Providing Care for Sexual and Gender Minorities

1. Providing Care for Sexual and Gender Minorities Bridget Skidmore, MD Child and Adolescent Psychiatry Department of Behavioral Medicine and Psychiatry West Virginia University

2. Objectives • Definitions and background • Guidelines • Resources

3. We can’t cover everything… • “The limitation of relying on a single presentation as an exclusive or one-time educational event is the inherent time restriction, forcing more superficial coverage of the material.” • And therefore, “All presentations should provide attendees with access to resources following their completion.” • From Gender Variant Children and Transgender Adolescents

4. Ever Evolving Guidelines • Changes in perspectives and language over time • Some of our currently active guidelines still have old language • Limited Evidence Base

5. Resources

6. Definitions: Sexual Orientation • The anatomic sex of the person to whom an individual is erotically attracted • Comprises components of sexual fantasy, patterns of physiological arousal, sexual behavior, sexual identity and social role. • Components can be congruent or incongruent. • Variability in components different definitions/perceptions, rates • Homosexual, heterosexual, and bisexual. • You may also hear pansexual, demisexual, asexual, etc.

7. Definitions: Gender and Identity • Gender – the perception of a person’s anatomical sex on the part of society • Gender Role Behavior – activities, interests, use of symbols, styles or other personal and social attributes that are recognized as masculine or feminine • Gender Identity – an individual’s personal sense of self as male, female, or other • Usually develops by age 3, is concordant with a person’s sex and gender, and remains stable over the lifetime • Identity – an individual’s abstract sense of self (equivalent to ego identity) • Usually consolidated in adolescence

8. Definitions: Gender Minority • Childhood Gender Nonconformity – variation from norms in gender role behavior • AKA gender variance and gender atypicality • Most children display some variability in gender behavior

9. Definitions: Gender Minority • Gender Discordance – discrepancy between anatomical sex and gender identity • AKA gender identity variance • Transgender – individual with gender discordance • Transsexual – transgender individual who makes their perceived gender and/or anatomical sex conform with their gender identity

11. How common? • Inherent difficulties in determining incidence/prevalence • Alternate definitions for orientation and gender identity • Cultural differences • Stigma • Variability over time (gender examples) • A 2007 review of studies showing prevalence rates of 1:11,900 to 1:45,000 for male-to-female individuals (MtF) and 1:30,400 to 1:200,000 for female-to-male (FtM) individuals • A 2015 update: “In the general population, gender ambivalence was present in 2.2 % of male and 1.9 % of female participants, whereas gender incongruence was found in 0.7 % of men and 0.6 % of women. ” -De Cuypere, G., Van Hemelrijck, M., Michel, A., Carael, B., Heylens, G., Rubens, R., .. . Monstrey, S. (2007). Prevalence and demography of transsexualism in Belgium. European Psychiatry, 22(3), 137-141.doi:10.1016/j.eurpsy.2006.10.002 -Van Caenegem, E., Wierckx, K., Elaut, E. et al. Arch Sex Behav (2015) 44: 1281. https://doi.org/10.1007/s10508-014-0452-6

12. Does transgender identity exist in other cultures? Is this new? • Gender minoritiesthroughout history and across cultures • Our societal understanding and view has changed over time • Further history available at the LGBT Mental Health Syllabus

13. Biopsychosocial Influences • Neuroanatomical • Neuroendocrine • Genetic • Societal

14. Psychosexual Development • Various developmental pathways • May proceed as: erotic fantasy experience identity social role • Order may be varied • Development may be “fluid,” with changes along the course • Sexual identity may occur prior to sexual experience

15. Sexual and Gender Minorities and DSM • Gender discordance is a core feature of Gender Dysphoria • Major changes from DSM IV-TR (GID) to DSM 5 • Diagnosis in children has been controversial • Mental illness vs social bias? • Sexual and gender minority youth develop depression, anxiety disorders, substance abuse and suicidality at rates that are elevated in comparison to general population youth

16. Gender Dysphoria in Children • A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least 6 of the following (one of which must be criterion A1) • 1. A strong desire to be the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender) • 2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typically masculine clothing and a strong resistance to the wearing of typical female clothing • 3. A strong preference for cross-gender roles in make-believe play or fantasy play

17. Gender Dysphoria in Children • 4. A strong preference for the toys, games, or activities stereotypically usedor engaged by the other gender • 5. A strong preference for playmates of the other gender • 6. In boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games and activities • 7. A strong dislike of one’s sexual anatomy • 8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender

