Week 3 - LGBT - Gender variance in adults and children and the assessment

Question 1

The majority of the population is cis-gender

WHat does this term actually mean?

Answer 1

This means that their gender identity is consistent with their phenotype and therefore the sex that they were assigned at birth

Question 2

What are the different sexes?

Answer 2

The different sexes are male and female- this is based on the genitalia, secondary sexual charactersitic and genetic analysis (Male - 46XY, female - 46XX

Question 3

What is gender identity?

What is it know as if gender identity correlates with the sex assigned at birth?

Answer 3

Gender identity is one’s personal experience of their own gender -
the gender identity can correlate with the sex assigned to the person at birth - in which case they are cis-gender

or

The gender identity may not correlate with the assigned sex in which case they are known as transgender

Question 4

Transgender people may also be heterosexual, homosexual, bisexual or asexual just as cis-gender people are
For clarity, transgender people are often referred to as androphylic or gynaephylic for their sexual orientation

WHat do these two terms mean?

Answer 4

Androphylic - this is a trans person who is attracted to men

Gynaephylic - this is a trans person who is attracted to women

Question 5

What is gender diversity?

Answer 5

This occurs when trans indivduals dress/behave in a way that is percieved by others as being outside of the cultural gender norm

Question 6

People may or may not experience ditress due to their gender diversity and therefore may seek treatment

What is gender diversity also known as?
What is gender diversity again?

Answer 6

Gender diversity is also known as gender non-conformity or gender variance

It occurs when trans individuals dress/behave in a way that is percieved by others as different to the cultural gender norm

Question 7

What is the term used to describe the distress experienced when the gender identity is non comformant with the phenotypical appearance?

Answer 7

This is gender-dysphoria

Question 8

The Human Rights Act (1998) and the Equality Act (2010) reinforce the NHS Constitution’s emphasis on personal dignity, full engagement in decision making and, the right to be offered and to exercise choice.

Under what act is it unlawful for clinicians to discriminate against trans-individuals?

Answer 8

It is unlawful under the Equality Act (2010) for clinicians to discriminate against trans-individuals.

Question 9

Disclosure of gender concerns to the GP can take enormous courage
What percentage of those with gender concerns have had a suicidal attempt?

Answer 9

34% have had at least one suicidal attempt which is 20 times higher than the national average

Question 10

What is widely used and high succesful as treatment for gender dysphoria in general practice?

What is gender dysphoria again?

Answer 10

Hormones are widely used as treatment for gender dysphoria -

occuing in trans individuals who dress/behave in a way that is perceieved by others as different from the cultural gender norms., gender dysphoria is the distress that can be caused when the gender diversity is non-conforming with the phenotypical appearance

Question 11

What is a trans man and what is a trans woman?

Answer 11

A trans man is a person who was assigned as a female at birth but identifies as a man

Trans woman - a person who was assigned as a male at birth but identifies as a woman

Question 12

Trans patients have a legal right to change their name and gender on their NHS records. Official name change does not require a Gender Recognition Certificate.

How many years must the patient lived in their affirmed gender role before applying for a gender recognition certificate?

Answer 12

The patient must have lived in their affirmed gender role for at least two years before applying for a gender recognition certificate

If a certificate is granted, the successful applicant can apply for new birth, marriage or civil partnership certificates.

Question 13

Why is it important that clinicians are aware of the patients assigned birth sex?
ie why should clinician be aware that a man is actually a trans man?

Answer 13

This is so that diagnoses are not missed - ie a trans man presenting with abdominal pain may have gynaecological pathology

Question 14

What type of screening should trans men be offered?

Should trans women be offere prostate cancer screening?

Answer 14

Trans men should be offered cervical screening

In a trans women, the prostate gland is maintained but testosterone levels are low and therefore regualr screening for prostate cancer is not recommended

Question 15

Children may also undergo gender variance (non-comformity/diveristy) and therefore help needs to be offered sooner rather than later

What if present for at least six months in children are possible indicators of gender non-conformity?

Answer 15

INsisiting that they are (or wish to be) a boy or girl in contradiction o their assigned sex
A strong desire for primary and secondary sexual characteristics that match the gender identiy
Significant distress and impaired social function in school and other environments

Question 16

Is it common practice to give hormone-blockers to pre-pubertal gender variant children?

Answer 16

This is not common however it may be common to give hormone blockers to children with precocious puberty

Question 17

What age is onset of precocious puberty in girls and boys?

