receptor level.
 Side effects are- breast swelling, GI upset,
drowsiness, headache, rash, confusion, fever,
decreased libido, vomiting, balance problems,
fever, elevated potassium.
 Very useful to measure free testosterone levels.
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Complications MTF
Cancers 2%
 Myocardial Infarction 2%
 Osteoporosis 1%
 Total Serious complications 5.4%
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Typical Hormone Levels
• Estradiol male 0.30-0.90 pg. /Ml. (Total)
• Free Estradiol (1.66-2.11%) .10-.50 pg./Ml
• Estradiol female 20-450 pg./Ml. (Total)
• Free Estradiol (1.49-2.85%) or .60-4.10 pg./Ml
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Typical Hormone Levels
• Testosterone male 260-1000 ng./Ml. (Total)
• Free testosterone % (1.0-2.7%) or 50-210 pg./Ml
• Testosterone female 15-70 ng./Ml. (Total)
• Free testosterone % (0.5-1.8%) or 1.0-8.5 pg./Ml
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Typical Hormone Therapies in F2M
• Testosterone Cypionate 100 mg IM weekly or 200
mg. every two weeks
• In Portland, often bought at Stroheckers
pharmacy
• Cannot give testosterone orally because of liver
toxicity
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Steps Before Initiating Hormone
Therapy
The DSM IV criteria
 The Harry S. Benjamin standards
 Physical exam
 Laboratory tests
 Contraindications for therapy
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Side Effects of Estrogen on
Genetic Males
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Excessive breast tenderness or discharge
Pituitary tumors and Hyperprolactinemia
Thromboembolic events (particularly first year of HRT)
High blood pressure
Breast cancer
Decreased libido, loss of erections, infertility
Depression or mood disorder
Loss of muscle mass (leg cramps, 30% loss of strength)
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Side Effects of Testosterone on
Females (F2M)
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First changes are deepening of the voice in about 1-3
months
Periods cease within 1-2 months (titration) with IM shots
Cream takes 6-8 months
Facial hair develops in 6-24 months and may take five
years to maximize. Highly individual results
Acne develops in 2-4 months
Skeletal structure does not change (???)
Breast size does not change
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Side Effects of Testosterone on
Females (F2M)
Muscle mass increases about 30%, reduces fat
and redistributes fat to male pattern
 Facial Changes
 Effects on bone
 Effects on skin
 Psychological effects—”Roid Rages”
 Neurologic effects-
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Changes on Testosterone in FTM
Cliteromegaly-seems to occur very early
 Length is 1.5 to 2.5 inches
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History and Physical Examination
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Must be done to look for preexisting medical conditions
which would complicate or preclude hormone therapy
After hormone therapy is instituted, regular visits should
be carried out at three to six month intervals to look for
complications and adjust doses
Insurances sometimes will cover this as hormone
replacement therapy
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Contraindications for Hormone
Therapy
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Strong family history of breast cancer in first degree
relatives or presence of breast cancer in genetic males
Uncontrolled high cholesterol in genetic females
Strong family history of osteoporosis in genetic females
Extreme obesity
Coexistent mental illness, particularly uncontrolled
depression
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Contraindications for Hormone
Therapy—Caveats for the Patient
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Usually with good medical care and treatment of
underlying illness, hormone therapy can be started.
Honesty is very important in dealing with the physician.
The physician is not the enemy.
He or she is your best ally to get where you want to go to
and to arrive safely.
Achieving your dream is not satisfying if you are dead or
stroked out.
