developmental approaches to caring for transgender
TRANSCRIPT
Developmental Approaches to Caring for Transgender & Gender DiversePediatric & Adolescent Patients
Michelle Forcier MD MPHProfessor Pediatrics, Alpert School of Medicine
Brown University, Providence RI
Here is What a Standard Slide Looks Like
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With bulleted text And sub bullets
Objectives
Discuss human development w gender perspective Discuss how patient centered, developmental paradigms to gender might
reduce bias and stigma that create disparities and lead to risks Provide initial strategies for appropriate and competent care Understand the role of providers in promoting culture changes that respect
diversity
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DisclosuresDISCLOSURES
• Consultant Planned Parenthood • Royalties Up To Date
• All medications off label• I am an optimist
Why Talk About Gender with Kids?
Professional responsibility AMA, AAMC, AAFP, AAP, SAHM, APA Recommend training on LGBTQIA health
Exclusion of coverage illegal in some states Lack of formal medical training no longer “good excuse”
Pediatric responsibility Anticipatory guidance & prevention Future planning Models & promotes diversity, equity for all children
5Reproductive Justice under the Social Justice Umbrella
CDC Behavioral Risk Factor Surveillance System (BRFSS) 2016National estimate transgender persons 0.6% =1.4 million Range 0.3% ND to 0.8% HI
Highest 18-24 versus older adults
This survey does not include < 18 youth
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Sexual Orientation and Gender Identity of Middle School Students
Shields JP, et al. “Estimating population size and demographic characteristic of LGBT youth in middle schools.” J Adol Hlth. 2013:248-50.
Transgender Gender Identity
1.3%
Non_Hetero Sexual Orientation
15.9%
Perpective: Gender Care is Primary Care
Patient Centered
Consent Based
Primary Care
Listen to our patients
Address patient identified needs, concerns, goals
100% of patients experience gender!!
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Reproductive Justice Framework:Intersectionality of Our Children’s Health Care Rights
1. Bodily autonomy2. Right to self determine3. Right for safe, healthy environment
with opportunity to develop potential
4. Responsibility for most marginalized
SisterSong 1997 … Especially fitting for children & adolescents
Developmental ParadigmGender, sexuality are universal, normalizedVariance is expected aspect of biology & human
developmentDiversity not = deviance but celebrated
Meet patient goals (nothing to “diagnose” or “treat”)Address, reduce minority stress
Advocate, empower ALL childrenModel, elevate cultural expectations
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Patient-centered
Consent-based
Developmental care
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~ 3 years oldCan label themselves as a girl or boy
Between ages 1 and 2Conscious of physical differences between sexes
Awareness of Gender Identity
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By age 4Gender identity relatively stable, recognize gender constant
All pre-pubertal children play with gender expression & roles
Passing interest or trying out gender-typical behaviors Interests related to other/opposite sex Few days, weeks, months, years
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Gender Play
Behaviors and expression may be nonconforming, but children can still feel they are in right-gendered body
Gender Diversity
Cross gender expression, role playing Wanting other gender
body/parts Not liking one’s gender &
body (gender dysphoria)
AgenderNon binaryRefuses to ascribe to
typical masculine or feminine assignmentsCan change, shift
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PersistentConsistentInsistent
DiverseFluid
Nonconforming
Are we doing our part?
Missed Opportunities for Screening & Identification2 Contemporary Pediatric Studies
Time spent talking about sexuality
35% spent ZERO time 30% spent 1-35 seconds 35% spent more than 36 seconds
Alexander SC et al. JAMA Pediatr. 2014 Henry-Reid Pediatrics 2010;125:e741-747.
How Often do Pediatricians Ask About Sexual Orientation During Adolescent Well Visits?
Where is gender???
