Gender dysphoria an update for general physicians

Transcription

1 Gender dysphoria an update for general physicians Simon Page Consultant Endocrinologist Regional RCP meeting Feb

2 Terminology Transvestism Sexual interest in cross-dressing Disorder of Sexual Development (DSD) Rare e.g. CAH, XX males, androgen insensitivity syndrome, 5 alpha reductase deficiency Gender dysphoria (ICD10 classification) Trans-female male to female Trans-male female to male Gender fluid (non binary) Gender identity vs sexual orientation Regional RCP meeting Feb

3 DSD a case SH Born 1989 Female From Pakistan Acute Medicine 2010 Headache Noted to be virilised Male body habitus Deep voice No breast development Female external genitalia Cliteromegaly Endocrine bloods T 22.1 nmol/l (0-2.8) SHBG 9 nmol/l (18/114) LH 10.4 mu/l (N) FSH 11.5 m/l (N) DHEAS 5.8 nmol/l (N) A dione 8.1 nmol/l (N) Oestradiol 240 pmol/l (N) 17OHP 4.6 nmol/l (0-12) Karyotype 46 XY(SRY) Male genotype Regional RCP meeting Feb

4 SH MR pelvic imaging Testes and associated structures Regional RCP meeting Feb

5 SH Urine steroid profile (King s College Hospital) Consistent with 5 alphareductase deficiency. Inability to convert testosterone to dihydrotestosterone (DHT) failure to develop male external genitalia in utero. Sertoli cell AMH secreted in utero from testes suppressing female internal organs development. Genetic tests (Cambridge) Confirmed diagnosis. Regional RCP meeting Feb

6 SH Outcome? Lengthy discussions with SH and with family and GP. Situation explained. Wished to remain in female gender Management Testes removed Feminisation with oestrogens Vitamin D Bone health (DEXA) monitoring Regional RCP meeting Feb

7 SH (and her sister MH) Testosterone Oestradiol Regional RCP meeting Feb

8 DSD rare and complex Karyotype Phenotype Gonad Syndrome Fate 45 XO Female Ovaries Turner s syndrome Streak ovaries; Hypogonadism; Primary amenorrhoea 45 YO Lethal 46 XX Female Ovaries Normal female Normal development 47 XXX Female Ovaries Normal fertility Normal development 46 XY Male Testes Normal male Normal development 47 XXY Male Testes Kleinfelter s syndrome Small testes; Hypogonadism; Azospermia 47 XYY Male Testes Normal fertility Normal development Congenital adrenal hyperplasia XX male SRY transfer Androgen insensitivity syndrome 5 alpha reductase deficiency Regional RCP meeting Feb

9 Gender Dysphoria 1920 s Copenhagen Einar and Gerda Weignar (artists) Einar posed as a female life model for his wife Einar develops an attraction for a female physical appearance and begins living as a woman named Lili Elbe Ultimately Lili becomes the first ever recipient of male to female gender reassignment surgery Died in Sept 1931; misjudged surgery to transplant a womb Regional RCP meeting Feb

10 Regional RCP meeting Feb

11 Gender issues in the news Attitudes towards transgender people are "20 years behind" those towards gay, lesbian and bisexual (LGB) individuals, Kellie Maloney has said. The boxing promoter told the BBC's Victoria Derbyshire programme the transgender community was "frightened to come forward", adding: "We're seen as freaks, we're seen as perverts." Regional RCP meeting Feb

12 Gender Dysphoria Definition The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment The transsexual identity has been present persistently for at least two years The disorder is not a symptom of another mental disorder, endocrine disorder or a chromosomal abnormality. Regional RCP meeting Feb

13 Prevalence Overall prevalence for gender dysphoria 4.6 per 100, per 100,000 for trans women 2.6 per 100,000 for trans men. Time analysis found an increase in reported prevalence over the last 50 years. Arcelus et al., European Psychiatry 2015 Increased risk of self harm compared with cisgender controls Marshall et al., Int Rev Psych 2015 Regional RCP meeting Feb

