Harold Husovsky, MD Associate Professor of General Medicine at SUNY Health Science Center
Care of the Transgendered Syracuse University, 1/09/07
Goals Introductions Definitions Statistics Evaluation Treatments Follow-up care Advocacy
Harold Husovsky, MD Board Certified internist since 1986 Associate Professor of General Medicine at SUNY Health Science Center, since 10/90 13 years experience with transgendered(tg) care Approximately 50 clients husovskh@upstate.edu
Organizations and Standards WPATH: World Professional Association for Transgender Health. -International Journal of Transgenderism (Volume 9 #3/4 2006) Harry Benjamin:The Standards of Care for Gender Identity Disorders (Current 6 th edition), (SOC)
Definitions Gender Identity Disorder(GID s): -The preferred term is Transgendered -It is a general term which can be broken down into the following:
Definitions Transsexualism: 1) The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his/her body as congruent as possible with the preferred sex through dress, cosmetics, hormones and surgery. 2) The transsexual identity is present for at least 2 years 3) The disorder is not a symptom of another mental disorder. 4) Do not confuse with Disorders of Sex Development
Definitions Transvestism: 1) The individual wears clothes of the opposite sex in order to experience temporary membership in the opposite sex. 2) There may or may not be a sexual motivation for the cross-dressing. 3) The individual has no desire for a permanent change to the opposite sex.
Definitions Gender Identity Disorder of Childhood - Separate criteria for girls and boys - Involves rejection of their genetic sexual identity s anatomy, stereotypic behavior, and physiologic functions. - Also called gender variancy.
Psychological Consequences Untreated, patients are at higher risk than the general population for: 1) Depression/Anxiety 2) Addictive behavior 3) Suicide 4) Even higher risk in teen/pre-teens
Why a Gender Identity Disorder? To qualify as a mental disorder, the behavioral pattern must result in a significant adaptive disadvantage to the person and cause personal mental suffering. The label is clinical, not social and not political
Statistics Around 2.5x more common for-male-to female (MTF) than female-to-male(ftm) 1:12,000 males and 1:30,000 females One third of them will proceed to gender reassignment surgery.
Statistics (cont.) MTF s usually seek psychological/medical treatment during middle age FTM s are typically younger BUT with increasing familiarity and exposure, both are presenting at younger ages
Sexual Orientation Mostly reflects the same distribution as in the non-tg population Important to separate sexual identity from sexual orientation A genetic male who is living as a female and is attracted to men will consider herself to be heterosexual
Causes of Transsexualism Most researchers believe that gender identity has a complex, multifactorial origin Transsexualism is likely related to the neuroanatomy of the brain Krujiver&Zhou:The Journal of Clinical Endocrinology & Metabolism Vol. 85, No. 5 2034-2041 (2000)
The Mental Health Professional (MHP) Usually the first to encounter the patient after the PCP. Can come from many fields: psychology, psychiatry, social work, counseling, or nursing.
Recommended Minimal Credentials Masters or equivalent in a clinical behavioral science field from an accredited institution and board. Specialized competence with DSM- IV/ICD-10 Sexual Disorders Documented competence in psychotherapy CME in treatment of GID s
10 Tasks of the MHP 1) Diagnose the GID 2) Diagnose and treat any co-morbid psychiatric condition 3) Counsel on treatment options 4) Engage in psychotherapy 5) Ascertain eligibility and readiness for hormone and surgical therapy
6) Make formal recommendations to medical/surgical colleagues 7) Document patient s history in a letter of recommendation 8) Be a colleague on a team of professionals with an interest in GID s 9) Educate family, employers, and institutions about GID s 10) Be available for follow-up care of gender patients
Triadic Therapy Once diagnosis of GID is made, the therapeutic approach ideally includes 3 phases: 1) A Real Life Experience(RLE) in the desired role 2) Hormones of the desired gender 3) Gender reassignment surgery
Along the way Some will change their minds Some will come to an accommodation with their sexual identity without medical intervention Some will cut their treatment short of Real Life Experience/Hormones/ Surgery
The MHP helps patients with: Activities: 1) Cross-dressing 2) Changing body through: hair changes, breast binding, prostheses 3) Cosmetics 4) Support groups, internet resources 5) Learning about legal rights and procedures
The MHP helps patients with: Activities (cont): 6) Get involved with recreational activities of the desired sex 7) Episodic cross-gender living, eventually leading to RLE
The MHP helps patients with: Processes: 1) Acceptance of personal sexual orientation 2) Acceptance of need to maintain job 3) Acceptance of need to maintain relations with spouse/children 4) Acceptance of need to minimize family distress
The MHP helps patients with: Letters of recommendation for hormones/surgery, to include: 1) Pt s identifying characteristics 2) The initial and evolving diagnoses 3) Duration and history of professional relationship 4) Eligibility and readiness criteria met
The MHP helps patients with:(cont) 5) Degree to which patient has followed the SOC and likelihood of future compliance 6) If the MHP is part of a gender team 7) Phone number for physician to call for confirmation
One letter from MHP is required for hormone treatment and/or breast surgery
