Aug 012016
 

Welcome back to Open Minded Health Promotion! This week we’re looking at health promotion for transgender men and individuals assigned female at birth. Depending on your history some of these tips will apply more or less to you.

TransgenderPlease remember that these are specific aspects of health in addition to the standard recommendations for everyone (e.g., colonoscopy at age 50). Based on your health and your history, your doctor may have different recommendations for you. Listen to them.

All transgender men should consider…
  • Talk with their doctor about their physical and mental health
  • Practice safer sex where possible. Sexually transmitted infections can be prevented with condoms, dental dams, and other barriers. If you share sexual toys consider using condoms/barriers or cleaning them between uses.
  • Consider using birth control methods if applicable. Testosterone is not an effective method of birth control. In fact, testosterone is bad for fetuses and masculinizes them too. Non-hormonal options for birth control include condoms, copper IUDs, diaphragms and spermicidal jellies.
  • If you’re under the age of 26, get the HPV vaccine. This will reduce the chance for cervical, vaginal, anal, and oral cancers.
  • Avoid tobacco, limit alcohol, and limit/avoid other drugs. If you choose to use substances and are unwilling to stop, consider strategies to limit your risk. For example, consider participating in a clean needle program. Vaporize instead of smoke. And use as little of the drug as you can.
  • Maintain a healthy weight. While being heavy sometimes helps to hide unwanted curves, it’s also associated with heart disease and a lower quality of life.
  • Exercise regularly. Anything that gets your heart rate up and gets you moving is good for your body and mind! Weight bearing exercise, like walking and running, is best for bone health.
  • Be careful when weight lifting if you’re newly taking testosterone. Muscles grow faster than tendon, thus tendons are at risk for damage when you’re lifting until they catch up.
  • Consider storing eggs before starting testosterone if you want genetic children. Testosterone may affect your fertility. Consult a fertility expert if you need advising.
  • Seek help if you’re struggling with self injury, anorexia, or bulimia. Trans men are at higher risk than cis men for these aspects of mental health.
  • If you have unexplained vaginal bleeding, are on testosterone, and have not had a hysterectomy notify your doctor immediately. Some “breakthrough” bleeding is expected in the first few months of testosterone treatment. Once your dose is stable and your body has adapted to the testosterone you should not be bleeding. Bleeding may be benign but it may also be a sign that something more serious is going on. Contact your doctor.
  • In addition, talk with your doctor if you have pain in the pelvic area that doesn’t go away. This may also need some investigation. And s/he may be able to help relieve the pain.
  • Be as gentle as you can with binding. Make sure you allow your chest to air out because the binding may weaken that skin and put you at risk for infection. Be especially careful if you have a history of lung disease or asthma because tight binding can make it harder to breathe. You may need your inhaler more frequently if you have asthma and you’re binding. If this is the case, talk with your doctor.
  • If you’ve had genital surgery and you’re all healed from surgery: there are no specific published recommendations for caring for yourself at this point. So keep in touch with your doctor as you need to. Call your surgeon if something specific to the surgery is concerning. Continue to practice safe sex. And enjoy!
Your doctor may wish to do other tests, including…
  • Cervical cancer screening (if you have a cervix). The recommendation is every 3-5 years minimum, starting at age 21. Even with testosterone, this exam should not be painful. Talk with your doctor about your needs and concerns. Your doctor may offer a self-administered test as an alternative. Not every doctor offers a self-administered test.
  • Mammography even if you’ve had chest reconstruction. We simply don’t know what the risk of breast cancer is after top surgery because breast tissue does remain after top surgery. Once you turn 50, consider talking with your doctor about the need for mammography. In addition, if you’re feeling dysphoric discussing breast cancer then it may be helpful to remember that cis men get breast cancer too.
  • If you have not had any bottom surgery you may be asked to take a pregnancy test. This may not be intended as a transphobic question. Some medications are extremely harmful to fetuses. Hence doctors often check whether someone who can become pregnant is pregnant before prescribing. Cisgender lesbians get this question too, even if they’ve never had contact with cisgender men.