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Long Term Effects of Hormone
Therapy
Thromboembolism (clotting abnormalities)
 Arteriosclerosis (heart disease)
 Osteoporosis (thinning of bones)
 Cancer
 Dementia
 Little actually known
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Complications MTF
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291 Males to Females ages 24 to 79
3 cases mild liver disease
4 cases of detected osteoporosis in MTFPO age 35-52
1 case of pulmonary embolus antithrombin 3 defect
1 case of death myocardial infarction age 49 smoker no
aspirin
1 case of death, MI, 1 wk after srs, smoker, ASA, patch
42
1 case of myocardial infarction age 52 during hair
transplant nonsmoker, no ASA
1 case during SRS Thailand prev smoker, no ASA
1 case Sudden death age 49 smoker not started HRT
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Complications MTF
1 case of prolactin secreting tumor
 2 cases of carcinoma of the throat
 1 case of small cell carcinoma lung
 1 case of malignant Melanoma
 1 case of invasive prostate cancer –10 years on 10
mg of Premarin
 2% incidence
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Complications FTM
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Females to males
2 cases of liver disease alcoholic suspect in one
No need to stop hormones
Increase in red cell mass in all test from HCT of about
38 to 50-52
No strokes, heart attacks or breast cancer
Frequent vaginitis
Acne
Three cases of sleep apnea (size 16 neck)
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Survival
Be flexible
 Support groups
 Churches
 Journal
 Internet
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Identification
The importance of proper identification
 The role of the therapist
 Drivers licenses
 Letter of passage
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Real Life Test
The real life test is the period of time that one
must work in the gender one is becoming
 With completion of the real life test, one can seek
the two letters for Gender Reassigment Surgery
(Sex Change Surgery)
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Real Life Test
Usually one year
 One has to work as the future gender
 Time off work for SRS
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Real Life Test
Difficult for individuals because of numerous
licensing agencies, insurance companies,
employers, prejudice
 Real life test is difficult especially for
professionals
 Loss of family, friends, home, life
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Facial Surgery
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Forehead
Nose
Upper lip
Chin—sliding genioplasty
Jaw
Tracheal Shave
Doug Osterhoud, MD
Electrolysis
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Sex Reassignment Surgery
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Sex Reassignment Surgery is the goal of many but not all
who are transgendered
Can be offered only after the real life test
Not an option for physicians with GID
There is a harmony in having your body match your
mind
Less fear of being “caught” in social situations
The two letters—MA, PhD., MD
Ten surgeons in the world
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Sex Reassignment Surgery in
Females to Males
Sex Reassignment Surgery in F2M usually limited
to Breast reconstruction “top surgery”
 Genital surgery limited
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In The End
After all of the above what is left?
 Time and experience
 Posttraumatic Stess Disorder—regret, loss
 Memories and reflections
 Dreams, feelings and thoughts become one
 To gaze on ones own countenance with peace
 To savor the milieu, to just live
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How long Does it Take
Range is 2 to 5 years
 Real answer is at least 5 years
 Probably a lifetime
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Importance
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Why is it important for Health Professionals to
understand transsexuals?
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Most Important
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It is not a choice of life, it is a biological imperative.
Individuals with this cannot make it go away. It is a pain
similar to what one feels in the death of a child. Often
face with loss of all they hold dear, transsexuals often
consider or attempt suicide. The transsexual is often an
individual of extraordinary courage.
It is not an attempt to deceive but to survive.
Who you are and who you love are different areas of the
brain. Over 30% male to female transsexuals stay with
their mate if they can.
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Why Is It Important For Professionals
to Understand Transsexuals
There are many of us--thousands
 We hide because of fear and prejudice
 We are 16 times more likely to be murdered
 We have the highest unemployment of any
minority group
 Not associated with any other mental or medical
condition
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Why is it Important For Professionals
to Understand Transsexuals
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Do we deprive the community of human beings because
we do not understand?
If a human were burned or paralyzed, would they be less
a human being?
Transition does not change the essence of a Human being
Would any Medical Professional deny a patient the only
internationally recognized treatment for a condition
because they do not themselves understand it.
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Why is it Important For Professionals
to Understand Transsexuals
The Health Professional may be the first outside
of the transsexual themselves to know what is
really happening.
 How you respond may influence the future of that
patient.
 Almost all transsexuals consider suicide when the
shell breaks. Estimates of 20% active attempt.
 Suicide without a letter
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Gender Dysphoria
A human being who survives this has a unique
perspective on both genders that can be helpful to
others
 You may be the only professional between a
successful transiton and suicide
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Gender Dysphoria
The Federal Aviation Administration is charged
with maintaining the safety of the public in
Aviation in the United States
 A Pilot who is diagnosed with Gender Identity
Disorder is not allowed to fly again until they
have fully transitioned to their new gender and
have had surgery. There is no other way back to
the cockpit.
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Resources
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Web Resources
annelawrence.com
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Web Resources
sarabecker/t/index.htm
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Web Resources
sarabecker/t/index.htm
[email protected]
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Questions?
He who asks a question is a fool for five minutes
He who fails to ask a question is a fool for life
Old Chinese Proverb
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Questions
A New Years Prayer
Dear Lord, please give me…
A few friends who understand me
and yet remain my friends
A work to do which has real value,
without which the world
would feel the poorer…
A mind unafraid to travel,
even though the trail be not blazed
An understanding heart…
A sense of humor.
Time for quiet silent meditation.
A feeling of the presence of God.
And the patience to wait
For the coming of these things,
with the wisdom to know them
when they come
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-W. R. Hunt.
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