Transcript for:
Lecture by Dr. William Powers on Transgender Care

i am dr william powers i am the sole practitioner at the powers family medicine center which is this huge office of three exam rooms in farmington hills i have a very unique doctor in that i treat transgender patients and i never set out to do this i had one patient with congenital adrenal hyperplasia and after i diagnosed him with that they told me that their sibling you know basically that you know my sister says she's my brother now can you help them and i said um so they came in and i met them and you know i basically said sure i'd love to provide this care for you and this was down in monroe county and there was nobody down there that would do transgender care like no one and they just didn't have access to it so i said sure this is something that i will do um let me talk to my attending first i had a super cool attending jessica sharon who basically said if you get certified in the wpath method you can do it i said okay so me and the patient went to the classes i learned how to do it and then i had one then i had two then i had four and then by the time i graduated from residency i had 50. i was nominated for resident of the year for my clinic it was pretty cool but afterwards i couldn't find a job because a lot of people didn't want to hire somebody that took care of transgender people it just like wasn't the thing that they wanted in their clinics and i know this because me and my wife who's sitting right there would apply to the same thing and we were both chief at our program both had excellent board scores and she would get a call back and i wouldn't so i realized pretty quickly that you know something was amiss and a couple places were honest enough to say yeah we don't want those people here so fast forward a few years later and i now open my own clinic i have about 1500 transgender people that i've seen over the past few years and i have developed a new way of doing hormonal transitioning that is different from the wpath method it requires less drugs and it's safer and we're going to talk about it but first what i want you guys to basically take from this understanding gender dysphoria and transgender patient preventative medicine for transgender people and understanding the process of basic hormonal transitioning at the end of this lecture you should know how to transition someone it's not that hard if you can handle treating diabetes you can handle this diabetes is vastly harder than this lecture's designed to be presented to physicians so there are people in the audience that i recognize that are not physicians understand it's not meant for you but you can still be here it's totally welcome to but some of the language is very medical in nature and not all of it is super pc also no major medical society has any transgender guidelines no ama no acog no nothing um the two main sets of guidelines are the ucsf and the wpath which is the world professional association for transgender health they have not changed the whole lot ucsf is probably the better of the two wpath has been more or less the same for like the past 40 years i haven't really updated it a whole lot and then mine which are not officially published yet but will be and i'm working on it so anyways because i have so many patients i derive information different than a normal practice about 75 of my patients now are transgender which is pretty wild um so i see things that other people don't because when you have that much and you're a doctor and doctors are good at pattern recognition you spot patterns and you start to see things that are interesting like last week i had four patients with a tertiary nipple all transgender i don't see that that often but then all of a sudden in a row they all were a thing i don't know if it was just like statistical anomaly or what but now i'm looking for third nipples on trans patients and it makes sense for malaria inductive abnormalities and other things would be associated with gender dysphoria which we're going to talk about there's been a couple people over the years that are not doctors that have helped me with this i didn't get all this knowledge because i'm such a genius i got a lot of it because transgender women and transgender men are experimenting on themselves in the street with diy hormones and some of them are biochemists and some are very smart people who figured some stuff out shared it with me and i listened and tried it and it worked better than what everybody else did so i credit them here how do they view me uh so i walk into a room and i see a patient and it's a young transgender man he's say 18 to 25 years old and i say hey i'm dr powers nice to meet you what can i do for you testosterone like what testosterone i'm here for testosterone i'm like well i'm sorry why why why do you want test out like there's just no like you're they're there for a purpose and you'll understand by the end of the lecture why this is and why transgender people react this way towards medical providers but basically they view me as a date a gatekeeping doctor robot i am the guy who gives them testosterone i am the thing they have to get passed in order to get it this is literally how they view us and this is not what we are um i am very much not a normal professional doctor um i have a lot of really interesting hobbies i was just talking about how i heat my house with bitcoin mining big computer nerd um i used to have two guinness world record cats one was the tallest cat to ever live and the other one had the longest tail ever on a cat i'm really good at manipulating the biology of living things and i designed a diet for them that i thought would be biochemically ideal for feline species it seems like i was right i play a lot of pokemon go and i'm into steampunk i do cosplay i'll be going this weekend to detroit comic con probably dressed like that so that's electric forest me and my wife went to tomorrowland this year in belgium so we do a lot of fun stuff so why did everybody do this well um it's scary people are afraid of doing it there's a lot of personal beliefs that people have i don't agree with that okay um there is no major medical association that says this is how you're supposed to do it so when you are in court being sued for what you did what do you point to and say this is the standard of care there is none it's all off label none of these drugs are approved to treat transgender people for gender anything completely all off label and we live in a litiginous society so everybody's afraid of that why do i do it um ethics autonomy um basically if you can go to some other doctor who will split your tongue in half and you know make you look like the lizard man and you can make that decision as an informed adult i think this is a lot less than that and we let people do with body modification but really the main reason and why i started doing it um was suicidality now 41 of transgender people will attempt suicide by age 30. just let that like that's an enormous number like 41 of them will try and kill themselves they commit suicide at a rate higher than every other medical condition there is combined cancer hiv all of those diagnoses that are horrible chronic pain they don't still don't kill themselves anywhere near as much as gender dysphoria so why do people have it um it is not a mental illness it is effectively the modification of the neural architecture due to something and here are some of the somethings des is diethylstilbestrol it is a drug that was used basically um back in like the 30s to 70s in the us elsewhere in the world more it's 600 times stronger than estrogen it's a super potent estrogen and if you give it to somebody you do so because they had a miscarriage and it was a wonder drug called dusplex and we handed it out like candy because a woman had a miscarriage you gave them this they next one carried a term we think happens when you expose a male fetus to a super estrogen throughout the entire pregnancy i don't know we do it's this congenital adrenal hyperplasia is a virilization disorder related to 17 beta hydroxylase 21 hydroxylase deficiencies aromatase excess or deficiency is when the aromatase enzyme which copies basically uh blue blue hormones androstenedione testosterone over to esterone estradiol that being either too strong or not strong enough can screw things up klein felters and intersex syndrome xxy technically all of these are under the intersex umbrella which are disorders of sexual development which is what we now call the dsds so intersex even as a word we're not really using as much because the where do we draw the line of as what is intersex how far do you have to go would be considered intersex we don't really have a description for that delicious super cool um you're xx but due to a freak thing that occurs at conception the sry gene from a y chromosome gets copied over to you and so despite being xx you have a penis and testicles and look like me but they're xx and they're infertile uh pcos everybody knows pcos androgen and sensitivity syndrome so this is in the media right now because of a runner called caster seminaia she has partial androgen and sensitivity syndrome so castor has a vagina and breasts and looks like a very masculine woman she's xy this condition if you have it and i've seen this personally once i had a 17 year old girl who came to me completely unrelated to my transgender clinic was the daughter of one of my other patients who'd never had a period she just didn't have one and that was weird so they sent me in and i was all right well let's check you out i went to do the pap and she had no cervix and i was like okay so this is either malariagenesis or this and when i carry a typeder she was x y it was not a fun diagnosis to give a young girl like that what's really interesting is they're actually generally very