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 o 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 Video from Seattle Children’s: • Dyslipide mia , we ig ht g a in, hype rte nsio n https:/ / www.yo utub e .c o m/ wa tc h? v=dmjSE f2o g 1A • 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

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 Video from Seattle Children’s: • Hype rpro la c tine mia , hype rte nsio n https:/ / www.yo utub e .c o m/ wa tc h? v=8_g dL CXK l5Y He mb re e . E ndo c rine So c ie ty Clinic a l Pra c tic e Guide line 2017

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 o 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