And most importantly: Take care of your mental health. We lose far too many people every year to suicide. Perhaps worse, far more struggle with depression and anxiety. Do what you need to do to take care of you. If your normal strategies aren’t working then reach out. There is help.

Want more information? You can read more from UCSF’s Primary Care Protocols and the Gay and Lesbian Medical Association.

Jul 182016
 

Transgender youth are a special population. Because of the relative novelty of treatment at any age much less for youth, data are scarce. A recent review article examining the published data on transgender youth was published. Let’s take a look at what they found.

First, how about prevalence? How many youth self identify as transgender? There are very, very, few studies that get good numbers on this. One study in New Zealand found that 1.2% of secondary school children identified as transgender, and 2.5% weren’t sure about their gender.

As we well know, being a gender and sexual minority can often be associated with health disparities. And this review reports on that too. Identifying as transgender was associated with negative psychological health. Specifically, being bullied, having symptoms of depression, attempting self harm, and attempting suicide were all more common in transgender youth than in cisgender youth. How much of that was because of discrimination and how much was because of gender dysphoria was not explored.

Researchers have also found that being transgender and having autism appear to go together. No one is quite sure why yet. There’s still a lot of research to be done to figure that out.

One interesting difference in the literature stands out to me, though. It appears that transgender men are more likely to self harm and transgender women are more likely to be autistic. Among cisgender people, cis women are more likely to self harm and cis men are more likely to be autistic. There are theories for why that sex difference exists, but there’s little to no agreement. It could be related to social environments, hormones, the environment in the womb, or any number of other factors. But the observation that transgender men and women more resemble their sex than their gender for self harm and autism is worth investigating further.

What about the effects of hormone therapy for transgender youth? Especially puberty suppression, which is the unique factor for their treatment? As a reminder, the treatment of transgender youth is largely based on the Dutch model. At puberty, children go on puberty suppressing drugs. They then go on hormones (and thus begin puberty) at age 16 and are eligible for surgery at age 18. There are efforts to deliver cross-sex hormones earlier, but the Dutch model is the standard that most of the research is based on. A Dutch study found that the psychological health of transgender youth improved after surgery. Their psychological health even equalled that of their cisgender peers! The researchers also found that youth continued to struggle with body image throughout the time they were on puberty suppression only. But their self-image improved with hormone therapy and surgery. None of the children regretted transitioning. And they said that social transition was “easy”.

One challenge to that particular Dutch study is that the Dutch protocol excludes trans youth who have significant psychiatric issues. A young person with unmanaged schizophrenia, severe depression, or other similar issue wouldn’t be allowed to start hormones. So the research was only on relatively psychologically healthy youth to begin with. It’s difficult to say if that had an effect on the study’s results. It’s also difficult to say whether the psychological health of a trans youth is the cause or the result of their dysphoria. A trans youth with depression might well benefit from hormone therapy, after all.

There are multiple questions still unresolved when it comes to treating transgender children. Does puberty suppression have a long term effect on their bones? Are there long-term physical or psychological health effects of early transition? How should children with serious psychological conditions be treated (besides the obvious answer — with compassion)? And on, and on.

The medical and scientific communities are working on answering these questions. But it will take time. And in the mean time — physicians and families do they best they can with what information we have. If you have, or are, a transgender youth please consider participating in a study so we can do even better for children in the future.

Want to read the review for yourself? The abstract is publicly available.

Jul 042016
 

On June 17, 2016 The Lancet, one of the UK’s most prestigious medical journals, published an entire series dedicated to global transgender health.

The World Professional Association for Transgender Health biennial conference happened over the weekend of June 17-21. I wasn’t able to go this time around, so I can’t report on it directly. But! It looks like it was a fabulous conference. Topics ranged from surgical techniques to cancer prevention to health and psychological care for transgender youth. You can see the schedule yourself.

