Tag Archives: depression

Review of Clinical Management of Youth with Gender Dysphoria in Vancouver – Part I – Demographics

This article is a report on health care provided to youth with gender dysphoria at a clinic in British Colombia, Canada. I’m going to focus on just the demographics in this post and do another post later.

QUICK OVERVIEW

The clinic saw a dramatic increase in the number of their teenage patients from 2006-2011. This is similar to other clinics serving teenagers with gender dysphoria.

Most of their patients were trans men (born female). This is similar to the current situation at other clinics for teenagers, but different from the past at other clinics. It is also different from most European clinics for adults.

Their patients had other psychiatric diagnoses including mood disorders, anxiety disorders, and eating disorders. The patients in this study had more psychiatric problems than teenagers studied at a clinic in the Netherlands.

7% of their patients had an autism spectrum disorder. This is similar to the results of a Dutch study of children and teens with gender dsyphoria.

Suicide attempts are a serious problem among their patients. 12% of their patients had attempted suicide before coming to the clinic; 5% attempted suicide after their first visit to the clinic. The decrease is encouraging, but clearly we need to do more to help patients during and after transition.

Some of their patients had to be hospitalized for psychiatric problems. 12% of their patients had been hospitalized before coming to the clinic, but only 1% were hospitalized after the first visit.  Again, we need to be sure to provide support during and after transition.

THE INCREASE IN TEENAGE PATIENTS

The clinic has seen a fairly dramatic increase in the number of teenage patients from 2006-2011. They went from fewer than 5 cases/year before 2006 to nearly 30 cases in 2011.

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Number of new patients with gender dysphoria seen in 1998-2011. MtF, black bars; FtM, hatched rectangles.

This parallels what has happened at a similar clinic in Toronto, Canada and a clinic in the Netherlands.

Unlike the other two studies, the majority of the patients at this clinic were always trans men (born female). In fact, before 2006 almost all of the patients were trans men. After 2006, the number of trans women patients (born male) began to increase. However, trans men still made up 54% of all the patients they saw between January 1998-December 2011.

This is different from the pattern found in the clinics in Toronto and Amsterdam. In those two clinics the patients were mostly trans women before 2006, but after 2006 they were mostly trans men.

It’s hard to know what these numbers mean because we don’t know how common gender dysphoria is among teenagers.

“The prevalence of adolescent-onset gender dysphoria is not known, and there are limited accurate assessments of prevalence of transgenderism in adults in North America. However, the prevalence of adults seeking hormonal or surgical treatment for gender dysphoria is reported to be 1:11 900 to 1:30 400 in the Netherlands.”

Does this increase reflect an increase in the number of teenagers with gender dysphoria? If so, why are the numbers increasing?

Alternatively, is this increase due to people with gender dsyphoria seeking physical transition at a younger age?

Statistics on most European clinics have shown many more trans women transitioning than trans men (the pattern is reversed in Japan and Poland). Now the statistics on Canadian and Dutch teenagers show more trans men transitioning than trans women.

Are there more trans men than in the past? If so, why?

Or are trans men transitioning at a younger age than trans women? But then why did the other two clinics treat more teenage trans women than teenage trans men in the past?

BASIC DEMOGRAPHICS OF THE PATIENTS IN THIS STUDY

The clinic at British Colombia Children’s Hospital saw 84 youth with a diagnosis of gender dysphoria from January, 1998 to December, 2011.

45 of the patients were trans men, 37 were trans women, and 2 were males who weren’t sure of their gender identity.

Two of the trans women had disorders of sex development – one had Klinefelter syndrome (XXY chromosomes) and one had mild partial androgen insensitivity syndrome (i.e. her body made androgens, but they didn’t fully affect her).

The median age at the first visit was 16.8, the range in ages was from 11.4 to 22.5.

