Caring for Transgender Adolescent Patients Part 1: Initial Evaluation & PCP Perspective

1. Caring for Transgender Adolescent PatientsPart 1: Initial Evaluation & PCP Perspective

2. Objectives Differentiate natal sex, gender identity, gender expression & sexual orientation Describe spectrum of gender & sex Explain how bias & victimization create disparities Discuss systems issues that impact care Provide initial management strategies for appropriate & competent care

3. Case 1 Patient “ R “ • R is an 8 y/o natal male • During the visit, R’s parent expresses concern that • “Most of his friends are female.” • “He hates sports.” • “I caught him wearing his older sister’s clothes and make-up last week.” • “He loves to paint his nails.”

4. Case 1 Patient “ R “ • What is your initial reaction? • Are you concerned? • Should his parent be concerned?

5. Spectrum of Gender & Sex Female Male Natal Sex/Anatomy Female Male Gender Identity Masculine Feminine Gender Expression Attracted to Females Attracted to Males Sexual Orientation

6. Awareness of Gender Identity Between ages 1 and 2 —Conscious of physical differences between sexes At 3 years old —Can label themselves as girl or boy By age 4 —Gender identity stable —Recognize gender constant

7. Case 1 Patient “ R “ • You ask R’s mother if you can speak to R in private to ask • How he views his gender • Does he feel more like a boy or girl? • Does he have a preferred name? • How could his parents help? • How does he feel about parents’ concerns

8. Case 1 Patient “ R “ • R reports • Sometimes wishes he was a girl but prefers the pronoun “he” • Sadness that his mother is upset • Unsure what gender he would be if he could choose • He would like to play with girl things without feeling bad • What do you do next?

9. Case 1 Patient “ R “ • Explain to R & his mom that • Exploring gender roles & gender expression during childhood is common • R may or may not have gender identity concerns as he matures • Support from family is essential • Offer yourself as a resource

10. Spectrum of Gender and Sex Female Male Natal Sex/Anatomy ? Female Male Gender Identity Masculine Feminine Gender Expression

11. Case 2 Patient “K” • K is a 12 yro natal female brought in by her mother for mood & behavior concerns • As you explore these concerns, you learn • K identifies as male & gender expression is very masculine • K is distressed by onset of puberty & not sure what to do next

12. Transgender Umbrella term for individuals & communities A person whose identities do not conform unambiguously to conventional notions of male or female gender roles, but combines or moves between these two

13. Transgender Umbrella • Cross-dresser • Pre/post-operative • Intersex • Femme queen • Femme boi or Femme boy • Drag queen/king • Bi-gendered • Gender bender • Two-spirit • Stud • Gender queer

14. Identities and Transition

15. DMS IV Gender Identity Disorder (GID) • ICD 9 code 302.85 • Long standing • Strong identification with other gender • Disquiet about sex assigned • Sense of incongruity with sex role • Not physically intersex • Clinical discomfort & impairment with life activities

16. Epidemiology • 1994 DSM-IV American Psychiatric Association prevalence • 1:30,000 males • 1:100,000 females • 2009 review (Zucker & Lawrence) • Prevalence may be 3-8 x numbers reported in DSM-IV

17. Etiology • Etiology unknown likely multi-factorial • Possible causes • Genetic variations • Intrauterine hormonal exposure • Anatomical differences in brain structure & activation

18. Case 2 Continued Patient “K” 13 yro natal female with male gender identify & expression, distressed by onset of puberty K is interested in not having periods, looking as male as he can & has done some preliminary investigation of transgender What do you do next?

19. What Not To Do DON’T Interview with parent in room Assume name or pronoun Assume gender identity & expression correlate Disclose without patient’s consent Dismiss parents as a source of support Dismiss as a phase Refer for reparative therapy

20. Setting Up the Initial Assessment • Establish privacy • Ask mom to step out of room • Explain what can (& can’t) be kept confidential • Establish trust & rapport • Ask name & preferred pronoun • Ask goals of visit • Getting to know the person • General adolescent health assessment HEADDSSS • Leading into more detailed & sensitive history

21. Strength & Risk Assessment • Assess personal strengths, resources, goals • Assess social support & resources • Address risk taking or safety concerns • Mental health—depression, anxiety, self harm, suicide • Substance use/abuse • Sexual activity—STI & pregnancy prevention

22. Stigma & Bias Leads to Risk • Identifying as transgender is not in itself a mental health disorder • Social stigma is a problem • Familial rejection • Social isolation (friends, dating) • Fear of physical attacks • Mental health concerns for transgendered • Depression • Suicidality • Body image issues • Substance abuse

23. Gender Experience Long standing Uncomfortable/not id with natal sex Impairs ADLs • Review history of gender experience • Open ended encouragement “Tell me your story in your own words” • Ask about specific feelings, thoughts, behaviors, preferences • Parent may offer excellent insight into early childhood • Document prior efforts to adopt desired gender • Clothing, make up, play • Hormone use if any • Review patient goals

24. Case 2 Continued Patient “K” • Engage parent(s) to support their child • Explore parent’s concerns & priorities • Assess parental support & knowledge • Facilitate discussion & negotiations • Establish expectations for all stakeholders • Incorporate patient goals, with parent expectations, & management options

25. Case 2 Continued Patient “K” • Consider appropriate referrals to providers with experience in transgender care • Assess GID/gender non-conformity • Assess readiness for transition • Mental health provider • Assess/treat other mental health concerns • Medical provider • Assess & consent for hormonal management

26. Referrals & Seeking Specialized Care • Most mental health & medical providers will not have expertise in transgender health • Transgender health “specialists” • Variety of providers with experience &/or training in caring for transgender patients • Wide variety of disciplines, degrees, specialties

27. Case 2 Continued Patient “K” • Medical & mental providers confirm • GID • Benefit from delaying puberty or hormones • K’s mother is supportive • Are these recommendations in-line with national consensus and/or guidelines?

