View - Texas Tech University Health Sciences Center El Paso
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View - Texas Tech University Health Sciences Center El Paso
Transgender Healthcare Colt Meier, Ph.D. Provisionally Licensed Psychologist Objectives • Define basic terminology • Understand the barriers to culturally competent health care • List the numerous treatments available for gender dysphoria • Question and Answer – Text 409-782-6059 Where do we start? • In order to work sensitively with transgender people one must – Be educated on terminology – Consider what these terms mean on a personal level – Understand the unique needs and experiences of this population • Value systems and religious convictions – Kindness and respect What is transgender? • Let’s talk about what it is not first • LGBTQ acronym – Gender is not the same as sexual orientation – Why do all the letters go together? • • • • • Developmental Psychological Medical Spiritual Legal Language and Terminology (Crooks & Baur, 2010) • Three parts of gender (everyone has a gender) – Physical, Biological, or Anatomical Sex – Gender Expression • External – Gender Identity • Internal Sex Gender Expression Gender Identity • One’s felt sense of self as being a girl, a boy, both, or neither – Internal – Child usually voices gender between 2 and 5 years old (Zucker & Bradley, 2005) • One “just knows” their gender – Psychological, cultural, social construct – Tied to pronouns • Mr./Mrs./Ms. and He/him/she/her Language and Terminology • Intersex – Physical sex differs from cultural expectations • Gender non-conformity (Gender variance) – Gender expression differs from cultural expectations • Transgender – Gender identity differs from cultural expectations Language and Terminology • Transgender Specific Terms – Male to Female (sex to gender identity) • MTF • trans woman • She, her, hers; Ms./Mrs./Dr. – Female to Male • FTM • trans man • He, him, his; Mr./Dr. – Non-binary • • • • Genderqueer Two Spirit Agender Gender neutral pronouns – They, them, theirs; Mx./Dr. Diversity of identities • Unlimited ways of being Terminology Basics o o o o o o o Sexual Orientation??? Transsexual: Clinical term, gender affirmation seeking Gender Dysphoria Binding/Tucking Transition/ Affirmation: the process of body changes Passing: perception is in line with intention Non-Disclosing (colloquially: Stealth): not selfdisclosing, seeking to remain invisible, blend in, just be o Cisgender: not transgender Language and Terminology National Snapshot o Four times more likely to live on < $10,000 annual income o Double the rate of unemployment overall o 4x the rate for trans people of color o 90% harassed on the job – 71% report hiding gender at work o 78% report work performance improvement after transition o 16% work in street economies for income (sex &/or drugs) o Twice the national rate of homelessness o 53% harassed in public accommodations o 29% by police o 12% by judges and court officials o 57% experience family rejection Grant, J. M., Mottet, L. A., Tanis, J., Herman, J. L., Harrison, J., and Keisling, M. (2010). Injustice at Every Turn: National Transgender Discrimination Survey Report on health and health care. <http://www.thetaskforce.org/downloads/reports/reports/ntds_report_on_health.pdf> Barriers to Transgender Health Care • 70% of transgender reported previous bad experiences with health care (Shipherd et al., 2010). – Being refused care – Being blamed for their health status – Health care professionals using abusive language with or about them – Providers being physically rough, refusing to touch them, or using excessive precautions • Concerning in the context of high rates of trauma exposure and PTSD symptoms (Shipherd, Maguen, Skidmore, & Abramovitz, 2011). National Medical Care o Inadequate training in medical schools (ObedinMaliver et al., 2011; JAMA) o 25% harassed in places of medical care o 24% denied equal treatment in doctor’s offices & hospitals o 19% were refused care when being transgender was disclosed o 2% physically assaulted in doctor’s offices or hospitals Grant, J. M., Mottet, L. A., Tanis, J., Herman, J. L., Harrison, J., and Keisling, M. (2010). Injustice at Every Turn: National Transgender Discrimination Survey Report on health and health care. <http://www.thetaskforce.org/downloads/reports/reports/ntds_report_on_health.pdf> Trans Texans (n = 266) Medical Discrimination • 85% report having to educate their doctors • 26% experienced mistreatment by a doctor or hospital staff • 20% report being refused medical care due to their transgender status • 53% do not come out in all medical settings • 25% did not seek out medical care when sick or injured due to discrimination Transgender Suicide Risk Factors Discrimination, Rejection, and victimization 1. By Parents/Family of Origin 2. By Other Significant People 3. By Strangers ~ Increased by any of the Following ~ Low Self-Esteem - History of Depression History of Substance Abuse – Job Loss Harassment – Discrimination – Assault – Poverty Clements-Nolle, K., Marx, R., and Katz, M. (2006). Attempted Suicide Among Transgender Persons: The Influence of Gender-Based Discrimination and Victimization. Journal of Homosexuality, 51(3), 53-69. PMID: 17135115 DOI: 10.1300/J082v51n03_04 Protective Factors for Suicide o o o o o o o o Strong connections to family and other supports Access to effective clinical interventions Restricted access to lethal means Skills in problem-solving, conflict resolution, & coping Frustration tolerance and ability to regulate emotions