substance use in transgender individuals myo thwin myint, m.d., f.a.a.p. department of psychiatry...
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Substance Use in Transgender Individuals
Myo Thwin Myint, M.D., F.A.A.P.
Department of Psychiatry & Behavioral SciencesDepartment of Pediatrics
Tulane University School of Medicine
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Introduction
Sex◦Biological indicators
◦Males & females
Gender◦Public lived roles
◦Boy/man & girl/woman
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When Mismatch OccursStigma
Prejudice & discrimination
Physical/sexual abuse/neglect
Minority stress
Psychological stress
Mental health problems
Alcohol & drug problems
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Outline
Definitions
Characteristics of transgender
Psychiatric & substance use D/O
Treatments
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Outline
Definitions
Characteristics of transgender
Psychiatric & substance use D/O
Treatments
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Gender IdentityGender Identity
♂
♀
Alternative
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Trans…Trans…
Transgender: identity ≠ natal sex
Transexual: undergone transition
Transvestism: cross-dressing
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Sexual OrientationSexual Orientation
Androphilia: to ♂
Gynephilia: to ♀
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Outline
Definitions
Characteristics of transgender
Psychiatric & substance use D/O
Treatments
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Gender Dysphoria (DSM-5)Children: 6+ for 6+ months
◦Desire being other gender◦Cross-dressing◦Cross-gender roles in play◦Preference in toys of other gender◦Other gender playmates◦Rejection of typical natal gender toys
◦Dislike of one’s sexual anatomy◦Desire for characteristics of other
Must → distress/impairment10
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Gender Dysphoria (DSM-5)Adol./Adults: 2+ for 6+ months
◦Incongruence
◦Desire to be rid of one’s sex characters
◦Desire for other gender’s sex characters
◦Desire to be other gender
◦Desire to be treated as other gender
◦Having feelings of other genderMust → distress/impairment
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Gender Gender NoncomformityNoncomformityNot = gender dysphoria
Gender conformity:Behavior/appearance as society expects
Gender nonconformity:Acting gender atypical by society
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Gender Gender NoncomformityNoncomformityNot indicative of sexual orientation
Can apply to people w/o distress
Varies w/ time & place© Alcohol Medical Scholars Program 13
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Gender DysphoriaGender Dysphoria
Only some transgender individual
At times of significant distress
Related to gender incongruence© Alcohol Medical Scholars Program 14
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Diversity, Not Diversity, Not Pathology Pathology
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PrevalencePrevalence
0.01% natal ♂
0.003% natal ♀
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Course: PersistersCourse: Persisters
30% natal ♂
50% natal ♀
Predictors◦Intensity of early dysphoria◦Seen in adolescents
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Course: DesistersCourse: Desisters
Natal ♂◦Androphilic attraction◦Self identify as gay/homosexual
Natal ♀ ◦Gynephilic attraction◦Self identify as lesbian
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Course: Late OnsetCourse: Late Onset
Natal ♂◦Transvestic behavior ◦Gynephilic attraction◦Self identify as lesbian post transition
Natal ♀ ◦No transvestic behavior◦Androphilic attraction◦Self identify as gay post transition
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Differential DiagnosisDifferential Diagnosis
Gender roles noncomformity:◦Tomboyism◦Girly-boy
Transvestic disorder (D/O)◦Cross dressing for sexual excitement
◦Causes distress/impairment© Alcohol Medical Scholars Program 21
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Differential DiagnosisDifferential Diagnosis
Body dysmorphic D/O◦Thinking body parts are not well-formed
◦Focusing on alteration/removal
Schizophrenic & other psychotic D/O◦Hearing voices/paranoia◦Rare to have gender delusion only
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Outline
Definitions
Characteristics of transgender
Psychiatric & substance use D/O
Treatments
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Prevalence: Any Prevalence: Any Psych. DxPsych. Dx
70% Lifetime
40% Current
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Prevalence: SuicidePrevalence: Suicide
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W/ MDDTrans-gender
General populatio
n
Ideation 60% 40%
Attempt 30% 10%
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Prevalence: Psych. DxPrevalence: Psych. Dx
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D/OTrans-gender
General populatio
n
Socialanxiety
7%
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Prevalence: Psych. DxPrevalence: Psych. Dx
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D/OTrans-gender
General populatio
n
Socialanxiety
45% 7%
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Prevalence: Psych. DxPrevalence: Psych. Dx
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D/OTrans-gender
General populatio
nSocial
anxiety45% 7%
Major depressi
ve7%
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Prevalence: Psych. DxPrevalence: Psych. Dx
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D/OTrans-gender
General populatio
nSocial
anxiety45% 7%
Major depressi
ve26% 7%
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Prevalence: Psych. DxPrevalence: Psych. Dx
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D/OTrans-gender
General populatio
nSocial
anxiety45% 7%
Major depressi
ve26% 7%
PTSD 9%
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Prevalence: Psych. DxPrevalence: Psych. Dx
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D/OTrans-gender
General populatio
nSocial
anxiety45% 7%
Major depressi
ve26% 7%
PTSD 13% 9%
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Prevalence: Substance Prevalence: Substance UseUse
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Trans-gender
General populatio
n
Cocaine 40% 15%
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Prevalence: Substance Prevalence: Substance UseUse
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Trans-gender
General populatio
n
Cocaine 40% 15%
Meth > 40% 5%
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Prevalence: Substance Prevalence: Substance UseUse
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Trans-gender
General populatio
n
Cocaine 40% 15%
Meth > 40% 5%
IV drugs 40% 25%
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Prevalence: Substance Prevalence: Substance UseUse
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Trans-gender
General populatio
n
Cocaine 40% 15%
Meth > 40% 5%
IV drugs 40% 25%
Tobacco 70% 20%
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Outline
Definitions
Characteristics of transgender
Psychiatric & substance use D/O
Treatments
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Physical Rx: HormonesEstrogen for ♂ → ♀
Testosterone ♀ → ♂
Suppressors to block puberty
High rate of use w/o supervision
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Physical Rx: Hormones
Possible side effects◦Hypomania/mania◦Psychosis
Interactions w/ substance use◦Smoking + estrogen → risk of clot
◦Smoking + testosterone → risk of heart disease
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Physical Rx: Surgery
Irreversible
Only 1-2% regret
Improves dysphoria sx & psych fxn
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Psychotherapy
Explore identity, role, expression
Address negative impact
Alleviate internalized hatred
Enhance support
Improve body image
Promote resilience42
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Psychosocial Rx
Voice & communication therapy
Hair removal
Learn to dress as identified gender
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Rx BarriersDiscrimination
Hostility & insensitivity
Strict binary gender segregation
Lack of group acceptance 44
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Primary CarePediatricians
Family Medicine
Internists
Coordinating care
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Mental Health
Assess comorbid diagnoses
Monitor psychiatric sx
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Other Rx SpecialistsOther Rx SpecialistsEndocrinologists
Urologists
Gynecologists
Plastic surgeons
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Rx Outcomes
80% w/o gender dysphoria
75% ↓ ↓ anxiety & depression
80% quality of life48
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Summary
Be familiar w/ changing terms
Being transgender not = pathology
Dysphoria needs interventions
Higher rates of psychiatric diagnosis
Be mindful of Rx barriers49
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ResourcesWorld Professional Association for
Transgender Health (www.wpath.org)
Center of Excellence for Transgender Health (www.transhelath.ucsf.edu)
American Psychiatric Association (www.psych.org)
American Academy of Child & Adolescent Psychiatry (www.aacap.org)
American Academy of Pediatrics (www.aap.org)
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