At the first clinic visit, most patients were in school grades 8-10 (32%) or grades 11-12 (48%); 12% were in grades 5-7, and the remaining 8% were in college/university or no longer attending school.*

PSYCHIATRIC COMORBIDITIES

Diagnoses made by a mental health professional:**

35% of the patients had a mood disorder (20 trans men, 7 trans women and probably the two males with uncertain gender identity)

24% had an anxiety disorder (15 trans men, 4 trans women and probably one male with an uncertain gender identity)

10% had ADHD (2 trans men, 6 trans women)

7% had an autism spectrum disorder (2 trans men, 4 trans women)

5% had an eating disorder (2 trans men, 2 trans women)

7% of their patients had a substance abuse problem (2 trans men, 4 trans women)

26% of their patients had two or more mental health diagnoses (12 trans men, 9 trans women) and probably one male with an uncertain gender identity.

Suicide attempts:

10 of the teenagers attempted suicide before coming to the clinic (12%). 6 of them were trans men and 2 were trans women. Perhaps the other two were the two males who weren’t sure of their gender identity.

4 of the patients attempted suicide after the first visit to the clinic (5%). Three of them were trans men and one was a trans woman.

Psychiatric hospitalizations:

12% of the patients had been hospitalized for a psychiatric condition before coming to the clinic – seven trans men and three trans women.

One trans man was hospitalized for a psychiatric condition after the first visit to the clinic (1%).

Conditions requiring hospitalization included posttraumatic stress disorder, depression, substance abuse, behavioral issues, psychosis, and anxiety.

Mood, puberty blockers, and hormones:

One trans woman and one trans man discontinued the use of a puberty blocker after they developed emotional lability (7% of the patients who took the puberty blocker). The trans man also had mood swings.***

One trans man had significant mood swings as a side effect of testosterone treatment. (3% of the patients who took testosterone.)

Two trans men temporarily stopped testosterone treatment due to psychiatric conditions – one was depressed and one had an eating disorder. (5% of the patients who took testosterone.)

One trans man temporarily stopped testosterone treatment due to distress over hair loss. (3% of the patients who took testosterone.)

Gender differences:

Trans men were significantly more likely to have depression or anxiety disorders than trans women. 44% of trans men had mood disorders compared to 19% of trans women. 33% of trans men had anxiety disorders compared to 11% of trans women.

There were no significant gender differences in other mental health issues.

27% of trans men had two or more psychiatric diagnoses compared to 24% of trans women. This seems surprising given that trans men were more likely to have mood and anxiety disorders.

The most important issue is the number of suicide attempts.

Why were there four suicide attempts after the first visit to the clinic?

Were the suicide attempts related to the two patients who developed emotional lability on blockers? or the trans man who developed mood swings after taking testosterone?

Were they related to the trans man who stopped taking hormones due to depression? Was he the same person as the trans man who developed mood swings on testosterone?

What about the trans man who stopped his hormones due to an eating disorder?

When were the suicide attempts? Were they before the patients got blockers or hormones? Did they happen after stopping hormones for any reason? Or were the patients already on hormones or blockers?

Could they have been prevented by more therapeutic support before treatment? during treatment?

Is there a way to identify which patients are at risk for suicide attempts during or after treatment?

It is encouraging to see that there were fewer suicide attempts after the first visit to the clinic than before, but it is not enough. We need to do more.

We also need more data on the decrease in the number of suicide attempts after coming to the clinic. Was it statistically significant? Was the time period before the first visit to the clinic equal to the time period after the first visit to the clinic?

Psychiatric comorbidities comparison

Compared to a clinic in the Netherlands, these patients were more likely to have mood disorders (35% vs. 12%), but about as likely to have anxiety disorders (24% vs 21%).

5% of the Vancouver patients had an eating disorder while none of the patients in the Dutch study did.

7% of the patients in this study had a substance abuse problem while only 1% of the patients in the Dutch study did.

26% of the patients in this study had two or more psychiatric diagnoses. In comparison, only 15% of the teenagers in the Dutch study had two or more psychiatric disorders.

Finally, the Dutch study found that trans women were at higher risk for having a mood disorder or social phobia while this study found that trans men were at higher risk for mood and anxiety disorders.