Increasing Evidence
1. Early identification has known benefits >> potential risks
2. Parent & family acceptance offer critical protective factors Short & long term healthier outcomes
3. Child health professionals can improve early support & improve resources
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Who & When to “Screen”? All children! Developmental stages Opportunity for improving child/family
communication & support
Diverse or nonconforming gender expression
Concerns/problems with Mood Behavior Social
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Ask! Parent(s)
• Child play, hair, dress preferences
• Concerns with these
• Concerns with behavior, friends, getting along at school, school failure, bullying, anger, sadness, isolation, other?
Ask! Patient
• Do you feel more like a girl, boy, neither, both?
• How would you like to play, cut your hair, dress?
• What name or pronoun (he for boy, she for girl) fits you?
• What does it mean to be girl, boy, both, neither?
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Gender Screening “Tools”
Images taken from The Gender Book, are publically available on the book’s website, www.thegenderbook.com
Remind Youth
& Parents
…
What Is ??
“Healthy”
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Gender & sexual development are natural parts of human development
Gender & sexual expression vary
Gender & sexual diversity are different than risk
Open, honest communication is critical to healthy decision-making, behaviors, support, and access to care
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Historical Approaches to TGD Children
Allow some experience puberty, to age 15-16 or Tanner 4, then start
GnRH analogues or hormones
Gender identity stableStart GnRH analogues at Tanner 2
Initiate hormones several years later
Living in Asserted Gender
Gender identity stableInitiate puberty with hormonescongruent with gender identity
No treatment until 18(after full pubertal experience)
GCS
https://ceitraining.org/
Delemarre-van de Waal, Cohen Kettenis (2006)
Reconfirmed over time….OlsonKR 2016, deVries AL 2014, Steensma TD 2013, deVries AL 2012, Spack NP 2012, deVries AL 2011, Steensma TD 2011, Steensma TD 2013, Malpas J 2011, Teurk CM 2012, Bussey K 2011, DeVries 2010, Wallien MS 2008, Drummon 2008, Zucker 2005, Green 1987, Davenport 198624
Seminal Puberty Blocker Work : Early Intervention
Early blocking of puberty followed by cross gender hormone replacement At follow-up, all 54 patients were satisfied with their pubertal development▫ No patients decided to stop GnRH agonist therapy▫ All patients eligible decided to take cross gender hormones▫ There were no adverse events from GnRH agonists
No suicidesNo street hormones
Self esteem Social support General health status
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Depression Substance useSuicidality
Predicts improved Protects against
Ryan CJ; 2010, 2009
N=245 LGBT Retrospective assess family accepting behaviors in response to gender & sexual minority status
TransYouth Project
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(2016) 73 children, ages 3-12
Symptoms of depression, anxiety Rates depression (50.1) and anxiety (54.2) No higher than 2 control groups
Siblings & cis age- and gender-matched children
Olson KR, Durwood L, DeMeules M, et al. Mental Health of Transgender Children Who Are Supported in Their Identities. Pediatrics. 2016;137(3):e20153223
(2017) 116 trans, 122 controls, 72 sibs ages 6-14
Symptoms of depression, self worth same
Slightly higher anxiety
NIH Patient Reported Outcome Measurement Information System
Large-scale (>150 children) longitudinal study transgender children, 25 states
Dunwood L, McLaughlin KA, Oslon KR. Mental Health and Self-Worth in Socially Transitioned Transgender Youth. J Am Acad Child Adolesc Psych. 2017 Feb;56(2):116-123.
Significantly lower than TGD children in previous studies
Minoritizedperson
Stigma
Prejudice, Discrimination, Abuse,
Lack of Acceptance, Isolation, Esteem,
ResourcesMinority
Stress
Anxiety, Depression
Suicide, Substance Use, SES
Disadvantage, Victimization
Minority Stress Theory
27Adapted from O’Hanlan, et al (1997). A review of the medical consequences of homophobia with suggestions for resolution. JGLMA;1:25-39.)
