TRANS HEALTH CARE 2013: A VIEW FROM THE
FRONTLINES
ACHA ANNUAL MEETING
BOSTON 2013
Norman Spack, M.D.
Co-Founder, GeMS-DSD Program
Endocrine Division
Boston Children’s Hospital
Associate Clinical Professor of Pediatrics
Harvard Medical School
Norman Spack MD
Boston Children’s Hospital
I have no financial relationship(s) to
disclose within the past 12 months
relevant to my presentation.
AND
My presentation does include discussion
of off-label use of GnRHa agonists
DEFINITIONS
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GENDER IDENTITY = PRIVATE
EXPRESSION OF GENDER ROLE
(PSYCHOLOGICAL, EMOTIONAL
GENDER IDENTIFICATION)
GENDER ROLE = PUBLIC
EXPRESSION OF GENDER IDENTITY
OBSERVATIONS FROM
ADULT
TRANS PATIENTS
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Challenge of gender attribution-being “read”
Genotypic skeleton: habitus, height, acral
size
Male pattern hair loss in MTF
Lengthened vocal cords in MTF
Small fortune on electrolysis ($120/wk)
Significant prevalence of family stress
counterphobic social/gender behavior
High prevalence of psychiatric Dx & Rx,
including 1 suicide; gestures; violence
Getting from FTM
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Goals
– Virilize (4 cm clitoris)-quite effective
– Suppress menses (norethindrone,
tamoxifen)
– Remove breasts (size determines surgical
method)
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Methods
– Androgen Rx: Testosterone injections, gels
(BTB), oral (never)
– GnRH analogues (histrelin implant)
– Oophorectomy, Hysterectomy
(laparoscopic)
GIVING “T” SUBQ
(per the late Jack Crawford)
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WARM BOTTLE SLIGHTLY IN HAND
USE 3 cc SYRINGE 25G 5/8” NEEDLE
INJECT >1 cc AIR INTO BOTTLE
DRAW TESTOST. DOWN SLOWLY
INJECT LATERAL BUTTOCK (EASY
FOR PATIENT TO SELF-INJECT)
RUB INJ. SITE 15 SECS.TO DISPERSE
Getting from MTF
Suppress serum Testosterone
via GnRHa or Estrogen (4-10 mg/d)
or both (1-2 mg/d)
 Develop breasts
 Preserve scalp hair/suppress facial
 Spironolactone and/or Finasteride
 Reduce cost of electrolysis
 Suppress erections
 Limit masculine facial bone strux
 Voice, hgt, skeleton-> “gender
attribution”
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The Amsterdam Experiment
Treatment of adolescent transsexuals at Tanner
2-3 using GnRHa analogues to:
1) Suppress spontaneous pubertal
development
2) Allow for balanced decision regarding sex
reassignment
3) Achieve optimal final height and bone
development
4) Prevent side effects of pubertal delay using
cross-gender sex steroids ~ age 16
The HPG axis and Puberty
?
kisspeptin neurons
kisspeptin
?
GnRH neurons
pulsatile GnRH
pituitary
FSH/LH
gonads
testosterone, estradiol
secondary sexual characteristics
PUBERTY
GeMS Requirements
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Tanner 2-5
IN COUNSELING WITH GENDER
THERAPIST > 6 MONTHS
REFERRAL LETTER FROM THERAPIST,
RECOMMENDING MEDICAL Rx
SUPPORT OF BOTH CUSTODIAL
PARENTS
NO SEVERE PSYCHOPATHOLOGY
Demographics for All
Patients since 1998
Total
Biological Females
Biological Males
N (%)
128 (100)
67 (52.3)
61 (47.7)
Age of
presentation,
mean ± SD*
15.0 ± 3.6
15.3 ± 3.5
14.6 ± 3.7
-
4.1 ± 1.4,
median 5
3.6 ± 1.5,
median 4
Tanner stage,
mean ± SD and
median**
* No significant difference between biological sexes, p=0.25 by Student t-test.
** Significant difference, p=0.012 by Wilcoxon rank-sum test.
Psychiatric History
N (%)
With psychiatric diagnosis before CHB
evaluation*
62 (48.4)
On psychiatric medications
43 (33.6)
With prior psychiatric hospitalizations
11 (8.6)
History of self-mutilation
28 (21.9)
History of suicide attempt
12 (9.4)
* 13 patients presented with more than one psychiatric diagnosis.
Histrelin implant
What Do We Know and Infer About
Transgender College Students?
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Very mixed bag requiring different
approaches by health services
– Some will have declared their gender dysphoria at a very
young age:
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Persist at puberty and receive optimal pubertal suppression
Arrive on campus on cross-sex hormones
Possibly “bottom surgery” for MTF’s, “top surgery” for FTM’s
Have the luxury of “going stealth”
– Some will have been discouraged via “reparative Rx,” but
persist as trans at college
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Parental guilt at home
– Some will receive hostile family response; “thrown away”
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These students suffer from “PTSD” and non-treatment
Some, in middle or high school will confuse gender
dysphoria with sexual orientation, then realize they
are transgender
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Hopefully, these students will have had counseling
and hormonal rx
– Occasional student may have suppressed his/her
gender dysphoria feelings until away from home
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Some may have previously behaved in a very “cisgender” way (i.e. super-macho behavior in true MTF)
A student may have witnessed first community of
gender-non-conformity at college: a major challenge
for the health service, counseling in a vacuum
– Experience in counseling and evaluation students
with gender dysphoria is essential
– Consider parent triangulation and potential
splitting; “this happened because of college!”