attractive and ultra feminine they're like the most feminine human you could possibly imagine because they have no functional testosterone ability whatsoever no body hair nothing prenatal exposure to estrogen androgens obviously psychological disorders there is a strong association between autism spectrum and asperger's and uh gender dysphoria the cag repeat sequence variance is pretty cool um so on the end of the testosterone receptor just like how when you think about like trinucleotide repeat sequence diseases the testosterone receptors like a g t a a g h e a t a g a you know doing its thing and then when you reach the end of the code for it it goes c a g c a g c a g c a g c a g a certain number of times the more number of times the more resistant it is like the binding ligand energy the ka changes to hold off testosterone the shorter it is the more sensitive i have seen people who have completely normal labs i have a patient that has completely normal androgen labs assigned female at birth and has a full beard completely normal that this is the only explanation i can have for it is the receptor is ultra sensitive to the effects of testosterone and of course neuroanatomical structural variants um i include abuse history in here because it was formerly the cause of why people are transgender they must have been abused as a kid i have one patient one in 1500 that reports this they identify as non-binary they were physically sexually and emotionally abused as a kid and to them the idea of identifying as female is vulnerable and weak and so they use they them pronouns they they don't identify as male and nf is female they just identify as what we call an envy or a non-binary person slang is e-n-b-y-n-b if you see that written down but basically i included in because it's a thing i have seen it um like i have seen one case of what's called autogynophilia which is where a patient sexualizes the idea of themself as a woman a male patient does and then wants to transition for the sexual gratification aspect of it i have seen it once in six years so it is definitely not a common thing but they do happen um okay so the overwhelming majority of women that have this disease congenital adrenal hyperplasia are same-sex attracted like like 99 of them and the the severe the severity so to speak of their same-sex attraction is correlated with the degree of viralization so the more severe the disease the gayer they are that's a known phenomenon with them that's been documented to death um but basically if you have this and you're a woman you're attracted to women or maybe you're one percent that isn't as catholic or something i don't know um but the short and narrow here is that 5.2 percent of women with cah identifies male statistically 0.3 percent of women identify as male obviously this is doing a thing we can clearly see that that is a thing it's blatantly obvious there's a direct correlate prenatal exposure to des which we already talked about it was first noted in 1954 known as male pseudohermaphrodisism there you're seeing undescended testicles hypospadias and testicular feminization syndrome in boys then of course we started seeing archives of general psychiatry and other people doing about it and then no one really cared because you know being gay at that time was not so many people talked about but um when you know all the women started the daughters of des started getting vaginal clear cell adenocarcinoma then all of a sudden they pulled it um but the reason i bring the des up is i have a very interesting situation so i have two patients that i just coincidentally had they're both from the same area they each decided the transition so they came to me for the purposes of hormonal transitioning they got a 23 and me done and discovered they had a sibling that they didn't know about and they were like oh my god so they they contacted each other and reached out and the irony of this is that each of them was afraid to tell the other one because they were you know brothers that they had transitioned they were so afraid that they had just gotten the sibling and that the sibling would be intolerant to the fact they were transgender and then that would be it like that they finally found this person and then they wouldn't be there the hilarity is that when one finally came out to the other one before they were gonna meet they're like hey just so you know when i show up i'm gonna be wearing a dress um because what they had seen for photographs prior to that was prior to them the transitioning the other person didn't reply they didn't reply for like 24 hours and my first patient was freaking out and then finally when they replied they were like i didn't know how to respond to this but i'm also transgender so they went and they looked up some of their medical history and they had found out mom it had multiple miscarriages beforehand it was in the right time period for des one of the patients has hypospadias it's like it was like a whole thing so it's really fascinating it's just sheer coincidence down in a row i had these two people who one was given up for adoption and the other one was kept that's how this panned out kind of wild uh this is pretty much the most conclusive thing that i can use to point to bigotry and be like you're wrong when people are like these people are mentally ill i'm like yep here you go no they're not they're not their brains are literally wired structurally to look like their preferred gender before the taking of any hormones whatsoever so if i take a 18 year old female who says i identify as male transgender man and i scan his head in an mri machine the mri machine will spit back to me this is a male brain we can actually do that and we've been able to do this over and over again starting at 2009 up to 2015 is the most recent time the studies were done it's been repeated four times same findings every single time we structurally can see gender identity on neuroanatomy and neural architecture now so as i have said this is definitely not a thing and people are always like these people are mentally ill we should be treating them you know with with therapy and helping them out we can't do that we've we've tried um extensively attempted to use counseling and ssris and everything else to make these people feel better and you know congruent with their gender but it would be no different than basically telling someone who has red hair that we don't accept your red hair and you have to dye it which is basically what they do in society until they come out there's nothing they can do about it they're stuck this way their neural architecture is wired this way so the best that we can do for them in medicine is to at least make their external appearance congruent with how they feel about themselves secondary to that taking the hormones actually gives them the sense of wellness that does not seem to come with the hormones their other previously assigned so what's really strange is not only just does giving them estrogen give them or testosterone in the body that they want when they're on that hormone depression and other psychiatric things go away the patient feels more well which is really neat because whenever i meet a new trans patient and they come in with severe depression and they want to transition i never start an ssri before i start hormones because the overwhelming majority of them don't eat it once they start hormones the depression issue goes away so i was under the impression for a while that there was this concept that the overwhelming majority of transgender people if offered the opportunity to take a pill go to bed and wake up in the morning cis cis being is what you are if you are if your gender identity how you view yourself in your head is the same as what you see when you look down you are cisgender transgender like think about chemistry i mean cis and trans opposite side they've switched with these people i had always thought that they would respond accordingly to this and they would say yup this is how i feel and i would i would gladly take the pill and be cis right away so i i thought that and i had this in my old lecture and i recently updated it because it's not true actually i pulled my patients and i got about i think 300 and something people and what i effectively got was uh where is it here this is the replies that i got from people um where am i looking at there you go see over 300 respondents 30 percent of people said they would take the pill the rest spoke really against it some people were very even offended that i had even talked about the possibility of such a pill and how it was threatening to their identity and this is what they said basically i would never accept a pill that would make me happy with my assigned at birth gender this would effectively be personality death the person who existed after taking that pill would no longer be me i'm a woman and that's very important to who i am and how my experience has been shaped now if you offered me a magic perfect immediate transition button i'd pass that in the heartbeat but the idea is this person viewed their identity their gender identity as core to who they were as a human being kind of like if you were to think about doing a lobotomy on someone you would take out a piece of who they are those neurons those memories comprise effectively the essence of what that person is so to remove that would remove that aspect of their person now what was very fascinating about this is some of the things that people said here having contemplated that myself i can appreciate their desperation if there was a way to live happily without all the pain and loss i would have done it in a heartbeat for me the magic pill was transitioned but it was a very bitter pill to swallow even knowing how hard it is and what they had to go through to do this the social osterization the loss of