Community support (any positive community) Positive beliefs about future and life in general Cultural or religious beliefs discouraging suicide Suicide Prevention Resource Center (SPRC) at Education Development Center, Inc. (EDC). http://www2.sprc.org/collegesanduniversities/campus-data-risk-and-protective-factors -The adult transgender suicide attempt rate in the US is 41% -The US adult suicide attempt rate 10.4% NGLTF & the National Center for Transgender Discrimination. (In Press). Attempted suicide among transgender persons: National transgender discrimination survey. (A Study of 6,500 Gender variant people in the United States) Suicide Prevention Resource Center (SPRC) at Education Development Center, Inc. (EDC). http://www.sprc.org/stateinformation/PDF/statedatasheets/sprc_national_data.pdf AND http://www2.sprc.org/collegesanduniversities/campus-data-prevalence Trans Health Care • Two General Rules – Most health care for trans people has nothing to do with being trans – Health care and screening are based on the organs present and hormonal status Reducing Gender Dysphoria o Social o manner of expression o name and/or pronouns o Medical o Hormones and/or surgeries o Legal o Documentation changes o Private o Part-time o Full-time General Care and Trans Care • Medical providers: you already know 90% of what you need to know • 100% of the medical treatments and most of the surgeries are used in cisgender patients • Like any patient with a rare disease – 1 in 2500 General Healthcare Needs • Screening and Preventive Medicine • Disease Treatment Cancer Screening • Remember: Work with the organs present • Screening – Pelvic Exams – Mammograms – Pap Smears – Prostate Exams General Health Screening • Screening – Cardiovascular – Diabetes – Infectious Disease – Musculoskeletal/Osteoporosis – Sexual Health – Substance Use Trans Specific Healthcare • Pre-hormones – – – – – – Not every patient desires hormone tx Physical transition goals? Support systems? Out to family, partner, work/school? Source of info? Options MD Responsibility Trans Specific Health Care • Hormones WPATH SOC v 7 Feminizing Hormones • Estrogen • Anti-androgen • Progesterone? Masculinizing Hormones • Testosterone Trans Specific Healthcare • Surgeries – Not every patient desires surgical procedure(s) • Multiple surgical treatment options – Chest – Genital – Facial What About Surgery Regret??? • Pfäfflin & Junge (1998) – 74 f/u studies and 8 reviews published b/w 19611991 – Less than 1% long term GRS regret in over FTMs – 1.5% regret in MTFs • Studies after 1991 show even lower rates of regret • Less than 2% long term CRS regret in over 1,000 FTMs (Green, dickey, & Meier, 2012) Predictors of Regret • • • • • Inadequate diagnosis Undiagnosed major psychiatric comorbidity Lack of social support Personal social instability Unrealistic expectations Predictors of Satisfaction • Early onset of gender dysphoria • No psychiatric illness • Social and family support • Criteria for hormones and surgeries in the WPATH Standards of Care U.S. Surgical Experience • FTM – – – – Breast reduction 90% Hyst BSO 50% Genital surgery 10% No need to stop testosterone pre-op • MTF – – – – Breast augmentation ~50% Genital surgery MOST Facial feminization DVT precautions as indicated FTM Chest Surgery • Top surgery/Chest Reconstruction – Liposuction, double incision, peri-areolar Double Incision FTM Chest Surgery Peri-areolar FTM Chest Surgery FTM Internal Genital Surgery • Hysterectomy BSO – Laproscopic – Robotic – Abdominal FTM External Genital Surgery • Metoidioplasty • Phalloplasty – Scrotoplasty with testicular prostheses – Vaginectomy – Urethroplasty FTM External Genital Surgery Metoidioplasty Phalloplasty MTF Breast Surgery • Breast Augmentation MTF Breast Surgery MTF Genital Surgeries • Ochiectomy • Vaginoplasty – Penectomy – Clitoroplasty – Labiaplasty • Prostate remains after surgery Vaginoplasty Facial Feminization Surgery • • • • • • Rhinoplasty Laryngochondroplasty (tracheal shave) Facelift Eyelid and brow lift Chin and cheek implants Lip augmentation Hormone Treatment and Electrolysis Hormone Treatment plus Facial Feminization Surgery Fertility/Reproductive Options • FTM – Oocyte cryopreservation – Gamete cyropreservation – Pregnancy • MTF – Sperm donation Resources http://transhealth.vch.ca/resources/ careguidelines.html http://transhealth.ucsf.edu/trans?pa ge=protocol-00-00 Q&A • [email protected] Etiology • No definite answers • Many parents are concerned that something they did made their child become transgender. • Things that do NOT cause a child to be transgender – divorce, neglect, wishing you had given birth to the other sex, using fertility drugs to conceive, encouraging your child to play sports too often or not enough, or other parental thoughts, behaviors or experiences Etiology • Genetics – Twin studies • Brain – Hypothalamus (BTSc) in MTFs (Zhou et al., 1995) – Microstructure of White Matter in MTFs and FTMs (Rametti et al., 2010) – Neural network of body representation (Lin et al., 2014) • Hormones – Elevated rates of PCOS (58%; n = 69) in FTMs (Baba et al., 2007) – polymorphism of the CYP17 in FTMs (Bentz et al., 2008) How many? • It depends: 1 in 200 to 1 in 100,000 • 1 in 2,500 people in the US have had trans related surgery • In a population the size of Texas= 26 million – 26 mil / 200 = 130,000 will be transgender – 26 mil / 500 = 52,000 will desire to transition – 26 mil / 2500 = 10,400 potentially could have had at least one type of gender related surgery
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