DR.
MADELINE DEUTSCH: So to discuss youth, I’m
going to give you kind of an overview of the
approach to use.
And this is going to be a very basic gloss
over.
In fact, I think the most important point
about addressing youth -- and this is something
that Dr. Bockting touched on, is if we can
identify youth at a prepubertal or pubertal
age we can prevent the viralization and the
progress of their natal puberty we can avoid
a lot of the undoing that has to happen in
the medical -- in the doctor’s office if
the patient presents as an adult.
And we can reduce trauma associated with living
in the wrong gender and body.
And it will allow socialization and development
potentially at the same time in pace with
their peers, which really can have a profound
effect on development.
We can go to the next slide.
So the general approach of the provider would
work with child, family, school, other stakeholders,
whomever that might be.
It could be clergy; it could be extended family
members, friends, whatever it is.
And the role of mental health is central to
this process, and the mental health provider
ideally, you have experience with transgender
youth issues, should be involved.
Putting all of these folks together, some
decisions can be arrived at as to what would
be the process moving forward.
Do you allow the child to cross dress at home
only?
Do you allow them to maybe dress in their
preferred clothing on weekends when they go
out of the house to dinner but not to school?
Or do we allow them to socially transition?
Or do we allow the child, the prepubetal child,
to go to school dressed in the gender that
they prefer?
And then once the child arrives at puberty,
in general -- on a very, very basic level
here -- but in general when the child arrives
at puberty, ten or stage two, we feel that
that child has experienced enough of their
natal gender to at that point -- we feel comfortable
if the child is still exhibiting cross-gender
feelings and desires, that is a time to consider
a medical intervention.
And so medical intervention is available;
our team gives a puberty blocker, which would
be used for several years, up to several years,
that will arrest the process of puberty while
other issues come into play.
So perhaps there’s a parent who has some
concerns.
Perhaps both parents are supportive of you
progressing with the hormonal transition,
but are waiting to move to another neighborhood
or waiting for the child to enter high school,
or any other of a number of issues.
Once a time arises where folks are ready to
begin a social hormonal transition, cross-gender
hormone treatment can be begun.
Sometimes this can be begun without a course
of puberty blockers, depending on the overall
circumstances.
And surgery is generally not done in youth.
There have been a couple of cases reported
in the media and in the literature, but surgery
at this point for those who are interested,
in general, is delayed until age of majority.
We can go to the next slide.
And so as I mentioned, this really allows
children to progress in their chosen gender.
And these are just some other specifics of
hormone care that I don’t want to get too
into that.
We can go to the next slide.
So cancer risk and screening.
I’m just going to put these up here and
just mention that they exist.
They’re something that we need to think
about.
There’s really limited data on the screening
and the long-term risk for all of these conditions.
These are things that we have to think about.
We can go to the next slide.
Great.
So this is a review article that was published
in 2008.
It was reviewed in the literature and they’re
basically reporting -- this is from a group
from the Netherlands, the leader in transgender
research, and there are a few cases of hormone-related
cancer in transsexuals.
I want to point out that so far endometrial
cancer as of this time had not been encountered.
Since then, there has been one case in literature
of endometrial cancer.
But that notwithstanding, this says one of
two things.
We really -- one, it says there’s not a
lot of smoke, so there’s probably not a
big fire.
So what this means is that there’s probably
not a lot of hormone-related cancer in transgender
people, likely not more than the general population.
What it also says is that we very well could
be missing large [parts] of the population
in our studies and there could be patients
who are either not being detected, and are
dying of other conditions or dying undetected.
And so this again is a call for improved epidemiologic
surveillance of this population.
We can go to the next slide.
A general dictum of protective screening in
transgender patients is if you have an organ
it must be screened, so we should take an
organ inventory of all of our patients and
determine which one is ones they have and
have a screen for it.
And something else that I’d like to point
out from a research perspective is it is entirely
possible that we might do research and find
out that pelvic examinations on transgender
men are not necessary at all.
And this is looking at things from a [inaudible]
perspective.
For example, the breast self-examination is
now not recommended in most circumstances
because it has not been found to improve outcome.
So we find that there’s one or two cases
reported of endometrial cancer in the literature,
and we have transgender men who periodically
present with some vaginal spotting, we might
find that a work up with an ultrasound and/or
endometrial biopsy is not warranted and not
from a population health standpoint affect
outcome.
And that’s important to look at in transgender
people because a pelvic exam, a vaginal ultrasound
is a much bigger deal to a transgender man,
in some circumstances, than it might be in
your general population of women in your practice.
So just, again, thinking about transgender
patients from a different perspective and
thinking about some of the psychosocial issues
that are wrapped around their medical care.
We can go to the next slide.
Some of the long-term considerations; I’m
going to put this citation here just so that
you have it is the large population, a couple
of 1,000 patients; patients from the Netherlands
mortality was not higher in a comparison group,
particularly after they’ve switched to using
safer forms of estrogen, which had been different
from previous ones, which is where the risk
of blood clots comes from, which is now that
we have new forms of estrogen is not as much
of an issue.
We can go to the next slide, please.
Quality of life outcomes; we know from several
recently published studies from Spain as well
from here in the United States, but hormone
therapy reduces anxiety, depression, and improves
social functioning.
We’ve found that surgery improves global
functioning, quality of life.
The regret rates are very low, and malpractice
rates are effectively nonexistence in caring
for the population with respect to regret.
Some miscellaneous issues, documentation is
always something to think about as well as
diagnostic coding.
I don't know that -- I honestly think that
we probably need to skip this slide and move
forward in the interest of time.
The future, we have this fantastic report
from the Institute of Medicine, which tells
us that we need to do research on LGBT people,
transgender people.
Next slide.
The American College of Obstetricians and
Gynecologists this past December, released
a physician statement directing that specialty
to prepare to care for transgender patients.
This is groundbreaking and I really hope that
other professional societies follow suit.
We can go to the next slide.
So wrapping up with some of the resources;
the Center for Excellence Protocol, which
I was centrally involved in its development,
are in my opinion the number one resource
for U.S. providers to turn to for transgender
guidance.
It’s kind of your first resource.
They are the most recent evidence and expert
opinion-based treatment protocols, and they
are specifically tailored to U.S. health care
issues.
Other guidelines from Europe and Canada are,
to be quite honest, focused on systems where
some more resources may exist, and these are
focused on more of resource poor settings,
that use the protocol.
We can go to the next slide.
I’m just going to pass through a couple
of other resources that are available here
that improve our guidelines.
They are a complete set of guidelines and
are great and more in-depth set of guidelines.
I’m not sure how applicable they are to
a U.S. setting.
You can go to the next one.
And just some additional references, a fantastic
review, if you’re looking for a quick eight-page
read that is really very straightforward and
makes sense, and you want to find out how
to take care of patients tomorrow morning,
this is a great place to start for transgender
care.
Next reference, please.
And this is a long-term outcome study by a
group in the Netherlands.
Next reference.
And some additional references, including
a fantastic primer on adolescent patients,
which is five pages long, from my colleagues
at Children’s Hospital.
And we can go to the next slide.
This is my contact information.
I apologize for going slightly long.
It is wonderful to be here.
As a transgender woman myself, I’m so proud
to have this ability to help work with and
improve the health and care for transgender
people.
Thank you very much.