Hormone Therapy Improves quality of life Limits psychiatric co-morbidity Definitely helps with Real Life Experience Androgens for females Estrogens, testosterone-blocking agents, and progestins for males
Eligibility Criteria for Adults Age 18 years Demonstrate knowledge of hormone effects, benefits, and risks A documented Real Life Experience of at least 3 months, OR a period of psychotherapy specified by the MHP after the initial visit
Readiness Criteria for Adults Further consolidation of gender identity during RLE or psychotherapy Continued or improving control of other mental health issues (substance abuse, sociopathy, suicidality) Patient will take medicines responsibly
Hormone Effects Maximum effects may take up to 2 years continuous treatment Results vary according to age and individual
Hormone Effects (cont.) MTF: >breasts, shifting body fat, <body hair, <upper body strength, softening of skin, <fertility/testes/libido/erections FTM: deeper voice, >clitoral size, mild breast atrophy, >facial/body hair, >upper body strength, <hip fat, wt gain, >libido
Hormone Effects (cont) In MTF s, all effects (except breast enlargment) are reversible In FTM s, facial hair growth, male pattern baldness and voice changes are not reversible
MTF Regimens (Tables1&2) Estrogen (17β-estradiol) plus Spironolactone Progestins Alternative forms of Estrogen Finasteride Use free testosterone level as guide (See TableB1), goal: low end of normal female range
MTF Regimen Risks Blood clots Prolactinomas Emotional lability, somnolence Weight gain, diabetes, HTN Liver disease, gallstones
FTM regimens Testosterone preparations See Table3 Use free Testosterone levels as guide (See Table B2).Goal: normal male range or desired changes After 2 years (or orchiectomy) dosage is reduced. (shoot for low normal male range on free Testosterone)
FTM alternative agents Progestins can be used to assist with menstrual suppression Gonadotropin-releasing hormone analog (e.g. leuprolide acetate) can be used if Testosterone/progestins are not tolerated
Androgen Risks Increase in lipids Infertility Emotional lability, >libido Destabilization of underlying psych disorders Liver tumors/dysfunction
Hormone Risks Relative contraindications: cigarettes, HTN, obesity, age>65, heart disease, Cancer Risk-benefit assessment always needed
Post Gonadectomy Hormone requirements decrease by 1/3 to1/2
Prescribing Physician's Responsibilities Do a full History and Physical including: -Family Hx -Sexual Hx -Psychosocial Hx -Medicine/Surgical Hx -Assess present expectations and future plans
Prescribing Physician's Responsibilities(cont) Monitor labs (see TablesB1&B2) Modify risk factors: cigs, HTN etc. Prophylax appropriately: All MTF s on 81mg of aspirin Screen for prostate/breast/cervical CA Provide written statements for patients to carry with them Consent forms should be signed before starting meds (see appendixc&d)
Prescribing Physician's Responsibilities(cont) Follow-up every month during initiation Then every 3-4 months during 1 st year Then every 6 months Monitor free Testosterone levels every 3 months(mtf s), or 2-4weeks (FTM s) until stable See details in TablesB1&B2
TREATMENT IS LIFELONG CARE SHOULD BE LIFELONG
Breast Surgery Re: role of MHP-Equivalent of starting on hormones. 1 letter of recommendation needed For FTM s, usually the 1 st (and sometimes only) surgical step taken. Often done at same time as starting hormones MTF s can consider surgery if social gender role not satisfied after 18mts of hormones
COSTS MTF: Breast Augmentation -$3000-8000 FTM: Bilateral mastectomies -$4000-7000
Gender Reassignment Surgery Effective and medically indicated Not experimental, elective or cosmetic At the same time, not a small step or a minor procedure Critical (and sometimes difficult) to find qualified surgeon
Eligibility Criteria for Genital Surgery Legal age At least 12 months of continuous hormones At least 12 months of full time Real- Life Experience If required by MHP, regular participation in therapy. Not an absolute criteria
Eligibility Criteria for Genital Surgery (cont.) Demonstrable knowledge of the cost in time and money of hospitalization, possible complications, and required follow-up Awareness of different competent surgeons
Two letters are required for Gender Reassignment Surgery. One from the MHP, and one other (usually based on an evaluative exam only. If MHP has master s degree then second evaluator should be MD or ph.d).
Readiness Criteria for Genital Surgery Demonstrable progress in consolidating one s gender identity Demonstrable progress in dealing with work, family, interpersonal issues and other mental health issues (substance abuse, sociopathy, suicidality)
Surgeon Board certified urologist, gynecologist, plastic surgeon or general surgeon Should have special competence in genital reconstructive techniques
Genital surgery for the MTF May include: orchiectomy, penectomy, vaginoplasty, clitoroplasty, and labioplasty Sexual sensation is key objective along with acceptable cosmesis Other possible surgeries: thyroid chondroplasty, other facial and tummy cosmetic procedures
Genital surgery for the FTM Usually more difficult, may require multiple procedures May include: Hysterectomy, salpingooophorectomy, vaginectomy, metoidoplasty, scrotoplasty, urethroplasty, testicular prostheses, and phalloplasty.
Costs MTF: $18,000-35,000 FTM: $30,000-100,000 plus
Gender Reassignment Surgery Toby R Meltzer, MD, Portland, OR Pierre Brassard, MD and Yvon Menard, MD, Montreal, Quebec
Post-Transition Follow-up Strongly encouraged Not always available There are local surgeons who are willing to see patients for follow-up
Advocacy Awareness of difficulties and obstacles our clients face Name change (legal and driver s license) Hospitalization Discrimination