Answer 17

Precocious puberty is puberty occurring before age 8 in girls and age 9 in boys

Question 18

From what Tanner stage can hormone blockers be give to pubertal children?

Answer 18

Hormone blockers can be given from tanner stage 2 - when the testes reach 4mm volume in males

Question 19

What age is normal puberty in girls and boys?

When is delayed puberty in girls and boys?

What is breast budding known as?
What is onest of menses known as?

Answer 19

Average Puberty Age
Girls - 11 years
Boys - 12 years

Delayed Puberty Age

Girls - 13
Boys - 14

Breast budding - thelarche - usually female first sign of puberty
Onset of menses - menarche
Development of body odour and hair - adrenarche

Question 20

How would you describe:

• A full-time change of gender role?
• People (including children and adolescents) whose gender expression or behaviour is atypical?
• The discomfort experienced when the gender identity is not congruent with the assigned sex, and the gender role typically associated with that sex?

Answer 20

A full-time change of gender role - Transition

People (including children and adolescents) whose gender expression or behaviour is atypical - Gender variance / diversity / non-conformity

The discomfort experienced when the gender identity is not congruent with the assigned sex, and the gender role typically associated with that sex - Gender dysphoria

Question 21

How would you describe:

• A person who was assigned female at birth and who identifies as a man (or towards the masculine end of the gender spectrum)?
• .People who do not identify as men or women, but are somewhere on the spectrum between these categories?
• People who do not see themselves as being on the gender spectrum at all?

Answer 21

• A person who was assigned female at birth and who identifies as a man (or towards the masculine end of the gender spectrum) - Trans man
• .People who do not identify as men or women, but are somewhere on the spectrum between these categories - Non-binary
• People who do not see themselves as being on the gender spectrum at all - Non-gender

Question 22

What are the most recent estimates of the percentage of the population, who propose to
undergo, are undergoing or have undergone ‘gender reassignment’?
Select one:

a. 0.01%
b. 3%
c. 0.1%
d. 1%

Answer 22

d - 1%

Question 23

The Equality Act covers all people who are proposing to undergo, are under-going or
have undergone reassignment

Select one:

True

False

What year was the Equality Act made?

Answer 23

True

The Equality Act was made in 2010

Question 24

A GP refuses to refer a trans person to specialist services, stating that this is because of
his/her religious beliefs.
Does refusal on these grounds amount to a potential breach of legislation?

Select one:

a. Yes
b. No

Answer 24

Yes - this is in breech of the Equality Act 2010 which states clinicians cannot discriminate against trans people

Question 25

Suicidal feelings are unusually high in the trans population. The percentage of trans
people who have attempted suicide at least once is:
Select one:

a. 40-50%?
b. 20-30%?
c. 30-40%?
d. 10-20%?

Answer 25

c - 30-40%

stated as 34% in the online module

Question 26

A patient presents to you as a man but describes herself as a trans woman. She explains that she has been self prescribing estradiol and a hormone-blocker obtained from the internet continuously for the past 3 months.
She describes having been acutely depressed prior to taking hormones. She is now less stressed, and feels much better in herself.
Which ONE of the following steps would you be unlikely to take?

Refer to the local community mental health team, or if the patient is unde 16, to the Community Adolescent Mental Health Service (CAMHS)

Refer to a specialised gender identity service

Replace the patient’s medication with known products, in dosages advised by the specialist provider

Stop the medication

Take a history, examination and order investigations, looking for possible contraindications

Contact the patients gender specialist (if the person has already been referred) for advice regarding medication and dosage

Answer 26

D - stop the medication - doing this can have significant psychosocial effects on the patient as well as reversing any physical or physiological effects of the meds

Question 27

Trans Men - Which of the following medications may trans men need? You may choose
more than one option

• a. Testosterone
• b. Oestrogen
• c. GnRHa

Trans Women - Which of the following medications may trans women need? You may
choose more than one option.

• a. Oestrogen
• b. GnRHa
• c. Testosterone

Answer 27

Trans men may require both a and c - Testosterone and GnRHa (although not always required) - testosterone alone for trans men is often adequate

Trans women require both GnRHa to suppress tesosterone levels and Oestrogen

Question 28

It is common practice to give hormone-blockers to pre-pubertal gender variant children
?

• True
• False

From what Tanner stage can hormone-blockers be given?

• a. Tanner 1
• b. Tanner 2
• c. Tanner 3
• d. Tanner 4
• e. Tanner 5

Answer 28

Hormone blockers are not commonly given to prepubertal children but can be given to children with precocious puberty

Hormone blockers can be given from Tanner Stage 2