GE NDE R- AF F IRMING HE AL T H INT E RVE NT IONS F OR - - PowerPoint PPT Presentation

GE NDE R- AF F IRMING HE AL T H INT E RVE NT IONS F OR CHIL DRE N AND ADOL E SCE NT S: F ROM CL INICS T O T HE COMMUNIT Y

Annie Hoope s, MD, MPH (she / he r ) T he Adole sc e nt Ce nte r Ka ise r Pe rmane nte Wa shing ton

IF YOU RE ME MBE R 3 T HINGS

• Multidisc iplina ry mo de l o f c a re fo r T

GD yo uth

• Dive rsity o f a ffirma tio n jo urne ys
• Po sitive impa c t o f pa re nta l suppo rt a nd

a ffirming e nviro nme nts

CARE GUIDE L INE S

GE NDE R AF F IRMAT ION MAY INCL UDE

• Psyc ho so c ia l a ffirma tio n
• Pub e rty b lo c ke rs
• Ge nde r-a ffirming (c ro ss se x) ho rmo ne the ra py
• I

nte g ra te d with c o mpre he nsive a nd g e nde r-a ffirming prima ry c a re

• Ge nde r-a ffirming surg e rie s
• L

e g a l a ffirma tio n

DIVE RSIT Y OF AF F IRMAT ION JOURNE YS

PSYCHOSOCIAL AF F IRMAT ION

• So c ia l
• Pro no uns
• Na me
• So c ia l g e nde r ro le
• Psyc ho lo g ic a l
• Addre ssing psyc ho so c ia l he a lth c o nc e rns
• Ha ving suppo rt in tra nsitio n pro c e ss
• Addre ssing inte rna lize d stig ma a nd

tra nspho b ia

E L ICIT ING GE NDE R IDE NT IT Y

• Kids: “Some kids tell me they think of themselves as girls, some as boys, some

a s pa rt g irl a nd b o y, o r so me thing e ntire ly diffe re nt. Ho w do yo u think a b o ut

yourself?”

• Teens: “There are lots of ways people describe their gender identity, how do

you think of yours?”

• “Tell me what that term means to you?”
• Ro le o f dia g no stic e va lua tio n

PUBE RT Y BL OCKE RS

• Blo c ke rs a re g o na do tro pin re le a sing ho rmo ne

(GnRH) a g o nists

• GnRH
• Pulsa tile re le a se fro m the hypo tha la mus
• Stimula te s pituita ry re le a se o f lute inizing a nd

fo llic le stimula ting ho rmo ne s (L H a nd F SH)

• L

H a nd F SH

• Stimula te the g o na ds to pro duc e se x ste ro ids

(e stro g e n, pro g e ste ro ne a nd te sto ste ro ne )

ME CHANISM OF ACT ION OF BL OCKE RS

• L

a rg e no n-pulsa tile do se o f GnRH a g o nist flo o ds the pituita ry

• I

nitia l re le a se o f F SH a nd L H

• I

nitia l surg e o f se x ste ro id ho rmo ne s

• Me nstrua l b le e ding 14-28

da ys a fte r inje c tio n

• F
• llo we d b y a me no rrhe a
• E

nd re sult

• Suppre ssio n o f
• F

SH a nd L H se c re tio n

• T

e stic ula r re le a se o f te sto ste ro ne

• Ova ria n re le a se o f e stro g e n

a nd pro g e ste ro ne

GNRHA T RE AT ME NT

• Whe n?
• At le a st T

a nne r (se xua l ma turity ra ting ) sta g e 2

• Me a n a g e fo r the first sig ns o f pub e rty
• 10.5 ye a rs in o va ry-b o die d pe o ple , ra ng e 8 to 12 yrs
• 11.5 ye a rs in te stic le -b o die d pe o ple , ra ng e 9 to 13 yrs
• Wha t
• I

ntra musc ula r le upro lide a c e ta te (L upro n)