family jobs like literally everything they still would do it and what was really fascinating is people early in transition before starting were like give me the pill but people who had already transitioned who'd gone through the personality growth and changes as a human being were like no no no i'm not doing that this is who i am that was pretty neat to see that actually stratified out so what about the surgery does the surgery actually work well here you go let's start with first the just hormones so these are people talking about just hormones here and even though they had gone on undergone gender affirming surgery these are the the general population responses approximately four out of five people report significant improvements across the board that they are better life better quality of life sexual function happiness depression all those things improved when we look at surgery the regret rate for surgery this is the best study ever done oman read it a lot and there's a subreddit called the donald and it's obviously you know donald trump subreddit and they constantly post this one study this very small study that was done that talks about how all these people regretted having gender affirming surgery yeah it's a terrible study this study was done over a 50-year time frame on 760 people who underwent gender affirming surgery of them 2.2 percent regretted having it done lasik like getting your eyes corrected has a 5 regret rate so these people literally had their genitals reconstructed and 2.2 percent of them were like meh i wouldn't do it again that's that's the regret right here so this is legitimately how many people said that they benefited from having it done that is probably below even the complication rate i'd imagine way more than that many had complications or problems and it didn't turn out exactly as they wanted and they were still happier and better off as a result so how do i do it how do we actually take somebody from one gender and transfer them to the other one this is how it's basically done in your body how you became the gender you are now that you express physically as your phenotype so you have we're going to talk about two gender identity gender expression sexual identity these things are all different and i'll get into it later but this is basically how humans make sex hormones this is what i do all day i look at these things i order these labs and i fix them how is it done nearly everybody has to go through some form of psychiatric evaluation most of them have a w path letter which is a letter from a therapist that says this person meets the criteria for gender dysphoria and i think they'd be a good candidate for hrt however some of them do not and those that do not are usually because they're from a lower socioeconomic class they have medicaid like a meridian or molina or crappy insurance and paying 175 dollars an hour to a therapist for six months every week is not something within their price range so for them i offer something called informed consent informed consent is effectively what you give when you go get a tattoo you say i am an adult and i understand the risks and benefits of this i will not do informed consent on someone who has a major psychiatric history if you are bipolar with mania you better not be manic when you come to me to do this i will make sure you are stable before i will do it if you have ever had psychosis of any kind nope you go to psychiatry for clearance but if a perfectly educated and consenting stable adult on no medicines comes to me and says i want to do this i go okay so i give them this form the form has every risk and benefit that can possibly happen for it's like 15 pages long and they study it and they learn it and they go to this place called transcend the binary where basically there are a bunch of doctors and pharmacists people who volunteer their time to meet with these people and quiz them and make sure they truly understand and if they do they write them a letter that says this patient understands the risks and benefits and then they come back and along with their physical examination and lab work i start them as we said there pretty much what i just talked about in terms of informed consent all right so here's where we get so female to male so you have a kid any kid comes to you i don't care whether you are internal medicine or family medicine or guy it doesn't matter kid comes to you and says i want to transition and they are pre-pubertal they are not ready for hormones so to speak they wouldn't naturally be making their own just give them lupron all you do is you press pause on puberty and it just stops they stop growing breasts their penis gets no bigger their testicles get no bigger they don't get any facial hair it's just you keep them in kid's stage pause and you give them time the total risk of doing this is if they're on lupron for many years their end bone mineral density will not be as high as it would have been had they gone through puberty earlier but that's about it that's pretty much the risk the other risk is they kill themselves which to me is like you know you know when you're 70 your bone mineral density versus you diet 11. so i block these kids i say yep you're blocked your hormones are blocked go to gender therapy and they go and they go to see psychiatry and gender therapists and they figure out whether or not this is the right thing for them for some kids it is for some it's not they literally will grow out of it it's a it's a phase they went through for whatever reason but for the ones that don't they come back we start them on hrt when is the age appropriate time which is effectively puberty lupron is the drug that's used to do this every now and again i have a female to male patient who can't use lupron or they can't get it covered i'll use a nastrazole which is an aromatase inhibitor which blocks the conversion of the blues to the pinks basically in order to treat someone for a female to male hormonal transitioning we use testosterone in pretty much any imaginable form don't use dhea because it just gets metabolized into more female hormones it's a myth that that works in that way it actually makes their problem worse but a lot of people think that this is a good idea but in general i use about 100 milligrams a week injectable there are there is oral testosterone in europe it's not a thing we really have we have a small thing called estra test which is like a little dose of testosterone for postmenopausal women with low libido it's not nearly enough to transition with and it's not something i would recommend because it has increased cognitivity problems but basically injectable tea or transdermal tea or how pretty much everybody does with the exception of some very rare patients who get something called a testopel which is a testosterone implant and you replace them every four to six months so you get some rapid changes that occur and some changes that take a little longer um some of the things that are changed is the increased musculature and decreased body fat uh development of facial and body hair deepening the voice male pattern baldness which happens way more often than people wish it did but it's the trade-off you make um enlargement of the clitoris is like almost immediate like we're talking within weeks it'll start to grow um growth spurt closure of growth plates so the interesting part about this is that when it comes to treating trans women and trans men that are kids i tend to block i tend to let the trans men kids like female to male go longer on lupron and the reason for this is that they grow taller so testosterone and estrogen close epiphyseal growth plates so if you hold them open longer by not giving them the hormones earlier they grow taller and they fit into society better which is very much a heightened you know sort of thing but regardless if the end goal is for them to pass i try and get them as tall as i can so this is kind of effectively if you think about it why you see a lot of transgender women this is my theory total theory but that you see transgender women who are very tall like inordinately tall like six foot six and they tend to stand out and you're like wow those trans women are tall like collectively my transgender women are probably like five ten like they are taller than average would be for the average american man and i think this is because of resistance to testosterone due to whatever other genetic mutations they have and they have a ton of them that i could go through results in longer growth plates my trans men it's the opposite they tend to be shorter much much shorter um usually between five foot and five three and that's just the way it works out so i believe that this is the reason why it's linked one of the coolest things you can do if you really want to be doctor off label like me is you can use minoxidil which is rogaine on the face do not do this until the patient has peach fuzz and by peach fuzz i mean like you ever been driving along in the car and the sun is setting and you look over your left at your mom or whatever female person you have in your life and you're like oh my god their face is so hairy right we've all experienced that it's and it's the light refracting through the light on their face they're vellus hair okay some people have more vellus hair than others but if you have a lot of vellus hair to begin with when you start using tea it starts to thicken to become that sort of peach fuzz that then becomes facial hair minoxidil causes the transformation of vellus hair into terminal hair subsequently you can use it on the face but don't do this until effectively you have gotten fuzzies or you are wasting their time and getting somebody to be compliant with a thing that they rub onto their face once or twice a day is difficult especially when they don't see any results when the results that