Title: Transgender Health AMA Week: We are Ralph Vetters and Jenifer McGuire. We work with transgender and gender-variant youth, today let's talk about evidence-based standards of care for transgender youth, AUA!

Abstract

Hi reddit!

My name is Ralph Vetters, and I am the Medical Director of the Sidney Borum Jr. Health Center, a program of Fenway Health. Hailing originally from Texas and Missouri, I graduated from Harvard College in 1985. My first career was as a union organizer in New England for workers in higher education and the public sector. In 1998, I went back to school and graduated from the Harvard Medical School in 2003 after also getting my masters in public health at the Harvard School of Public Health in maternal and child health. I graduated from the Boston Combined Residency Program in Pediatrics at Boston Children’s Hospital and Boston Medical Center in 2006 and have been working as a pediatrician at the Sidney Borum Health Center since that time. My work focuses on providing care to high risk adolescents and young adults, specifically developing programs that support the needs of homeless youth and inner city LGBT youth.

I’m Jenifer McGuire, and I am an Associate Professor of Family Social Science and Extension Specialist at the University of Minnesota. My training is in adolescent development and family studies (PhD and MS) as well as a Master’s in Public Health. I do social science research focused on the health and well-being of transgender youth. Specifically, I focus on gender development among adolescents and young adults and how social contexts like schools and families influence the well-being of trans and gender non-conforming young people. I became interested in applied research in order to learn what kinds of environments, interventions, and family supports might help to improve the well-being of transgender young people.

I serve on the National Advisory Council of GLSEN, and am the Chair of the GLBTSA for the National Council on Family Relations. For the past year I have served as a Scholar for the Children Youth and Families Consortium, in transgender youth. I work collaboratively in research with several gender clinics and have conducted research in international gender programs as well. I am a member of WPATH and USPATH and The Society for Research on Adolescence. I provide outreach in Minnesota related to transgender youth services through UMN extension. See our toolkit here, and Children’s Mental Health ereview here. I also work collaboratively with the National Center on Gender Spectrum Health to adapt and expand longitudinal cross-site data collection opportunities for clinics serving transgender clients. Download our measures free here.

Here are some recent research and theory articles:

Body Image: In this article we analyzed descriptions from 90 trans identified young people about their experiences of their bodies. We learned about the ways that trans young people feel better about their bodies when they have positive social interactions, and are treated in their identified gender.

Ambiguous Loss: This article describes the complex nature of family relationships that young people describe when their parents are not fully supportive of their developing gender identity. Trans young people may experience mixed responses about physical and psychological relationships with their family members, requiring a renegotiation of whether or not they continue to be members of their own families.

Transfamily Theory: This article provides a summary of major considerations in family theories that must be reconsidered in light of developing understanding of gender identity.

School Climate: This paper examines actions schools can take to improve safety experiences for trans youth.

Body Art: This chapter explores body modification in the form of body art among trans young people from a perspective of resiliency.

We'll be back around noon EST to answer your questions on transyouth! AUA!

Hi Ralph and Jenifer, and thank you for doing this AMA.

I think the topic of evidence-based standards of care for transgender youth is incredibly interesting. I imagine in some ways it has been a challenge for the field to even begin to address this question since there has historically (and even today) been so much taboo surrounding the topic.

I was hoping you could give a historical overview of how the community has thought about providing care to transgender youths and how this has evolved over time. It would be especially interesting if you could point to some key findings that motivated changes in the field (for example studies that invalidated antidepressants for gender dysphoria or studies that demonstrated utility of puberty blockers).

Thanks!

SirT6

This is Jenifer. Well...where to begin. The World Professional Association of Transgender Health (WPATH) has published standards of care and is now on version 7. The historical compilation of versions 1-6 is available for purchase on the website. These are developed collaboratively through clinical consensus and the developing research base. Puberty blocking first was tried by Peggy Cohen-Kettenis in the late eighties in collaboration with the endocrinologist at the Dutch gender clinic in Amsterdam. Several studies now have documented the long term well-being of that first cohort of youth to receive puberty blockers. Here is a citation for one I co-authored: De Vries, A. L. C., McGuire, J. K., Steensma, T. D., Wagenaar, E., Doreleijers, T., Cohen-Kettenis, P. T. (2014). Prospective young adult outcomes of puberty suppression in transgender adolescents, Pediatrics, 134, 696-704. doi:10.1542/peds.2013-2958 In the earlier years, children were given less latitude to express cross-gender identities, and efforts were made to suppress cross-gender play and expression. Over time, the negative response to that suppression became evident and the focus became more on supporting young people in healthy holistic development, without making gender a primary focus. Each culture responds a little differently to children's desire to socially transition or outwardly take roles of a gender different from their assigned birth sex. Some environments require that children identify as either a boy or a girl and don't allow room for a child to be non-binary or uncertain. Current community discussions tend to focus on features of children's social transitions (at school or home, who to tell), the age to begin or not using puberty blockers (at Tanner stage II versus waiting for a certain age), when cross-sex hormones can begin, and the age certain surgeries can occur. Policy issues that come up have to do with parents who may not agree about a child's social transition, use of bathrooms and locker rooms, and sex-segregated activities.


