I'm Joshua Safer, the Executive Director of the Center for Transgender Medicine and Surgery here at Mount Sinai in New York. The biggest barrier to transgender healthcare is the lack of informed clinicians to deliver that care. Here at Mount Sinai, we strive to be both a model in healthcare delivery and to serve as a resource for transgender health education. This course is a unique online opportunity to learn the fundamentals of transgender healthcare. Please join my colleagues and me. Welcome to the Mount Sinai course, Transgender Medicine for the Primary Care Provider. The goals to be achieved following completion of this course are for providers to outline typical care strategies for transgender individuals, to anticipate both transgender-specific and general healthcare concerns that may arise in the course of care for transgender individuals, and to advise patients regarding transgender medical and surgical treatment options. The Center for Transgender Medicine and Surgery at Mount Sinai was established both to provide care for patients and to serve as a model of transgender healthcare delivery in an Academic Medical Center. The important elements of our program include a single point of contact for transgender and gender nonconforming individuals who can then navigate to appropriate medical services. Specifically, for our program, we have assembled expert clinicians to provide the needed transgender care. Areas of focus include primary care for adults, adolescent medicine, mental health, endocrinology and surgical services including genital surgery, chest surgery, obstetrics and gynecology, urology and voice therapy. In this course, some of our expert faculty from the Icahn School of Medicine at Mount Sinai will review key elements that we believe are necessary for the general provider to feel confident in the care of their transgender patients. Joining me to present to you are the Mount Sinai Transgender Programs Director of Psychiatry, Hansel Arroyo; our Clinical Program Director, Zil Goldstein; and our surgeon, the first graduate from our pioneering Transgender Surgery Fellowship Program, Bella Avanessian. Our modules will include this introduction along with modules that will cover assessment of transgender individuals, primary care for the transmasculine individual, primary care for the transfeminine Individual, strategies for transgender hormone therapy, initiation and maintenance of hormones for the transmasculine patient, initiation and maintenance of hormones for the transfeminine patient, and then modules with surgical options for transgender individuals. In this first section, we will focus on why the establishment approach to transgender medical care shifted, concentrating on the evidence for the biological underpinnings for gender identity. Our objectives will include understanding the evidence base underlying the current model in which gender identity has a substantial durable biological component. We will then go on to outline the basic healthcare delivery framework shift. For background and understanding the shift in the thought process for conventional medical providers, we need to go back and recognize that for many decades, the factors for determining gender identity were thought to be either environment, that is, what you were taught by your parents, and you've just been going along with it passively ever since, or that gender identity is just a societal construct, or that gender identity is a passive response to anatomy. That is, you look down between your legs, you saw what you have there, and have been living there, that way ever since. There is a substantial shift in this model, and that paradigm shift is to think that there is a biological component, something programmed into our brain which confers gender identity. What I want to do next is walk through some of the evidence base for the biological nature of gender identity, which I put into four categories, roughly in order of the strength of the evidence in each of the categories. The first category is historical attempts to manipulate gender identity. The primary groups studied are intersex individuals, where, with variances in genital development, there was thought to be an interest in surgical correction of those genitalia. The thought process was that if gender identity was passive, the surgeries could be done, that would be those that would be most feasible. Then, as now, creation of female genitalia, that is, creation of a vagina, was considered a more straightforward surgery than creation of male genitalia, that is, creation of a penis. The best investigation of the impact of this approach comes from a study at Johns Hopkins in a paper that was published in the New England Journal in 2004. Surgeons there were treating cloacal exstrophy, which is a condition with maldevelopment of the gut and the genitals. The treatment was to create female genitalia only because that was the more straightforward surgery to do. That approach included XY individuals because of the understanding at the time that gender identity was passive and that these individuals could be successfully raised as girls after this surgery and with the appropriate engagement of their parents. What surprised investigators, however, is that despite this very aggressive program, both the surgery and the rearing, a majority of the kids actually had male gender identity. In fact, at the point at which they published the study, all of the children who knew their medical history and were still participating in the study were reporting male gender identity, and only five individuals who did not yet know their medical history were still living as girls or young women. The next category is twin studies. For that, I want to look at really one paper which is a summary of the case reports of transgender individuals with twins. In the circumstance where the transgender individual had a fraternal twin, none of the cases reported that twin being transgender also. By contrast, for transgender individuals with identical twins, and here I need to pause and point out that the term identical twins is not quite accurate. Identical twins are really just very similar. For transgender individuals with an identical twin, the chance was found to be about 40 percent that the identical twin was also trans, something that we call a 40 percent concordance rate. For perspective, with type 1 diabetes, an entity where the biological components are well-known, the concordance rate is 50 percent. So, what this all means is that individuals with closer DNA have a greater chance of also being transgender. Moving on to the third category, I want to talk about exposure to androgens or male hormones or specifically testosterone with two circumstances. The first are individuals who are exposed to greater amounts of testosterone in utero, who have XX or female chromosomes and would usually be predicted to have female gender identity. In a specific circumstance called virilizing congenital adrenal hyperplasia, study show that about five percent of the individuals, who have XX chromosomes, still have male gender identity. That means that 95 percent, the overwhelming majority, have female gender identity like you would expect. But five percent have male gender identity, and this is in contrast to the general population where maybe a half a percent up to perhaps a full percent of individuals are transgender, but certainly far less than five percent. The second situation is the opposite, individuals with complete resistance to androgen or complete androgen insensitivity syndrome. What that means is that their androgen receptors, the receptors for male hormone for testosterone, are not effective, and cells that depend on that testosterone are not influenced by that male hormone. Those individuals have female appearance externally and importantly here, have female gender identity. What that suggests is that there are at least some individuals who are dependent on some amount of testosterone in order to be able to have male gender identity. Now, we don't think that this explains being transgender broadly. We don't have any evidence that transgender individuals have differing degrees of testosterone. However, at least for some individuals with a certain propensity, testosterone, the male hormone, can influence gender identity. The last category is the category of trying to associate brain anatomy with gender identity. For a medical audience, they actually have the weakest data. The classic study from the 1990s that really illustrates the point is one where investigators stained region of the hypothalamus which is called the bed nucleus of the stria terminalis. What they had observed is that the staining for a typical man, as you see on your left, was quite intense, where the staining for a typical woman, right next to that, is much less intense. What they were trying to do in the 1990s was identify a pattern that they might associate with homosexuality. In the third panel, you see staining for a gay man, which you can observe is essentially the same as the staining pattern for the straight man all the way on the far left. But the mistake they made in the 1990s was that they thought that gender identity and sexual orientation were the same thing. So, they accidentally included stains from transgender women, that is, male to female, along with the stains from the gay men. So, on you're very far right, you see that panel has a stain from a transgender woman. Note that it has the same pattern as for the cisgender, that is, the not transgender woman in the second panel. The point then is that the staining pattern followed gender identity. Switching gears though, if this is biology, what is it that we need to know to provide good care for our transgender patients? So, I invite you to come with me and to learn from my colleagues and myself as we go through what we believe are the fundamental concepts that you require to provide care for your transgender patients.
