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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.