Why is the psychiatric comorbidity higher in the Vancouver patients?

The authors of the report suggest that it might be because the average age of their group was higher than the average age in the Dutch study – 16.6 year vs 14.6 years. It might simply be that older teenagers have had more time to develop mental health issues.

They also suggest that there could be differences in diagnostic criteria. Both groups seem to have been using DSM-IV diagnoses, but the Vancouver data was based on clinic notes while the Dutch data was based on interviewing parents. It may be that parents underestimate their children’s problems. For example, they might not realize that their teenager has a substance abuse problem or an eating disorder.

In addition, the Vancouver study includes all 84 patients their clinic saw between 1998-2011. In contrast the Dutch group invited 166 parents to participate in their study, but only 105 parents did so. It is possible that the 61 parents who did not participate had children with more problems, although the authors suggest that the inconvenience of travelling to the center was the main issue.

Finally, the Dutch group has 17 teenagers who were referred to the clinic but dropped out after just one session, “mostly because it had become evident that gender dysphoria was not the main problem.” These patients might have had more psychological comorbidity than others.

It is hard to compare this to the Vancouver clinic, however, because the Vancouver clinic’s focus is on endocrine care. 93% of the patients they saw had already been diagnosed with gender dysphoria by a mental health professional. Were there teenagers in Canada who discovered that gender dysphoria was not the main problem and did not go on to the clinic? If so we would expect the two clinics to have similar rates or psychological comorbidity. If not, we might expect a higher rate of comorbidity in Canada.

A final possibility is that the Canadian teenagers with gender dysphoria simply have more psychological problems than Dutch teenagers with gender dysphoria. Perhaps they experience more bullying and violence. Perhaps they had less supportive parents.

As usual, we need more studies. Why are the numbers of teenagers at clinics for gender dysphoria increasing? What is the prevalence of gender dysphoria among teenagers? How common are psychological comorbidities? Are trans men or trans women more at risk for depression and anxiety? What can we do to prevent suicide attempts after treatment begins? How can we better support patients with gender dysphoria during and after transition?

Original Source:

Clinical Management of Youth with Gender Dysphoria in Vancouver by Khatchadourian K, Amed S, Metzger DL in J Pediatr. 2014 Apr;164(4):906-1.

 

*This would suggest that 48% of the students were 16-17 years old, 32% were 13-15, 12% were 11-12, and 8% were 18-22.5.

** The table indicates that these were diagnoses made by a psychiatrist or psychologist. There were other diagnoses the authors didn’t include in the table: 1 patient with trichotillomania, 2 with borderline personality disorder, 1 with psychosis not otherwise specified, 1 with adjustment disorder, 2 with tic disorders, and 1 with oppositional-defiant disorder. I am not sure why these diagnoses weren’t included; perhaps they weren’t made by mental health professionals.

***The blockers being used were gonadotropin-releasing hormone analog or GnRHa.

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Depression and Gray Matter in the Brain

Depression causes gray matter in the brain to decrease. This is important to keep in mind when looking at studies of trans people’s brains as many trans people have experienced depression.

These are just a few links to studies looking at depression’s effects on the brain. A smaller hippocampus seems to be particularly related to depression, although studies have also found a link to an overall decrease in gray matter.

The bottom line is that studies of gray matter and gender identity need to take into account past and present depression in both trans people and controls.

For anyone with depression, the bad news is that it’s not good for your brain. The good news is that you can do things for your brain – exercise, meditate, and learn.

You may be able increase the volume of your hippocampus with regular exercise. Eight weeks of mindfulness meditation increases the volume of your hippocampus and may increase the gray matter volume in other areas of your brain as well. You can increase your gray matter by learning a new skill like juggling or by reading text written backwards. Going to medical school affects your gray matter.

Back to the studies and the link between gray matter volume and depression.

State-dependent changes in hippocampal grey matter in depression. 