they do see is all of the hair that they've grown so far falling out if you do not warn them about it they will stop using the drug ironically this is the stage when it's the most important because why it's falling out is the transformation from vellus to terminal and that middle velo terminal stage causes a shedding event the hair cells basically die off drop the shed they lose the hair and then they start again with a new stronger terminal follicle that makes the you can hear the scritchies that's that's it that's terminal hair that's what you're trying to make this drug will do that way like i can get a beard on somebody in under a year which is pretty wild where otherwise it takes years to build that you think about few birds boys they get the dirt stash and blah blah like my patients are like year year and a half out and they have a full beard all right so i do something unusual there are two types of genital surgery for trans men one is called a phalloplasty where we create a neopenis and the other is a metoidoplasty it used to be you can basically have your penis or feel it too that is no longer the case there are some new surgeries that actually give you a sensory phallus but at for the longest time that was basically your options we basically sever the clitoris pull it out and then more or less attach it there and it becomes sort of a small penis and then there's testicular implants to be placed into the labia and there's a vaginectomy that this you know the vagina canal is closed and this is what you get i'm able to achieve considerably greater growth than other doctors because i dreamed up this idea of using incredibly concentrated testosterone directly to the clitoris so they literally use 15 which is about 10 times stronger than android gel and they put it directly on the clitoris every day and it grows and they are beating my door down to get it because people are coming and be like i heard you got this cream and like it's just spreading throughout the community that it's a thing that i've dreamed up but nobody's done it before um it actually is very interesting i don't have a slide in here yet but i should um about the fact that i actually use a compounded weak testosterone a 0.5 or weaker on the penises of transgender women a lot of times the corpora the internal structure doesn't get any smaller that stays the same but the skin atrophies so you end up with like an overwrapped kielbasa so they get an erection it is extremely painful and the skin can split just like kind of a postmenopausal woman's vagina so what i do for them is i give them this low dose topical tea applied to the penis which regenerates the tissue softens it and gives it its elasticity back the other reason is that i do it is on my male to female kids who were blocked they don't really grow much of a penis because they don't have the testosterone to make it grow so there's a very famous transgender girl named jazz jennings who went through her whole surgery thing and outlined and the biggest complication she had was her vagina was about this deep and it was because jazz had never been allowed to go through regular puberty which means that she had more or less than a toddler penis it just it never grew any and that's what they were able to use to make the tissue to do the knee vagina so as funny as it is to say about six months before any of my patients go for gender affirming surgery i start slathering them up with 0.5 testosterone every day this will make the biggest strongest penis possible to go into battle that you're going to use to turn into a neo vagina this is very important to do this because they've often spent 4 5 10 years on blockers and experienced significant genital atrophy as a result the same can also happen in reverse to transgender men but not as often testosterone seems to be a little friendlier to the vagina whereas estrogen is a thing that just does not work on trans women's penises like don't even bother estrace will not work to help them with this issue same idea with male to female lupron is used to do the blockade there is a tremendous discussion and argument over what is the best way of doing hormones it's mine i assure you but it's not really a thing that has been settled on anybody yet so i'll present you mine and the other options you guys can decide for yourselves male to female i mean you get feminization breast development adipose redistribution testicular atrophy possible infertility so infertility is a thing that people talk about a lot and i've actually have not experienced it that much of my patients so when i have a transgender woman who decides that they want to father children and they still have not had an orchiectomy and they would like to produce sperm i stop their blockers i stop their estrogen i stop everything and i put them on a drug called clomid colombia is also used for fertility purposes in women clomiphene but it increases the lh and fsh secretion from the pituitary which thereby kind of restores the testicles and they can go from these atrophy little wimpy squishy grapes to being like solid hard large marbles within the span of about two to three months then they can give themselves a you know a sperm donor or they can do whatever they need to do to drop their sample or impregnate their partner and then go right back to how they were before and i have done this a bunch so i've actually not had a patient that was infertile that i couldn't fix except for the ones that had an orchiectomy and there's nothing i can do about that um once you've once you've had that that's pretty much the end of the game um anyways so same sort of things in reverse um this is an interesting slide so when i start people out i start them between 6 and 10 milligrams a day spread over the course of the day ideally i would love to have them dose it five times a day but few people are that compliant so i usually am happy with three like four milligrams in the morning two in the afternoon four at night almost every other doctor will tell you take all your pills at once it doesn't matter that's wrong and here's why when you spread the dose over the course of the day they don't crash these people who are dosing 10 milligrams of estrogen first thing in the morning 12 hours later they've half-lifed out three times they feel like and they always wonder i'm so tired in the evening well yeah because you have hormones only part of the day and that is absolutely not how an ovary works it's not like an ovary wakes up at 8 a.m like has its morning coffee squirts out some estrogen and then goes to sleep for the remainder of the day it doesn't work like that so why would we do this to humans i don't know but i don't um what i discovered that's a really large portion of my treatment is this thing called estrone and estradiol's ratio estrone is a metabolite of estradiol and it's also a thing that's produced from anderstein dione it is about four percent as strong as regular estrogen irregular estrodial should i say and it is a competitive agonist for the binding site i have found some transgender women have a mutation where their body will take estradiol and converted into estrogen lots of it to the point where it's 20 30 times greater amount of estrone than estrodiol i think this may be actually related to development of their gender dysphoria and we're going to talk about it now earlier you saw this slide and on that slide this arrow went like this just down that is wrong and it has historically been taught that way and it is wrong and specifically the reason it's wrong is there's two enzymes there 17 beta oxido reductase and hydroxylase which are involved in the processing of those two hormones it goes in reverse it is reversible and i have found increased or mutations of increased function going one direction or decreasing the other direction which screws up this ratio so what does it matter well let's say that you have a patient and we're going to just follow the w path standard here really quick not my methods we're going to say the w path so estradiol you get it back it's a hundred to me that's too low i like it over 300 but wpath likes them 100 to 200 so they say that's okay great all right everything's fine keep transitioning have a good day i get your estrone back and while your estradiol is 100 this is 500. most cis women are really around 100 never over 200 ever their physiologic range never goes that high so what's up with that oh i better lower your estrogen yeah your dose is not enough here you don't have enough estrogen i need to increase it to get you close to 200. oh nope you have too much i have to decrease your dose up nope here's your total estrogen this is pretty much peak ovulatory levels this is fine depending on which lab you ordered and how you looked at this patient you would come to the wrong conclusion which is why my whole point is estrone is a key component that you need to measure when you're looking at this estrone also is important to measure in any of your women that have had breast cancer or a thrombotic event because it is implicated in the development of both so as we talked about here the effective estradiol level in this patient is much lower than 100 picograms per milliliter so let's imagine this all right so we got these chairs over here okay these are estrogen receptors so let's say we have 10 guys up here wearing estrogen shirts and they're like i'm estradiol 10 of them and then i have 50 wearing estrone shirts and we play musical chairs what assortment of people are you going to get in there i mean obviously 5 out of 6 chairs are going to be occupied by the people wearing the estrone shirts because there's way more of it but they both bind to the receptor it's just that when the estrone binds it only gives four percent of the effect subsequently the irony of this is that giving transgender women who have this