14 A growing issue Regional RCP meeting Feb

15 Clinics Newcastle Leeds Sheffield Nottingham Northampton NHS England to map gender identity services as a first step in achieving equitable access for patients NHS commissioning 2015 Exeter Regional RCP meeting Feb 2018 West London Clinic Tavistock clinic 15

16 Standards and guidelines Regional RCP meeting Feb

17 Assessment 1- Assessment 1 by Clinician A for 90 minutes 2- Assessment 2 by Clinician B for 90 minutes 3- Network meeting by Clinicians A & B for 60 minutes and patient invited to bring relative/friend(s) Diagnosis Gender Dysphoria/Transsexualism? No yes, ready for LE yes, no ready for LE Therapy and evaluate Discharge or refer elsewhere Invited patient into the Life Experience Treatment programme Live in chosen gender, change documentation Start hormone treatment Refer to Endocrinology, Voice coaching, group or iindividual therapy if indicated Electrolysis where indicated Meet every 3 months to monitor transition After a minimum of 2 years: 2 expert opinions required for readiness for Gender Reassignment Surgery (GRS) Refer to surgeons / GRC Follow up

18 Trans-females Trans females require oestrogens and usually an androgen blocker. The progressive changes they may see include: Loss of erection Loss of muscle mass Softer skin and hair Breast growth (most often in the standard female range) Body fat redistribution Facial and body hair are generally not significantly affected by female hormones. It is highly unlikely that any head hair already lost will regrow, although the hormone regimen will likely stop further loss. Female hormones will not affect vocal pitch. Regional RCP meeting Feb

19 Trans-females - HRT Objectives Oestradiol blood levels pmol/l Suppression of testosterone to < 1.5 nmol/l Manage expectations Define risks Regional RCP meeting Feb

20 Androgen suppression Regional RCP meeting Feb

21 Androgen control plan B/C/D Spironolactone Androgen receptor blocker/inhibitor of testicular steroidogenesis mg daily Monitor renal function and serum potassium Cyproterone Acetate Progestin and androgen receptor antagonist mg daily May increase prolactin Finasteride 5 alpha reductase inhibitor Male pattern balding Regional RCP meeting Feb

22 Expectations Regional RCP meeting Feb

23 Trans-males Trans males require androgens. There is generally no need to block oestrogens. They changes they may see are: Enlargement of the clitoris Increase in muscle mass Marked body hair Coarsening of hair and skin Deepening (breaking) of the voice Some lessening of breast size If the trans man has the genetic propensity for it he could develop male pattern baldness. Generally recommended to have hysterectomy and BSO after 2-3 yrs on androgens. Regional RCP meeting Feb

24 Androgens Objectives Testosterone in upper 1/3 of male reference range Manage expectations Define risks Regional RCP meeting Feb

25 Expectations Regional RCP meeting Feb

26 Benefits - QoL Meta-analysis 28 trials 1833 patients with GID 1093 M-F; 801 F-M All studies observational, no control groups Results 80% improvements in GID 78% improvements in psychological health 80% improvements in QoL 72% improvements in sexual function Murad et al., 2010, Clinical Endocrinology Regional RCP meeting Feb

27 Risks Regional RCP meeting Feb

28 Risks Trans-females VTE 2-6% prevalence (oral ethinyloestradiol) No increase risk with other oestrogen preparations Routine screening for thrombophilic disorders not required Patches safer (> 40yr in particular) Elective surgery CVD No clear data as yet Mortality Early data suggested increased mortality Related to IVDU, HIV, CVD (oral ethinyloestradiol) and self harm Van Kesteren et al., 1997 Clin Endoc Asscheman et al., 2014, Andrologia Asscheman et al., 2011, E J Endocrinol Asscheman et al., 2011, E J Endocrinol Regional RCP meeting Feb

