Hi reddit, my name is Dr. Johanna Olson-Kennedy, and I have spent the last 11 years working with gender non-conforming and transgender children, adolescents and young adults. I am the Medical Director of the Center for Transyouth Health and Development at Children’s Hospital in Los Angeles. Our Center currently serves over 900 gender non-conforming and transgender children, youth and young adults between the ages of 3 and 25 years. I do everything from consultations for parents of transgender youth, to prescribing puberty blockers and gender affirming hormones. I am also spearheading research to help scientists, medical and mental health providers, youth, and community members understand the experience of gender trajectories from early childhood to young adulthood.
Having a gender identity that is different from your assigned sex at birth can be challenging, and information available online can be mixed. I love having the opportunity to help families and young people navigate this journey, and achieve positive life outcomes. In addition to providing direct patient care for around 600 patients, I am involved in a large, multi-site NIH funded study examining the impact of blockers and hormones on the mental health and metabolic health of youth undergoing these interventions. Additionally, I am working on increasing our understanding of why more transyouth from communities of color are not accessing medical care in early adolescence. My research is very rooted in changing practice, and helping folks get timely and appropriate medical interventions. ASK ME ANYTHING! I will answer to the best of my knowledge, and tell you if I don’t know.
I'll be back at 2 pm EST to answer your questions, ask me anything!
Do you know if there are any ongoing (or pending?) studies on the clinical effectiveness of estrone vs. estradiol in MtF individuals?
Anecdotally, different dosing regimens affect the E1/E2 balance, yielding radically different feminization trajectories. It would be nice to see that confirmed clinically, and new dosing guidelines generated to reflect that.
(More info: see slides 28-31 here.)
I don't know of any, but I think these are critical.
We've all heard about the shockingly high suicide rate amongst transgender individuals as compared to the general population. Fortunately, there is also substantial evidence that transitioning drastically reduces this rate [1, 2, 3, 4], sometimes to near that of the general public .
What are the primary factors contributing to transgender suicide before a patient undergoes SRS transitions? What about after transitioning? Has your institution seen changes in these rates over time as the medical community becomes better equipped to handle transgender care?
Clinically we have seen that suicidality is lower once youth move forward with whatever interventions are most appropriate for them.
Hi, Thank You for the chance to ask these questions.
The Tavistock Clinic is the only NHS-approved gender identity treatment center for children and adolescents in the UK. Every child diagnosed with GID is referred to this clinic so these numbers are population-based. Last year, almost twice as many natal females (929) were referred to the centre as natal males (490) and yet, until six years ago, natal males used to be the majority.
The number the teenage referrals who are natal girls has now grown to over 70% – and these proportions are not stable: in the last decade the number of girls referred to the clinic has increased sharply. It seems that gender dysphoria doesn't happen for these natal girls until age 11 or 12. http://www.standard.co.uk/lifestyle/london-life/where-girl-meets-boy-why-are-child-referrals-to-londons-gender-identity-clinic-rising-so-sharply-a3245416.html
Are you seeing a similar sharp increase in the proportion of teenage girls being referred for gender reassignment at your clinic? If so, what do you think might be the causes of it?
Yes, that is the case here in Los Angeles, and I think similar for most clinics around the US. I think those youth often do not experience gender dysphoria as connected to their primary sex characteristics until chest development. I think trans girls generally dislike their genitals right away, and because as a society we have little room for "boys" who want to look and play like and with girls, those kids come to the attention of parents and professionals in childhood. For trans boys, they start their discomfort with their physical bodies when their chest begins to develop, and that becomes the social cue to gender them as girls. I think that blockers have changed the landscape for transmasculine youth in addition to the increased prevalence of transmasculine narratives being available in the media. Is it possible that there has always been more transmasculine individuals, but that because there was no cultural understanding of trans men (all accounts of trans experience have historically been negative portrayals of broken adult trans women) there was no collective understanding that transmasculine experiences existed? I don't know, but I could speculate. Additionally, transmasculine internet community is vast.
Given the FDA's investigation into Lupron because of the 10k adverse reaction filings, is there any increased hesitancy in the medical community to prescribe puberty blockers?
Is there an alternative if these drugs are proved to be as harmful as the reports suggest?