This study found that patients who were currently depressed had lower volumes of gray matter in the hippocampus compared to both healthy controls and people who had had depression before but were not currently depressed. After taking citalopram, the patients with current depression had more gray matter in the hippocampus.

Insular and Hippocampal Gray Matter Volume Reductions in Patients with Major Depressive Disorder.

This study found that patients with major depressive disorder had “a strong gray-matter reduction in the right anterior insula. In addition, region-of-interest analyses revealed significant gray-matter reductions in the hippocampal formation.”

The effects were stronger for people who had had more episodes of depression than people who had only had one episode.

The more episodes of depression a patient had, the less gray-matter volume they had in the right hippocampus and right amygdala.

They conclude:

“The anterior insula gray matter structure appears to be strongly affected in major depressive disorder and might play an important role in the neurobiology of depression. The hippocampal and amygdala volume loss cumulating with the number of episodes might be explained either by repeated neurotoxic stress or alternatively by higher relapse rates in patients showing hippocampal atrophy.”

In other words, having depression might affect the hippocampus or having a small hippocampus might make you get depressed more often.

Association of Depression Duration With Reduction of Global Cerebral Gray Matter Volume in Female Patients With Recurrent Major Depressive Disorder

This study found that the more months the patients had spent being depressed, the less total cerebral gray matter they had. More months of depression was also linked to less frontal gray matter, less temporal gray matter, and less parietal gray matter. The study only included female patients who had recurrent depression. They did not control for the anti-depressants the patients used, so it is possible that the medicines affected their gray matter.

Gray matter volume abnormalities in individuals with cognitive vulnerability to depression: A voxel-based morphometry study.

This study looked at people who don’t have depression but who might be vulnerable to it. The “cognitively vulnerable” group was chosen by their answers to two questionnaires. The first questionnaire looked at thinking styles that may contribute to depression – people may be vulnerable to depression based on how they think about causal attributions, consequences, and self-worth characteristics. The second questionnaire asked about symptoms of depression.

Cognitively vulnerable people had less gray matter volume in the left precentral gyrus and right fusiform gyrus compared to controls. In addition their right fusiform gyrus and right thalamus were smaller compared to people who had major depressive disorder. Patients with major depressive disorder had reduced gray matter volume in the left precentral gyrus and increased gray matter volume in the right thalamus.

They conclude:

“Reductions in brain gray matter volume exist widely in individuals with CVD. In addition, there exist similar abnormalities in gray matter volume in both CVD subjects and MDD patients. Reductions of gray matter volume in the left precentral gyrus might be correlated to the negative cognitive styles, as well as an increased risk for depression.”

Of course, we don’t know which way the causality goes – is the cognitive style causing a lower gray matter volume in the left precentral gyrus or is the lower volume of gray matter causing the cognitive style?

Widespread reductions in gray matter volume in depression.

This study found that people with major depressive disorder had 4.4% less global gray matter volume than controls. This would be the decrease expected in 14 years of normal aging.

The differences were greatest in the front and temporal lobes, but there were also significant differences in the parietal and occipital lobes.

There was not a significant difference in the cerebellar volumes.

The cortex was thinner in the left medial orbitofrontal cortex for the patients with depression.

The authors conclude:

“Our data demonstrate conclusively that widespread GM volume abnormalities are present in patients with depression. These alterations are substantial, corresponding to the amount of GM volume loss that, when averaged over the whole brain, would be expected from nearly 14 years of normal aging. The GM loss is also highly regionally specific, with focal regions showing decreases in GM volumes of nearly twice the magnitude of the global measure. The distributed and regionally specific nature of these alterations provides compelling support for considering MDD as a condition that involves the impairment of networks across the brain.”

Small frontal gray matter volume in first-episode depression patients.

This study found that patients who had had their first episode of depression had less gray matter volume in the frontal lobe than healthy controls. The lower volume was not correlated with length or severity of the illness. The patients had not yet taken any medication for their depression. The authors suggest that the changes in gray matter could have occurred before the symptoms of depression. (Although they also could have been caused by the depression, we really can’t tell.)