mutation estradiol creates a enormous amount of estrone in their liver which then competes with the estradiol for the receptor binding site so they start transitioning and then stop because they get the initial feminization burst from estrogens effectively and then they can never get past that they just get stuck colloquia and the reason i dream this up is i'm like why are people keep saying this shots are better shots are better i couldn't transition till i went to shots like what would the difference be between oral and shots like i i don't get it and i started looking into the biochemistry of this until i finally dreamed this up with sigrid who i quoted at the beginning of the lecture who i gave credit to brilliant woman but anyways the relative speed of the enzyme the 17 beta hydroxy steroid oxide reductase and hydroxy star dehydrogenase is interchangeable so depending on where your mutations are how many allelic polymorphisms you have in either direction you're going to either go towards this end of the reaction or the other end and this is important for transitioning what's really weird is that i have found elevated estrogen levels and transgender women who later went on to have screwed up ratios in this problem before they started transitioning meaning their body was taking when they had non-elevated levels of of total estrogen their total estrogen is like borderline high or normal but their estrogen is high because they're shunting into this now i think that this is particularly interesting because i have previously been like estrone's bad no terrible estro and i've been doing that for years once i discovered this what i recently figured out was that the patients that i started on pills that i switched to shots ended up having better feminization in larger end stage breasts than the patients i started on shots and i couldn't figure out why that was and so i started to think about it and when it talks about when we talk about thelarky which is the development of breast before menarche theolarkey is the development of the breast bud and then it's initial you know formation that comes from the adrenal glands primarily from estrone being released in the adrenals after that happens eventually there is an inversion when the ovaries kick on and then you start to progress to tanner 3 10 or 4 then you start cycling and you having a period and then you progress to 10 or 5 and the breasts round out so i realized huh maybe this would be better so i actually let my patients stay on oral pills even if they have a crappy ratio for six to twelve months then i switch them because effectively i'm mimicking thelarky in a cis girl who would go through the same sort of thing what's really interesting and i have yet to totally suss out the mechanism for this i've had patients that have been on shots for an extremely long time frame like three four five years where they are considered done this is as far as they're going to progress no more further feminization and i added an oral dose of two milligrams at bedtime swallowed not sublingual not buckled swallowed deliberately creating estrone and all of a sudden they start progressing again despite the fact that their estrogen level goes up against this ratio it almost seemed contrary to my theory but i believe the mechanism for this is that the estrone is actually uptaken into the cell and converted to a different form called e1s estro esterone one sulfatase or sulfate the sulfatase enzyme is the thing that does it and that form e1s hangs out and does nothing it's sulfated it just chills but it can be pulled immediately and then converted to estrodial intracellularly now the serum drifting around estradiol around your body yeah that's great you have that you have a high level but it doesn't do anything unless it's inside the cell this is picked up easier and taken into the cell so it acts as a reservoir for e1s and in these patients who've been on shots a really long time who might have a depleted estrone reservoir it seems to re-trigger growth in them so what i do now is when somebody's maxed out like totally maxed out i give them this oral dose for a month and if they start progressing again they start getting more breast development i have a phrase that i say all the time which is sore boob is more boob um if they're sore they're growing that's a general marker for it if they develop tenderness again then we start we continue with this if they don't i don't i don't do it past a month all right so as i talk about i start them all that way if the ratio is poor i switch them to injectable if the ratio is good they can be maintained that way i'd say even since i would say about half now i really should update this i used to say about a third to a quarter but i'd say about half of them have this genetic issue where they just cannot process it properly um there are the options for transdermal estrogen and implants i rarely use these mostly because i can never seem to get as high on a level as i would like but i have a couple patients who have the mutation with the estrogen issue and they are just terrified of needles they just won't use them they're just like no no no shots and i'm like okay well uh you're stuck how you are or this and the option is either transdermal gel or usually two to three max dose patches simultaneously um there is also estrogen implants but they're not approved in the us through any sort of like fda okayed drug like testopel is the testosterone one there isn't an estrogen one but you can get it compounded at a compounding pharmacy and then do the same thing it does exist in europe so this is what i think is going on here and this is just a theory so i don't you can take it with a grain of salt but i believe that this is actually the cause of why a lot of these people turn out to be transgender women so if you have this mutation which i said about half of my patients do where they crank out this massive estrone level so when i say that to be clear they'll have an estradiol of 100 150 and i'll measure their estrone someone broke the record the other day by having an estrodial of 100 and an estrone of 3827 normal estrone is 100 to 200. so that gives you a concept of like how bad the mutation was in them what they are effectively doing is i'm giving them estrogen their their liver is like cool estrone pile pile and it just starts stacking up more and more and more well if you think about it what is the other time that a male fetus besides being a transgender woman would be exposed to estrogen pregnancy so in pregnancy you are exposed to mom's estradiol i eliminated my mom's i just went nope and got rid of it because i don't need it and my body produced its own androgens which is why i turned out with my sry gene expression to be a boy i am a boy if you hadn't known i do also identify as one um but if you have this mutation you're gonna take mom's estrogen and you're gonna crank it into estrone now mind you estrang isn't a super powerful estrogen but we already know it's enough to at least give people breasts so if you're exposed to this throughout your entire development period by taking mom's estradiol converting it to estrogen and building up this reservoir inside your fetal body what do you think is going to happen to your neural architecture well i don't know it's not like we don't have a comparative analysis in des which shows us exactly what happens when we expose a developing fetus to high levels of estrogens so this is why i think at least some transgender women who have this mutation are trans because of this mutation and the sick irony of it is that later in life when they go to try and actually transition you put the hormones back in it makes it harder because their body actually fights them by converting the estradiol i'm using two estrone so this is an example of a patient just like what i was talking about i used i really should use my new patient the one i just got the crazy labs on the other day because it was it's even more pronounced than this one but basically this patient had an ester dial of 78 and an estrone of 2100 when i checked it they were told um that this is as far as they could go they've been on hormones for like 10 years and that was it they were kind of happy with how far they had progressed with their transition but their prior doctor would only be checking the estrodiol level they ranged anywhere from like 80 to 200 and everything was fine um four months after i correct the ratio i i saw them as a patient i'm like hey listen you have this thing let me fix this for you and they were like very suspicious because when someone's been doing the same thing for 10 years it's hard to convince them to change but they did they listen to me and holy crap did they change we're talking they went from like a small b to a d by the end of the year and within four months it was blatantly obvious that i had done something very different with this patient they were thrilled because they had thought that they had gone as far as they could go and it was because they had this mutation um i have seen this which i'm trying to figure out right now uh norvier and coba cystat i in my african-american transgender women are 57 hiv positive i'll repeat that 57 of my african-american trans women are positive already it's that's that's real uh white is about 7 to 12 depending on the state so in short a lot of them i have on hiv treatment i also treat hiv the thing i do in my clinic and a lot of the older slash middle and not the brand newest drugs but the ones maybe the past five years to 10 years ago use this cobocystat it's a booster it basically inhibits the cytochrome p450 enzyme keeping the level of the drug higher in the serum norvir did the same thing um and they screw with estrogen metabolism so it also makes this problem even worse so i would recommend if you have a transgender woman you're