I actually have sequestered all of the adverse event reports on Lupron from the FDA via a FOIA request. I am currently looking them over to see how exactly adverse and related the findings are. Remember that every AER (adverse event report) is not screened for causality or even temporal relationship to medication. For example - if a 78 year old cisgender man was on Lupron for prostate cancer, and experienced pain, they report it because he happens to be on Lupron. So while I do believe that there are potentially long term side effects for those who went on Lupron for clinical entities such as precocious puberty, it is difficult to distinguish if Lupron was the cause of symptoms that may actually be related to whatever was causing the precocious puberty. That being said, safety is an important part of all medical care, which is why I chose to pursue a better understanding off the reported events myself. I can't answer for the rest of the medical community, who seems hesitant to prescribe blockers at all, regardless of the FDA investigation.
I have a few questions to help my understanding in the matter.
Is transgender a mental health issue? More so, is it due to chemicals in the brain, hormone imbalance, or similar things?
Is gender reassignment surgery truly the best solution, or is it a temporary fix until medicine advances further to help with the psychological aspect?
Now that the LGBT community has become more main stream and accepted, are you seeing more children and teens come in who may not actually be trans but rather are trying to fit in or find some way to find an identity?
What percent of people who follow through with gender reassignment surgery go on to lead happy lives and no longer suffer from depression/identity crisis? Do most patients continue to suffer from mental health issues?
Thank you for taking time to do this AMA. Please know that none of these questions are meant to be offensive in any way. I just want to have a better understanding of the trans community and what they are truly going through.
I want to address # 3, as I am wrapping this up here, because the other questions have been fairly comprehensively addressed. What is true is that unpacking the gender binary is becoming increasingly popular, because I think youth recognize that it is not adequate for deeper human existence. Gender roles are largely archaic in many regards. SO are youth experimenting with gender bending? Yes, absolutely. But they are not in distress. They are bending in solidarity with a movement to dismantle an obsolete set of gender rules, and stand in solidarity with their trans friends and the community. There are distinct differences in these youth. They are not likely to stick a needle in their body every week to be trendy. There is no reward for being trans. I can't get adolescents to finish ten days of antibiotics. It is so critical to differentiate between distress and social change.
Hi Dr. Olson-Kennedy, and thank you for doing this AMA. You write:
I am involved in a large, multi-site NIH funded study examining the impact of blockers and hormones on the mental health and metabolic health of youth undergoing these interventions
Can you tell us a bit more about the study design (prospective endpoints, patient selection, interventions tested etc.)?
We had Dr. Joshua Safer share some of his work discussing the safety of hormone therapy for transgender individuals with us yesterday. One thing that struck me was that so much of what we know about the safety and efficacy of HT comes from case studies. Are there, or are there plans for, randomized controlled trials for HT or other interventions - say puberty blockers for young adults, or gender reassignment surgery for adults - in order to better understand the true impact of these interventions?
Hi there, it is an observational study, because having an untreated control group is unethical. Because so many of the questions that we are trying to get answers to are in the realm of mental and behavioral health, using a different control group, say one where parents won't consent to treatment, would present too many confounders. We are broadly looking at the impact of puberty blockers and hormones (two separate cohorts) on mental health outcomes, behavioral outcomes and physiologic parameters.
Just wondering what do you think the most egregious misconception or falsehood that is widely believed regarding transgender youth?
The most egregious falsehood is that we might accidentally make a child or teen trans who isn't by trying to lessen their distress. Assumption of cisgender fragility.
Hi, Doc Olson, Is there any legislation on the minimum age for transgender surgery?
There is not. The tricky piece of those surgeries that remove gonads is the fertility preservation aspect. Interestingly, as we block more trans youth, fertility is going to be impacted for those who continue on gender affirming hormones. We have a poor understanding of all the ways in which we might be able to preserve fertility in pre-or early pubertal gonads.
How do you know (or be comfortable enough to treat with drugs and surgical options) that a 12 year old child knows they are the wrong sex?
What is the sucide rate of a transgender without drugs/surgery vs that of one without?
Are there any long term studies of people who underwent gender reassignment, and if so, what is the general consensus?
What are the negative effects of not having gender reassignment medical treatments?
In my practice, about 50% of youth had contemplated suicide, and about 30% had attempted at least once.
How do you handle trans youth who do not have the support (legal, emotional, or financial) of their parents?
Depends on their age. For minors, it can be tricky. Trying to find support groups can be helpful. I really try to help parents understand the importance of their support, but I have to admit I lay awake at night thinking about all of the kids who are not getting care. :(
Since sexuality can be fluid and can shift throughout a person's lifetime, how can you be sure that a gender identity would also not shift? I've often wondered how I would handle having a transgender child, and would be concerned about the ability for a child to make a "mature" judgment on their gender identity; are there risks of misjudging patients?
