Sep 102013

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.

Jun 212013

Image © Kristy Peet. Used under creative commons license: CC BY 2.0A third case report of a meningioma in a trans woman has just been published.

A meningioma is a tumor of the meninges, the tissues between the skull and the brain. Most meningiomas come from the arachnoid mater, through which the cerebrospinal fluid sluggishly flows. Meningiomas are mostly (90%) benign, meaning they are not cancerous and will not spread throughout the body. Current treatment is surgery to remove the tumor, with radiation available if surgery is not possible.

There is some thought that sex hormones are a factor in the growth of meningiomas. Women are more likely to develop a meningioma than men. Like some breast tumors, meningiomas have also been found to be sensitive to estrogen and/or progesterone. Sensitivity refers to the tumor cells having receptors for certain hormones, and responding to those hormones. In the case of some estrogen-sensitive breast cancers, the estrogen increases the growth of the tumor.

This case was in Australia. The patient had been on estrogen and an anti androgen (cyproterone acetate), and had had genital surgery years before. Her tumor was benign, though sensitive to progesterone and estrogen, and was surgically removed. Unusually, her tumor came back and was removed again. She underwent radiation treatment. She is reported to have chosen to stop hormones and has made a full recovery.

Whether hormone therapy influences the growth of meningiomas is unknown. So far, the data are mixed and there is no consensus in the medical community. The other two case reports continued hormone therapy with no recurrence of the tumor. To stay on the safe side, however, the authors recommend that hormone therapy be discontinued upon diagnosis of a meningioma. They also suggest that a history of meningioma may be a contraindication for starting hormone therapy.

All individuals, trans or cis, should seek medical advice if they have any neurological symptoms. This includes symptoms associated with meningiomas such as headaches, seizures, blurred vision, double vision, weakness in arms or legs, numbness, or speech problems.

This case report was published in International Journal of Transgenderism. The abstract is publicly available.

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.

Feb 202013

CC BY-NC-ND 2.0 - Santiago Alvarez

A new study has come out examining the differences between eating disorders and transsexuality. It’s not immediately obvious why those two should be compared. The causes of both are unknown. When you don’t know the cause of a phenomenon it’s often useful to compare it to other phenomena that seems similar. Both eating disorders and transsexuality can be categorized as body-centered phenomena; eating disorders involve weight, transsexuality involves sex characteristics. However there are differences; people with eating disorders are more likely to have other psychiatric diagnoses (e.g., borderline personality disorder) than trans people are. Trans people seem to have psychiatric diagnoses as frequently as the general population, though the data are still tentative.

This Italian study compared three groups, all roughly the same size (100 participants):

  • Trans people, both trans women and trans men. Both pre-op (no sexual reassignment surgery) and post-op folk were included. There were roughly equal numbers of trans men and trans women, and of pre-ops and post-ops. Trans participants had to have a diagnosis of Gender Identity Disorder.
  • People with eating disorders, divided into three groups: anorexia nervosa, bulimia nervosa and binge eating disorder. These participants were mostly female, except in the binge eating group which was half female.
  • Control participants with normal BMI who did not have an eating disorder and were not trans.

What did they measure? The researchers measured demographics, “anthropometric measurements” such as height and weight, psychiatric evaluations to verify diagnoses, psychological symptoms, and body uneasiness. Body uneasiness is multifaceted, including general body/weight dissatisfaction, compulsive self-monitoring (e.g., spending a lot of time in front of the mirror), feeling disconnected from one’s body, and worrying about specific body parts.

What did they find? Results included…

  • Pre-op trans folk had: a) higher levels of body uneasiness than people with eating disorders, b) lower levels of body satisfaction than post-op trans folk, and c) higher levels of depersonalization than all other groups.
  • There was no difference in overall body uneasiness between trans men and trans women. However, there were differences in various aspects of body uneasiness. Trans women were more likely to be concerned about weight gain than trans men. Trans women also self-monitored about as much as people with eating disorders, more than trans men and the control group.
  • Trans participants had lower levels of psychopathology than people with eating disorders. There was no difference between the trans participants and the control group for psychopathology.
  • Pre-op trans women were more likely to have adjustment disorder than all the other groups.

