The Medical Treatment of Transgender Youth
GeMS Program
Boston Children’s Hospital
Jeremi Carswell, MD
PUNS 9/8/16
I have no disclosures
except off label uses of
medications
1
Terminology
• Biological Sex (Natal): The gender a
person is assigned at birth
• Gender Identity: A person’s internal sense
of gender
• Transgender: Gender identity is not
aligned with biological sex.
• Cisgender: Gender identity is aligned with
biological sex.
Historically Speaking
• … the Hebrew Bible, when read in its
original language, offers a highly elastic
view of gender…In Genesis 3:12, Eve is
referred to as “he.” In Genesis 9:21, after
the flood, Noah repairs to “her” tent.
Genesis 24:16 refers to Rebecca as a
“young man.” And Genesis 1:27 refers to
Adam as “them.” -NYT Op/Ed M. Sameth 8/12/16
Ancient History
AGDISTIS
- Child of Zeus and Gaia
- Possessed both male and female
organs
- Wild, uncontrollable nature
DIONYSUS (Bacchus)
-Olympian God
-Androgynous
appearing
-2nd century
Ancient History
HERMAPHRODITUS
-Child of Hermes and Aphrodite
-fell in love with the nymph Salacis
-physical forms were merged into
androgynous god
“Jane”
• 11 year old assigned male; presents with
intense gender dysphoria
• History includes
– Intense dislike of ”boy’s” clothing
– Sitting to urinate
– Fights surrounding haircuts
– Desire to dress in sister’s clothing
10
What now?
•
•
•
•
Is this gender dysporia
Is this a ’phase’
Will it continue?
Do we ‘treat?
11
Gender Dysphoria
• DSM-V diagnosis
• Discomfort or distress caused by
discrepancy between the gender identity
and assigned sex
• Implication is that treatment will help
alleviate discomfort/distress
• Umbrella Term
Gender Dysphoria
• Diagnosis of Gender Dysphoria
– Who is qualified to make this diagnosis?
• A term that is becoming outdated?
13
SPECIAL FEATURE
Clinical Practice Guideline
Endocrine Treatment of Transsexual
Persons: An Endocrine Society Clinical
Practice Guideline
Wylie C. Hembree, Peggy Cohen-Kettenis,
Henriette A. Delemarre-van de Waal, Louis J.
Gooren, Walter J. Meyer III, Norman P. Spack, Vin
Tangpricha, and Victor M. Montori*
Columbia University and New York Presbyterian Hospital (W.C.H.), New York, New York
10032; VU Medical Center (P.C-K., H.A.D.-v.d.W.), 1007 MB Amsterdam, The
Netherlands; Leiden University Medical Center (H.A.D.-v.d.W.), 2300 RC Leiden, The
Netherlands; Andro-consult (L.J.G.) ChaingMai 50220, Thailand; University of Texas
Medical Branch (W.J.M.), Galveston, Texas 77555; Harvard Medical School (N.P.S.),
Boston, Massachusetts 02115; Emory University School of Medicine (V.T.), Atlanta,
Georgia 30322; and Mayo Clinic (V.M.M.), Rochester, Minnesota 55905
15
Guidance
• 1.1 We recommend that the diagnosis of gender identity
disorder (GID) be made by a mental health professional
(MHP). For children and adolescents, the MHP should
also have training in child and adolescent developmental
psychopathology. (1 ⊕⊕○○)
• 1.2 Given the high rate of remission of GID after the
onset of puberty, we recommend against a complete
social role change and hormone treatment in prepubertal
children with GID. (1 ⊕⊕○○)
• n.b. ⊕⊕○○ denotes “low quality evidence”
16
“Jane”
• “Jane has had an affirmed female gender
identity since a very young age. She
would dress up in girls' clothing and all of
her friends were girls growing up. In 4th
grade, she made a social transition, living
full-time as female.”
17
Worriers
• What do kids worry about
• What do parents worry about
• What do clinicians worry about
Kids
•
•
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•
•
•
•
•
•
•
What is wrong with me?
Did God make a mistake?
What will my friends think?
Is this feeling about gender or sexuality?
Will my family still love me? What if they don’t?
Will I be bullied? Teased? Killed? Kill myself?
What if I am wrong? How can I be sure?
What about my grandparents? Siblings?
Will I ever have a “normal” life?
Will I ever be able to transition? Pass?
Parents
•
•
•
•
•
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What is wrong with my child?
What did I do wrong?
How will I explain this to family and friends?
What if this is just a phase?
Is my child conflating sexuality and gender?
How can I keep my child safe from bullies, selfharm, suicide?
• How can I understand this from my religious or
cultural perspective?
• Will I ever accept this? What if I don’t?
• How do I know what the right thing to do is?
Providers
•
•
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•
•
•
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Do we know enough to make a recommendation?
What should we do with the gender fluid youth?
Who do we ‘rule out’ from treatment? Defer?
Is the child too young for an intervention?
What if we’re wrong?
What about brain development?
What about psychosocial maturity?
