substance use in transgender individuals myo thwin myint, m.d., f.a.a.p. department of psychiatry...

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

Introduction

Sex◦Biological indicators

◦Males & females

Gender◦Public lived roles

◦Boy/man & girl/woman

© Alcohol Medical Scholars Program 2

When Mismatch OccursStigma

Prejudice & discrimination

Physical/sexual abuse/neglect

Minority stress

Psychological stress

Mental health problems

Alcohol & drug problems

3© Alcohol Medical Scholars Program

Outline

Definitions

Characteristics of transgender

Psychiatric & substance use D/O

Treatments


Outline

Definitions



Treatments


Gender IdentityGender Identity

♂

♀

Alternative


Trans…Trans…

Transgender: identity ≠ natal sex

Transexual: undergone transition

Transvestism: cross-dressing


Sexual OrientationSexual Orientation

Androphilia: to ♂

Gynephilia: to ♀


Outline

Definitions



Treatments


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

© Alcohol Medical Scholars Program

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


Gender Gender NoncomformityNoncomformityNot = gender dysphoria

Gender conformity:Behavior/appearance as society expects

Gender nonconformity:Acting gender atypical by society


Gender Gender NoncomformityNoncomformityNot indicative of sexual orientation

Can apply to people w/o distress

Varies w/ time & place© Alcohol Medical Scholars Program 13

Gender DysphoriaGender Dysphoria

Only some transgender individual

At times of significant distress

Related to gender incongruence© Alcohol Medical Scholars Program 14

Diversity, Not Diversity, Not Pathology Pathology


PrevalencePrevalence

0.01% natal ♂

0.003% natal ♀


Course: PersistersCourse: Persisters

30% natal ♂

50% natal ♀

Predictors◦Intensity of early dysphoria◦Seen in adolescents


Course: DesistersCourse: Desisters

Natal ♂◦Androphilic attraction◦Self identify as gay/homosexual

Natal ♀ ◦Gynephilic attraction◦Self identify as lesbian


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


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

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


Outline

Definitions



Treatments


Prevalence: Any Prevalence: Any Psych. DxPsych. Dx

70% Lifetime

40% Current


Prevalence: SuicidePrevalence: Suicide


W/ MDDTrans-gender

General populatio

n

Ideation 60% 40%

Attempt 30% 10%

Prevalence: Psych. DxPrevalence: Psych. Dx


D/OTrans-gender

General populatio

n

Socialanxiety

7%



D/OTrans-gender

General populatio

n

Socialanxiety

45% 7%



D/OTrans-gender

General populatio

nSocial

anxiety45% 7%

Major depressi

ve7%



D/OTrans-gender

General populatio

nSocial

anxiety45% 7%

Major depressi

ve26% 7%



D/OTrans-gender

General populatio

nSocial

anxiety45% 7%

Major depressi

ve26% 7%

PTSD 9%



D/OTrans-gender

General populatio

nSocial

anxiety45% 7%

Major depressi

ve26% 7%

PTSD 13% 9%

Prevalence: Substance Prevalence: Substance UseUse


Trans-gender

General populatio

n

Cocaine 40% 15%



Trans-gender

General populatio

n

Cocaine 40% 15%

Meth > 40% 5%



Trans-gender

General populatio

n

Cocaine 40% 15%

Meth > 40% 5%

IV drugs 40% 25%



Trans-gender

General populatio

n

Cocaine 40% 15%

Meth > 40% 5%

IV drugs 40% 25%

Tobacco 70% 20%

Outline

Definitions



Treatments


Physical Rx: HormonesEstrogen for ♂ → ♀

Testosterone ♀ → ♂

Suppressors to block puberty

High rate of use w/o supervision


Physical Rx: Hormones

Possible side effects◦Hypomania/mania◦Psychosis

Interactions w/ substance use◦Smoking + estrogen → risk of clot

◦Smoking + testosterone → risk of heart disease


Physical Rx: Surgery

Irreversible

Only 1-2% regret

Improves dysphoria sx & psych fxn


Psychotherapy

Explore identity, role, expression

Address negative impact

Alleviate internalized hatred

Enhance support

Improve body image

Promote resilience42


Psychosocial Rx

Voice & communication therapy

Hair removal

Learn to dress as identified gender


Rx BarriersDiscrimination

Hostility & insensitivity

Strict binary gender segregation

Lack of group acceptance 44


Primary CarePediatricians

Family Medicine

Internists

Coordinating care


Mental Health

Assess comorbid diagnoses

Monitor psychiatric sx


Other Rx SpecialistsOther Rx SpecialistsEndocrinologists

Urologists

Gynecologists

Plastic surgeons


Rx Outcomes

80% w/o gender dysphoria

75% ↓ ↓ anxiety & depression

80% quality of life48


Summary

Be familiar w/ changing terms

Being transgender not = pathology

Dysphoria needs interventions

Higher rates of psychiatric diagnosis

Be mindful of Rx barriers49


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)


substance use in transgender individuals myo thwin myint, m.d., f.a.a.p. department of psychiatry...

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