This morning, the president announced that transgender people will not be allowed to serve in the military due to, "the tremendous medical costs" that it would entail.

What are the typical medical costs to patient and employer assuming the employee's insurance is decent? How do transgender care costs compare to other ongoing medical conditions such as diabetes? Or the care needed for a typical veteran after service ends? Is it really that expensive for insured patients?

firedrops

Hi, this is Jenifer. The Rand corporation did a study last year of the costs and determined that the costs were not a reason to exclude trans people from service. This is currently covered as the NY Times lead article today. For an individual, a $30,000 surgery is likely a significant amount to save, especially if that person faces employment discrimination as a trans person. In the world of health care costs, that amount is less than many health issues. When asked about costs of transition care, I redirect people to consider the cost of not covering transition and the cost of things like lost productivity, depression, and suicide attempts. Covering transition with insurance is a better investment every time. Most other countries are covering transition related care at this point.


In regards to schools, have there been significant changes to how sex education covers trans issues?

I went to school in Australia in the 90's to 2000's, and being gay was barely talked about, let alone being trans. With such a lack of information I did not have the knowledge to realise it's actually possible to transition. It would have changed my life for the better.

andreabbbq

This is Jenifer. Each state, and in some cases school district, sets its own policy about sex education and what will or will not be covered. In MN there has been considerable effort to improve inclusive sex education so the LGBT issues will be covered. Sometimes trans issues get covered in other sorts of classes like government or literature through current events or assigned books. Here is the citation for a study I co-authored on inclusive sex education. If someone knows how to include the link to the study - please feel free. There is not much research on inclusive sex ed. Snapp, S., McGuire, J. K., Sinclair, K. O., Gabrion, K., & Russell, S. T. (2015). LGBTQ-Inclusive Curriculum: Why Supportive Curriculum Matters. Sex Education, 15, 580-596. doi:10.1080/14681811.2015.1042573


If gender identity is defined as an internal feeling, by what criteria did the GSM 5 determine that Gender Identity Disorder was no longer descriptively a psychological disorder?

To strengthen the argument, what non-emotional care do professionals provide in supporting transgender individuals? Will treatment then imply it is a disability not a disorder?

Thanks!!

bokertovelijah

This is Jenifer. You are bringing up points that literally thousands of people have been debating for decades about the physical versus psychological nature of gender identity, and whether or not people in the transgender identity umbrella should be viewed as having a "disorder." The process has already begun for the next DSM. Answers below do a great job of summarizing the physical and psychological care someone might receive. As a non-clinician, and researcher, I prefer to back away from the urge to label something as either physical or psychological or as a disorder or not. Think about Autism and Dementia, both long viewed as psychological, which now have more and more physical indicators. Gender identity has both physical and psychological components across a full spectrum of identity. Cisgender people will develop elements of their gender expression and psychological identity based on components of their physical body. A clear example is when a cisgender woman chooses to accentuate or to downplay her femininity through her body curvature. Some people will require support from professionals to fully realize and express their gender. This support may include things like voice coaching, hormones, counseling, or surgery. We create diagnostic codes as a way to categorize reasons for support, and how to pay for them. It's a bit of a clunky system, and gets endowed with a moral authority that sometimes interferes with its primary function as a system of classification.


Hi! I'm at a UK university and am on the committee of one of the men's sports societies. This year we became the first sports society in our university to have a transgender student as part of our society. The person in question was a woman at birth but now identifies as a man, but is pre-op and is not having any treatment as of yet.

As a consequence our student union has put a lot of pressure on us to be as accommodating as possible - however some of the things they have required us to do actually make the student in question more excluded than included - things like 'if this student complains we'll shut you down' have led to roughly half of committee meeting time focusing around this student.