18. Gender Dysphoria in Children • B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning • Specify if: • With a disorder of sex development (e.g. a congenital androgenital disorder such as congenital adrenal hyperplasia or androgen insensitivity syndrome)

19. Gender Dysphoria in Adolescents • A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least 2 of the following: • 1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in younger adolescents, the anticipated secondary sex characteristics) • 2. A strong desire to be rid of one’s primary and/or secondary sex characteristicsbecause of marked incongruence with one’s experienced/expressed gender (or in younger adolescents, a desire to prevent the development of the anticipated secondary sex characteristics). • 3. A strong desire for the primary and/or secondary sex characteristics of the other gender

20. Gender Dysphoria in Adolescents • 4. A strong desire to be of the other gender(or some alternative gender different from one’s assigned gender) • 5. A strong desire to be treated as the other gender(or some alternative gender different from one’s assigned gender) • 6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender) • B. The condition is associated with clinically significant distress or impairment in social, occupational or other areas of functioning.

21. Gender Dysphoria in Adolescents • Specify if: • With a disorder of sex development • Posttransition: The individual has transitioned to full-time living in the desired gender(with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen– namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g. penectomy, vaginoplasty in a natal male; mastectomy or phalloplasty in a natal female). • Also an “Other Specified Gender Dysphoria” and “Unspecified Gender Dysphoria” • Examples: Less than 6 months duration, or insufficient information for more specific Dx

22. Principle 1: Appropriate Assessment • A comprehensive diagnostic evaluation should include an age-appropriate assessment of psychosexual development for all youths. • Questions about sexual feelings, experiences and identity • Nonjudgmental, unassuming • Using gender-neutral language • “Is there someone special in your life?” • Appropriate screening for hypersexuality as indicated • Stereotyped views of homosexual individuals as hypersexual is not supported by research • Consider sexual abuse, family dysfunction, conduct problems, mood disorder

23. Principle 2: Confidentiality • The need for confidentiality in the clinical alliance is a special consideration in the assessment of sexual and gender minority youth. • These youth may watch social cues vigilantly to determine if it is safe to talk • Clinicians should consider potential risks to patients of premature disclosure • Emphasize reasonable expectations of privacy with patients • Often desirable to allow youth to set the pace of self-discovery

24. Principle 3: Family/Cultural Context • Family dynamics pertinent to sexual orientation, gender nonconformity, and gender identity should be explored in the context of the cultural values of the youth, family and community. • Families have considerable variation of reactions • Children frequently predict these reactions poorly

25. Principle 3: Family/Cultural Context • Parental feelings can include • Anxiety, anger, loss, shame or guilt • Fear for child safety in setting of social stigma • Feelings related to secondary stigmatization for parents • Co-parenting conflicts • Parents may have differing acceptance or transition timeline • Paternal stereotypical gender norm – safety/protection focus • Maternal stereotypicl gender norm – nurture/acceptance focus • Despite this, over time the majority of parents become affirming and are not distressed.

26. Principle 3: Family/Cultural Context • Rejected youth suffer negative effects on their sense of identity, self-esteem and capacity for intimacy. They are at risk for school drop-out, homelessness, substance abuse, depression and suicide. • Assess family ideas, cultural background, and any distorted expectations • Youth who are also of ethnic minority may be less likely to be involved in sexual minority social activities or to disclose sexual identity. • Religious tolerance varies widely. • Utilize support groups or referrals for therapy (individual, family, etc.) as needed

27. Principle 4: Comorbidities/Risks • Clinicians should inquire about circumstances commonly encountered by youth with sexual and gender minority status that confer increased risk. • Bullying • Increased risk of depression, anxiety and suicidal thoughts • School programs can be effective • Psychotherapy helpful • Suicide • Increased risk (3-4x more likely to self-report SA in the past 12 mo), particularly prior to self-acceptance • Protective factors include family connectedness, adult caring, and school safety • Other mental health concerns • Depression, anxiety, eating disorders, substance use

28. Comorbidities/Risks • Increased risk of use of alcohol, nicotine and other substances • 20-50% of homeless youth are of sexual or gender minorities • Medical risks associated with any sexual activity • Self-identified lesbian youth have higher rates of unintended pregnancy than heterosexual female youth

29. Principle 5: Foster Healthy Development • Clinicians should aim to foster healthy psychosexual development in sexual and gender minority youth and to protect the individual’s full capacity for integrated identity formation and adaptive functioning. • Youth/family acceptability of minority feelings can change with intervention, as can the capacity to incorporate these feelings into healthy relationships • Striving toward healthy development as youth navigate family, peer and social environments that may be hostile • When orientation/identity is uncertain, fostering development without prematurely assigning a path.

