What do you need to know??
Mandy Nicoles, MA, ATC A.J. Duffy III, MS, ATC, PT Emerson College Widener University
64th Annual EATA Meeting Boston, MA
January 8, 2012
Why this? Why now?
Personal examples of transgender SA
Terminology/Treatment
Understanding the language and the methods of transitioning
Navigating the legislation
Introduction into high school, college and international polices and procedures
Medical/Psychological implications
Role of the athletic trainer in the overall care of athlete
Birth/Assigned Sex: Refers to the sex assigned to an individual at birth
Intersex: Refers to individuals born with both male and female anatomical, physiological and/or chromosomal characteristics
Gender Identity: Refers to an individual’s deeply felt sense of being either female or male
http://www.ncaa.org/wps/wcm/connect/0eece8804378fefdbaecba6bcdc87ae7/NCAA+TSA+Issues+Resource.pdf?MOD=AJPERES&CACHEID=0eece8804378fefdbaecba6bcdc87ae7
Gender Expression: Refers to a socially construct set of behaviors, appearance, mannerisms and dress associated with the male/female genders
Transgender: Is an adjective used to describe a diverse group of individuals who transcend the culturally defined categories of gender
Gender Non-Conforming: Refers to individuals whose gender expression differs from stereotypical expectations and those who are perceived as androgynous (National center for
transgender equality)
http://www.ncaa.org/wps/wcm/connect/0eece8804378fefdbaecba6bcdc87ae7/NCAA+TSA+Issues+Resource.pdf?MOD=AJPERES&CACHEID=0eece8804378fefdbaecba6bcdc87ae7
Transsexual/Transitioned: Refers to individuals who have transitioned or are in the process of transitioning from one gender to another.
Individuals who have completed their gender transitions can either be referred as transsexual or as transitioned
Trans Man: A female transitioning to a male
Trans Female: A male transition to female
Gender Dysphoria: Refers to the distress caused by a discrepancy between a person’s gender identity and sex assigned at birth
As well as the associated gender role and/or primary/secondary sex characteristics (Fisk, 1974; Kudson, DeCuypere
& Blocking, 2010)
Some individuals may experience gender dysphoria at such a level that the distress caused meets the criteria for formal diagnosis
DSM IV Criteria:
1. A strong and persistent cross-gender identification
2. Feelings not concurrent with a physical intersex condition
3. Feelings causing clinically significant distress or impairment in social, occupational, or other important areas of functioning
4. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex
A disorder is a description of something with which a person struggles with, NOT the person’s identity
http://pn.psychiatryonline.org/content/38/14/32.full
Gender dysphoria continued
Transsexual, transgender and gender non-conforming individuals are not inherently “disordered”
Only some gender non-conforming people experience gender dysphoria at some point in their lives
The distress of gender dysphoria, when present, can be diagnosable for which various treatment options are present
Gender expression/Pronoun change Dress/present in public as opposite gender
Request to be referred to by the opposite pronouns
Complete name change (socially/legally)
Hormone Replacement Therapy Medically alternating the levels of testosterone and
estrogen in the system
FTM (Female to Male) Testosterone – injection, oral, transdermal
MTF (Male to Female) Estrogen – oral or transdermal
Sexual Reassignment Surgery
Can vary drastically in anatomical region, type, extent and number of surgeries
Common surgeries include but are not limited to:
Bilateral Mastectomy
Hysterectomy
Chest Reconstruction/Augmentation
Genital reconstruction
Facial Reconstruction/Feminizing
Most SRS are not covered by insurance
patient will be responsible for a majority of the cost
During 2008-2009 > 90% for LGBT student grade 6-12 reported verbal harassment
Over 50% reported physical
Only CA and WA have specific sport policies which include protection for transgender students
New England/Tri State
No policies, only MA/NH address gender
Policies in NJ/DE/PA
Case by case
NCAA does not prohibit transgender student athletes from participating in collegiate athletics
Individual eligibility will be dependent on stage and type of treatment
Team eligibility can be affected by a student athletes transition
Transgender student athletes NOT undergoing HRT:
Trans Male(FTM): may compete on a men’s or women’s team
