The 6th Annual Transgender Medical Symposium occurred in May in Fort Lauderdale. This free event drew 140 people. The two-day symposium discussed many medical and mental health issues that the transgender community faces.
Christopher Bates, a member of the Organizing Committee, urged the attendees to re-engage with activism, “Our struggle as a community of diversity is not over.” Virtually every speaker emphasized that to show respect to transgender people, people should use the pronouns and name that the transgender person has chosen.
Transgender youth psychological issues
LGBT youth now self-identify as LGBT relatively early. Many people develop a relatively fixed sexual orientation in early adolescence. Most people, however, develop a relatively fixed gender identity well before puberty. Some people, however, will develop a gender identity mismatched with their physical body. When people talk about transgender youth today, the term “youth” can now include six year olds. This opens up a whole other arena of LGBT rights.
A new pediatric specialty, transgender pediatric care, has emerged. Part of this specialty involves using medications to suppress puberty and its gender-linked physiological changes. With puberty suppressed, neither beards nor breasts will develop. This makes matching physical bodies with gender identities much easier, and less expensive. If the youth begins to feel at ease in their physical body, they can stop the treatment and experience puberty consistent with their physical body.
Some youth with gender identity issues will grow into transgender adults. Others will resolve their gender identity issues. These different outcomes involve two related conditions: gender dysphoria and gender nonconformity. According to Dr. Alejandro Diaz, a pediatric endocrinologist, gender dysphoria “leads to clinically significant distress and/or social, occupational, and other functional impairment, with increased risk of suffering distress or disability.” Gender dysphoric people experience persistent discomfort with their physical body and its expected gender roles. This becomes an internally generated distress.
Gender nonconformity leads to “behaviors and interests that fall outside what is considered ‘normal’ for a person’s biological sex.” Gender nonconformity does not involve mismatch between someone’s gender identity and their physical body. Unlike gender dysphoria, persistent distress does not characterize gender nonconformity. When gender conforming people harass gender nonconforming people to enforce gender norms, it can lead to an externally generated distress. Many lesbians, gay and bi men exhibit gender nonconforming interests and behaviors.
Some youth with gender identity issues will match their gender identity with their physical body when puberty occurs. Some grow into LGB adults. Those whose bodies and gender identities remain mismatched will grow into adulthood with persistent gender dysphoria. They grow into transgender adults. Some of these transgender adults will also identify as LGB. The line separating the LGB from the T can easily blur.
The process to distinguish gender dysphoric youth from gender non-conforming youth has four components: 1) the desires and development of the youth; 2) the legal requirements for obtaining the consent of youth; 3) the psychological assessment for gender dysphoria; and 4) the medical assessment for biomedical treatment. Only, the youth’s parent or legal guardian can provide consent for their medical procedures. If the youth has emancipated, however, the youth, themselves, can consent to their own medical procedures.
Kathy Doll and Maria Mejia, of SunServe, specialize in LGBT youth mental health issues. They led a workshop on “Caring for Gender Non-Conforming and Transgender Youth”
Therapists have to work within family systems to treat transgender and gender nonconforming youth. The law requires therapists to provide a minor’s parents with all information about the minor upon request. The therapist must create a safe-space of trust between the therapist and the youth. Without that trusting space, the youth with gender issues will be unable to speak. Youth with gender issues may not want their parents to know everything about their issues.
Doll said that the therapist should be proactive from the first meeting with the parents. The therapist should inform the parents that the therapist would protect the youth’s confidentiality. The therapist would only disclose the content of therapy in the case of a threat of possible harm. If parents reject this condition, Doll could not work with their child.
Transgender Youth Medical Issues
Dr. Alejandro Diaz specializes in pediatric endocrinology. He led a workshop, “Medical Treatment for Transgender Youth.” Diaz asserted that pediatricians should identify the behaviors and complaints of gender dysphoric and gender non-conforming youth.
The pediatric endocrinologist determines which biomedical treatment to employ. Their choices include wait and see, puberty suppression, male or female hormone therapy, or surgical transition. Laws set the minimum age for the latter two treatments. The endocrinologist can only begin the medical intervention, if three conditions have been met. First, the transgender youth wants the medical intervention. Second, their parents have to have given their approval, unless the youth has emancipated. Third, the mental health professionals think it appropriate.
Almost all the effects of medical treatment can be reversed. If the transgender youth wants to stop puberty suppression, they can stop. Puberty will ensure with no permanent physical damage, but suppression could have weakened bones. Male and female hormone treatments are partly reversible. Only surgery is non-reversible.
Transgender youth issues present a new set of challenges for the LGBT coalition. They are much greater than just who gets to pee where. They involve sexual and gender self-determination.
Dr. Sheryl Zayas of Care Resource lead the workshop, “Hormone Therapy for Female-to-Male (FtM) and Male-to-Female (MtF)” transgender people. Hormone Therapy has two goals: to reduce the effect of the hormones of the birth sex and increase the influence of the identified sex.
