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