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.

Mar 212016
Rainbow infinity symbol -- representing the diversity and spectrum of autism

Rainbow infinity symbol — representing the diversity and spectrum of autism

Recent evidence suggests that there may be an association between autism spectrum disorders and being transgender. What started as an observation made by a few physicians is now gaining evidence in peer-reviewed research. This week, I take a look at a new research paper that shares new data on the association.

First, some background. Autism is a spectrum of disorders. The core is difficulty with social interactions along with repetitive or restricted interests or behaviors. People with autism lack an innate sense of the “socially correct” thing to do. They may struggle to see the world from other people’s perspectives. People with autism are often said to think in a “quirky” manner, different from many people. At its most severe, an individual with autism can be unable to take care of him or herself. They may be profoundly mentally disabled and need life-long care. At its least severe, a person with autism can be a socially awkward but brilliantly intelligent scientist. They may make critical breakthroughs because of that “quirky” thinking.

So — did this study find that trans people were more likely to be autistic? Or that people with autism are more likely to be trans? It’s more subtle than that. Let’s look at the methods…

This study reviewed the medical records of roughly 2,000 children in a specific center in New York. Roughly 3/4 did not have autism. The other 1/4 were diagnosed with autism. They did not have a subgroup of individuals who were diagnosed as transgender. Instead, they looked at a specific question on a standardized clinical survey that had been used with all the children. The question asked the children to agree or disagree with the statement: “I wish to be the opposite sex”.

(edit, 3/23/16: For clarity’s sake, “I wish to be the opposite sex” is different from “I am the opposite sex” or “I should have been the opposite sex”. Different trans, genderqueer, or gender non-conforming people may agree with those different statements differently.)

So they were specifically looking at non-autistic and autistic children and asking: “Are autistic children more likely than non-autistic children to report desiring to be the opposite sex?” Technically, this isn’t the same thing as a diagnosis of gender dysphoria or transgender. The authors describe it more as “gender variance” — a pretty good description. And a decent approximation since they could’t go back to get the children an official diagnosis.

What did they find?

5.1% of the children with autism said that they did wish to be the opposite sex. Only 0.7% of non-autistic children said that they wished to be the opposite sex. It didn’t matter whether the children were assigned males or females at birth. It also didn’t matter what age they were.

That’s a huge difference. That means autistic children are 7.76 times more likely to have some gender variance.

Why might autism and gender dysphoria (transgender) be associated? We don’t know why some people are autistic, and we don’t know why some people are trans. The authors hypothesize about the effects of common environmental effects, like birth weight and autism severity.

I wonder if it has to do with some of the different ways that people with autism think. People with autism tend to think differently about the world from people without autism. They often report a sensation that they are strangers or aliens, somehow apart from the rest of the world because of that difference of thinking and perceiving. That sense of alienation can extend to one’s body. People with autism are also less likely to perceive or care about culturally defined sex roles (e.g., only girls wear dresses). Perhaps these differences play a role? I’m only hypothesizing here. If any trans people with autism would like to share their thoughts, please let me know in the comments or send me an e-mail.

Regardless, it’s slowly becoming clear as more and more papers are published that people with autism are more likely to be transgender than people without autism. It’s time we took a good look at the association and made sure that medical and psychological health care is available and appropriate for these populations.

Want to read the study for yourself? It’s publicly available from the journal Transgender Health.

Mar 142016
Baby shower items! by Ana Fuji

Baby shower items! by Ana Fuji

A recent review of fertility preservation in trans and intersex people was published in the new journal Transgender Health. It’s a topic only briefly addressed previously on Open Minded Health (in trans 101 for trans people). Using the review as inspiration then, this week I’ll cover options and factors to consider when it comes to having biological children.

The basic technique in fertility treatments is the harvesting of sperm or eggs. Those sperm or eggs can then be frozen for later use or used for fertility treatments such as in vitro fertilization. For this to work, ovaries or testes have to be producing those eggs and sperm. This means the person has to be past their natal puberty and produce enough viable eggs and sperm that they can be harvested.

For transgender adults, sperm/eggs are best harvested before any hormones are taken. Hormones do reduce fertility, although they are not considered reliable enough to be used as birth control. The amount of estrogens or testosterone needed to have an impact on fertility is currently unknown, but it seems to be different for everyone. So your safest bet is to store egg/sperm before beginning hormones if you can afford it and if having a biological child in the future is important to you. Surgical removal of ovaries/uterus/testes does, of course, make a person sterile and unable to have future biological children.

Trans men who still have a uterus can carry a child but need to be off testosterone to do so as testosterone is harmful to fetal growth. Transgender women cannot carry children with current medicine.


A flowchart for fertility possibilities for trans youth — click to enlarge

For transgender youth it’s more complex. If the youth hasn’t gone through their natal puberty (e.g., for someone assigned female at birth that would be a female puberty) enough to have fertile sperm/eggs, then they have no sperm/eggs to harvest. Going from pre-puberty to puberty blockers to gender-appropriate hormone therapy means that, with today’s technology, there is no future fertility for the youth. If the youth has been on puberty blockers only, the blockers can be removed and the youth allowed to go far enough into natal puberty so that sperm/eggs can be harvested, and then transition. However going through natal puberty is often traumatic for trans youth, and may not be worth it for the youth. There are experimental options currently being used for children with cancer — taking ovarian or testicular tissue from the child and freezing it for future use. However it’s very experimental and I don’t know of anyone doing it for trans youth at this time.

With trans youth there is the added concern of ethical decision making. Children and adolescents cannot give informed consent. That’s the job of the parents or legal guardians. But their desires may clash with that of the youth, possibly causing harm. Depending on the family the question of fertility may or may not be problematic.

For intersex people or people with differences of sexual development, the effect on fertility depends on the specifics of the medical condition. But there are some larger concepts we can talk about. First — being intersex does not automatically mean a person has no fertility. Many of the intersex medical conditions do result in lower fertility. The potential treatment depends on what’s actually causing the low fertility.

  • If the ovary/testis itself is considered “abnormal” (e.g., a mosaic ovary), the effect on fertility is often failure of the ovary/testis. In this case, there’s little that modern medicine can do. The person can try the experimental preservation technique of harvesting and freezing ovarian/testicular tissue, but that’s an experimental technique.
  • If the root cause is hormonal (e.g., congenital adrenal hyperplasia), then it’s possible that sperm/eggs can be harvested. Hormonal treatment may also help fertility.
  • If the root cause is a higher risk of ovarian/testicular cancer, fertility preservation depends on whether the person is pre- or post- puberty. Treatment for an ovary/testicle that has a high risk of becoming cancerous is removal of that ovary/testicle. So if the person has already gone through puberty and is about to have the organ removed, sperm/eggs can be harvested before. If they are pre-pubertal, they can try the experimental technique of freezing the tissue.

Genetic counseling may also be useful for intersex people, as some differences of sexual development conditions are genetic and can be passed down to biological children. Intersex people should receive fertility counseling from physicians knowledgeable in their particular condition at as young an age as possible to maximize their options.

Lastly — never forget that having biological children isn’t the only way to have children. Adoption, fostering, and co-parenting are all wonderful things and are not any less valid ways to have children than having a biological one. If the laws in your state allow, consider adopting, fostering, or co-parenting.