30. Principle 6: Conversion Therapy is Harmful • Clinicians should be aware that there is no evidence that sexual orientation can be altered through therapy, and that attempts to do so may be harmful. • “Reparative therapy” caused no change in sexual orientation, but significant harm to self-esteem. • No evidence that homosexuality can be prevented by encouraging gender conformity • No medically valid basis for attempting to prevent homosexuality • Adult efforts to prevent homosexuality in children undermine protective factors against suicide and may increase the risk of bullying

31. Principle 7: Natural Course • Clinicians should be aware of current evidence on the natural course of gender discordance and associated psychopathology in children and adolescents in choosing the treatment goals and modality. • Most children have some amount of gender nonconforming behavior • A smaller group will have more consistent nonconformity and display gender identity discordance • Even marked gender nonconforming behavior may be associated with ambiguous or no cross-sex wishes

32. Principle 7: Natural Course • Gender dysphoric feelings eventually desist in majority of children • Age 10-13 is a major transition point • Changes in bodies, social environment, sexual attraction • Higher intensity GD in childhood is strongest predictor of persistence

33. Principle 7: Diagnosis • Clinical interview is gold standard for DSM diagnosis • Structured instruments (questionnaires) available • Differential diagnosis includes disorders of anatomical sex development • Endocrinological evaluation/treatment may be indicated • Referral by a mental health provider, or initial assessment by specialty qualified hormone provider (WPATH Standards of Care) • WPATH HBIGDA Standards of Care • World Professional Association for Transgender Health • Harry Benjamin International Gender Dysphoria Association

34. Principle 7: Treatment • Often a multidisciplinary approach – pediatrics, psychiatry, endocrinology, surgery, etc. • Gender discordance in children • All practice guidelines recommend that pre-pubertal gender-nonconforming children who are impaired/distressed by this nonconformity be assessed by a mental health practitioner trained in child development • These providers should be aware of the WPATH SOC

35. Principle 7: Therapy treatment • Gender discordance treatment in children/adolescence • Proposed goals of treatment include • Reducing desire to be other sex – Ethically rejected • WPATH and AACAP have positions against this • No evidence of benefit. Evidence of risk for harm • Gender discordance only persists in a small minority of untreated cases • Decreasing social ostracism and distress • Reducing psychiatric comorbidity • Optimizing adjustment and wellbeing

36. Principle 7: Therapy treatment • No empirical treatment models • “Watchful waiting” – allowing natural developmental path and address social risks • “Affirmative model” – support to live in the gender that feels most comfortable • Support Groups • In person and online • Resources for friends/family

37. Non Hormonal/Surgical Treatment • General agreement to start with more reversible interventions before more irreversible ones • Examples: • Breast binding • Padding • Genital tucking or penile prostheses • Changes in name and gender markers • Voice and communication therapy • Hair removal

38. Principle 7: Treatment • No data to guide decisions regarding the risks/benefits of sending children to school in their desired gender • Bathrooms in the news • “The West Virginia Department of Education expects counties to ensure all students, regardless of gender identity, have adequate privacy protections in any restroom and/or changing facility … Our county superintendents have and will continue to ensure the safety of all students, and, if needed, address transgender identity on a case by case basis.” Quinn, R. (18, December 18). Assistant principal who confronted transgender student in restroom suspended. Charleston Gazette-Mail.

39. Principle 7: Deciding on Treatment • Gender dysphoria treatment in adolescents • In consideration of hormonal/surgical treatments • Goal: help youth make developmentally appropriate decisions about sex reassignment • Lower rates of mental health problems when gender discordance is treated in adolescence than when it is deferred to adulthood • If no treatment, teens may use illicitly obtained sex hormones or other medicines • Generally recommended to defer sex reassignment until adulthood, or at least until the wish to change sex is unequivocal, consistent, and made with appropriate consent

40. What is the Evidence Base for Medical Treatment? • Studies based on current Standards of Care show improvement in the following: • QOL measurements • Gender Dysphoria severity • Body Image • Externalizing behaviors • Depression • Anxiety • Suicidality • Substance use • Self confidence • Interpersonal sensitivity