fixing this problem on and they're on one of these drugs consider one that is an unboosted regimen um i'm not the first person to discover this it's kind of crazy this has been known in medical literature for literally almost 15 years 2005 varied roots of administration affects the way that estrogen metabolism is done right here you can see this was the study estrone is a weak estrogen only four percent of the estrogenic activity of estrodiol i'm not the first guy to dream this up um i already talked about that however we've known that it's bad we know this association with estrogen receptor positive breast cancer relationship between estrogen estrogen metabolites the post-menopausal breast cancer risk this doesn't say here but i'll tell you that the abstract the conclusion is estrone's bad causes cancer estrogen sulfate promotes human breast cancer cell replication the effective estrone on thrombin generation may explain the different thrombotic risk between oral and transdermal hormone replacement therapy so i only use only in my practice bioidentical hormones that's it if you come in and ask for something else i say nope and in 1500 patients in five years i have had zero complications not a single dvt pulmonary embolism nothing not even one and i use doses way higher than what the wpath says is safe statistically i should have had like five but i've had zero and i think this is the reason is that i only use bioidenticals and i pay attention to this estrone generates thrombin so if we're giving people lower electrical and they have this mutation and all of a sudden they have an astronomical amount of thrombin in their blood what do you expect all right let's talk about blockers so sometimes it's necessary to use blockers the testosterone sometimes will just go down on its own you give somebody estrogen or progesterone but sometimes you really got to beat it as a result you use blockers and the historical way of doing this is stuff like finasteride and spironolactone which i despise and i'm going to talk to you about why but the crux of what i do is to use bioidentical hormones and on very rare occasion an androgen receptor inhibitor called bicolutamide to do this job so i don't prescribe spiro if you come to me on spyro i will take you off of it i will not write it it is the standard of care according to every major medical group everywhere except for me i'm going to let you know they're going to tell you to write spiro why we think a potassium-sparing diuretic that causes and this is known depression fatigue visceral adiposity like it increases serum cortisol levels which is probably the reason why people get visceral adiposity we know that it has issues with breast development um so this was a really cool study that took every single transgender woman from like europe and this whole distribution like thousands of people and they looked at what they had used in terms of hormones up to that point and when they stratified out for different examples and different things they found that the spiro group was significantly more likely to seek breast augmentation than every other group there is a theory that spironolactone causes premature nipple plate fusion meaning that basically the breasts are not able to achieve the full size they would have otherwise because you have cooked them with spiro early on in development so i have also seen this in some patients who took high dose spiro who that almost no matter what i do and we're talking i even have one patient that i'm currently doing something i said i would never do i'm putting topical estrogen on the breasts and which is like i and the reason i'm doing it is that they have failed transdermal injectable oral i've had their dose their estradiol level like 900 where they're living at near like what would be considered crazy dose and still no breast development so i said okay well then they said i'm gonna go get breast augmentation surgery and i said okay i'd rather you not because i always think of kanye west's mom who went in for routine breast augmentation and died it's not without complications or surgical problems or capsular contracture or other issues so let's try one more thing i can screen for breast cancer but i don't have a crystal ball to say whether my patient reacts to anesthesia and dies under the knife so that's what we're doing right now and with that patient i've had modest growth so far but i think that they may be a person who is fused prematurely with spironolactone so i get testosterone levels on people with the intent of erectile function if you don't want it and most of my transgender women do not they say no no make it go away i don't want to get morning erections i don't want anything like they hate it uh they call it the dysphoria worm i mean there's the what is the other one that i always say oh god i'm trying to remember now the sadness noodle i mean it's just like there's so many funny things that my patients have said to me before that i like try to store in my head but regardless if they don't want it to function i keep it about 15 which is the adrenal levels that are produced when you shut somebody down using the powers method which we're going to talk about if they want a higher than that i keep them around 50. anecdotally african-american trans women want erectile function whites don't i don't know why that is it's just the thing culturally that i have noted overwhelmingly to be true in a fact of like 90 10. when it comes to white transgender women they're usually like meh they're either apathetic or they like they don't want it very rarely like it needs to keep working whereas with my african-american trans women almost every single one of them would like to preserve their erectile function it's like critically important i know if it's a cultural difference or what but it's something that i'm aware of and i cater to by helping them do this depending on what testosterone i keep them pegged at all right so there are other blockers uh that i don't use because they're terrible five alpha reductase inhibitors so there's a brand new drug out right now that is uh injectable and it treats um post-menopause i'm sorry postpartum depression so women that are like severely severely depressed right the problem with this drug is it have to be infused and has to be infused slowly over a 48-hour period so you have to be in the hospital with the severe depression and then they hook you up to it and they infuse it into you and it's aloe pregnant alone which is a neuro corticosteroid that is involved in depression we find that it is heavily depleted in women with postpartum depression giving it to them makes them feel better do you know what else depletes neural alloprogenolone five alpha reductase inhibitors it blocks the synthesis of it i wonder why there's such severe depression associated with the usage of finasteride but yet we hand it out like candy just like oh you have some hair problems here have some finasteride oh you got prostate cancer finasteride meanwhile these people are severely depressed because we're literally depleting a neurocorticoid which is super important to their general functioning i don't write these like almost never and when i do i write them topically and that's it i have a compounded finasteride or dutasteride with minoxidil at ten percent that i put on the head but i won't use it morally on people because there's just no reason to do it the other reason it's stupid is that the overwhelming majority of transgender women have a very low testosterone to begin with five alpha reduce inhibitors don't block testosterone at all all they do is prevent the conversion of testosterone to dihydrotestosterone three times stronger testosterone it's a more potent form so if your total testosterone is 10 why do you have the patient on finasteride you cannot imagine how often i have people come to me that have a testosterone of 0 10 15 that are on finasteride and this and that and i'm like what is your doctor doing because you just expose them to the side effects for no reason so don't do that dutasteride can also be used topically like i talked about i have a compound that does that um never prescribe any of these things to somebody who basically has a low t because you're just you're giving them side effects for no reason so there was a drug called flutamide uh there still is actually and it is a incredibly potent anti androgen receptor inhibitor the best way to describe how it works and i love this drug class is here's a testosterone receptor spyro all these other things block or reduce t levels but flutamide bicolutamide and enzoludamide do this they're like a bowl that sits over top of the receptor they prevent the binding of the ligand so it just sits here and inhibits the ability for testosterone to do anything about 50 milligrams a day of bicolumide is enough to inhibit about 400 nanograms per deciliter so pretty solid amount of tea you can just wipe out by using bicolutamide now the reason i use bicolutamide instead of flutamide is that flutamide has a horrible reputation it is like the angry mean cousin of bicolutamide that causes liver failure bicolutamide causes hepatic irritation in about one in 500 people i've seen it once ever and it was very mild we're talking like their ast and alt went to like 60 compared to the other things they're on i generally also use picoludamide for another really cool reason if i took it so i had prostate cancer and i take it no estrogen no nothing just bicolutamide i'll grow breasts it causes gynecomastia the reason it does this is that when you inhibit the binding of testosterone the body recognizes that it's not getting sex hormone signaling and so it up regulates the expression of the estrogen receptor on the cell surface membrane thereby sensitizing the cell to estrogen why are we giving people a testosterone poison that