• Histre lin I

mpla nt (Suppre lin L A o r Va nta s)

CL INICAL E F F E CT S OF GNRHA

• Will slo w do wn
• Pub e rta l de ve lo pme nt
• Bo ny c ha ng e s o f pub e rty
• Andro g e n-de pe nde nt ha ir g ro wth
• De e ping o f the vo ic e , e nla rg e me nt o f la rynx
• BMD do e s no t inc re a se a s e xpe c te d b ut is b e lie ve d to c a tc h up with

sub se q ue nt se x ste ro id a dministra tio n

• Co mple te ly re ve rsib le
• I

f imme dia te ly fo llo we d b y c ro ss-se x ho rmo ne s pa tie nt will be no t be fe rtile

• No e ffe c t o n fe rtility if disc o ntinue d

De vrie s a l 2011 J Se x Me d

CL INICAL E F F E CT S OF GNRHA

• Ma y
• I

mpro ve psyc ho lo g ic a l func tio n

• But ha s no t b e e n fo und to impro ve g e nde r dyspho ria
• I

nc re a se a dult he ig ht in a ffirme d ma le s

• De c re a se a dult he ig ht in a ffirme d fe ma le s

De Vrie s e t a l; Pe dia tric s 2014 De Vrie s e t a l; J Se x Me d 2010

WHY USE PUBE RT Y BL OCKE RS?

 Pro vide time to e xplo re g e nde r inc o ng rue nc e  Pre ve nt se x c ha ra c te ristic s tha t a re diffic ult o r impo ssib le to

re ve rse

• Adam’s apple
• Ma le pa tte rn ha ir g ro wth
• Vo ic e de e pe ning
• Bre a st de ve lo pme nt

BL OCKE RS A FT

ER PUBE

RT Y

• Pre ve nt me nstrua tio n
• Pre ve nt furthe r a ndro g e n e ffe c ts
• Give pa re nts a c ha nc e to c a tc h up
• Use d po st pub e rty will NOT

c a use re g re ssio n in

• Pe nis, b e a rd, b o dy ha ir, Ada m's a pple , sho ulde rs, ja w
• Bre a st o r hips
• Allo ws use o f lo we r do se s o f a ffirming ho rmo ne s

GE NDE R AF F IRMING HORMONE S

• T

ypic a lly initia te d b e twe e n a g e 14-16 (wide ly va ria b le )

• Numb e r o f ye a rs living sta b ly in a ffirme d g e nde r ro le
• Numb e r o f ye a rs o f pub e rta l suppre ssio n
• De g re e o f dyspho ria
• Distre ss b e c a use physic a l de ve lo pme nt is o ut o f sync with pe e rs

 Pub e rty is 2-3 ye a r pro c e ss – mimic this in pa tie nts who sta rte d b lo c ke rs in

e a rly pub e rty

• T

ho se who pre se nt la te r in a do le sc e nc e ha ve a lre a dy e xpe rie nc e d ne a r-full pub e rty so ho rmo ne re g ime ns ma y b e inc re a se d to full re pla c e me nt do se s o ve r a sho rte r inte rva l

• I

de a lly c o ntinue b lo c ke rs until g o na de c to my

MASCUL INIZING HORMONE S

T e stoste rone inje c tions, patc h, or g e l

Pa rtia lly re ve rsib le e ffe c ts

• Inc re a se d le a n musc le ma ss / de c re a se d sub c uta ne o us

fa t

• Ma sc uline pa tte rn ha ir g ro wth
• Che st tissue a tro phy po ssib le
• I

rre ve rsib le e ffe c ts

• De e pe ne d vo ic e
• Clito ro me g a ly
• Adve rse e ffe c ts
• Ac ne
• Po lyc ythe mia , tra nsa minitis
• Dyslipide mia , we ig ht g a in, hype rte nsio n
• Mo o d la b ility

He mb re e . E ndo c rine So c ie ty Clinic a l Pra c tic e Guide line 2017 Olso n J. L GBT He a lth 2014