The Pentagon has announced that it will begin allowing transgender people to openly serve in the US military next month. No details on what that means for veterans or formal military who were dismissed from service because of that status have yet been revealed. Source.

President Obama has declared Stonewall a national monument.

Apr 252016
 

For many reasons, transgender women as a group are at high risk for sexually transmitted infections (STIs). The types of STIs a trans woman is at risk for changes after vaginoplasty but doesn’t go away. Reports of (neo) vaginal infection by gonorrhea and chlamydia are rare, for example. Trans women with (neo) vaginas may be at higher risk for HIV because of the greater possibility of a vaginal tear. Relatively little is known about the risk for other STIs, such as the human papilloma virus (HPV). Today I take a look at a new paper on HPV infection in post-vaginoplasty trans women.

HPV, the Human Papilloma Virus

HPV, the Human Papilloma Virus

HPV is a virus spread by skin-to-skin contact. There are different types of the virus. Some types cause warts (NSFW link). All warts are caused by a version of HPV. Warts that are on the genitals or anus are caused by specific types of HPV that are considered sexually-transmitted infections (types 6 and 11). The warts can be uncomfortable or painful. They can be very small or grow to become large masses. Warts themselves are fairly harmless otherwise.

The types of HPV that don’t cause warts are more dangerous. Those include types 16, 18, 31, and 33. These types don’t cause warts, but they cause changes that can lead to cancer. Cancers that have been associated with infection include cervical cancer, vaginal cancer, anal cancer, penile cancer, and some throat/oropharyngeal cancers. As you can tell from where these cancers happen, these types of HPV are often sexually transmitted. Screening tests for associated cancers include cervical pap smear, anal pap smear, and testing for the virus.

HPV can be prevented by vaccine and by barriers such as condoms and dental dams. Most vaccines prevent both the cancer-causing and genital wart-causing types. There is no cure for infection. Treatment is limited to removal of warts and treatment for cancers.

What about HPV infection in post-vaginoplasty trans women? Since HPV is a skin-to-skin contact infection, the (neo) vagina can still be infected by HPV. What has been reported in the medical literature about HPV infection? This paper presented 4 cases of vaginal HPV in their clinic and summarized 9 reports that had previously been reported in the medical literature. So they discussed 13 reports of HPV total.

They only reported symptomatic HPV cases. So only women who were having pain, discomfort, or other symptoms from an infection were discussed.

Most of the women had had a penile inversion vaginoplasty. One woman had a sigmoid vaginoplasty, one had a “split skin graft” (NSFW) vaginoplasty, and one was unknown. Split skin graft is a technique that uses skin from elsewhere on the body, and is sometimes used for cis women who were born without a vagina.

Of the four new cases discussed in the article, all came to the clinic with pain, either vaginal or vulvar. Three of the four women had genital warts, which were removed. The fourth had a white discoloration (“leukoplakia”), also caused by human papilloma virus. The pain and symptoms of all four were resolved with treatment and the lesions did not come back. All four were HIV negative and had previously had penis-in-vagina sex with at least one cis man.

There was less reported about the 9 cases that had previously been reported in the medical literature. 7 out of the 9 had genital warts. 6 of those 7 had the warts successfully removed. The 7th had to have a vaginectomy to remove the warts. Of the two who did not have warts, one had vaginal cancer and had to have a vaginectomy and chemo. The last had a pre-cancerous lesion, and we don’t know what happened to her.

The types of treatment for warts varied. Some were removed successfully with medication. Others were removed surgically. Still others were removed with laser or electricity.

Ultimately — all these results sound like what happens with cis women. Warts happen, cause pain or distress, and are treated. Less commonly, HPV causes cancer or pre-cancerous lesions and that is treated.

What this article brings to attention is that trans women need HPV prevention as much as everyone else. HPV vaccination for people up to age 26 is recommended. For those older than 26, barriers during sex with partners is a useful tool.

UCSF recommends “periodic” visual examination of the (neo) vagina to look for changes that may be pre-cancerous lesions. But they don’t define what “periodic” means. Cis women get pap smears every 3-5 years; 3-5 years may be a reasonable range for trans women too, but we just don’t know for sure. So if you’re concerned, talk with your physician about screening.