Countering Minority Stress
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Minority stress
Identity congruent with anatomy/physiology
Puberty in gender identified. living safely in identified gender
Early identificationResources, connection,
supportChange cultural
appreciation for diversity
Social stigma
Familial rejectionSocial isolation
Fear of physical attacks
Improved Health Outcomes
Mental health Social
Medical Financial
Educational
Pro-diversityResiliency
Supporting authentic development to improve quality of life
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Talking with all children about their gender development
Children with gender diversity or questions • Establish early, strong social support
• See when concerns identified, ideally BEFORE puberty• Gives providers time to engage with family and patient, build
rapport & trust• Offer relief to patient worried about upcoming puberty
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• Facilitate emotional, social, physical state that more closely represents individual’s sense of self• Experience single puberty congruent with internal identities
• Prevent unwanted &/or permanent secondary gender/sex characteristics • Reduce need for future medical, surgical interventions
• Reduce depression, anxiety, risk-taking facilitates mental health supports
Consider “blocking” puberty• Effects fully reversible• “Buys time” for parents to learn more & adjust• “Buys time” for patient & prevent unwanted secondary physical changes • Sends message of hope
Starting Gender Affirming Medical CarePuberty Blockers
Assess needs & goals identity & “phenotype” Physical (Tanner stage) Psychological Social
Patient-centered consent process Review benefits, risks, common & uncommon side
effects Stress reversible, completely Review follow up, monitoring
Timing1. Is the youth ready?2. Is the parent(s) ready?3. Tanner stage 4. 2nd gender characteristics5. Is age congruent w peers?6. What is current, predicted,
desired adult height?7. Emotional benefits
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GnRH Agonists Injectibles
Leuprorelin(Triptorelin, Goserelin)
Monthly $500-1000 3-monthly depot $1500-
2000
Long Acting ImplantHistrelin
24 + months $3500 (Vantas) $20 000 +(S li )
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Continuous GnRH secretion Suppress FSH, LHInitial ↑ LH, FSH followed by desensitized pituitaryLH, FSH secretion suppressed
Benefits >> Risks.
Puberty Blockers
No female breast developmentStop widening pelvisBlock menses dysphoria Delay early epiphyseal closure, add
height Low dose T for promoting height
Avoid bigger, heavier skeletal changesAvoid adam’s appleAvoid male pattern face, body hairStill useful for some Tanner 4-5 w
minimal external gender characteristicsEstradiol earlier for earlier puberty &
height reduction
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Asserted Boys Asserted Girls
BlockersMiddle Puberty
• Won’t take away characteristics already developed but can stop further development & distress
• Very effective at suppresses menses • Allows for lower E/T doses, slower
titration as no need to suppress
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Early puberty
• Limited tissue for later gender affirming surgeries
• Sterility if GAH allowing for mature spermatogenesis or oogenesis• Mature gamete production occurs late in
puberty, associated with significant secondary sex characteristics
Blockers
From the Endocrine Society 2017 Guidelines:36
Late Puberty & Beyond
• GnRH analog + estradiol or testosterone might allow for successful phenotypic changes with lower GAH doses
• “…[In certain situations, such as above] continuation of GnRH analog treatment is advised until gonadectomy…”
Implications for genderqueer & nonbinary people
Progestins as BlockersCan be used an alternative to GnRH agonists• Payment Issues• Access• Patient or Parental Concerns
Not as effective Menses suppression but not phenotype changes Limited research in assigned males.• Concern for issues with bone metabolism and
perimenopausal symptoms with chronic use.