Video from Seattle Children’s:

https:/ / www.yo utub e .c o m/ wa tc h? v=dmjSE f2o g 1A

F E MINIZING HORMONE S

Androg e n bloc ka de

• Co ntinuing b lo c ke rs
• Allo ws lo we r do se s o f e stro g e n; e ve n hig he r

do se s ma y no t b lo c k e ffe c ts o f te sto ste ro ne

• Spiro no la c to ne
• Bic a luta mide

De c re a se d he ig ht po ssib le

• With a dministra tio n o f e stro g e n g ro wth

pla te s will c lo se

Video from Seattle Children’s:

https:/ / www.yo utub e .c o m/ wa tc h? v=8_g dL CXK l5Y

F E MINIZING HORMONE S

17 be ta e str a diol pills, pa tc h or inje c tions

• Pa rtia lly re ve rsib le
• De c re a se d fa c ia l a nd b o dy ha ir
• F

a t re distrib utio n

• De c re a se d spo nta ne o us e re c tio ns
• So fte ne d skin
• I

rre ve rsib le

• Bre a st tissue g ro wth
• Clo sure o f g ro wth pla te s
• Adve rse e ffe c ts
• T

hro mb o e mb o lic dise a se

• L

ive r dysfunc tio n, c ho le lithia sis

• Hype rpro la c tine mia , hype rte nsio n

He mb re e . E ndo c rine So c ie ty Clinic a l Pra c tic e Guide line 2017

Video from Seattle Children’s:

https:/ / www.yo utub e .c o m/ wa tc h? v=8_g dL CXK l5Y

F OL L OW- UP

• Ong o ing me nta l he a lth suppo rt
• Me dic a l fo llo w-up
• Asse ss c linic a l re spo nse
• Mo nito r fo r unde sire d side e ffe c ts
• Mo nito r la b s
• Affirming prima ry c a re a nd spe c ia lty se rvic e s
• Vo ic e tra ining

BINDE RS, PACKE RS & ST P DE VICE S

GE NDE R- AF F IRMING SURGE RIE S

• ”Top” surgery
• T
• c re a te a ma sc uline c he st sha pe o r e nha nc e b re a sts
• “Bottom” surgery
• Surg e ry o n g e nita ls o r re pro duc tive o rg a ns
• F

a c ia l fe miniza tio n

• Ha ir re mo va l

A NOT E ABOUT CONSE NT

F AMIL Y ACCE PT ANCE

• Suic ide ra te s a mo ng T

GD yo uth a re sig nific a ntly lo we r a mo ng tho se with stro ng ly suppo rtive pa re nts (4% vs 60%)

• T

GD yo uth who de sc rib e a t le a st 1 suppo rtive pe rso n in the ir life re po rt sig nific a ntly le ss distre ss tha n tho se who o nly e xpe rie nc e re je c tio n

• I

n c o mmunitie s with hig h le ve ls o f suppo rt, no n-suppo rtive fa milie s te nde d to inc re a se suppo rt o ve r time , le a ding to dra ma tic impro ve me nt in me nta l he a lth o utc o me s

Olso n, K .R., Durwo o d, L ., De Me ule s, M., & Mc L a ug hlin, K . A. (2016). Me nta l he a lth o f tra nsg e nde r c hildre n who a re suppo rte d in the ir ide ntitie s. Pe diatr ic s, 137 (3), 1-8. Rya n e t a l. F a mily Re je c tio n a s a Pre dic to r o f Ne g a tive He a lth Outc o me s in White a nd L a tino L e sb ia n, Ga y, a nd Bise xua l Yo ung Adults. Pe diatr ic s. 123-1.2009

COMMON PARE NT AL CONCE RNS T HAT MAY DE L AY ACCE SS T O GE NDE R- AF F IRMING T RE AT ME NT

• F

e a r o f ha ra ssme nt

• F

e a r o f re je c tio n b y pe e rs o r o the r fa mily

• F

e a r o f physic a l ha rm

• Wo rry a b o ut pre se rva tio n o f fe rtility o ptio ns
• Wo rry a b o ut a ppro pria te timing o f tra nsitio n
• Grief/loss of “former” identity
• F

e a r o f re g re t re g a rding tra nsitio n

• Ho w do I

kno w the y are ac tually transge nde r?