28. Treatment Guidelines GID • World Professional Association for Transgender Health (WPATH) • Adolescents may be eligible to begin masculinizing or feminizing hormone therapy as early as age 16, preferably with parental consent. • 6 months mental health professional involvement is an eligibility requirement for triadic therapy including real-life experience or hormone therapy http://www.wpath.org/documents2/socv6.pdf

29. Treatment Guidelines GID • Endocrine Society (2009) • Suppression of puberty at Tanner stage 2 • Treatment for youth <16 with GnRH analogues • Followed by cross gender hormone therapy age 16

30. Treatment Goals Improve quality of life by Facilitating transition to physical state that more closely represents the individual’s sense of themselves Experience puberty congruent with gender Prevent unwanted secondary sex characteristics reducing need for future medical interventions Avoid depression, risk taking Establish early, strong social support

31. Three Views on Treatment of GID in Adolescents • No treatment until 18 Full pubertal experience • Allow some experience of puberty • Until age 15–16 or Tanner 4 • Then start GnRH analogues or hormones • Gender identity stable, GID DSM criteria met • Start GnRH analogues Tanner 2 (age 12–13) • Initiate hormones several years later

32. Benefits of Early Treatment • If transgender identified pre/early puberty consider “blocking” puberty • GnRH effects fully reversible • “Buys time” & avoid reactive depression • Psychotherapy facilitated when distress eased • Prevent unwanted secondary sex characteristics • Reduces needs for future medical interventions

33. Phases of Transitioning

34. Beginning Hormonal Treatment • Assess readiness for transition • Physical (Tanner stage) • Psychological • Social • Review risks & benefits of hormone therapy • Differentiate between reversible & irreversible physical changes • Establish next steps for “real life” experience

35. Planning for Hormonal Treatment • Prescribing provider will establish • Informed consent • Reasonable goals, expectations • Baseline screening labs • Set up referrals &/or follow up • Provider & patient should establish • Disclosure when patient is ready • Sources of social support • Impact on school or work

36. Case 3 Patient “B” B is 16 y/o MTF kicked out by her mother’s boyfriend for being “gay” B presents as female B’s is new to you & present with chief complaint of “genital rash” What next?

37. Case 3 Patient “B” Home Education/ employment Activities Development/maturity Drugs Safety (P)sych Sexuality • Establish safety, trust, rapport • Evaluate problem patient wants help with • If time…begin HEEADDSSS assessment knowing health risks for transgender population HEADDSSS screen reveals • Victimization at home & school • Sex work with consistent unprotected anal (receptive) & oral sex • Depression, considered suicide in past • Substance use, meth & alcohol • Street hormones & silicone injection • Last HIV test one year ago

38. Sexual Health History • What are gender(s) of your partner(s)? • Have you ever had anal, genital, or oral sex? • Do you give, receive, or both? • How many partners have you had in past six months? • Do you use condoms …. never, some, most, all of the time? • Any symptoms of STIs…. For all identities & orientations

39. Risk Behaviors MTF Youth Garofalo R, et al J Adolesc Health 2006;38(3):230–6.

40. Risk Behaviors MTF Youth AIDS Behav. 2009 Oct;13(5):902–13.

41. Case 3 Continued Patient “B” • What immunizations? • Hepatitis A & B • HPV Given B’s sexual & drug history • HIV serology • Syphilis serology • NAAT urine GC/CT • Rectal GC /CT • Pharyngeal GC • Hepatitis C

42. Harm Reduction Counseling • Safer sex options • Facilitate condom use • Plan for STI testing • Support & survival • Housing/shelter/food referral • Vocational assistance • Substance abuse screen/counseling • Mental health screen/counseling • Close follow-up

43. Trans Survival… Barriers to Care • Loss of parental & familial support • Loss of housing, emotional & financial care • Lack of health care • Loss of insurance/ability to pay • Access, availability of health providers • Concerns re confidentiality, rights to care • Social stigma • Hostile or violent social environments • Mental health sequelae

44. Create a Trans-Friendly Environment Visible non-discrimination policy Staff training, openness Use preferred pronoun & name Transgender inclusive materials Unisex/Individual bathrooms Respect confidentiality, don’t “out”

45. Transgender Youth Part 1 Take Home Points • Children & youth may explore gender as well as sexual identity • Provider role • Assessing individual goals, needs, risks • Facilitating communication, support of family • Referrals for support & resources • Creating safe space for all youth

46. Caring for Transgender Adolescents Part 2: Understanding Medical Management & Providing Ongoing Primary Care

47. Sexual Orientation Gender Expression Sexual Behaviors Paradigm of Sexuality Gender Identity Biological/Natal Sex

48. Transgender Treatment Goals Improve quality of life by Facilitating transition to physical state that more closely represents the individual’s sense of self Experience puberty congruent with gender Prevent unwanted secondary sex characteristics reducing need for future medical interventions Avoid depression, risk taking Establish early, strong social support

49. Three Views on Treatment of GID in Adolescents • No treatment until 18 Full pubertal experience • Allow some experience of puberty • Until age 15–16 or Tanner 4 • Then start GnRH analogues or hormones • Gender identity stable, GID DSM criteria met • Start GnRH analogues Tanner 2 (age 12–13) • Initiate hormones several years later

50. Patient “K” • K is a13 yro natal female identifying as male with some male gender expression • Currently uses given name in most social situations • Would like to use pronoun “he” & male name • K, his parents, other members of his health care “team” agree • He is experiencing GID • His gender identity as male is stable • He would like to transition to male