Transgender and Gender Non-

Conforming Youth: Innovative

Approaches to Care in 2016

Johanna Olson-Kennedy, MD

The Center For Transyouth Health and Development

Children’s Hospital Los Angeles

&

Aydin Olson-Kennedy, ACSW, MSW

Director, Los Angeles Gender Center

Prepared for the Integrating Care Conference

October 20, 2016

Faculty Disclosure

The speakers do not have financial relationships

with the manufacturer(s) of any commercial

product(s) and/or provider(s)

of commercial service(s) discussed in this CME

activity.

The authors do intend to discuss an unapproved

use of a commercial product in the

presentation.

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2010 2011 2012 2013 2014 2015

Nu

mb

er

of

Re

ferr

als

Year of Referral

Referrals by Year: Center for Transyouth Health

and Development

transmasculine

transfeminine

Cisgender/Transgender

“Adjacent”

“Across”

Cis

Trans

When do we begin to gender?

It’s a …

What happens when a child

does not fit into their

assigned categories?

F M

What is Social Transition?

• Outward expression of the internal

gender

• Living in asserted gender

• Whatever that means to the child

• Clothes, hairstyle, names, pronouns

• REVERSIBLE

Presentations of transgender

adolescents• Early asserters

– Socially transitioned in childhood

– Not socially transitioned in childhood

• Peri-pubertal asserters

• Post-pubertal asserters

Onset of Puberty

• Depression

• Anxiety

• Suicidality

• Social isolation

• Self-harm

• High-risk sexual behavior

• Maladaptive coping

GnRH analogues

• Mimic the actions of gonadotropin releasing hormone (GnRH) initially resulting in a surge of LH and FSH

• GnRH receptors are down regulated and desensitized, resulting in inhibition of LH and FSH secretion

GnRH analogue treatment

• GnRHa effects are reversible

• “Buy time” and avoid reactive depression at the same time

• Prevention of unwanted secondary sex characteristics

• Future surgeries potentially prevented

• Psychotherapy is facilitated when distress is eased

GnRH analogue dosing

• Histrelin implant – 50 mg every 1-2 years

• Leuprolide acetate – Dosing 7.5 mg, 11.25

mg and 22.5 mg IM monthly, three monthly

• Subcutaneous lueprolide acetate

delivered subcutaneously – 7.5mg to 30

mg; no intermediate dose

• None of these medications are FDA

approved for the purpose of suppressing

puberty in gender non-conforming youth

Phases of Transitioning

• Reversible - clothes, hair, shoes, toys,

name, pronouns and puberty blockers

• Partially reversible - cross sex hormone

replacement therapy

• Irreversible – gender confirmation

surgeries

Gender Dysphoria in

Adolescents and Adults

A. Marked incongruence between one’s experienced/expressed

gender and assigned gender, of at least 6 month’s duration, as

manifested by at least two of the following:

1. A marked incongruence between one’s experienced/expressed gender

and primary and/or secondary sex characteristics (or in young

adolescents, the anticipated secondary sex characteristics)

2. A strong desire to be rid of one’s primary and/or secondary sex

characteristics because of a marked incongruence with one’s

experienced/expressed gender (or in young 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

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

important areas of functioning.

Hormones

Goals of cross sex

hormones• Goals

• Masculinize or feminize the body

• Improve quality of life

• Improve body esteem

• Decrease gender dysphoria

• Diminish anxiety, depression

• Decrease high risk behaviors

Hormonal Intervention –

Transgender females

Feminizing Process

1. Block testosterone

a. Block testosterone production

a. GnRH analogues – central blocking

b. spironolactone

b. Block peripheral effects of testosterone

a. spironolactone

2. Induce development of female secondary sex

characteristics

Induction of feminizing

features

• Estrogen

• Progesterone

• Breast Development

• Broader Hips

• Softening of skin

• Fat redistribution• Loss of muscle

• Genital changes

Hormonal Intervention –

Transgender Males

Trifecta of dysphoria for transmasculine patients

Gender dysphoria

Female chest

contour

Menses

Voice

Therapeutic Goals of

Masculinizing Hormone Therapy

• Male pattern body hair

• Increased muscle mass

• Amenorrhea

• Breast reduction

• Deepening of voice

Testosterone

• Facial Hair

• Body Hair

• Pubic Hair

• Genital Development

• Muscle Development

• Voice Deepening

Induction of Masculinizing

Features

Reversible changes of

testosterone• Increased libido

• Redistribution of body fat

• Cessation of ovulation and menstruation

• Further muscle development

• Increased sweat and changes in body odor

• Prominence of veins and coarser skin

• Acne

• Alterations in blood lipids

• Increased red blood cell count

Irreversible changes of

testosterone

• Deepening of the voice

• Growth of facial and body hair

• Male pattern baldness

• Clitoral enlargement

• Possible shrinking/softening of chest tissue

Benefits of early treatment

• Improves family functioning, school performance

• Prevents suffering and risk taking

• Leads to social change and improves quality of

life

• Spares surgical interventions

• Affords a gender concordant puberty

• Gift of SELECTIVE DISCLOSURE

Hormones Save Lives

Gender Dysphoria

Gender dysphoria is widely

described and experienced

as PERSISTENT

physical/emotional/and/or

psychological distress due to

discomfort with one’s

assigned sex

• Gender Dysphoria

isn’t always

experienced or

expressed as being

related to one’s

genitals or secondary

sex characteristics

Other Ways Gender Dysphoria May

Present Disinterest or disengagement with life

Unexplainable feeling of not

fitting in

– Feeling non-human

– Shape shifter

Unexplainable anger

Unexplainable depression or

anxiety (even after starting

medical transition)

Disordered eating

Cutting/Burning/Self-Harm

Hyper masculinity/femininity

Loneliness/Isolation

Depression/anxiety/OCD

Gender Noise

Friends

Therapy

Education

Family

Future

Relationships

Self-Care

Genital

Surgery

G

e

n

d

e

r

D

y

s

p

h

o

r

i

a

Chest

Surgery

Cross Sex

Hormones

Trans Masculine

Genital Surgery

G

e

n

d

e

r

D

y

s

p

h

o

r

i

a

Cross Sex Hormones

FFS

Trans Feminine

Vocal Cord Surgery

13 18 21 25 30

Graduate

Go to college

Gender dysphoria The day you’ve spent the

last 5 years waiting for -

HORMONES

Career/perma

nent

independenc

e

Graduate

from CollegeMove

out

Planning and hoping for surgery

16

Start your life

and begin to

think about

future?Drivers License

Puberty/gender

dysphoria

Still planning and hoping for surgery

Surgery?

Self-esteem,

Adaptation/Integration

• Overall sample, (N = 239)

• The minimum age of identifying was 3 and the maximum was

65, with the mean age being 13.

• The minimum age of disclosure was age 3, and the

maximum was 66, with the mean age being 27.

• There was an 14 year difference between age of

identification and disclosure.

Coming in Before

Coming Out

Have you

thought about

this?!

Privilege and Exchange of Status

White trans Men - Acquire authority

• Freer gender expression

• Increased social capital

• Must now navigate rape culture,

patriarchal society, male privilege

and performance of masculinity

Privilege and Exchange of Status

Trans Women – lose authority

• Increased fear of safety

• More rigid rules of feminine expression

• Decreased social capital

• Negotiation of patriarchy, misogyny,

sexism, etc.