Fall, 2005
Norman Spack, MD
Assistant Professor of Pediatrics, Harvard Medical
School
Clinical Director, Endocrine Division, Children's
Hospital, Boston, MA
Transgendered individuals are people who, by all known biologic measures, are male or female,
yet feel like a member of the opposite sex. The discomfort they suffer is
called gender dysphoria. Theirs is a relatively rare condition and cannot be
explained by factors such as chromosomes, prenatal hormones or toxin exposure,
genital variability, postnatal circulating hormone levels, gender of rearing,
birth order, or the presence or absence of same-sex siblings.
Is it possible that the brains of the transgendered are
uniquely "wired"? Subtle differences between female and male brains have been
reported for decades in research studies that identify gender-related size
differences between specific brain nuclei by staining slices of post-mortem
specimens.1 One recent study showed that
the nuclei of transgendered male-to-females (MTFs) are the size of the nuclei
of genetic females. 2 An earlier study revealed
that males dying of prostate cancer who had been treated for years with female
hormones, and females dying of virilizing adrenal tumors, had nuclei consistent
with their genetic sex. 3 Their hormonal
exposure did not affect the gender-specific nuclei of their brains.
Gender dysphoria is listed as a psychiatric condition in the
psychiatric diagnostic coding manual DSM-IV. I believe that the psychiatric
manifestations are a reaction to the situation, not the underlying condition. A
transgendered individual who has not had hormonal therapy or surgery may
require psychopharmacologic medications, but after a patient receives medical
and/or surgical treatment, psychotropic medicines are often unnecessary.
Nearly all transgendered adults recall feelings of being in
the wrong body early in childhood. Patient histories resonate with the common
theme of dressing secretly in the clothes of the opposite gender during
childhood. However, the age at which a transgendered individual fully
acknowledges his or her gender identity varies from mid-childhood to middle
age. Delayed acknowledgment can usually be traced to a fear of stigmatization and
rejection by family, friends and employers.
The majority of children who express recurrent interest in
being the opposite sex are not transgendered, although many become homosexual. 4 A small percentage of children who are
emphatic and consistent in their desire to be the opposite gender (less than
20% of the above) prefer to be called by a pronoun and name consistent with
their gender identity. Their friends, dress and activities correspond with that
identity. Their greatest fear is puberty because of the irreversible changes
that threaten how they are perceived (their "gender attribution"). During
adolescence, when unwanted and permanent secondary sexual characteristics
transform the patient's body into an adult form that is asynchronous with the
brain, depression and anxiety are typical reactions. When menses become a
monthly reminder of femaleness in a teenager with a male identity, self-abusive
behavior is common. The incidence of suicide among transgendered youth is high. 5 Adult transgendered individuals who find it threatening
to acknowledge their gender identity publicly may adopt a lifestyle of marriage
and parenthood that matches their genetic sex. Inevitably, maintaining this
charade takes its psychic toll.
Who is qualified to assess a patient's condition for
referral for endocrine treatment and ultimate surgery? "Standards of care" have
been created by the Harry Benjamin International Gender Dysphoria Association,
a professional society that includes mental health professionals, endocrinologists,
internists and surgeons (www.hbigda.org). The standards define stages of
treatment, beginning with "extensive exploration of psychological, family and
social issues" by a mental health professional who has abundant experience
working with this population, and only then moving to physical intervention,
which should take place in stages, from reversible to irreversible interventions.
Physicians may be uncertain how to address transgendered
patients who have not legally changed their name and gender but have
transitioned to a gender role consistent with their gender identity. Some
states require reconstructive surgery - genitoplasty or mastectomy - before
allowing name and gender changes on documents such as driver's licenses and
health insurance cards. Whether or not patients have made legal changes or
undergone surgery, they are entitled to the dignity of being referred to by the
name and pronoun of choice. Male-to-female patients should be offered a gown in
the exam room, and female-to-male (FTM) patients should be asked what they
prefer to wear during the exam. No assumption should be made about the
patient's sexual orientation. Like anyone else, a transgendered individual may
be straight, gay or bisexual. Sexual orientation reflects physical attraction,
not gender identity.
The labeling of transgenderism as a psychiatric condition
has the ironic effect of inducing psychological problems in transgendered
individuals. This fuels the notion that a psychiatric disorder is at the heart
of the condition, which influences the diagnostic coding and billing structure.
Under the DSM-IV code, few health insurers in the United States cover the cost
of hormonal replacement therapy. Mastectomies in FTMs, which cost $6,000 to
$10,000, and genitoplasties (sex reconstructive surgery) in MTFs, which cost
$15,000 to $25,000, are considered by almost all health insurers to be cosmetic
surgeries on patients with a mental illness.
To enable patients to transition physically, endogenous
gonadal sex steroid output must be lowered to levels consistent with the gender
of choice, which may not be easy. Both MTFs and FTMs require supraphysiologic
doses of "crosshormones": estrogen for MTFs, testosterone for FTMs. High dose
estrogen poses a risk of blood clots, which can be fatal if they travel to the
lungs (pulmonary embolism) and doses of testosterone sufficient to prevent
menses can induce hypertension, cystic acne and excess red blood cell
production with the risk of blood flow "sludging." Alternatively, endogenous
sex steroids can easily be suppressed by GnRH analogues, which block pituitary
gonadotrophin (LH and FSH) release, enabling cross-hormone treatment to be
accomplished with safer physiologic doses of estrogen or testosterone.
Unfortunately, GnRH analogues are prohibitively expensive in the US, and
patients are forced to take the higher doses of sex steroids until they have
their gonads removed. Genitoplasty in MTFs and reduction mammoplasty in FTMs
are not covered by most health insurers, and patients may have to wait years
saving for it.
