View - Texas Tech University Health Sciences Center El Paso

Transgender Healthcare
Colt Meier, Ph.D.
Provisionally Licensed Psychologist
Objectives
• Define basic terminology
• Understand the barriers to culturally
competent health care
• List the numerous treatments available for
gender dysphoria
• Question and Answer
– Text 409-782-6059
Where do we start?
• In order to work sensitively with transgender
people one must
– Be educated on terminology
– Consider what these terms mean on a personal
level
– Understand the unique needs and experiences of
this population
• Value systems and religious convictions
– Kindness and respect
What is transgender?
• Let’s talk about what it is not first
• LGBTQ acronym
– Gender is not the same as sexual orientation
– Why do all the letters go together?
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Developmental
Psychological
Medical
Spiritual
Legal
Language and Terminology
(Crooks & Baur, 2010)
• Three parts of gender (everyone has a gender)
– Physical, Biological, or Anatomical Sex
– Gender Expression
• External
– Gender Identity
• Internal
Sex
Gender Expression
Gender Identity
• One’s felt sense of self as being a girl, a boy,
both, or neither
– Internal
– Child usually voices gender between 2 and 5 years
old (Zucker & Bradley, 2005)
• One “just knows” their gender
– Psychological, cultural, social construct
– Tied to pronouns
• Mr./Mrs./Ms. and He/him/she/her
Language and Terminology
• Intersex
– Physical sex differs from cultural expectations
• Gender non-conformity (Gender variance)
– Gender expression differs from cultural expectations
• Transgender
– Gender identity differs from
cultural expectations
Language and Terminology
• Transgender Specific Terms
– Male to Female (sex to gender identity)
• MTF
• trans woman
• She, her, hers; Ms./Mrs./Dr.
– Female to Male
• FTM
• trans man
• He, him, his; Mr./Dr.
– Non-binary
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Genderqueer
Two Spirit
Agender
Gender neutral pronouns
– They, them, theirs; Mx./Dr.
Diversity of identities
• Unlimited ways of being
Terminology Basics
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Sexual Orientation???
Transsexual: Clinical term, gender affirmation seeking
Gender Dysphoria
Binding/Tucking
Transition/ Affirmation: the process of body changes
Passing: perception is in line with intention
Non-Disclosing (colloquially: Stealth): not selfdisclosing, seeking to remain invisible, blend in, just be
o Cisgender: not transgender
Language and Terminology
National Snapshot
o Four times more likely to live on < $10,000 annual income
o Double the rate of unemployment overall
o 4x the rate for trans people of color
o 90% harassed on the job – 71% report hiding gender at work
o 78% report work performance improvement after transition
o 16% work in street economies for income (sex &/or drugs)
o Twice the national rate of homelessness
o 53% harassed in public accommodations
o 29% by police
o 12% by judges and court officials
o 57% experience family rejection
Grant, J. M., Mottet, L. A., Tanis, J., Herman, J. L., Harrison, J., and Keisling, M. (2010). Injustice at Every Turn: National Transgender
Discrimination Survey Report on health and health care.
<http://www.thetaskforce.org/downloads/reports/reports/ntds_report_on_health.pdf>
Barriers to Transgender Health Care
• 70% of transgender reported previous bad
experiences with health care (Shipherd et al., 2010).
– Being refused care
– Being blamed for their health status
– Health care professionals using abusive language
with or about them
– Providers being physically rough, refusing to touch
them, or using excessive precautions
• Concerning in the context of high rates of trauma
exposure and PTSD symptoms (Shipherd, Maguen,
Skidmore, & Abramovitz, 2011).
National Medical Care
o Inadequate training in medical schools (ObedinMaliver et al., 2011; JAMA)
o 25% harassed in places of medical care
o 24% denied equal treatment in doctor’s offices &
hospitals
o 19% were refused care when being transgender was
disclosed
o 2% physically assaulted in doctor’s offices or hospitals
Grant, J. M., Mottet, L. A., Tanis, J., Herman, J. L., Harrison, J., and Keisling, M. (2010). Injustice at Every Turn: National Transgender
Discrimination Survey Report on health and health care.
<http://www.thetaskforce.org/downloads/reports/reports/ntds_report_on_health.pdf>
Trans Texans (n = 266)
Medical Discrimination
• 85% report having to educate their doctors
• 26% experienced mistreatment by a doctor or
hospital staff
• 20% report being refused medical care due to their
transgender status
• 53% do not come out in all medical settings
• 25% did not seek out medical care when sick or
injured due to discrimination
Transgender Suicide Risk Factors
Discrimination, Rejection, and victimization
1. By Parents/Family of Origin
2. By Other Significant People
3. By Strangers
~ Increased by any of the Following ~
Low Self-Esteem - History of Depression
History of Substance Abuse – Job Loss
Harassment – Discrimination – Assault – Poverty
Clements-Nolle, K., Marx, R., and Katz, M. (2006). Attempted Suicide Among Transgender Persons: The Influence of
Gender-Based Discrimination and Victimization. Journal of Homosexuality, 51(3), 53-69. PMID: 17135115 DOI:
10.1300/J082v51n03_04
Protective Factors for Suicide
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Strong connections to family and other supports
Access to effective clinical interventions
Restricted access to lethal means
Skills in problem-solving, conflict resolution, & coping
Frustration tolerance and ability to regulate emotions
Community support (any positive community)
Positive beliefs about future and life in general
Cultural or religious beliefs discouraging suicide
Suicide Prevention Resource Center (SPRC) at Education Development Center, Inc. (EDC).