Want to know more about HPV? The CDC has good information.

Want to read the study for yourself? The abstract is publicly available.

Mar 282016
 

In the United States, spironolactone is the oral anti-androgen of choice for trans women. It’s the cheapest and is well tolerated by most people. Outside of the United States cyproterone acetate, also known as Androcur, is the preferred drug. This week I take a look at this drug, how it works, and why it hasn’t been approved for use in the United States.

The chemical structure of cyproterone

The chemical structure of cyproterone

Cyproterone is an anti-androgen. It blocks androgen receptors, preventing testosterone and other androgens from having their effects. By blocking those receptors, it reduces the amount of testosterone in the body through a mechanism called negative feedback. Cyproterone is chemically similar to progesterone and has some progesterone-like effects as well. Outside of transgender care it’s also used for prostate cancer, as combination antiandrogen and hormonal birth control for cis women (e.g., Dianette), and for chemical castration of sex offenders.

It’s available both as a pill and intramuscular injection. The pill form should be taken every day at the same time after a meal. The dose often used for transition in the literature is 100mg/day. Anecdotally I’ve been told that lower doses, such as 25-50mg/day, have been used. The injection is given once every 1-2 weeks.

Cyproterone acetate is not risk-free and is definitely not for everyone. Most seriously, cyproterone is associated with liver damage. That damage can be severe. It can lead to liver failure even after the drug is stopped. Damage has been reported with doses over 100mg/day. Because of this, people on cyproterone should have their livers regularly monitored with blood tests. The drug should not be combined with other drugs that can cause liver damage. That includes alcohol and many prescription drugs. Individuals with known liver damage/disease should not take cyproterone.

There is also some question of whether the drug is associated with some cancers. In particular, liver cancer and some brain cancers. Specifically, hepatocellular carcinoma and meningioma are the cancers of concern. Researchers are still exploring this connection. Other negative side effects of cyproterone include allergic reactions and worsening of depression.

Many trans women are concerned about fertility. The effects of cyproterone alone, without estrogen, on fertility are somewhat known. Sperm count goes down with oral doses as low as 50mg. Infertility can happen in as little as 2 months. The infertility is reversible once cyproterone is stopped. Fertility returns anywhere from 3-20 months. But remember — no anti-androgen is a birth control method. Please use birth control if you or your partner are at risk of pregnancy.

In the literature, 100mg/day is the dose that seems to be preferred for transition. No cases of liver cancer in trans women have been reported. However some women do have higher levels of liver enzymes. That’s a sign that the drug is causing some damage to liver cells. Transdermal, instead of oral, estrogen is recommended to reduce potential liver damage and blood clots.

Cyproterone is a potential alternative for trans women. So why hasn’t the FDA approved it? That’s a little murky. I wasn’t able to find public document describing the reasoning. But the biggest reason cited by other sources is the concern of liver damage. The FDA is likely trying to do its job and protect the population from drugs that cause more harm than good. In its efforts it may well overstretch. Cyproterone only rarely causes liver problems, and those problems can be screened for with regular blood tests. However it’s important to remember that there are safer alternatives still available. Spironolactone and the GnRH agonists (puberty blockers) are generally safer and mostly well tolerated. Other androgen receptor blockers (e.g., bicalutamide), while not in common use for trans care, are also available and have lower rates of liver damage. So there’s little pressure on the FDA to approve a riskier drug.

So in summary — cyproterone is an androgen receptor blocker in use outside the United States for trans care, prostate cancer, and birth control. It’s biggest side effect is potential liver damage. It’s not FDA-approved for use in the US probably because of that liver damage. People currently using the drug should be under a physician’s supervision.

Want to learn more? The wikipedia article on this drug is super excellent!

Note on references — I pulled most of my information from LexiComp, which I have access to through my university and can’t easily reference. However, prescribing information is publicly available and has much of the same information.