• What if this is just a phase ?
• Why can’t we wait until they have finished puberty or they are an adult before

we talk abo ut me dic al transitio n? What if my c hild re gre ts this?

Ja nic ka e t a l/ Ado le sc Me d 029 (2018) 20-43

COMMUNIT Y SUPPORT

Schools In Transition

A G uide for Supporting Transgender Students in K-1 2 Schools

• Sc ho o l po lic ie s to suppo rt a nd

a ffirm T GD stude nts

• Co mmunity suppo rt g ro ups a nd

a dvo c a c y e ffo rts

• I

nc lusive insura nc e po lic ie s

• Anti-disc rimina tio n la ws

PROMOT ING SE XUAL HE AL T H OF GE NDE R DIVE RSE ADOL E SCE NT S

• We lc o ming e nviro nme nts
• Visua l c ue s
• All-g e nde r re stro o ms
• Co nfide ntia lity
• I

nc lusive he a lth e duc a tio n c urric ula

Q CARD

T he Q Ca rd is tri-fo ld po c ke t c o mmunic a tio n re so urc e de sig ne d to simulta ne o usly e mpo we r L GBT Q yo uth to a dvo c a te fo r the mse lve s a nd e duc a te he a lthc a re pro vide rs. I t a llo ws yo uth to fill in the ir se xua l o rie nta tio n, g e nde r ide ntity, pe rso na l g e nde r pro no uns, a nd a ny spe c ific c o nc e rns.

http:/ / www.q c a rdpro je c t.c o m

INCL USIVE L ANGUAGE

• Affirma tio n vs. tra nsitio n
• Se x a ssig ne d a t b irth vs. b io lo g ic a l/ na ta l/ re a l se x
• A pe rso n with o va rie s/ ute rus/ c e rvix vs. wo ma n
• A pe rso n with pe nis/ te stic le s vs. ma n
• Che st vs. b re a sts
• Ge nita ls o r fro nt ho le vs. pe nis/ va g ina / vulva
• Ble e ding vs. me nstrua tio n
• Pe o ple who me nstrua te / ha ve a pe rio d vs. wo me n
• Pe rso na l g e nde r pro no uns vs. pre fe rre d pro no uns

HE ARING F ROM YOUT H

• AHI

Vide o (7:43m) https:/ / www.yo utub e .c o m/ wa tc h? v=CHN3YhMi-5A

IF YOU RE ME MBE R 3 T HINGS

• Multidisc iplina ry mo de l o f c a re fo r T

GD yo uth

• Dive rsity o f a ffirma tio n jo urne ys
• Po sitive impa c t o f pa re nta l suppo rt a nd

a ffirming e nviro nme nts

RE SOURCE S

• https:/ / www.g e nde rspe c trum.o rg
• https:/ / www.umhs-a do le sc e nthe a lth.o rg / impro ving -c a re / spa rk-tra ining s/ lg b tq -yo uth-se rie s/
• Guide line s
• AAP: https:/ / pe dia tric s.a a ppub lic a tio ns.o rg / c o nte nt/ 142/ 4/ e 20182162
• E

ndo c rine So c ie ty: https:/ / www.e nd o c rine .o rg / g uide line s-a nd -c linic a l-pra c tic e / c linic a l-pra c tic e - g uide line s/ g e nde r-dyspho ria -g e nde r-inc o ng rue nc e

