Evaluation and Treatment of Gender NonConforming Youth
Jeremi Carswell, MD
I have no disclosures
except off label uses of
medications
1
Overview
• WHAT
– What is gender incongruence?
– What is gender dysphoria?
•
•
•
•
WHEN
WHO
WHY
HOW
3
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.
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
• 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 ⊕⊕○○)
• n.b. ⊕⊕○○ denotes “low quality evidence”
8
Overview
• WHAT
• WHEN
– When did this all this begin?
• WHO
• WHY
• HOW
9
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
11
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
Overview
• WHAT
• WHEN
• WHO
– Who is “real” and who is “going through a
phase”
• WHY
• HOW
14
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
• 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 ⊕⊕○○)
17
Overview
•
•
•
•
WHAT
WHEN
WHO
WHY
– Why do we treat children/adolescents the way
that we do?
• HOW
18
19
20
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])
22
Overview
•
•
•
•
•
WHAT
WHEN
WHO
WHY
HOW
– How do we do this?
– How does GeMS work (and a little history)
23
GENDER CHANGER
13
How?
• 1. Suppress Puberty
• 2. Wait
• 3. Give desired gender hormones (crosssex hormones)
25
Pop-Quiz on PUBERTY!
True or False:
1. The appearance of pubic hair = puberty
2. The first sign of puberty in a male is acne
3. The height spurt in females is an early event
of puberty
4. The average time between breast budding to
menarche is 2-3 years
26
Physical changes during puberty
27
28
The Hypothalamic-Pituitary-Gonadal
Axis
???
Hypothalamus
(+)
Gonadotropin-releasing
hormone (GnRH)
Pituitary
(+)
Luteinizing hormone (LH)
Follicle-stimulating hormone (FSH)
Ovary/Testis
29
Physiology
30
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
33
34
Male to Female (Transfemale)
• Goal: suppression of androgens and
secondary characteristics
• How?
– Progestins with antiandrogen activity
(spironolactone)
– GnRH agonist (“blocker”)
– ESTROGEN
4
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
37
Transfemale: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
Female to Male (Transmale)
• Goals:
– Breast minimization/avoidance
– Height
– Avoid periods
– Masculinization
12
Female to Male (Transmale)
41
Testosterone
• Typical dose: 50 mg SUBCUTANEOUSLY
weekly
• Cypionate vs. enanthate
42
Transmale: Timetable
Effect
Expected onset
Maximum
Skin oiliness/acne
1-6 months
1-2 years
Facial/body hair growth
3-6 months
3-5 years
Scalp hair loss
12 months
Variable
Increased muscle
mass/strength
6-12 months
2-5 years
Body fat redistribution
3-6 months
2-5 years
Cessation of menses
3-6 months
n/a
Clitoral enlargement
3-6 months
1-2 years
Vaginal atrophy
3-6 months
1-2 years
Deepened voice
3-12 months
1-2 years
43
“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
46
“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.”
47
Jane: physical exam
• 2014: Tanner 2 PH, testes 6 mL bilaterally
48
Digging deeper
•
•
•
•
•
Is this gender dysporia
Is this a ’phase’
Will it continue?
Do we ‘treat?
Do Nothing?
49
Jane
• Full psychological Evaluation performed
• Blocker placed
– Testes decreased in size to 3-4 mL
• Cross Sex Hormones started
– Initiated CSH May 2016, currently ramping up
50
A Little About Our Clinic
• GeMS: Gender Management Services
– Started in 2007 by Dr. Norman Spack
• First pedi/adolescent clinic in the USA
• Reliance on mental health
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
56
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; Androconsult (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
57
Volume
2016
(Jan-June)
Screenings 286
2015
2014
300
172
Evaluations 52* *by 12/31/16 48
13
incl mini, 24 on
wait list
59
“With All Deliberate Speed”
60
Worriers
• What do kids worry about
• What do parents worry about
• What do clinicians worry about
Kids
•
•
•
•
•
•
•
•
•
•
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
•
•
•
•
•
•
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
•
•
•
•
•
•
•
•
•
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?
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
THANK YOU
69
70
72