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Gender transition pharmacotherapy
- 2. DISCLAIMER 1. Images usedin this presentation have been obtained with proper consent of the owner. 2. The presenter does not have any financial or business benefit associated with the presentation. 3. The presenter does not hold any leadership position in the domain of subject of presentation
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- 14. Pharmacotherapy of Gender Transition Dr.Saurabh Patil JR-2 Guide: Dr. Shruti Bhide Department of Pharmacology and Therapeutics Seth G S Medical College and KEM Hospital, Mumbai 9th January 2020
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- 23. Terminology Cis Man Cis Woman TransMan Trans Woman
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- 28. Terminology Term Meaning Example Gender Nonconforming Differentgender identity than gender at birth “I am a woman; but I like to live like a man.” Gender Identity Disorder Gender Nonconforming + Anxiety / Distress (ICD-10) “I am a woman; but I like to live like a man. And I feel like I am stuck inside this female body” Gender Dysphoria = Gender Dysphoria (DSM-5)
- 29. Epidemiology 4,87,803 = 0.04% (Bundleddefinition) <0.04% ? ? Estimated = 3.5% 1. Sawant N. Transgender: Status in India. Ann Indian Psychiatry. 2017;1(2):59. 2. Gates GJ. How many people are lesbian, gay, bisexual, and transgender? The Williams Institute. 2011. 3. Meerwijk EL, Sevelius JM. Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples. Am J Public Health. 2017 Feb;107(2):e1–8.
- 30. Coleman E, BocktingW, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism. 2012 Aug;13(4):165–232. GENDER NONCONFORMING GENDER DYSPHORIA Transition – Why, When, How
- 31. 1. Mahfouda S,Moore JK, Siafarikas A, Zepf FD, Lin A. Puberty suppression in transgender children and adolescents. The Lancet Diabetes & Endocrinology. 2017 Oct;5(10):816–26. 2. Mahan RJ, Bailey TA, Bibb TJ, Fenney M, Williams T. Drug Therapy for Gender Transitions and Health Screenings in Transgender Older Adults. J Am Geriatr Soc. 2016 Dec;64(12):2554–9. 3. Guss C, Shumer D, Katz-Wise SL. Transgender and gender nonconforming adolescent care: psychosocial and medical considerations. Current Opinion in Pediatrics. 2015 Aug;27(4):421–6. Age Current Practice Guidelines Adolescent Not recommended Puberty suppression Drug therapy Adult Recommended Drug therapy Surgical corrections Elderly Recommended with caution Drug therapy (monitored) Surgical corrections (limited) Transition – Why, When, How
- 32. Trans men Transwomen Psychotherapy Drug therapy Speech therapy Psychotherapy Drug therapy Speech therapy Breast reconstruction Breast augmentation Laser hair removal Penectomy Orchidectomy Vaginoplasty Clitoroplasty Labioplasty Vaginectomy Hysterectomy Salpingectomy Oophorectomy Phalloplasty Urethroplasty Scrotoplasty Penile prosthesis Hair transplant Thyroid chondroplasty Joseph A, Cliffe C, Hillyard M, Majeed A. Gender identity and the management of the transgender patient: a guide for non-specialists. J R Soc Med. 2017 Apr;110(4):144–52. Transition – Why, When, How
- 33. Pharmacotherapy Pharmacotherapy Hormonal Core Testosterone Oestrogen Supportive GnRH agonists Progestins Nonhormonal 5-alpha- reductase Inhibitors Aldosterone antagonists SSRIs 1. NarasimhanS, Safer JD. Hormone Therapy for Transgender Men. Clinics in Plastic Surgery. 2018 Jul;45(3):319–22. 2. Tangpricha V, den Heijer M. Oestrogen and anti-androgen therapy for transgender women. The Lancet Diabetes & Endocrinology. 2017 Apr;5(4):291–300. 3. Radix A, Davis AM. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons. JAMA. 2017 Oct 17;318(15):1491. 4. Irwig MS. Testosterone therapy for transgender men. The Lancet Diabetes & Endocrinology. 2017 Apr;5(4):301–11. 5. Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine Treatment of Gender- Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2017 Nov 1;102(11):3869–903.
- 34. Pharmacotherapy Pharmacotherap Hormonal Core Testosterone Oestrogen Supportive GnRH agonists Progestins 5 re In 1. NarasimhanS, Safer JD. Hormone Therapy for Transgender Men. Clinics in Plastic Surgery. 2018 Jul;45(3):319–22. 2. Tangpricha V, den Heijer M. Oestrogen and anti-androgen therapy for transgender women. The Lancet Diabetes & Endocrinology. 2017 Apr;5(4):291–300. 3. Radix A, Davis AM. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons. JAMA. 2017 Oct 17;318(15):1491. 4. Irwig MS. Testosterone therapy for transgender men. The Lancet Diabetes & Endocrinology. 2017 Apr;5(4):301–11. 5. Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine Treatment of Gender- Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2017 Nov 1;102(11):3869–903.