In the Netherlands and Belgium, national health insurance
covers all costs related to evaluation and treatment of transgendered
individuals, including children. 6 Interdisciplinary
gender teams evaluate patients psychologically, and patients become potential
candidates for sex reconstructive surgery at government expense after living
for at least a year in the gender of choice (the "real-life experience") while
taking corresponding sex steroid hormones. This discrepancy in coverage across
nations raises questions about US health insurance policy decisions.
Because treatment with cross-gender hormones has
irreversible effects, challenging choices inevitably arise. For the MTF,
estrogen produces breast enlargement and diminished sperm production. Some MTFs
request sperm banking before estrogen treatment or gonadectomy just to maintain
their reproductive capacity, regardless of who will receive that sperm. For the
FTM, testosterone produces a deeper voice, facial hair, temporal balding. Loss
of ovulation and menses ensue, and the ovaries become polycystic while
retaining retrievable ova. When cryopreservation of ova becomes technically
routine and successful, some FTMs will request the procedure to serve as egg
donors for their partner or surrogate.
A significant ethical question in transgender care concerns
potential intervention with children. Should transgendered children who have
had a careful and protracted evaluation by a skilled gender specialist be compelled
to complete puberty before being offered the same therapy used for adults? No
national or international protocol exists, and there are opposing views on how
to proceed. One side argues that physical intervention should be delayed until
the completion of puberty because teenagers are more likely than adults to
change their minds about their gender identity. The opposing view, with which I
concur, argues for early endocrinologic intervention to prevent the severe
depression that accompanies the onset of an unwanted puberty and to avoid the
physically and psychologically painful procedures required to reverse puberty's
physical manifestations.
A model protocol currently employed in the Netherlands
begins with a lengthy screening process in gender-variant pubescent teens at
the "Tanner 2" stage of pubertal development: breast budding in girls and
testicular volumes of 8 cc, preceding phallic enlargement in boys. At this
stage the pubertal manifestations are reversible. GnRH analogues are given for
at least two years, potentially until age 16, when adolescents in the
Netherlands are capable of giving informed consent to receive crosshormones. By
blocking puberty, GnRH treatment buys time for FTMs to achieve a height more
typical of males and for continued assessment of all patients' desire to
transition. If the Dutch clinical trial proves medically and psychologically safe,
it will become the standard of care in the Netherlands, and treatment will be
covered by the government health insurance.
Adoption of such therapy in the US, except by a research
protocol, is unlikely to be reimbursed by most health insurers as long as
transgenderism continues to be coded and billed as a psychiatric condition. The
only alternative drug capable of achieving comparable gonadotrophic suppression
is high dose progesterone, which has effects similar to high dose prednisone or
cortisone and can produce ACTH suppression, fluid retention, "moon face,"
central obesity and insulin resistance.
"Precocious puberty" is the only approved indication for
pediatric use of GnRH analogue therapy in the US. For a patient's insurance to
pay for this drug a physician would have to use this diagnosis for an
11-year-old FTM or 12-year-old MTF, even though the patient hardly meets the
age criteria of sexual precocity. If the Dutch protocol is approved by the
Harry Benjamin Society, would it be right for US health insurers to withhold
payment for GnRH in properly screened transgendered teens?
Transgendered individuals have long faced discrimination in
medical institutions, including physicians' offices and hospitals. 7 Reminiscent of the medical/psychiatric approach
to homosexuality not so long ago, some physicians and psychologists maintain that
the goal of psychiatric treatment is to convince transgendered individuals to
remain in the gender role of their genetic sex, which is an impossibility for
most patients. Everyone involved in patient care should have some awareness of
gender identity disorders, however rare they may be. Primary care physicians
interested in providing hormonal replacement therapy for transgendered patients
should consult the Harry Benjamin Society Standards of Care. Physicians and
mental health professionals who are neither comfortable nor sufficiently
knowledgeable to treat transgendered patients should refer them to more
experienced colleagues.
Footnotes
1 Woodson JC and Gorski
RA. Structural differences in the mammalian brain: reconsidering the male/female
dichotomy. In Matsumoto A (ed.) Sexual
Differentiation of the Brain, New York and London: CRC Press, 2000.
2 Kruijver FP et al.
Male-to-female transsexuals have female neuron numbers in a limbic nucleus. J Clinical Endocrinology &
Metabolism. 85(5):2034-41, 2005.
3 Zhou JN et al. A sex
difference in the human brain and its relation to transsexuality. Nature. 378(6552):15-16,
1995.
4 Zucker KJ and Bradley
SJ. Gender Identity Disorder
and Psychosexual Problems in Children and Adolescents, New York and
London: The Guilford Press, 1995
5 Kreiss JL and
Patterson DL. Psychological issues in primary care of lesbian, gay, bisexual,
and transgendered youth. Journal
of Pediatric Health Care. 11(6):266-74, 1997
6 Cohen-Kettenis PT and
Pfafflin F. Transgenderism and
intersexuality in childhood and adolescence. Making choices, Thousand
Oaks and London: Sage Publications, 2003
7 Feinberg L. Transgender warriors,
Boston: Beacon Press, 1996 Additional readings Boylan JF. She's not there. New York:
Broadway, 2003
Additional Reading
Brown ML and Rounsley CA. True Selves: Understanding transsexualism - for families, friends, coworkers, and helping professionals, San Francisco: Jossey Bass, 1996
Israel GE and Tarver DE. Transgender Care, Philadelphia: Temple U. Press, 1997
in collaboration with
Dartmouth-Hitchcock Medical Center
The opinions expressed in the journal, Lahey Clinic Medical Ethics,
belong to the individual contributors and do not represent the institutional position
of Lahey Clinic on any subject matters discussed.