Anomalous Gray Matter Structural Networks in Major Depressive Disorder

This study found that the gray matter in people with depression is connected differently from in controls.

They say:

“Depressed participants had significantly decreased clustering in their brain networks across a range of network densities. Compared with control subjects, depressed participants had fewer hubs primarily in medial frontal and medial temporal areas, had higher degree in the left supramarginal gyrus and right gyrus rectus, and had higher betweenness in the right amygdala and left medial orbitofrontal gyrus.”

and they conclude:

“Networks of depressed individuals are characterized by a less efficient organization involving decreased regional connectivity compared with control subjects. Regional connections in the amygdala and medial prefrontal cortex may play a role in maintaining or adapting to depressive pathology.”

Psychiatric comorbidity among patients with gender identity disorder – Partial Review

This study looked at the patients at a Japanese clinic for gender identity disorder to see if they had any other mental health issues. They did not find a high rate of autism spectrum disorders (ASDs).

This is not a review of the full study, just the information related to ASD.

Out of 579 patients that they treated, only 4 were diagnosed with Asperger’s disorder and there were no other cases of autism spectrum disorders.

In other words, less than 1% of this group had an ASD.

All of the patients with Asperger’s were born male.

This data is worth noting because it is so different from results in other countries. Are patients with autism not referred to the GID clinic in Japan? Is autism being diagnosed the same way in the different studies? Are adult patients less likely to have ASD than children and teenagers with gender dysphoria?

This data also highlights the fact the gender dysphoria and autism spectrum disorders are connected in males, not just females – in fact, in this case, they were connected only in males.

There is a theory that having an “extreme male brain” makes some girls with autism develop gender dysphoria. While that could still be true, it does not explain why males with autism would feel that they are females.

Instead of an “extreme male brain,” there might be some other mechanism that connects autism and gender dysphoria in both trans women (born male) and trans men (born female).

Another interesting aspect of the data was that they diagnosed 96% of the patients they saw with GID. Of the 24 patients who were not diagnosed with GID, half had severe psychological disorders like schizophrenia. Eight were excluded for homosexuality and four were excluded for transvestic fetishism.

I am not sure why they diagnosed such a high percentage of their patients with GID. Perhaps by the time people are referred to their clinic, they have been diagnosed by other doctors. It might also be somehow related to the definition of GID or the process of diagnosis.

I am assuming they excluded the gay patients because the patients discovered that they did not have GID and that the clinic is not excluding all gay patients. Most people with GID are attracted to people of their birth sex.

Other important results from the abstact:

“Using DSM-IV criteria, 579 patients (96.0%) were diagnosed with GID. Among the GID patients, 349 (60.3%) were the female-to-male (FTM) type, and 230 (39.7%) were the male-to-female (MTF) type. Current psychiatric comorbidity was 19.1% (44/230) among MTF patients and 12.0% (42/349) among FTM patients. The lifetime positive history of suicidal ideation and self mutilation was 76.1% and 31.7% among MTF patients, and 71.9% and 32.7% among FTM patients. Among current psychiatric diagnoses, adjustment disorder (6.7%, 38/579) and anxiety disorder (3.6%, 21/579) were relatively frequent. Mood disorder was the third most frequent (1.4%, 8/579).”

The horrifying part has been bolded. I’m putting off talking about it until another day when I can deal with it.

I’ll just add that the authors suggested that “the harsh circumstances in which most GID patients have lived in Japan might influence the high rate of suicidal ideation or self mutilation in GID patients.”

Original Article:

Psychiatric comorbidity among patients with gender identity disorder by Masahiko Hoshiai MDYosuke Matsumoto MD, PhDToshiki Sato MD, PhDMasaru Ohnishi MD, PhDNobuyuki Okabe MDYuki Kishimoto MDSeishi Terada MD, PhD, and Shigetoshi Kuroda MD, PhD in Psychiatry and Clinical Neurosciences Volume 64, Issue 5, pages 514–519, October 2010.