literally causes visceral adiposity and makes them feel like crap when this exists it's because people are afraid they're afraid of this drug but i'm not and i write it constantly you can get it for like 16 bucks a month at kroger with a good rx coupon um i only use this drug temporarily right at the start of hormone therapy until i'm able to achieve what i call capture captures the point when i own your endocrine system it does what i tell it it basically has stopped doing what it wants to do on its own and it does what i tell it to do and i'll explain you how i do that a little bit i have to edit the slide i've never seen a hepatic transaminase elevation once two weeks ago i actually saw for the first time like i said ast and alt went to 60. um all right so in not the united states there is cypertierone omegas exists here we have magestrol but cyproteron acetate cpa is a blocker that's used in europe constantly it's what everybody uses in europe it causes prolactinomas and meningiomas i don't use it because i can't but even if i could i still wouldn't but you need to be aware of it because if somebody comes in having taken it and they have you know their peripheral field loss or whatever you need to be aware that literally this thing can cause a brain tumor i once saw a patient abusing semetidine apparently semetadine can cause gynecomastia probably via its p450 inhibition um it screws with the cytochrome p450 system a lot and so subsequently people try and take it to get gynecomastia along with a thing called pueraria murifica which is a plant that's like one of the most powerful phytoestrogens you can get that isn't right estrogen without a prescription i have a lot of people who are xdiy meaning they like used to do this on their own from the street ordering it from like all-day chemists in india and getting it shipped to them and now they've come legit they come to see me because i offer the opportunity to inform consent all right progesterone everybody thinks i'm nuts that progesterone doesn't do anything they are wrong it does it wouldn't exist in the human body if it had no purpose if you don't give your transgender women progesterone they get pointy boobs i literally jokingly refer to it as trans cone boob syndrome they are pointy they literally look like madonna they don't turn out right it's a cone on a cone and it looks literally like the secondary nipple the areola is enlarged sitting on top of a strange cone-shaped breast because they never progress past ten or four they are stuck in tanner four unless you give them this they will not make it to five i have not seen patients make it other than this with progesterone however if you look up any other resource well not any other resource but most other resources will say that i am wrong however i also do not write this ever ever the fact that yaz and yasmin are still in the market with your spin around in them blows my mind why you guys know yaz right i mean it's it's a birth control it's like the most sued and legit litigious birth control to ever exist draspin around is eight times more deadly than every other progestin out there yet we still prescribe it to people why there's no need i don't have to do this because i have this this is bioidentical progesterone now what i do that's a little different and it is basically the crux of the method for me is that i use rectal and you have to think about the level of compliance i have for my patients that i convince them to use a rectal suppository every single night of their life and they do it the reason i do it is because when you take this orally about 95 of it is obliterated in the liver it just never makes it and their serum levels suck but when you use it rectally you wet it and your mouth are under the sink and up it goes and you go to bed the cool part is progesterone when absorbed in this way is a gaba agonist so it makes people sleepy so they sleep super well on they say it's the best sleep they've had in their whole life then the other benefit is that the distal third of the rectum unlike the entire rest of the gastrointestinal tract drains to the portal circulation i'm sorry not to the portal circulation the systemic circulation everything else goes to portal meaning goes to the liver first but the distal third goes out to systemic so when you put this in the distal third of the rectum the capsule will basically start to melt break down and then release and because it's an oil it doesn't get all sucked up instantaneously over the next 24 hours it is gradually absorbed then what's really neat about it um i think i have to go to a further slide to get to it but i'm just going to tell you now i discovered based on this based on lab results i had in the patient then i tried to find a comparative example and there's a 1998 study on sheep where they inject them with progesterone and they measure their lh and fsh and it goes to zero so i said i bet if i can get progesterone levels high enough i can do a thing like lupron because progesterone is actually a gnrh agonist now if you don't remember how the hypothalamic pituitary axis works gnrh agonists stimulate the pituitary continuously as in like basically they press the button and hold it down and once you do this you get a release of lh and fsh and then it stops in order for it to work normally you have to press press press press in a pulsatile fashion and that's how the pituitary regulates hormones so if you give them progesterone this way which acts as a gnrh agonist and is a constant stimulus lh and fsh fall to zero when your pituitary is no longer secreting lh and fsh and they are zero there is no signal to your testicles to make testosterone they go off just off i never have a patient now that i have to give any other blockers to or do an orchiectomy on there in fact what's really cool is their testosterone falls to usually about 10 to 20 which is the amount synthesized from the adrenal glands i know that it is because their lh and fsh are undetectable and their testicles are like totally after feet away so this is how it's working that is the crux of how i do hormones differently is this usage of rectal progesterone i have also used topical progesterone on alternating breasts and every now and again i have somebody and even one cis woman i did it too who had an asymmetrical breast and i used it to enlarge the smaller breast and like even them out and it actually worked and they got gains and they were very happy and then we stopped the drug and it kind of was like and it went back but not as bad as it was before it started so the presence of the progesterone effectively evens them out because topically the concentration they're getting is vastly higher than the systemic absorption i'm sure the other breast is touching some of that progesterone but when it's right on top of the right side it evened out the other breast which was kind of neat her period was a mess though but she didn't care it was that her surgery she was like i'm getting this fixed so i was one of those things kind of like my other patient talked about where it's you know a risk risk benefit ratio but rather than going under the knife they opted to do that w path uh progestins with the exception of cyber tyrone the inclusion of progesterone feminizing hormone therapy is controversial back in 2000 you see all these citations are always going to be like 80s 90s because this w path like they don't they don't update their stuff um because progesterones play a role in mammary development on a cellular level some clinicians believe these agents are necessary for full breast development however clinical comparison of feminization regimens with and without progestins mind you what this says here progestins not bioidentical progesterone it says progestins found the addition of progestins neither enhanced breast growth nor lowered serum levels of free testosterone which i just told you is absolutely not true and how it works um but that was 1986. there are concerns regarding potential adverse effects of protestants including depression weight gain lipid changes depression and weight gain i have absolutely seen and i've had to stop it on people for that reason it makes them hungry um and some people while they get depression other people they they feel much better on it it just is the way that like an ssri can make somebody better or worse it just does a thing but i would say the overwhelming majority of my patients tolerate it um i've seen people that got stuck at 10 or 4 go to 10 or 5. support for natural progesterone in clinical trials randomized controlled trials evaluating micronized progesterone in prometrium's product monograph not one single case of thrombosis or altered coagulation factors as mentioned not even one bioidentical progesterone does not cause an increase in thrombosis it also has a negative effect on cancer it actually makes you less likely to get breast cancer only bioidentical progesterone does this all the other progestins have a net negative every single one but we don't use them instead we're giving people yaz for some reason i don't know why um anyways continuing on oh wait here's some more that isn't enough for you no significant association of vte with concomitant micronized progesterone nor pregnant derivatives were significantly associated with an increased vte risk whereas micronized progesterone could be safe with respect to thrombotic risk this is known like this is the kind of stuff with medicine that just drives me nuts like we know this stuff but we keep giving people these things like even though this research is just totally out there and open like but yet every day here's your birth control with dr spinerone in it have a good day hope you don't die like all right and people who've undergone full surgery you have a successful energy in blockade sometimes t will drop to zero this