• WPAT

H Sta nda rds o f Ca re : https:/ / www.wpa th.o rg / pub lic a tio ns/ so c

• UCSF

: https:/ / tra nsc a re .uc sf.e du/ g uide line s

• https:/ / www.minus18.o rg .a u/ pro no uns-a pp/
• http:/ / www.impa c tpro g ra m.o rg / wp-c o nte nt/ uplo a ds/ 2014/ 12/ K

upe r-2014-Pub e rty-Blo c ke rs- Clinic a l-Re se a rc h-Re vie w.pdf

• T

ra ns Yo uth Pro je c t: http:/ / de pts.wa shing to n.e du/ sc dla b / re se a rc h/ tra nsyo uth-pro je c t-g e nde r- de ve lo pme nt/

• Ce le b ra ting Our Ma g ic T
• o lkit: http:/ / www.npa ihb .o rg / do wnlo a d/ T
• o lkit_v6_24.pdf

T HANK YOU!

Andre a .J1.Ho o pe s@ kp.o rg

E XT RA SL IDE S

ME DICAL T RANSIT ION F OR YOUT H IS COMPL ICAT E D: PARE NT AL CONCE RNS

• Ho w do I

kno w the y a re a c tua lly tra nsg e nde r?

• Wha t if this is just a pha se ?
• Why can’t we wait until they have finished puberty or

the y a re a n a dult b e fo re we ta lk a b o ut me dic a l tra nsitio n? Wha t if my c hild re g re ts this?

RE SIL IE NCE

• Ma ny tra nsg e nde r yo uth le a d no rma l, pro duc tive live s
• Usua lly de ve lo p re silie nt a da pta tio ns to so c ia l b ia se s a nd

mistre a tme nt

• Ma ny de ve lo p a nd po sse ss re ma rka b le stre ng th a nd se lf-

de te rmina tio n

E VAL UAT ION AND MONIT ORING

• He ig ht / we ig ht / blood pre ssure / T

a nne r sta g e

• b a se line a nd e ve ry 3-6 mo nths the re a fte r
• Ultra se nsitive fsh / lh / te stoste rone / e stra diol
• b a se line , 8 we e ks, o ne ye a r. Afte r first ye a r, e ve ry 6 mo a nd if a ny sig ns o f re -

e me rg ing pub e rty

• Bone a g e / vita min D
• b a se line a nd a nnua lly
• De xa sc a n
• b a se line a nd e ve ry o the r ye a r; in a ll pa tie nts e nsure a de q ua te c a lc ium inta ke ,

a nd we ig ht b e a ring a c tivity

• Re pla c e impla nt a fte r 3 ye a rs

2017 Guide line s e ndo rse d b y Pe dia tric E ndo c rine So c ie ty

MASCUL INIZING HORMONE S WIT H BL OCKE RS

• I

n po stpub e rta l pa tie nts

• inc re a se mo re ra pidly up to 75 mg / 2 wk fo r 1st 6 mo
• the n inc re a se up to 125 mg / 2 wk
• Adult do se - mo st pa tie nts re a c h no rma l ma le ra ng e o f

to ta l te sto ste ro ne a nd g o o d c linic a l re sults a t

• 50-75mg SC Q we e k o r
• 50-100mg I

M Q we e k o r 100-200mg I M Q 2 we e ks

• Adjust do se to mimic physio lo g ic te sto ste ro ne le ve ls 400-

700ng / dl

He mb re e . E ndo c rine So c ie ty Clinic a l Pra c tic e Guide line 2017 Olso n J. L GBT He a lth 2014

ME DICAL MONIT ORING

• E

ve ry 3-6 mo nths: ht/ wt / BP / T a nne r sta g e

• E

ve ry 6-12 mo nths: he mo g lo b in/ he ma to c rit, lipids, te sto ste ro ne , vita min D

• E

ve ry 1-2 ye a rs b o ne a g e a nd DE XA (la tte r until 25-30 yo )

He mb re e . E ndo c rine So c ie ty Clinic a l Pra c tic e Guide line 2017