However the main difficulty for us and the student is the understandable requirement of separate changing rooms before matches, and quite a bit of socialising within the specific team occurs whilst people are getting ready for the match, which this student cannot easily be part of.

What would you suggest we do as a society to ensure this student is included more? None of us on committee have ever had a transgender person as a friend or teammate before so we're all a bit clueless and the union are frankly unhelpful as their advice only extended as far as 'don't mess this up' rather than 'here's what you can do to make this better for them'.

Thanks for reading!

Edit: my apologies if I've used some terms people may find offensive - please educate me on any there may be above in replies below if I have and I'll change them! Thanks!

highlevelsofsalt

This is Jenifer. I have been thinking this over. Is it possible for him to just change with the rest of you? If someone is uncomfortable with the shower, he could wear a towel into and out of a stall. I would challenge the union on why exactly he can't change in the locker room with everyone. The concept of universal design guides current thinking in bathrooms and locker rooms. This means that the setup should be that anyone who does not want to be seen naked, or see others naked should be able to do that within the regular structure. Someone should not be singled out because they are trans. Does the locker room have stalls?


I have a friend who is currently writing a Master's thesis on his own experience with eating disorders as a male, with this issue largely seen as a female issue.

Given the normative approaches to treating eating disorders and the fact that these approaches are often marketed to teenage girls, where do transgender and gender-variant youths fall in terms of the treatment of eating disorders? I am assuming that teenagers in these categories experience similar or higher rates of body image issues etc.

npott438

This is Jenifer. We have a paper almost ready to submit on this. 19 of our 90 trans young people report an eating disorder diagnosis. People report using eating as a way to try to modify the body - get more angular, get more curvy, stop menstruation, feel bigger. Some of these gender concerns likely exist for cispeople as well, and recentering our understanding to be more trans inclusive should help to address links between gender and eating disorders all around.


I see gender non conforming mentioned a lot with trans youth. My understanding is that gender non conforming just means that they don't follow their tradition gender roles, such as a tomboy wearing boyish clothes or a boy who likes to have tea parties. I understand that these youth may need support if they are bullied for their choices, but I'm curious why they seem so prevelant when talking about trans youth.

Edit: I think people are missing the point of my question. I am asking why tomboys are included when discussing trans youth. They are not themselves trans, although gender noncomformity can be a sign, so it doesnt make sense. If by gender non conforming they mean non binary thats fine, but thats not how people seem to be using it.

lilyhasasecret

Jenifer here. Gender non-conforming (GNC) gets included often in research studies to explicitly include people who may identify as genderqueer or non-binary, and may not seek to transition or identify as transgender. Language norms of how groups are labelled change frequently. GNC also can and often does refer to cisgender people who don't fit stereotypical roles. In studies of trans youth, some may be socially transitioned and quite gender conforming to a binary gender identity different from the sex they were assigned at birth. Other GNC children may be more genderfluid or non-binary in their identity.


I think my question got deleted, so I'll ask it again: Yesterday someone make a comment on here that "dysphoria is linked to adult homosexuality" and that "Every single study on youth GD shows this."

Can you speak to this? Can someone send me links to these studies?

the_pissed_off_goose

I don't know why someone would say that. The early studies of persistence of gender dysphoria found that a large portion of assigned males who did not continue with a desire to transition grew up to become gay males. This was not true for assigned females who did not transition. Part of this finding (that occurred in several studies including one I am a co-author of that I will cite here) has to do with the fact that boys who act feminine were more likely to be brought into a gender clinic for evaluation, and thus enrolled in these studies even though they weren't really trans. They were just gay boys who were feminine. Here's the cite: Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., Cohen-Kettenis, P. T. (2013) Factors Associated with Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-up Study. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 582-590. doi:10.1016/j.jaac.2013.03.016


Hi Dr. Vetters & Dr. McGuire, thank you for doing the AUA!

In regards to ambiguous loss with trans people and families with a trans person, what percent are imposed on the trans person and what percent are self imposed?

