Transgender Medicine Flashcards
1
Q
Definitions in transgender medicine
A
- Sex – the physical differences between male and female bodies (N.B. - sex implies a biological basis for a behaviour when none necessarily exists)
- Gender – the attitudes, feelings and behaviours a given culture associates with a person’s biological sex; the social traits/characteristics that are associated with masculinity or femininity – ‘gender stereotypes’
- Gender identity – a system of beliefs about oneself - a sense of one’s masculinity and femininity. one’s subjective state
- Gender role/expression – the characteristics in one’s personality, appearance and behaviour that in a given culture or historical period are associated with being masculine or feminine
2
Q
Atypical sexual differentiation
A
- Congenital adrenal hyperplasia
- Excess adrenal androgens. Females can have ambiguous genitalia, precocious or delayed puberty, virilization. Some experience gender dysphoria, more masculine interests
- Increased rates of homosexuality & bisexuality
- 5-alpha-reductase deficiency
- Biological males can have ambiguous or female external genitalia at birth. Often raised as females but experience virilization at puberty.
- ~ 60% change gender role post puberty
3
Q
Gender Dysphoria
A
- The discomfort/distress caused by a discrepancy or incongruence between perceived gender (gender identity) and sex assigned at birth
- Diagnosis can have consequences
4
Q
Transsexualism
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- Has 3 criteria:
- The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment
- The transsexual identity has been present persistently for at least 2 years
- The disorder is not a symptom of another mental disorder or a genetic, intersex or chromosomal abnormality
NB – binary model of gender
5
Q
Gender identity disorder of childhood (girls)
A
- Persistent and intense distress (> 6/12) about being a girl, and has a stated desire to be a boy - not merely a desire for any perceived cultural advantage of being a boy - or insists she is a boy
- Either of the following must be present:
- Persistent marked aversion to normative feminine clothing and insistence on wearing stereotypical masculine clothing
- Persistent rejection of female anatomical structures, as evidenced by at least one of the following repeated assertions:
- That she has, or will grow, a penis
- Rejection of urination in a sitting position
- That she does not want to grow breasts or menstruate
- Not yet reached puberty
6
Q
Gender identity disorder of childhood (boys)
A
- Persistent and intense distress (>6/12) about being a boy and has a desire to be a girl, or, more rarely, insists that he is a girl
- Either of the following must be present:
- Preoccupation with stereotypic female activities, e.g. cross-dressing or simulating female attire, or an intense desire to participate in the games/pastimes of girls and rejection of stereotypical male activities.
- Persistent rejection of male anatomical structures as evidenced by at least one of the following repeated assertions:
- That he will grow up to become a woman
- That his penis or testes are disgusting or will disappear
- That it would be better not have a penis or testes
- Not yet reached puberty
7
Q
Gender identity disorder of childhood
A
- GD in childhood doesn’t always persist into adulthood (only 16%, most disappearing at onset of puberty)
- Persisters more likely to be natal female
- Natal males more likely to identify as gay/bisexual
- GD in adolescence more likely to persist
- Prepubertal children M:F is 6:1, adolescencts 1:1
8
Q
WPATH Standards of Care
A
- Provide clinical guidance on assisting transsexual, transgender and gender nonconforming people
- NHS Scotland has a Gender Reasignment Protocol
- Aim to diagnose gender disorder and manage associated psychiatric conditions appropriately
- Staged approach:
- 1 - Therapeutic exploration of the nature of gender identity (include support for family/carers)
- 2 - Puberty suppression (reversible - GnRH analogues)
- 3 - Gender affirming hormones (partially reversible)
- 4 - Gender reassignment surgery (must be >18 years)
9
Q
Risks of hormones
A
- Femninizing hormones
- VTE
- Gallstones
- Elevated liver enzymes
- Weight gain
- Hypertriglyceridemia
- CV disease
- HTN
- Hyperprolactinaemia
- T2DM
- Masculinizing hormones
- Polycythaemia
- Weight gain
- Acne
- Androgenic alopecia
- Sleep apnoea
- Elevated liver enzymes
- Hyperlipidaemia
- Destabilisation of some psychiatric disorders
- CV disease
- HTN
- T2DM
10
Q
Surgery for transmen
A
- Bilateral mastectomy and male chest reconstruction
- Hysterectomy and oophorectomy
- Metoidioplasty- hypertrophied clitoris is released and urethra redirected through
- Phalloplasty
- Radial artery flap
- Pubic
- Thigh
- Complications include:
- Dislodgement of erectile cylinders
- Mechanical failure of erectile mechanism
- Post surgery Urinary tract complications
- Neo-urethral stenosis
- Urethral fistula
11
Q
A
12
Q
Surgery for transwomen
A
- Thyroid chondroplasty (shaving Adam’s apple)
- Penectomy, orchidectomy, clitoroplasty, vulvoplasty and penile inversion vaginoplasty
- Colovaginoplasty
- Breast augmentation
- Facial feminisation
- Complications include:
- Granulation tissue- silver nitrate cautery
- Neovaginal hair growth-> hairballs
- Vascular occlusion of arterial supply to neo-clitoris
- Neovaginal stricture
- Ongoing need for dilation
- Post surgery Urinary tract complications
- Neo-urethral Urinary spraying
- Increased risk for UTI due to shortened urethra
13
Q
Mental health in transgender
A
- Higher prevalence of mental health disorders
- Most report improved mental health due to transitioning but 2/3 still report thoughts of suicide post transition
- Self harm reduced by referral
- ASD more prevalent in gender dysphoric population with less of a M:F sex ration difference
14
Q
Masculinising hormones
A
15
Q
Feminising hormones
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