Before a doctor can prescribe hormone therapy, a doctor, nurse practitioner, or mental health professional has to assess the individual for gender dysphoria. That condition involves a persistent state of extreme distress caused by a mismatch between a person’s gender identity and their physical body. Important considerations in that assessment include the following: 1) how out the person is to their significant others 2) whether they have a safe place in which to transition, and 3) if they want to have children. The latter has great importance as hormone therapy frequently results in sterility.
Transgender women (MTF) taking feminizing hormones should expect a reduced sex drive with fewer erections in the first three months. Within a few months, they will start to develop breasts and lose muscle mass. Their testicles will start to shrink. They will need electrolysis to remove body and facial hair. Feminizing hormones increase risk for blood clots. These hormones may also moderately increase the risk for breast cancer, and severe migraines.
Transgender men (FTM) taking masculinizing hormones can expect an increased sex drive. Their clitoris will enlarge, and they may develop facial and body hair, both of which may be permanent. Baldness may also occur. Their voice will deepen. Their vaginal wall may thin, making vaginal intercourse painful and may increase risk for HIV. If they are concerned about fertility, they may want to store their eggs. Masculinizing hormones increase the risk for cardio-vascular disease.
Zayas emphasized that “body parts prone to cancer have to be screened for cancer, regardless of gender identity.” In a similar vein, Dr. Lanalee Sam, Director of Women’s Health Services at Florida Medical Center said, “A uterus is good for having babies, getting cancer, growing fibroids, and bleeding. If you don’t want any of these, take it out.”
PrEP and Transgender People
Doctor of Pharmacology, Rob Shore, PrEP Coordinator, Department of Health (Broward), led a workshop, “PrEP and the Transgender Community.” He described the need for changes in HIV prevention: “If we keep doing what we have been doing, we will keep getting what we have been getting.” South Florida has had consistently high rates of new HIV cases since 2008. This area either has had the highest, or second highest, number of new HIV cases in the US. Shore emphasized that he was not “pushing” PrEP; he was educating people about it.
The acronym “PrEP” stands for Pre-Exposure Prophylaxis. Shore defined prophylaxis as “a measure taken to maintain health and prevent the spread of disease or an undesired state of being.” Most people already use other preventive measures such as birth control, vitamins, and car seat belts. While PrEP fails to prevent STDs other than HIV, birth control fails to prevent any STDs. Birth control only prevents pregnancy. Yet, birth control has gained great acceptance.
Shore used the “birth control” model of HIV Prevention to explain PrEP. As her risk for pregnancy changes, a woman will choose different types of birth control to match her changing levels of risk. PrEP represents a similar widening of choices for people at risk for acquiring HIV.
Some transgender women have participated in PrEP clinical trials, but too few for scientific proof. Nevertheless, PrEP has protected transgender women in these studies, much as it protected bio-women (anatomical females since birth). Only those who took Truvada regularly achieved protection.
Birth control pills contain lower doses of the same feminizing hormones, upon which transgender women depend. No bio-woman in the clinical trials reported drug interactions with birth control pills. The Center of Excellence for Transgender Health found a lack of evidence of drug interactions: “There is no evidence or clinical studies of potential drug interactions between different classes and combinations of antiretroviral medications (ARVs) and cross-sex hormone therapy (csHT) used by transgender women for gender transition and feminization.” The Center suggested that the doctor should monitor estrogen levels for signs of estrogen deficiency. If the doctor were to find estrogen deficiency, the transgender woman could simply stop taking PrEP. Her estrogen levels should then begin to rise.
Currently, PrEP consists of one Truvada pill per day. Each Truvada pill contains two antiretrovirals that prevent HIV from infecting a cell. Researchers selected Truvada as the antiretrovirals in Truvada have the least side effects.
To be effective, the antiretrovirals in Truvada have to reach protective levels. In order to prevent sexual acquisition of HIV, antiretrovirals need to saturate the rectum, the penis, the vagina, and the mouth. According to Shore, antiretrovirals will reach protective levels in the rectum until about 7 days after beginning PrEP, but they will not reach protective levels in the rest of the body until about 21 days after starting PrEP. One dose of PrEP will not provide immediate protection; people have to take PrEP regularly to achieve protection.
The California HIV/AIDS Research Program has awarded $9.4 million grants to study PrEP among both transgender women and transgender men. These grants will have a special focus on transgender women of color.
Researchers need more data about PrEP and transgender people, especially transgender men. Shore said that PrEP would be unlikely to threaten the transitioning process of either transgender women or transgender men. PrEP could benefit both greatly.
Transgender people face unique medical and psychological problems. In order to strengthen the LGBT political coalition, nontrans-identified people should become familiar with transgender health issues. This annual symposium provides a very useful resource to do so.
HIVEonline.org has resources for transmen and transwomen:
To download the booklet “Transgender Women and Pre-Exposure Prophylaxis for HIV Prevention", please visit
Care Resource is a trans-friendly clinic. To contact their Fort Lauderdale office, call 954-567-7141 or visit http://www.careresource.org. They also have offices in Miami.
For the CDC Factsheet about Transgender people and HIV, please visit http://www.cdc.gov/hiv/group/gender/transgender/index.html .
You can also call Patrick Whiteside of the Pride Center at 954-463-9005, Ext. 210.