41. Principle 7: Hormone Treatment • When reassignment is addressed • Sex hormone suppression under endocrinological management with psych consultation using gonadotropin-releasing hormone analogues that reversibly delay the development of secondary sex characteristics • Considered a fully reversible intervention • Avoids distress from unwanted sex characteristics • Minimizes later need for surgery • Delays the need for further treatment decisions until maturity allows further informed consent • No data on how long this can be maintained • Studied, showing beneficial effects on behavioral and emotional problems, depressive symptoms and general functioning

42. Principle 7: Hormone/Surgical Timelines • One approach • Age 12 – Start considering puberty suppression • Age 16 – Start considering cross-sex hormone treatment • Age 18 – Start considering gender reassignment surgery • Another approachis based on physical development, suppressing puberty at Tanner Stage 2 • Risks include effects on growth, bone mass development, future fertility, uterine bleeding and others

43. Endocrine SocietyGuidelines: Hormones • Given the high rate of remission of GID after the onset of puberty, we recommend against a complete social role change and hormone treatment in pre-pubertal children with GID. • We recommend that adolescents who fulfill eligibility and readiness criteria for gender reassignment initially undergo treatment to suppress pubertal development. • We recommend that suppression of pubertal hormones start when girls and boys first exhibit physical changes of puberty (confirmed by pubertal levels of estradiol and testosterone, respectively), but no earlier than Tanner stages 2–3. • We recommend that GnRH analogues be used to achieve suppression of pubertal hormones. • We suggest that pubertal development of the desired opposite sex be initiated at about the age of 16 years, using a gradually increasing dose schedule of cross-sex steroids.

44. Endocrine Society Guidelines: Hormones • Adolescents are eligible and ready for GnRH treatment if they: • 1. Fulfill DSM IV-TR or ICD-10 criteria for GID or transsexualism; • 2. Have experienced puberty to at least Tanner stage 2; • 3. Have (early) pubertal changes have resulted in an increase of their gender dysphoria; • 4. Do not suffer from psychiatric comorbidity that interferes with the diagnostic work-up or treatment; • 5. Have adequate psychological and social support during treatment; and • 6. Demonstrate knowledge and understanding of the expected outcomes of GnRH analogue treatment, cross-sex hormone treatment, and sex reassignment surgery, as well as the medical and the social risks and benefits of sex reassignment.

45. Endocrine Society Guidelines: Hormones • Adolescents are eligible for cross-sex hormone treatment if they: • 1. Fulfill the criteria for GnRH treatment AND • 2. Are 16 years or older. • Readiness criteria for adolescents eligible for cross-sex hormone treatment are the same as those for adults.

46. Cross-Sex Hormone Treatments • Feminizing/Masculinizing hormone therapy • MtF: Estrogen, Anti-Androgens, Progestins • Breast growth, decreased libido and erections, decreased testicular size, increased percentage of body fat compared to muscle mass • Anti-androgens: Medications from various drug classes that either reduce testosterone levels or activity • Spironolactone, cyproterone acetate*, GnRH agonists (goserelin, buserelin, triptorelin), 5-alpha reductase inhibitors (finasteride, dutaseride) • FtM: Testosterone, other agents (progestins, GnRH agonists) • Deepened voice, clitoral enlargement, growth in facial and body hair, cessation of menses, atrophy of breast tissue, increased libido, decreased percentage of body fat compared to muscle mass • Most changes occur over approximately 2 years, but timeline and extent of change are variable and poorly predictable

47. What are the Risks of Hormone Treatment?

48. What if patients want children later? • Hormone therapy limits fertility • Recommended that providers discuss reproductive options prior to medical treatments for gender dysphoria • MtF patients: Provide education about sperm preservation and consideration of banking sperm • FtM patients: Provide education about oocyte or embryo freezing • Options are more limited if hormonal treatment starts prior to development of reproductive function

49. Endocrine Society Guidelines: Surgery • We recommend referring hormone-treated adolescents for surgery when • 1) the real-life experience (RLE) has resulted in a satisfactory social role change; • 2) the individual is satisfied about the hormonal effects; and • 3) the individual desires definitive surgical changes. • Wesuggest deferring surgery until the individual is at least 18 years old.

50. Principle 8: C/L and Advocacy • Clinicians should be prepared to consult and act as a liaison with schools, community agencies, and other health care providers, advocating for the unique needs of sexual and gender minority youth and their families. • Seek information about the social system – Supportive or hostile environment? • Do not assume that all parties in the system know about the youth’s minority status • We have a unique ability to raise awareness and advocate to support nondiscrimination and equality