Aug 302014
 
Image of needle and syringe - click through to see source

Needles and syringes no longer look like this. Isn’t that wonderful?

Testosterone therapy for transgender men, and others who desire testosterone supplementation, typically involves intramuscular injections of testosterone. Intramuscular injections deliver the medication deep within a large muscle — typically a thigh muscle. From there the hormone can slowly work its way into the bloodstream to do its magic. Few other options exist, and those that do are either expensive or less effective (e.g., creams). Testosterone should not be taken as a pill because it’s very bad for the liver in that form. One possible alternative that has been discussed recently is subcutaneous testosterone injections.

Subcutaneous injections go just under the skin. Most people don’t get subcutaenous injections. The most common subcutaneous injection may be insulin injections for people with diabetes. Subcutaneous injections are also how fluids are given to cats in veterinary care.

Subcutaneous testosterone has been in sporadic recent use for trans men without any research showing how well it works. But that’s changed now with the publication of the article I’m going to summarize. ūüôā So let’s hop into it!

This was a study involving 36 male-identified trans youth from ages 13-24 (minors had parental consent). None had been exposed to hormones before. Hormone levels and other lab values were measured at the beginning and after six months.

For those interested in the specific technicalities of how the hormone was given, keep reading this paragraph. For those not, skip down to the next one! They were given testosterone cypionate suspended in sesame oil that was made at a local compounding pharmacy. The young men were given the injections by the clinical staff at first, but slowly taught to self-inject. Dosing was biweekly and started at 25mg per week, slowly increasing after that for some with a final dose ranging from 25-75mg.

So what did they find? How did it go? Positively!

About 92% of the young men in this study had testosterone levels in the “male” range at the 6 month check up. Similar goes for estrogen levels — by that 6 month check up their estradiol levels were down in the “male” range too. 85% of the young men who had been menstruating had stopped by that 6 month check up. Most periods stopped roughly around the 3 month mark. Other factors, like hemoglobin (red blood cell concentration) and cholesterol shifted but were not of clinical significance.

Two of the young men had allergic reactions to the sesame oil and were switched to cottonseed oil. This is a pretty well known reaction that happens in intramuscular injections too. Some also noticed small bumps around where they injected for a few days after injection. Those were the only reported side effects. Nobody reported unhappiness with their testosterone treatment method or asked to be switched to a different method.

All in all, a well put together study. Subcutaneous injection of testosterone so far appears to be a possible alternative to intramuscular injection. But it’s worth noting that commercial testosterone is intended for intramuscular injection and that type is not what was tested here. It may not be safe or effective to inject an intramuscular formulation as a subcutaneous one — ask your physician before changing how you use your medications!

As always: this is just one study. More need to be done to confirm these results. Regardless, I think these are good first results and look forward to seeing more.

Study was published in LGBT Health. Abstract is publicly available.

Disclaimer: I have personally met Dr. Olson (lead author of this study), worked with her in a small capacity, and have attended her talks at conferences. My interactions and impressions of her may have biased my interpretation on this study. However, I do my best to keep those preconceptions from affecting my judgment.

Sep 162013
 

This post is a legacy page, and was part of an on-going series, Trans 101 for Trans People. It covers questions about medical transition, hormones, surgeries, or seeking health care for transgender people.

For the material that once lived on this page, please see this page.

Please update your links to the full Trans 101.

May 192013
 

I got back from the 2013 National Transgender Health Summit¬†(NTHS)¬†in Oakland last night. What a fabulous conference! I’m still processing a lot of my notes, but wanted to give a quick report on it before I flood the blog with new resources.

First some basic information. NTHS is cosponsored by UCSF’s Center of Excellence for Transgender Health and the World Professional Association for Transgender Health. It’s designed for medical professionals, mental health professionals, advocates, health administrators, students, and others. I can’t speak for previous years, but this year it was a two-day event. Sessions were broken into various tracks: research, medical, mental health, policy, and special topics. And boy, did we cover quite a lot! And, as always, I wanted to be in five different places all at once.