29 Morbidity in 816 Trans-females Regional RCP meeting Feb

30 Risks Trans-males Polycythaemia Up to 15% - direct effect of testosterone on haemopoesis 3-5% require venesection or treatment withdrawal Persistent menses Relatively uncommon Options Increase T dose Add progestogen (e.g. Medroxyprogesterone) GnRH analogue IUCD Fertility Reduced (oocyte freezing an option before treatment started) Important to discuss contraception issues where relevant CVD Increase in TG s significance uncertain Limited long term date Regional RCP meeting Feb

31 Morbidity in 293 Trans-males Regional RCP meeting Feb

32 Other issues Future Fertility Sperm or egg freezing (not NHS funded) Hair removal NHS funded Face Scrotum (for GRS M-F) Speech therapy Can help trans females to some extent CV risk/smoking/lifestyle Regional RCP meeting Feb

33 Long-term effects of cross-sex hormonal treatment on bone mineral density in transgender persons Chantal M. Wiepjes Dept. of Internal Medicine and Center of Expertise on Gender Dysphoria VU University Medical Center, Amsterdam, the Netherlands

34 Methods Retrospective file record study Inclusion: - All persons once visiting the gender clinic - Start hormone therapy after years at start hormone therapy - DXA scan at baseline - And DXA scan after 2, 5, or 10 years 5,797 2,670 2,189 1, transwomen 359 transmen

35 Baseline characteristics Transwomen (n=503) Transmen (n=359) Age (median, IQR) 36 (26-45) 25 (20-35) Ethnicity (% white) 94.6% 91.6% BMI (mean, SD) 23.6 (4.2) 25.6 (6.0) T-score/Z-score lumbar spine -1.1 (1.3) / -0.9 (1.4) -0.1 (1.1) / 0.1 (1.1) T-score/Z-score total hip -0.7 (0.9) / -0.5 (0.9) 0.0 (0.8) / 0.1 (0.9) % Osteoporosis (T < -2.5) 14.3% 1.1% % Osteopenia (-2.5 < T < -1) 43.7% 24.2%

36 Results Transfemales Transmales

37 Summary Trans-females and trans-males Initial increase in LS and TH T-scores and Z-scores Higher increase in transwomen After 10 years The same LS T-score as baseline but higher Z-scores No difference between surgery groups Transmales T-scores and Z-scores increased most in highest age group - Postmenopausal

38 Health screening Breast screening (50-70yrs) Cervical screening (25-64yrs) AAA screening (65 yrs and over) Colon cancer (55-74 yrs) Trans female Trans male (if breast tissue present) (if cervix present) Regional RCP meeting Feb

39 GRS Trans-female Options Breast augmentation (after a minimum of two years on hormones non NHS funded). Thyroid chondroplasty and cricothyroid approximation are sometimes requested but may be subject to funding restrictions. Facial feminisation surgery (not funded on the NHS). Trans female GRS such as penectomy, orchidectomy, neovaginoplasty or cosmesis, and clitoroplasty are usually carried out through providers in London or Brighton (NHS funded). Trans-male Options Bilateral mastectomy and associated chest reconstruction. GRS for trans men generally includes hysterectomy and oophorectomy, as well as phalloplasty or metoidioplasty. Hysterectomy and oophorectomy are sometimes carried out separately and independent of the other procedures. The creation of a penis (phalloplasty or metoidioplasty) is generally carried out through providers in London or Brighton. Regional RCP meeting Feb

40 Phalloplasty Neovaginoplasty Regional RCP meeting Feb

41 Gender Recognition Act 2004 Confirmed diagnosis of gender dysphoria Lived in acquired gender role for > 2yrs Intends to continue if chosen gender Reports: Gender dysphoria specialists Another doctor usually GP Applications to Gender Recognition Panel Success Enables issue of new birth certificate Enables marriage with a person who is other than your legal gender Enables civil partnership with a person on the same gender as your legal gender Influences tax, NI and pension liabilities/benefits Regional RCP meeting Feb

42 Questions? Comments? Regional RCP meeting Feb