- 35. Pharmacotherapy otherapy s Nonhormonal 5-alpha- reductase Inhibitors Aldosterone antagonists SSRIs 1. Narasimhan S,Safer JD. Hormone Therapy for Transgender Men. Clinics in Plastic Surgery. 2018 Jul;45(3):319–22. 2. Tangpricha V, den Heijer M. Oestrogen and anti-androgen therapy for transgender women. The Lancet Diabetes & Endocrinology. 2017 Apr;5(4):291–300. 3. Radix A, Davis AM. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons. JAMA. 2017 Oct 17;318(15):1491. 4. Irwig MS. Testosterone therapy for transgender men. The Lancet Diabetes & Endocrinology. 2017 Apr;5(4):301–11. 5. Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine Treatment of Gender- Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2017 Nov 1;102(11):3869–903.
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- 68. Long term management BMI BP Mammography PelvicUSG Testosterone Estradiol Prolactin CBC RFT HbA1c Electrolytes Lipid Profile To repeat at (years) 0 0.5 1 1.5 2 2.5 3 4 5 6 7 …
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- 72. Recent Developments Drug Legend Domperidone NonpuerperialInduced Lactation Aromatase inhibitors FtM does not require anything other than testosterone 1. Reisman T, Goldstein Z. Case Report: Induced Lactation in a Transgender Woman. Transgender Health. 2018 May;3(1):24–6. 2. Chan KJ, Jolly D, Liang JJ, Weinand JD, Safer JD. ESTROGEN LEVELS DO NOT RISE WITH TESTOSTERONE TREATMENT FOR TRANSGENDER MEN. Endocrine Practice. 2018 Apr;24(4):329–33.
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Editor's Notes
- #3 Before I start with my seminar today, I need to get this out of the way. All pictures used in this presentation are used with proper consent. I do not have any conflict of interest for the subject matter.
- #4 On the LEFT, you can see a male hand. On the RIGHT, you can see a female hand.
- #5 Something more CONSPICUOUS. The person in GREEN is the person on right.
- #6 The WOMAN on LEFT is the MAN on RIGHT.
- #7 The MAN on right is the WOMAN on LEFT.
- #8 YES, they are the SAME person. Let me show you a GRADIENT.
- #9 YES, they are the SAME person. Let me show you a GRADIENT.
- #10 TOP LEFT to BOTTOM RIGHT. Yes, SAME person.
- #11 They are not all single. It WAS a couple. It IS STILL a couple.
- #12 This Jo. He is member of “World Professional Association for Transgender Health.” abbreviated as WPATH, an organization which has created standards for healthcare of transgender individuals. While I was researching for this seminar, I came across him in the most unusual way. I was asking for consent for the images of the images I showed you before. I met him while taking his consent.
- #13 She may not be young by body, but she is definitely young by heart.
- #15 With this in mind, let me present to you, the pharmacotherapy of gender transition.
- #16 We will start with the basics. We know what a male and female is.
- #17 Chromosomal gender assignment is also known as biologically/birth assigned gender. This is when a baby is born.
- #18 And when the baby grows up, it gets a sense of whether she is male or female.
- #19 This development is called as gender identity.
- #20 With time, growing children will express cultural symbolism assigned to each gender.
- #21 This is called gender expression.
- #22 At puberty and in adult life, the person may be attracted to people of opposite gender or same or even both. This is called sexual orientation.
- #23 We all know that people who remain same all over their life don’t have special terminologies, they are simply called MEN and WOMEN.
- #24 If they change their gender voluntarily, they are called transgender. A woman converting to man is called transgender man and similarly vice versa. For clarity, the people who do not transition are called Cis gendered.
- #25 So far, we have seen two states. Man and woman. This is called GENDER BINARY.
- #26 And now we are also seeing a third gender. Is this gender TRINARY?
- #27 No, there is a spectrum. People can be born male, female or intersex. People can identify themselves as men, women or both or even neither. People may express themselves in masculine way, feminine way or both! So you see there is a pattern here.
- #28 But for today’s seminar, we are only concerned with this part of spectrum, where people are not comfortable on the two extremes of their GENDER IDENTITY only.
- #29 These people may be comfortable with their state. They are called gender nonconforming. Those who are not, may have anxiety/distress associated with the state. This is diagnosed as Gender dysphoria. And ICD 10 uses an older term called Gender Identity Disorder, and the term is being phased out, because it is not an actual “disorder”. This is the ONLY indication for medical intervention for gender transition.
- #30 So how many people are there who are not comfortable at extremes? Census of India shows about 5 lakh. That’s less than 0.04% of the population! But the census used a bundled definition of trangender as neither male, nor female. Now that includes INTERSEX people, (KINNER) People with religious genital mutilation, (JOGTA) People who are gender nonconforming (HIJRA) As there are no clear definitions in existence. US Census has an estimated it to be 3.5% for their population. They have used estimation models, and not actual counts. WORLD prevalence is obviously unknown. But then you wonder, Why would someone transition from one gender to other, when would they do it and how they do it?
- #31 We do not do medical intervention when the person is comfortable in a nonextreme state of gender identity. If he is comfortable with him being able to be neither a full male or female identity. We definitely do it when the person is depressed, anxious, or distressed because of the gender “confusion”. The person may feel locked in a body of “wrong” gender.
- #32 When do we do it? It can be done at any age. Although textbooks and current practice both recommend that we wait till the person is truly sure of his gender identity.