Aside from the official session topics, though, there were some themes that stood out to me…

  • There’s a very strong need for cross-cultural trans care. Trans care, like lots of medicine, has been focused on white people. I admit to being guilty of this too! I don’t know how being trans is handled in, for example, an urban latino/a community, and I don’t know how I can best respond to those needs as a future health care provider. I met some folks who were involved in the¬†Trans People of Color Coalition, and I hope to not only educate myself but bring more awareness to my posts here.
  • There’s a disconnect in some areas between cultural knowledge about medical treatments in trans communities and medical knowledge. I want to give a shout out to Trystan Cotten, author of Hung Jury, for bringing attention to this within trans male communities. One of his examples? Something new for me, certainly: there are anecdotal reports that some trans men can have penetrative sex after metoidioplasty. Sounds like there needs to be a community-level conversation.
  • It sounds so far like the ICD-11 system will handle both the transgender/transsexual diagnoses and the paraphilia diagnoses much better than the previous ICDs and certainly better than the DSM system. More details when the preliminary criteria are out for comment.
  • Insurance coverages for trans-related care may improve with the Affordable Care Act. Again, more on this as information becomes more available.
  • There is a lot of research going on! Yay! I’ll try to link to some of the studies I heard about in a follow up.

Plus so much more! It was really exciting. I hope to post again with more information, links to lots of new resources and shout outs for on-going studies and organizations.

May 012013
 

One way to reduce stress and cortisol - CC BY 2.0 - flickr user eamoncurry123Summary: Research now indicates that cross-sex hormone therapy is associated with a lower cortisol awakening response in trans people, regardless of attachment style. Many confounding variables, however, were present in this study.

Transgender people have long asserted that gender dysphoria can be extremely distressing and that transition, including hormone therapy, helps relieve that dysphoria. Hormone therapy is known to improve self-reported quality of life, as measured by questionnaire. To my knowledge no other study has looked at stress-related biological factors in trans people. Biological factors are important because self-report is notorious for validity problems. This study looked at one such biological factor, called the cortisol awakening response.

What is the cortisol awakening response? Readers of the blog may remember the last time I spoke about¬†cortisol¬†(paragraph #2). For those who don’t remember…. cortisol is a “stress hormone.” When we’re stressed, whether by speaking in public or running from a lion, cortisol is released. It helps our body be ready for immediate survival by increasing blood sugar and helping with metabolism.¬†High cortisol levels over a long period of time can have many negative effects on health, including weakening the immune system. The cortisol awakening response is part of the¬†daily cycle, when blood levels spike about 20-30 minutes after waking in the morning.¬†The cortisol awakening response is larger in stressed people than in non-stressed people and can be affected by many things, including burn out, fatigue, aspirin, and sleep schedule. Awakening response is thought to be a good indicator of general stress levels and as a good indicator for stress-related disease risks.

Participants in this study were 70 trans people seen at the Gender Identity Unit of the University of Bari Psychiatric Department, roughly 64% trans women. All the participants had the same hormonal treatment; transdermal estradiol gel and cyproterone acetate (an anti-androgen) for trans women, intramuscular testosterone esters for trans men. They were assessed before hormone therapy and 12 months after starting hormone therapy. There was no significant difference in age, education, or occupation between the two groups.

The researchers measured perceived stress (a self-report of how stressed a person feels) in addition to the cortisol awakening response. The cortisol awakening response was measured by a blood test at 8:00am on three consecutive days, 1 hour after waking.

The results were striking. Before treatment, both perceived stress and cortisol levels were above the ¬†“normal” range. After twelve months of hormone therapy, both were much lower and back within normal ranges. There were no statistically significant differences between trans men and trans women.

However there are a number of confounds for this study. Cortisol levels vary with sex hormones. For example, the cortisol levels of menstrual women will vary depending on which part of the menstrual cycle they’re in. Could cross-sex hormone therapy have caused this change in cortisol levels? Maybe, but then I’d expect there to be a difference between the trans men and trans women in this study and there weren’t.

The researchers also did not appear to attempt to control for other factors which could have impacted the cortisol awakening response. Changes in sleep patterns (e.g., naps) or sleep quality (e.g., a noisy environment) have effects on the cortisol awakening response. As far as I can tell the researchers did not screen for these changes.

Cortisol and stress were not the only things measured in this study. The researchers also looked at attachment styles. Attachment styles are a psychological concept. The idea is that when we are children our interactions with parents, and how they respond to our needs, affects the type of “attachment” we have. Attachment styles are secure or insecure. A secure attachment often results in happy adult relationships. Insecure attachments include avoidant, anxious, and unresolved/disorganized styles.¬†Attachment styles may influence how we respond to stress, so they could have been a confound in this study if not examined.