So how do we interpret this? First there’s the difference between trans folk and people with eating disorders. This study confirmed the findings of previous studies. It agrees that trans people are much less likely to have psychiatric diagnoses than people with eating disorders. It also agrees that, in general, trans people are not at elevated risk for psychopathology than the general population. Given the way many psychiatric disorders come in clusters (e.g., mood and anxiety disorders), this may be further evidence that transsexuality is not a psychiatric condition.

The finding that pre-op trans women are more likely to have adjustment disorder requires explanation. Adjustment disorder is not like mood or psychotic disorders. It means that the person is having difficulty adjusting to a life change. For pre-op trans women, the source is obvious: their transition is a major life change and a major stressor. The fear of being “outed” and assaulted or ostracized is very real. Pre-op trans women are also likely o be early in transition and hormone therapy and have a harder time “passing” than trans men.

Why might trans women worry about weight more than trans men? The authors comment, “It could be speculated that [trans women]’s drive for thinness is a way to suppress masculinity and to correspond to a female ideal of attractiveness.” Absolutely! Trans women are women, and so they get all the societal messages encouraging thinness that all Western women receive.

I do, however, feel that one “finding” of theirs must be questioned. As part of demographics, the authors asked about sexual orientation. They then categorized their participants by attraction according to “genotypic sex” (XX, XY, XXY, XO, etc) So when they later reported that their trans participants were more likely to be attracted to the same genotypic sex than their controls and people with eating disorders, they were actually comparing straight trans people to gay cis people. That makes no sense! Of course there were more straight trans people than gay cis people – there are more straight people than gay people overall. Further, “genotypic sex” as a category makes no sense unless you actually check the genotype! Even then, it doesn’t necessarily correspond to phenotypic sex (the sex that the person looks like).The primary limitation to this study is their inclusion of only gender binary trans people who were diagnosed with Gender Identity Disorder. This excludes all genderqueer folk, who may have more difficulty with transition because of societal pressure to be seen as either male or female. Otherwise, I think this study was fairly well put together.

The authors conclude saying that “Our findings suggest that in eating disorder patients [body] uneasiness is primarily linked to general psychopathology, whereas in [transsexuality] this relationship is lacking.” In other words, they suggest that eating disorders come from a general state of psychological illness and that transsexuality does not. The data I have seen, as well as anecdotes from the trans community, agree with this conclusion.


Sep 212012

Because hormone therapy is known to slow and eventually stop sperm production, trans women who wish to have biological children must store their sperm before starting hormones. It is not known whether sperm production will resume if hormones are discontinued. Both the WPATH and Endocrine Society guidelines recommend considering sperm storage before starting hormone therapy.

Those recommendations aren’t without conflict. Some in the medical field have expressed concerns about the welfare of children born to trans parents. There are no empirical data available on those kids, but the authors of this study comment that “the lack of reassuring evidence cannot be used as a barrier against reproduction after gender transition.” I think they’re absolutely right. Further, the data on same-sex parenting help reinforce that it’s not the gender of the parent(s) that’s important for a child’s well-being. Factors like cooperation and stability are far more influential.

The authors note that there is little research surrounding reproduction in trans women, and that the research world has little understanding of the motivations and concerns affecting trans women’s reproductive decisions. Several issues they mention seeing in their clinic include cost, desire to transition quickly, and difficulty producing sperm for freezing. They also call for more research, so that clinicians better understand what trans women are facing and can improve health care.

I was really glad to see this article published. There was a lot of discussion of reproductive options for young trans people at the latest Gender Spectrum conference. It’s good to see it being discussed respectfully in the literature.

Link (Archives of Sexual Behavior)

EDIT: Yes, that title does look weird, doesn’t it? It really is the title of the article that was published.