– Some students who are comfortable in
their newly-expressed gender role and on
hormonal rx find that their fellow students
do not understand how a trans individual
in their affirmed role can be gay or lesbian
 ~55% of MTF’s and 25% of FTM’s
– Not all trans individuals desire surgery and
a small number reject hormonal rx
 MTF’s who either reject “bottom
surgery” or are waiting until they can
afford it are at risk for STD’s and HIV if
engaging in passive anal-receptive
intercourse
– Unprotected NOW means
unprotected in the PAST
– Some reject the binary notion of gender and see
themselves on a continuum, sometimes moving
between male and female
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Initially “gender queer;” in time, many will find
themselves affirming a male or female gender
If such a student is severely gender dysphoric:
may need to be referred for >weekly counseling
The student who accepts binary roles but unsure
of identity
Continually questions his/her gender identity
Feeds off the introspective process of college
education, particularly courses about gender
identity and role
In time, perhaps after some experimentation,
student is likely to get his/her questions
answered with potential help from health
service counseling
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Special circumstances:
– The gender-non-conforming student who has
Asperger’s Syndrome
 10% of our new patient population
 Has not shown nor expressed gender issues
until past ~2 years
 Extremely obsessive about desire to be the
opposite gender
 Parents confused: Is this just another
obsession?
 Pubertal patients do seem relieved by pubertal
suppression
– Faculty gender transitions:
 If it goes well, it is a tribute to everyone
involved
 When it goes badly, nowadays it goes to court
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The future: Looking brighter than ever
– More students arriving at colleges s/p counseling,
Rx, surgery
– More self-insured universities covering even
surgical care
– More insurers adding riders to provide coverage
– DSM-VI may delete transgenderism as a psychiatric
condition; therefore, medical/surgical benefits will
be paid
– Every medical student, house officer will be trained
in gender issues, even child psychiatrists
– Transgender individuals will no longer face
legalized discrimination in the USA
– Optimal care provided in Holland and USA will be
modeled by national health services everywhere
NEW ACADEMIC PROGRAMS
FOR TRANSGENDER YOUTH
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TORONTO- SICK KIDS
L.A. CHILDREN’S- MYRON BELZER
SEATTLE CHILDREN’S- DAN GUNTHER
BOSTON CHILDREN’S
UCSF CHILDREN’S HOSP
CHILDREN’S HOSP OF BRITISH COLUMBIA
NYU MEDICAL CTR.
MAINE MEDICAL CTR.
CHILDREN’S MEMORIAL HOSP, CHICAGO
SOON: COLUMBIA U, KANSAS CITY,?DALLAS
Resources
SUGGESTED READINGS
 Brill S, Pepper R. The Transgender Child: A
Handbook for Families and Professionals, 2008. San
Francisco: Cleis Press, Inc.
 Brown ML and Rounsley CA, True Selves:
Understanding Transsexualism. 1996. San
Francisco: Jossey-Bass Publishers.
 Ettner, Monstrey S, and Eyler AE(eds.) Principles of
Transgender Medicine and Surgery . 2007. New
York: The Haworth Press.
 Endocrine Society Manual of Clinical Practice for
Treatment of Transsexual Persons. Journal of
Clinical Endocrinology and Metabolism, Sept. 2009.
SUGGESTED WEBSITES
 Gender Identity Resource and Education
Society of UK
(GIRES): http://www.gires.org.uk
 Gender Spectrum Education and
Training: http://www.genderspectrum.org
 International Foundation for Gender
Education: www.ifge.org
 Parents, Families, and Friends of Lesbians
and Gays
(PFLAG): http://community.pflag.org
 Trans Youth Family Allies
(TYFA): http://imatyfa.org
 World Professional Association for
Transgender Health
(WPATH): http://www.wpath.org
PERSONAL REFERENCES:
Spack NP, Edwards-Leeper L, Feldman HA, Leibowitz
S, Mandel F, Diamond DA, Vance SR.
Characteristics of children and adolescents with
gender identity disorder referred to a pediatric
medical center. Pediatrics 2012; 129(3): 418-425.
Perrin E, Smith N, Davis C, Spack N, Stein MT. Gender
variant and gender dysphoria in two young children. J
Dev Behav Pediatr. 2010. 31(2):161-4.
Spack, NP, Clinical Crossroads, Management of
Transgenderism. JAMA 2013.209 (5): 478-484.
Hembree WC, Cohen-Kettenis P, Delemarre-van de
Waal HA, Gooren LJ, Meyer WJ, Spack, NP,
Tangpricha V, and Montori VM. Endocrine Treatment
of Transsexual Persons: An Endocrine Society Clinical
Practice Guideline. J Clinical Endocr Metab, 2009.
94 (9): 3132-54.
Edwards-Leeper L and Spack NP. Gender
Identity Disorder. In Augustyn M et al (eds.).
The Zuckerman Parker Handbook of
Developmental and Behavioral Pediatrics for
Primary Care, 3rd edition. Philadelphia,
Lippincott Williams & Wilkins, 2010.
Spack NP and Edwards-Leeper, L. Medical
Treatment of the Transgender Adolescent. In
Fisher M, et al (eds,) Textbook of Adolescent
Health Care , American Academy of Pediatrics,
2011.
Shumer D and Spack N. The Approach to
Transgender Youth. Levitsky, Lynne (Ed.)
Current Opinion in Endocrinology, Diabetes and
Obesity. Wolters Kluwer/Lippincott Williams
and Wilkins 2013. 20:69-73.