Trans Female(MTF): may compete on a men’s team but may NOT compete on a women’s team with out designating that team as a “mixed team”
Mixed Team
A team on which at least one individual of each gender is competing
Mixed team’s are only eligible for Men’s Championships
Transgender student athletes undergoing HRT:
FTM transitioning individuals will be affected by the NCAA banned substance list Medical exception for use of testosterone will be
required prior to competing
MTF transitioning individuals are required to take testosterone suppressing medication Must show proof of medication for at least one
calendar year
Administration of estrogen is not required but common
Eligibility:
Trans Male(FTM)
After receiving medical exemption may compete on a men’s team and is no longer eligible to compete on a women’s team
To date no athletes have applied for medical exemption
Tran Female(MTF)
Eligible for women’s team after one year of medication
Can compete on a women's team prior to completing of one year of medication
Team designated “mixed”
Can remain on a men’s team regardless of medication
IOC policy in place since 2004
Transition prior to puberty:
No restrictions with SRS
Transition after puberty:
Must have SRS
Gender change on all legal documents
HRT for minimum of 2 years post SRS
Important to consider/address certain athletic policies that would affect a transgender student athlete participation
Including but not limited to:
Non-Discrimination Policy
Transgender participation policy
Locker rooms and bathrooms
Team travel and hotel accommodations
Dress Code Policy
School/Athletic Mission Statements
What needs to be done???? Formulate a policy Need to involve the administration/sports
medicine/coaches/student life/health center
Need to consider NCAA involvement and if any appeals need to be made
Should formulate a plan to educate other staff, students and coaches on transgender issues and encourage open communication
Need to serve as the advocate for the SA and help coordinate care when necessary and maintain privacy and confidentiality
Formerly the Harry Benjamin International Gender Dysphoria Association
German Endocrinologist worked with Alfred Kinsey
Formed to Promote Evidence based care, Education, Research, Advocacy, Public
Policy and Respect for Transgender Health
Establish Standards of Care (SOC)
7th version presented September 2011
WPATH STANDARDS OF CARE 7TH VERSION WWW.WPATH.ORG
Social & Political Climate
Social Tolerance
Equality
Full rights of Citizenships
Socially
Clothing, hairstyles, name changes
Hormone Replacement (HRT)
Sexual Reassignment Surgery
Psycho Therapy
Individual, couple, family, group
Hormone Therapy
To feminize, masculinize, delay
∆ in Gender Expression/Role
Living part/full time in one’s gender identity
Combination of above
∆ 10 & 20 sex characteristics
Green & Flemming - 1990
87% MtF, 97% FtM were satisfied
Pfafflin – 1993
1-1.5% MtF, <1%FtM were dissatisfied
Physically mixed or atypical sex characteristics @ birth
Chromosomes
Internal reproductive organs
Genitalia both internal/external
Pattern does not fit typical definitions male/female
Most not visible
Many do not know they have this problem
Likely not discovered until a medical procedure
Prepubertal children mainly boys (Those Referred to a
clinic)
6-23% Persisted Into Adulthood (COHEN-KETTENIS, 2001; ZUCKER & BRADLEY, 1995)
12-28% in newer studies included females
Male: Female Range 6:1 to 3:1 in Clinically Referred (ZUCKER2004)
For Adolescents Appears to be higher
No real formal studies
70 Patients continued with GNR, hormone and Surgery (DEVRIES ET AL 2010)
Male: Female range 1:1 in Clinically Referred (COHEN-
KETTENIS & PFAFFLIN 2003)
Local support groups
WWW.DRCHRISTINEMCGINN.COM
WWW.TRANSEQUALTIY.ORG
WWW.MICHELEANGELLO.COM
WWW.TRASNGENDERCARE.COM
Need For Competent Therapist
Gender nonconformity & Dysphoria
Provide Info Regarding Options
Gender Identity and Expression
Assess Co-existing Medical Conditions
Assess for Hormone Therapy
Assess for Surgery
Highly recommended
Maximize person’s overall well being, quality of life and self fulfillment
Finding a comfortable gender role
Family therapy
Educate on behalf of the clients
Schools
Workplaces
Other organizations
Referral for peer support
* Key will be finding quality practitioners – www.wpath.org
Fully Reversible
Suppressive hormone
Partially Reversible
Hormone Therapy
Irreversible
Surgery
GnRH Analogues – HIGH COST
To Suppress Puberty Males – Decrease Testosterone Secretion
Females – Decrease Estrogen Secretion
May use Progestins, Oral Contraceptives
Why?