As an explanation, is it an Uncle saying he won't be around a trans family member or is it a Grandma refusing to respect her trans grandchild so the grandchild stops speaking to the grandmother?

liv-to-love-yourself

I am not sure I can say there are distinct "percents" of one sort of loss versus the other. I definitely saw both in our study. Also, families are getting more accepting with time and social exposure to other trans people and their stories. It has become less acceptable to reject one's kid for being trans. When a trans person leaves the family because the family is not respecting their identity or is behaving in verbally of physically abusive ways, I still "code" that as parent rejection in my research. The parents are the ones with more power in the relationship and have legal responsibilities to support their children without abuse. The more common scenario is that families concurrently engage in both accepting and rejecting behaviors, such as acknowledging identity but not letting someone come to extended family functions. The mixed messages and relational exclusion are really painful for youth to interpret. It harms relationships.


Hello, and thank you for the AUA!

I'm trans with a trans sibling. Have you had experience of families with more than one trans member? Do those families usually follow any particular mold, and if so, what? Is the treatment for youth in such families any different than for youth in families where they are the only trans person?

odious_odes

Hi- This is Jenifer. I have encountered trans youth with trans siblings a few times in my research. The treatment for youth would be the same. The main benefit is the siblings have this in common and the parents then have been through it once when it comes up for the second one. It may not come as a surprise to them.


Hello Ralph and Jenifer,

In my personal experience, I've noticed that online anime and gaming communities often have many LGBT members that are openly welcomed, but also very frequently use words that are typically considered slurs. The meaning typically bends away from what people in offline communities and eventually becomes a sort of term of endearment. Is there any research that confirms or denies that this observation is actually a real thing?

In your work with trans youth, is there any mention of online gaming or anime communities? Are experiences with those communites positive or negative? Is there a tendency for trans youth to reclaim words with traditionally negative connotations when in casual conversation with in-group peers?

itsnotmyfault

I think in many marginalized communities people reclaim and use words that were previously considered slurs. Queer is an example of this and I see it with youth as well. Lots of young people have told me they come out online before coming out in real life and they experiment with gender in online spaces first. It is a space where people can explore identity without a threat to physical safety that occurs in natural environments.


Hi, Ralph and Jenifer. Thank you for hosting this AMA. As a transman college student, I hear a lot about hormone therapy for treatment of dysphoria. A. Have there been any studies on the effects of hormones after years of use, physical, emotional, etc? B. There also seems to be a bigger focus on transwomen over transmen in research, what reasons might there be for this difference? Thank you for taking the time for this!

Elijah_MorningWood

This is Jenifer. I would add that NIH funding for LGBT issues has focused heavily (almost exclusively) on HIV over the years, which can translate to studies of transwomen who have male sexual partners. Transmen do have elevated HIV rates but not as high as transwomen and have been largely ignored by the HIV research world.


Hi Ralph Vetters and Jennifer McGuire! thanks for given us this opportunity to know more about transgender health.

My question is, we have this transformation Women's genitals --> Men's genitals

Do the "new" man ejaculate semen? And if they ejaculate, what it is?

PD: Sorry broken english

marowark

This is Jenifer. To my knowledge, with phalloplasty there is no ejaculation.


Thanks for coming to talk with us!

As a university professor, a few years ago I was shocked to find that a letter writer mentioned the candidate's trans status in a recommendation letter. I assume they should have omitted that and left the choice about disclosure to the student? What advice do you have for teachers working with trans students in their classes? Is there anything we should do beyond using their preferred pronoun and not referring to their trans status unless they do first in conversation?

asbruckman

In small classes or groups I offer people a chance to share names and pronouns as a matter of introduction. It communicates to the entire group that I am sensitive to the pronoun issue and want to respect people's identity. It's not appropriate to out people unless they ask you to. I have known people to ask letter writers to out them. They felt it would avoid awkwardness or potentially unsafe situations later on if the job was considering hiring them.


What positive purpose do gender roles serve? Seems like they are nothing but harmful stereotypes - why is it important or even a positive thing to encourage people, transgender or not, to identify with them?

Nofanta

This is Jenifer. I don't want to defend gender roles myself, but for the sake of education I will share some of the things that we are taught about them. They serve an organizational function in society, which may have at some point had more relevance for survival. In some cultural groups, gender roles are a critical element of power distribution. The enactment of roles also contributed to sexual attraction in some sexuality scripts.


What is the correct term for LGBTQ today? I said that and someone corrected me and I can't remember what I was supposed to say instead.

SeahawkerLBC

This is Jenifer. There is not one correct term. I use queer because it is fully inclusive. Some people use Sex and Gender Minority (SGM).


At what age do you think individuals should be able to have sex change surgery?

RadicalOwl

Most countries are limiting to age 17 or 18. Some are at 16. It is hard for me to imagine it being earlier than that.


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