Implications for genderqueer-nonbinary
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Decreases GnRH pulse frequency• Antagonistic effect• Low frequency stimulates FSH synthesis
• Increased frequency stimulates LH Synthesis• FSH stimulates follicular production of estradiol
Adolescents and Gender
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Setting Up the Initial Assessment
Establish privacy Ask parent to step out of room Explain what can (and can’t) be kept
confidential Establish trust and rapport
Ask name and pronoun Ask goals of visit
Getting to know the person General adolescent health assessment
HEADDSSS Leading into more detailed & sensitive
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To do• Interview only with parent in room
• All teens deserve private time
• Assume • Name or pronoun• Gender identity and expression
correlate
• Disclose without patient’s consent• Dismiss
• Parents as a source of support• As a phase
• Refer for reparative therapy
What not to do
Gender Experience 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, makeup, play Hormone use, if any
Review patient goals
Engage parent(s) to support their child Explore parent’s concerns and priorities Assess parental support and knowledge Facilitate discussion and negotiations
Establish expectations for all stakeholders Incorporate patient goals, with parental
expectations, and management options
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Starting Gender Hormones Assess needs & goals around “phenotypic transition”
Physical (Tanner stage) Psychological Social
Patient-centered consent process Review benefits, risks, common & uncommon
side effects Differentiate reversible & irreversible physical
changes Determine if realistic sense of what can and
can’t be impacted by hormones Review follow up, monitoring
Timing1. Is the youth ready?2. Is the parent(s) ready?3. Is age congruent w peers?4. What is current, predicted, desired
adult height?
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Estradiol Feminization
Sublingual Intramuscular Transdermal ?Implants
Agent 17 b estradiolEstradiol
CypionateValerate
Patch Gel
RouteDosing
2-12 mg daily Sublingual 30 minutes
5-20 mg IM Q 1-2 weeks
Subcutaneous?
0.1-0.4 mg +1-2 weekly
1 gm +2-3 times daily
RoutesDosingPlanning
1. Meet Goals2. Avoid Problems3. Physiologic Levels 42
TestosteroneInjectibles
Transdermal gel
Transdermal patch Implant
Agent cypionate enanthate enanthate undecanoate crystals dissolved in gel pellet
Brand name
Depo-Testosterone® Delatestryl® Xyosted® Aveed® AndroGel® Androderm® Testopel®
Dosing
40-120 mg SQ every week
previously40-200 mg IM every 1-2 weeks
50,75,100 mg (0.5ml) SQ weekly
750 mg (3ml) IM
Initiation FU dose 4 wksQ 10 weeks
5-10 g daily
~12 pellets(900mg) SubdermalQ 3-6 months
RoutesDosingPlanning
1. Meet Goals2. Avoid Problems3. Physiologic Levels
Holistic, comprehensive Diversity positive Strength based resiliency ] Non-judgmental harm reduction
Patient centered, consent based care
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Screening & Prevention According to What Parts Go Where & Risk
TGDMasc
• HPV vaccine & cervical cancer screening plans
• Discuss, offer contraception • GC screen NAAT
• Consider + • Trichomonas, Bacterial Vaginosis,
HSV, HIV• Consider PreP, PEP
http://www.cdc.gov/std/tg2015/specialpops
Screening & Prevention According to What Parts Go Where & Risk
TGDFem Offer HPV vaccine Test at least once per year HIV, HCV, Syphilis serology Urine, pharyngeal, rectal GC NAAT
Consider PreP, PEP
http://www.cdc.gov/std/tg2015/specialpops
PrEP protocol 1. Initial visit: History, labs, STI screen
Adherence assessmentConsent
2. Q 3 months follow-up: re-assess: need, adherenceLabs: HIV BMP
Trans Students Student Survey 9th and 11th graders, n=81,885 Trans/genderfluid/non-conforming n=2,168 (2.7%) Risk behaviors significantly higher among trans
than cis Emotional distress, bullying significantly more
common among birth-assigned females than males Protective factors
• Family connectedness• Student-teacher relationships• Feel safe in community
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School & Other Settings
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School & Other Settings
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Images taken from The Gender Book, are publically available on the book’s website, www.thegenderbook.com
Take-Home Points Screening for gender issues, like sexual
health concerns, important through life span Earlier parental support, along w early
medical engagement, can be lifesaving, decrease risks, improve outcomes
Mental health & social support is important General strength focused, harm reduction
strategies continue, incorporating knowledge of minority stress impact
Questions
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MICHELLE FORCIER, MD, MPH
Professor Pediatrics, Brown University School of Medicine, PVD, RI
[email protected] for phi [email protected] for other
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