http://www2.sprc.org/collegesanduniversities/campus-data-risk-and-protective-factors
-The adult transgender suicide attempt rate
in the US is 41%
-The US adult suicide attempt rate 10.4%
NGLTF & the National Center for Transgender Discrimination. (In Press). Attempted suicide among transgender persons:
National transgender discrimination survey. (A Study of 6,500 Gender variant people in the United States)
Suicide Prevention Resource Center (SPRC) at Education Development Center, Inc. (EDC).
http://www.sprc.org/stateinformation/PDF/statedatasheets/sprc_national_data.pdf AND
http://www2.sprc.org/collegesanduniversities/campus-data-prevalence
Trans Health Care
• Two General Rules
– Most health care for trans people has nothing to
do with being trans
– Health care and screening are based on the organs
present and hormonal status
Reducing Gender Dysphoria
o Social
o manner of expression
o name and/or pronouns
o Medical
o Hormones and/or surgeries
o Legal
o Documentation changes
o Private
o Part-time
o Full-time
General Care and Trans Care
• Medical providers: you already know 90% of
what you need to know
• 100% of the medical treatments and most of
the surgeries are used in cisgender patients
• Like any patient with a rare disease
– 1 in 2500
General Healthcare Needs
• Screening and Preventive Medicine
• Disease Treatment
Cancer Screening
• Remember: Work with the organs present
• Screening
– Pelvic Exams
– Mammograms
– Pap Smears
– Prostate Exams
General Health Screening
• Screening
– Cardiovascular
– Diabetes
– Infectious Disease
– Musculoskeletal/Osteoporosis
– Sexual Health
– Substance Use
Trans Specific Healthcare
• Pre-hormones
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Not every patient desires hormone tx
Physical transition goals?
Support systems?
Out to family, partner, work/school?
Source of info?
Options
MD Responsibility
Trans Specific Health Care
• Hormones
WPATH SOC v 7
Feminizing Hormones
• Estrogen
• Anti-androgen
• Progesterone?
Masculinizing Hormones
• Testosterone
Trans Specific Healthcare
• Surgeries
– Not every patient desires surgical
procedure(s)
• Multiple surgical treatment options
– Chest
– Genital
– Facial
What About Surgery Regret???
• Pfäfflin & Junge (1998)
– 74 f/u studies and 8 reviews published b/w 19611991
– Less than 1% long term GRS regret in over FTMs
– 1.5% regret in MTFs
• Studies after 1991 show even lower rates of
regret
• Less than 2% long term CRS regret in over
1,000 FTMs (Green, dickey, & Meier, 2012)
Predictors of Regret
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Inadequate diagnosis
Undiagnosed major psychiatric comorbidity
Lack of social support
Personal social instability
Unrealistic expectations
Predictors of Satisfaction
• Early onset of gender dysphoria
• No psychiatric illness
• Social and family support
• Criteria for hormones and surgeries in the
WPATH Standards of Care
U.S. Surgical Experience
• FTM
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Breast reduction  90%
Hyst BSO  50%
Genital surgery  10%
No need to stop testosterone pre-op
• MTF
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Breast augmentation  ~50%
Genital surgery  MOST
Facial feminization
DVT precautions as indicated
FTM Chest Surgery
• Top surgery/Chest Reconstruction
– Liposuction, double incision, peri-areolar
Double Incision FTM Chest Surgery
Peri-areolar FTM Chest Surgery
FTM Internal Genital Surgery
• Hysterectomy BSO
– Laproscopic
– Robotic
– Abdominal
FTM External Genital Surgery
• Metoidioplasty
• Phalloplasty
– Scrotoplasty with testicular prostheses
– Vaginectomy
– Urethroplasty
FTM External Genital Surgery
Metoidioplasty
Phalloplasty
MTF Breast Surgery
• Breast Augmentation
MTF Breast Surgery
MTF Genital Surgeries
• Ochiectomy
• Vaginoplasty
– Penectomy
– Clitoroplasty
– Labiaplasty
• Prostate remains after surgery
Vaginoplasty
Facial Feminization Surgery
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Rhinoplasty
Laryngochondroplasty (tracheal shave)
Facelift
Eyelid and brow lift
Chin and cheek implants
Lip augmentation
Hormone Treatment
and Electrolysis
Hormone Treatment plus Facial
Feminization Surgery
Fertility/Reproductive Options
• FTM
– Oocyte cryopreservation
– Gamete cyropreservation
– Pregnancy
• MTF
– Sperm donation
Resources
http://transhealth.vch.ca/resources/
careguidelines.html
http://transhealth.ucsf.edu/trans?pa
ge=protocol-00-00
Q&A
• ftmresearch@gmail.com
Etiology
• No definite answers
• Many parents are concerned that something they did
made their child become transgender.
• Things that do NOT cause a child to be transgender
– divorce, neglect, wishing you had given birth to the other sex, using
fertility drugs to conceive, encouraging your child to play sports too
often or not enough, or other parental thoughts, behaviors or
experiences
Etiology
• Genetics
– Twin studies
• Brain
– Hypothalamus (BTSc) in MTFs (Zhou et al., 1995)
– Microstructure of White Matter in MTFs and FTMs
(Rametti et al., 2010)
– Neural network of body representation (Lin et al., 2014)
• Hormones
– Elevated rates of PCOS (58%; n = 69) in FTMs (Baba et al.,
2007)
– polymorphism of the CYP17 in FTMs (Bentz et al., 2008)
How many?
• It depends: 1 in 200 to 1 in 100,000
• 1 in 2,500 people in the US have had trans
related surgery
• In a population the size of Texas= 26 million
– 26 mil / 200 = 130,000 will be transgender
– 26 mil / 500 = 52,000 will desire to transition
– 26 mil / 2500 = 10,400 potentially could have had
at least one type of gender related surgery