What if the child self-harms or kills themselves?
How can we treat with so little research?
A Little About Our Clinic
• GeMS: Gender Management Services
– Started in 2011 by Dr. Norman Spack
• First pedi/adolescent clinic in the USA
• Reliance on mental health
“With All Deliberate Speed”
24
The “Dutch Protocol”
Clinical management of gender identity
disorder in adolescents: a protocol on
psychological and paediatric
endocrinology aspects
Henriette A Delemarre-van de Waal and Peggy T Cohen-Kettenis
Amsterdam Gender Clinic, Departments of Pediatrics and Medical Psychology, Institute for Clinical and
Experimental Neuroscience, VU University Medical
Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
(Correspondence should be addressed to H A Delemarre-van de Waal; Email: [email protected])
GeMS Workflow
Patient makes initial contact
Team Meeting
t
h
e
a
r
p
y
Meeting with LICSW
Team Meeting
Meet with MD/NP
Team Meeting
Brief Psych Eval (Blockers) if
applicable
Full Psych Eval (if cross sex)
Feedback/MD or NP visit
Volume
New MH visits
MD visits
Jan – June 1 2014 95
Jan – June 1 2015 Roughly 120
(170 calls)
44
Jan - June 1 2016 127 (21 per
month)
49
June 1 – Sept 7
2016
26
79 (26 per month)
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A “How To”
PREPUBERTAL
PUBERTAL
1. Suppress puberty
1. +/- Suppress natal sex
hormones
2. Wait
2. Give cross sex
hormones
3. Give cross sex
Hormones
Gender Formation
Expressed
some
gender
dysphoria
in
childhood
Persists
6-23%
Desists
77-94%
Cohen Kettenis 2001, Zucker Bradley 1995
More likely to
be gay
Gender Formation
Expressed
some gender
dysphoria in
Adolescence
*
DeVries et al 2010
Persists
100%
*Referred to
gender clinic
and
commenced
treatment
31
Blockers
• Mimic the action of GnRH, diminishing
pulses of the GnRH
» a giant pulse
• Lupron
» Intramuscular, once a month-once every 3
months
• Supprelin LA
• Vantas
GnRH Agonists
“blockers”
35
3
6
Jane
• 2014: Initial Visit to GeMS
• Tanner 2 PH, testes 6 mL bilaterally
• Full psychological evaluation completed (4 hr)
• Blocker (histrellin) placed 1 month later
37
Male to Female (MtF)
• Goal: suppression of androgens and
secondary characteristics
• How?
– Progestins with antiandrogen activity
(spironolactone)
– GnRH agonist (“blocker”)
– ESTROGEN
4
MtF: Estrogen
• Oral
– Ethinyl Estradiol  increased risk of clotting +
not used
– 17-beta estradiol (Estrace)
• Transdermal (patch)
– Once weekly or twice weekly
• Injected (intramuscular)
– Not routinely used
6
Risks of Estrogen
• Irreversible infertility
– banking
• ? Contribution to depression
– May actually improve depression
•
•
•
•
? Effects on brain structures
No protection against STD
Breast Cancer
Clotting
41
MtF: Timetable
Effect
Onset
Maximum
Breast Growth
3-6 months
2-3 years
Decreased testicle size
3-6 months
2-3 years
Redistribution of body fat 3-6 months
2-3 years
Decreased muscle
mass/strength
1-2 months
1-2 years
Decreased body hair
growth
6-12 months
> 3 years
Decreased erections
1-3 months
3-6 months
8
Jane
• Continued in therapy with MH, seen/monitored q
4 months medically
– Testes decreased in size to 3-4 mL
• 2016
– Initiated CSH May 2016, currently ramping up
43
Female to Male (FtM)
• Goals:
– Breast minimization/avoidance
– Height
– Avoid periods
– Masculinization
12
Monitoring
• Every 2-3 months in the first year, 1-2
times/year thereafter
• What are we checking for?
– Testosterone
– Estradiol
– Electrolytes (if on spironolactone)
47
Outcomes
Before
Suppression
13.6 y/o
ASSESSMENT
At Initiation of Xsex hormones
16.7 y/o
ASSESSMENT
> 1 year before
SRS
20.7 y/o
ASSESSMENT
Findings
• Body Image
– Increased satisfaction (F>M) after SRS
• Psychological Functioning
– Improvement in global functioning and other
measures
– Transmen: decreased anxiety, anger,
externalizing
– Transwomen: slightly more symptomatology
Findings
• Objective Well Being
– 71% reported social transition easy
– 79% 3 or more friends
• Subjective Well Being
– NONE expressed regret during at any point
SUCCESS
If Only it Were this Easy
13
THANK YOU
• Organizers of PUNS
– Lorraine O’Grady and Christine Danielson
• GeMS
54
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“the expression of gender
characteristics, including identities,
that are not stereotypically associated
with one’s assigned sex at birth is a
common and culturally diverse human
phenomenon [that] should not be
judged as inherently pathological or
negative.”
WPATH Board of Directors Meeting, 2010