To allow more time to explore gender Identity
May facilitate transition for surgery
Bridging
1-6 months to find a provider
Post Gonad removal
Estrogen/testosterone for life
Must be adjusted t/o life
Prior to gonad removal
Initiation of HRT
Most challenging
EFFECT EXPECTED ONSET (MONTHS)
EXPECTED MAXIMUM EFFICIENCY (YEARS)
BODY FAT REDISTRIBUTION 3 - 6 2 - 5
DECREASED MM MASS 3 - 6
1 – 2
SOFTENING OF SKIN
3 - 6
UNKNOWN
DECREASED LIBIDO
1 - 3 1 – 2
DECREASED SPONTANEOUS ERECTIONS
1 - 3
3 – 6 MONTHS
MALE SEXUAL DYSFUNCTION VARIABLE
VARIABLE
BREAST GROWTH
3 - 6
2 – 3
DECREASED TESTICULAR VOLUME
3 - 6
2 – 3
DECREASED SPERM PRODUCTION
VARIABLE
VARIABLE
THINNING/SLOW GROWTH BODY/FACIAL HAIR
6 – 12 >3
MALE PATTERN BALDNESS NO REGROWTH, LOSS STOPS
1 - 3
1 - 2
EFFECT EXPECTED ONSET (MONTHS) EXPECTED MAXIMUM EFFICIENCY (YEARS)
SKIN OILINESS/ACNE
1 – 6 1 - 2
BODY/FACIAL HAIR GROWTH 3 – 6 3 – 5
SCALP HAIR LOSS
>12 VARIABLE
INCREASED MM MASS
6 – 12 2 – 5
BODY FAT REDISTRIBUTION
3 – 6 2 – 5
CESSATION OF MENSES 2 – 6 N/A
CLITORAL ENLARGEMENT
3 – 6 1 - 2
VAGINAL ATROPHY 3 – 6 1 - 2
DEEPENED VOICE
3 – 12 1 - 2
RISK LEVEL FEMINIZING HORMONES MASCULINIZING HORMONES
LIKELY INCREASED RISK
VENOUS THROMBOEMBOLIC DISEASE
GALLSTONES
↑↑↑ LIVER ENZYMES
WEIGHT GAIN
HYPERTRIGLYCERDEMIA
POLYCYTHEMIA
WEIGHT GAIN
ACNE
ANDROGENIC ALOPECIA (BALDNESS)
LIKELY INCREASED RISK WITH PRESENCE OF ADDITIONAL RISK
FACTORS
CARDIOVASCULAR DISEASE
POSSIBLE INCREASE RISK
HYPERTENSION
HYPERPROLACTIMEMIA OR
PROLACTINOM
↑↑↑ LIVER ENZYMES
POSSIBLE INCREASED RISK WITH PRESENCE OF
ADDITIONAL RISK FACTORS
TYPE 2 DIABETES
DESTABILIZATION OF CERTAIN PSYCHIATRIC DISORDERS
CARDIOVASCULAR DISEASE
HYPERTENSION
TYPE 2 DIABETES
NO INCREASED RISK OR INCONCLUSIVE
BREAST CANCER
LOSS OF BONE DENSITY
BREAST, CERVICAL, OVARIAN OR UTERINE CANCERS
Last step to treat Dysphoria
Not all desire this
Transsexual
Transgender
Gender non conformists
Cosmetic
Not medically necessary
Thus typically not covered by insurance
Reconstructive
Medically necessary – unquestionable therapeutic results
Insurance pay for all or part
Persistent, well documented gender dysphoria
Other medical/mental concerns well controlled
12 continuous months of HRT
12 continuous months of living in a gender role congruent with their gender identity Experience life in that role
Adapt socially
Different life experiences – family events, holidays, vacations etc.
May ↑ ↓ need for surgery
Due to HRT
20 effects of gonadectomy
Cancer screenings
Urogenital care
Pauline Moreno & Debra Label with Tammy
Young Zach Wahles and his family
Viral Youtube presentation to Iowa Legislators
Title IX
14th Amendment Equal protection clause
Several cases used this defense successfully
ENDA Employment non-discrimination act of 2009
Basic protection against work place discrimination
In honor of Matthew Shepard (WY) & James Byrd, Jr. (TX)
1st federal law to protect trasngenders
Removes prereq of engagement in federally protected activity
Voting or going to school
Allows Feds to investigate if locals choose not to
Tennis player 1977 – 81
Denied entry to 1976 US Open women-born-women policy
Sued USTA in NY Supreme Court
She won landmark case for transsexual rights
7 - states laws specific for transgender MA, NH, NJ, NY
7 - Courts have interpreted laws for sex discrimination to prohibit transgender nonconforming CT, MA, NJ, NY, PA
12 – student rights against harassment/discrimination MA, ME, NJ, VT
13 states enacted non-discrimination laws for sexual orientation & gender Identity expression
Maine New Jersey
Rhode Island Vermont
8 States for Sexual orientation only
Connecticut Delaware
Massachusetts New Hampshire
New York
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