Thanks for taking the time to answer!
I'm not sure what a "mature judgment" about one's gender identity is, but maybe sorting out the difference between gender and gender identity might be helpful. I think that we are born with our gender. The process of identifying it if it is different from assigned sex at birth is significantly more difficult than it is for cisgender people. Do people's gender identities shift, or does their ability to name their gender become increasingly nuanced as they work through that process and our language evolves?
Hi Dr. Johanna! Are you able to answer any questions on genetics and/or gene expression?
If so, is it possible for people transitioning to develop hereditary diseases with hormone treatment? Or inherit other kinds of genotypes from their parents? Because hormones activate gene expression, so then how likely is that that a person taking the "opposite", so to say, hormones could have their genetic makeup change as well, beside their phenotypes? And could we possibly study this?
And is HRT only studied from the view point of helping transgender people or also as the possible benefits to people in general?
If not, no worries, I will ask again some place else. Thank you however for you time. Have a good day!
This is a great question, and food for thought. We have a lot to learn from trans folks!
Hi! I'm a trans man and I was wondering about binding. I know it can cause damage to breast tissue, but to what extent and how quickly does it happen? I'm concerned about damaging my chest too much before I get to have top surgery, so I've been trying to wear my binder as little as possible. Thanks in advance!
Recommendation to bind only 8 hours or less a day, and certainly not at night. Here is a good article on binding:
Health impact of chest binding among transgender adults: a community-engaged, cross-sectional study
Sarah Peitzmeier, Ivy Gardner, Jamie Weinand, Alexandra Corbet & Kimberlynn Acevedo
Pages 64-75 | Received 11 Oct 2015, Accepted 16 May 2016, Published online: 14 Jun 2016
As someone who's about to start hrt next Wednesday, I've been quite curious about one thing. With the development in breast growth that's sure to come in the months to come, how much of an increased chance is there that at one point in my life, I may develop breast cancer?
So far, my mom, and grandma has had it, and personally I'd like to not get it. It won't stop me from transitioning, however it is quite annoying to think about in the back of my head.
There are some good answers below. It is the case that breast cancer is reported extremely rarely among transgender women, but monitoring would be the way to go!
Dad here of a possibly trans 18 year old (ftm).
How does a parent (or someone in your position) tell the difference between a teenager that has a legit gender identity crisis and a teenager that is just confused by life and his or her body?
I've known several mtf trans women growing up (mostly party friends) and one ftm trans man from my time in the military. I never had a problem seeing that person as the gender they claimed to be but with my daughter I am having a lot of trouble. They all acted as that gender (in my mind) but she does not.
I understand it's possible that my mind is filtering this differently because it's my child but I also see a trend among today's youth in that they get in clubs and it's cool to be some sort of gender that isn't the one you were born as.
When I was in high school everyone yearned for an identity. You were a jock or a nerd or emo or straight edge, etc. I see gender identity as the new "group".
My daughter is also suffering from crippling anxiety. Just knowing she has a math test the next day will sometimes cause her to lock up and cry. And from there it's just a depressed spiral of just being upset because she's upset. She gets sick from crying and then misses two days of school (and the math test)
Is the anxiety caused in part by her gender identity or is the anxiety just making her confused and upset and just looking for reasons to explain it?
I am sorry your young person is clearly struggling so much. I would advise you to seek out an experienced care team, and get your young person into care immediately.
I'm a trans woman (very nearly 18 years old) i suffer from an anxiety disorder and major depressive disorder. One of the things that worries me the most is that when i go to my doctor for a diagnosis of Gender Dysphoria, they will turn around and tell me I'm not who i feel i am. Is this normal, and how can i help myself deal with this anxiety?
Hi there! I think you could do a little investigating, and try to find a provider or clinic who is experienced in this work. Ask around in the community - the community is small enough that good providers are well known.
First of all, as a trans woman, let me thank you for all that you do! You make our lives that much more bearable.
My question isn't a sciencey one. Since you work with children you undoubtedly work with parents too. What do you say to parents who are less than supportive, doubtful of the treatment, or even hostile to the concept of GNC identity? Do you come across that mindset a lot?
Yes, I do come across this not infrequently. Much of my discussion with such parents who are stuck really depends on understanding their core beliefs and what is driving the concern. Thanks for your kind comments!
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