The researchers determined the attachment style of the participants with a structured interview. They found that trans people are more likely to have an insecure attachment (70%) than the general population with no psychiatric diagnoses (44%). Attachment style did not, however, appear to be correlated with cortisol awakening response or perceived stress.

In other words, the relationship trans people have with their parents did not appear to affect the stress-reducing effects of hormone therapy.

I do not really understand why these researchers chose to examine attachment style in this study. I think that knowing attachment styles may be useful for therapy or for the development of effective variations on therapies for trans people. But I don’t feel that the inclusion of attachment style was sufficiently justified in this study. Why look at attachment and not, for example, socioeconomic status or social support? I would think either of those would be more likely to have an impact on stress levels than attachment.

On the whole: I think that the cortisol results of this study are decent validation of the anecdotal evidence from trans people themselves, but that the exploration of attachment style in this context is a red herring.

The abstract is publicly available.

Apr 182013
 

CC BY-NC-ND 2.0 - flickr user seizethedaveThe first study of long-term effects of radial forearm flap phalloplasty was published just this month. The aesthetics, functionality, and health status of the donor site on the forearm was examined. This study was reported by researchers at the Center for Sexology and Gender Problems at Ghent University Hospital in Belgium.

Does “radial forearm flap phalloplasty” sound like gibberish? Let’s break it down.¬†Phalloplasty is one of the genital procedures available for trans men (the other is metoidioplasty,¬†which we’ve previously covered). In a phalloplasty, tissue from elsewhere on the body is used to make a penis.¬†“Radial forearm” refers to the part of the body used: a section of forearm, including blood vessels and nerves. “Flap” means the tissue from the forearm is removed completely from the body then put on in another location. “Flap” is in contrast to “pedicle”, where the tissue remains connected in one spot. So a radial forearm flap phalloplasty, essentially, is where tissue from the forearm is used to make a penis. At the same time, hysterectomy and bilateral oophorectomy are done.

As with any surgery involving a graft, both the donor and receiver tissues are damaged. This procedure leaves a scar on the forearm where The researchers report that scarring, reduced bone density, limited range of motion, decreased finger/hand strength, loss of graft, delayed healing, and sensory changes have all been reported. But how common are they? Enter the current research.

Who participated in this research? 44 trans men who had had the procedure. They were an average of 9 years post-surgery, with a range from 9 months to 22 years. Six had a metoidioplasty before their phalloplasty. The median age at surgery was 28. All participants were on hormone therapy, and had been for an average of 10 years; most on a mix of testosterone esters delivered intramuscularly (which is fairly standard practice). The trans male participants were compared to a control group of cis women. There was no weight difference (BMI) between the two groups, but there were more tobacco smokers in the experimental (trans men) group than in the control group (cis women). The control group was not on any metabolic or hormonal altering treatment. In addition to general questions (e.g., tobacco use, medications, medical conditions), the forearm scars of participants were assessed. Questions relating to scar pain, stiffness, and sensation were included. Bone density and body mass were also measured.

The results are very clear. The researchers found no differences in physical activity, lean mass (muscle and bone) of the forearm, or bone health between trans men and cis women. No bone breaks in the donor forearm were reported. In other words, there were no functional problems with the donor forearm. Most (70%) scars had enough blood flow. No itching or pain was reported. The age of the trans man at the time of surgery did not appear to be associated with any negative outcomes.

Best of all, most trans men were satisfied with the way their forearm scar looked. Here’s the breakdown:

  • 26% satisfied
  • 21% very satisfied
  • 30% neutral
  • 19% unsatisfied
  • 5% very unsatisfied

None of the trans men reported regretting their surgery because of their forearm scars. The threat of damage to the forearm itself from this procedure appears to be less than previously thought, though as always it’s not risk-free.

I have to object, however, to using only cis women as controls for a group of trans men. Trans men are not women. The trans men in this study had been post-op for as much as 22 years, meaning no ovaries, so very low levels of “female” sex hormones. Combined with testosterone therapy, their hormone levels much more closely resemble that of males than females. It just doesn’t make any scientific sense. Worse, it carries the subtext that trans men are women, not men. Brain evidence and anecdotal evidence from trans people themselves indicate otherwise, and that such attitudes are extremely harmful.

This research was published in the Journal of Sexual Medicine.