is bad um you don't wanna do this the hippocampus requires testosterone uh cis women have testosterone like it your memory gets impaired when your t falls to zero so you do not want to block somebody all the way to zero they have cognitive side effects from it don't do it um i will do this as we talked about earlier i use topical testosterone to the penis to restore the tissue and to grow it in trans kids that didn't got blocked too early effectively are you being safe obviously you got to keep following these patients i usually see them every three to six months when they're early in transition i see them like monthly as i'm constantly running labs on them to adjust things and monitor make sure that their lipids stay good their liver enzymes are okay it's pretty regular change um i do this phq two or nine they get asked and they come in they're basically like you know are you feeling depressed how are you doing okay i don't always do the nine at every visit at every new patient i run a full nine but usually they ask people how are you feeling depressed how are you doing at very least when they get checked in to evaluate people for depression um preventative medicine we're gonna talk about all right so here we go surgeries so how am i doing for time here oh geez all right um metoidoplasty so this is what we talked about earlier you sever the clitoris you bring it out this is pretty much what you start with you can see the enlarged clitoris from the uh testosterone exposure here is being extracted this is the urethra being mapped out because the urethra is then going to be used to fit into this graft and here's the end stage penis what you get is a penis um that would fit perfectly fine on like a 10 year old at best but that's about as big as it gets but you can feel it and the sensation's normal but the really the most important part of this is you can stand and pee you can walk into a urinal and go and be a guy and that's the most important thing to a lot of these patients phalloplasty however is the creation of a neophallus an actual penis this is not just done to trans people it's also done to cis men who've lost their penis to war or cancer or god knows what and here's how it's done we basically usually take a graft of skin from the thigh or forearm and you more or less wrap a tube in a tube and graft it on and surgically it's shaped with certain interrupted like sutures that create a corona and a glands on the whole thing there are different ways of doing it you can do a free flap phalloplasty where you basically take something from the inside of the leg or elsewhere and you transfer the flap to be able to do it you can use a pedicle flat with a pedicle flap you basically have the blood supply coming in instead of being removed and you keep it attached the way you're doing that radial forearm flap is more of a new way of doing it you basically take the forearm radial forearm area along with the graft of the uh of the radial artery so you can basically preserve the blood supply to the tissue and then they pull it across and they close the wound that they created to make the the phalloplasty go through effectively do the thing um after the penis has been made like basically you wait like a year until the penis is like healed it's healed as could be and then we do the erectile prosthesis and we put that in um these are relatively new uh free fibula flap um which is kind of neat there's a dorsal flower i'm sorry a latissimus dorsi or muscular cutaneous latitude dorsiflap there's just other ways of doing this but you can take a skin graft from pretty much anywhere and make it into a penis but these are the different ones that are done this one though is cool and it's brand new and i think it's really really neat um so basically they take a kind of the same way that we do vein stripping you take like the harvest from the saphenous well they take a piece of flesh from down here that's innervated by a nerve uh the serial nu serial nerve or lateral cutaneous nerve or any of these these regions and they make the penis with it but what they do is they graft the nerve onto one of the branches of the dorsal clitoral nerve if it takes the dorsal clitoral nerve extends the sensation across the entire neophallus so basically it's as if the penis has the sensation of the clitoris but distributed over the entire penis which is i don't know but that seems to me like how a penis would feel for someone who just had a penis the whole thing has sensation but if it fails you still have sensation at the base of the penis because the clitoris is still buried there so they still do get some erogenous sensation this is the newest way of doing it that is really brand new here's an erectile prosthesis it's kind of kind of cool basically in the ball on the right here there is some fluid and you squeeze it like a pump and it goes up past the valve and then it fills up the penis and you get an erection and then when you're done you squeeze a little relief valve and the fluid goes back in and basically this is the mechanism for which we implant there's usually a bladder in these things it's held up in the abdomen that holds additional fluid just so that they're able to get a full inflation penis transplant is a thing that has been done a couple of times on people who lost their penis in the war they're all cis men this will probably get done to trans men at some point same as a uterine transplant to a transgender woman which has now been done successfully in cis people but it hasn't been done yet but it's kind of neat what's more neat than this though is that there's a new way of doing these things with these organs where basically you could take a penis and throw it on an acid bath and what you pull out after it's been acided down is like kind of like a skeletal leaf like you see in the fall like that you know that leaf that's like got the veins but all the internal structures gone they can use things like that to then create a scaffold which is non-immunogenic that can be anybody's penis then take your stem cells put it in the culture bath and then your stem cells populate over the scaffold and make a penis they've done this with a trachea and an ear and a couple other random things now and they're looking to do with the penis next top surgery is basically what we refer to as mastectomy um it's something that transgender men get there's two ways of doing it there's a double incision procedure where you incise underneath the breast and this is for larger breasts and you make these two undercuts and that's this is this effectively and you will see these scars on trans men they're pretty much a mark of the process or if their breasts are small enough you can use keyhole procedure where you literally go into the areola and more or less roto-rooter the inside out remove everything and then attach the areola back on best guy in the world at this is a guy named daniel medalli in cleveland i have literally never seen anything less than an eight or nine out of ten like every single one he does is perfect vaginoplasty this is sue porn's work over here uh this guy was the best vaginoplasty surgeon to ever live he is retired now or he's retiring um but he's in thailand and he is unbelievably good um where like if you look at it you're like no that's a vagina like you'd have no idea they're perfect um however i have seen some serious hack jobs come out of some other places where i look at it and i'm like i mean that's a vagina where it's pretty bad and the patients have to undergo a lot of revision surgeries to try and deal with the complications that come when it's done wrong however this patient as you can see comparatively that's much depth they have they have effectively almost a normal vaginal depth there and this is shortly after surgery you can basically do a vaginoplasty a couple different ways a penile inversion is the most common um they will do this by taking the penis filleting it effectively removing some of the internal structures moving the glands back to be the neoclitoris and then using the penile skin to make the vaginal canal as i said before it's important to have a big healthy penis because it's what's going to be making a big healthy vagina if you don't have enough penile skin you end up with a very shallow small vagina that's painful and has other issues and when there's not enough skin or if a patient so i have a patient right now it's very it's a very unfortunate situation but this butcher who i'm not going to name but he's in michigan he's a urologist when the patient was very mentally ill went to him and said they wanted to have a panectomy done everything this guy cut off everything he took off the scrotum took off the penis everything and left the patient with basically a urethral hole that's it they came to me like i'd like to transition now but i have no tissue and when i examine them that's what i saw there was literally nothing there it was just a urethral hole and basically a tiny amount of scar tissue surrounding it that patient is a candidate for this a colo vaginoplasty where we use a segment of colon to create it along with a free flap to be able to make the labia or a new type called a peritoneal pull through technique which is not really done all that much yet but they use the peritoneum itself to create a vaginal canal and the cool part about the peritoneal pull through is it sweats it effectively releases fluid like any other peritoneum does in the body which moistens the vagina naturally and tends to have better internal cultures meaning more lactobacilli more normal vaginal flora there's other surgeries if they have facial feminization surgery which they basically undo what i have which is cro-magnon face where i've got the big neanderthal orbital ridge and jowl and butt chin and everything else they shave these things down and reshape the face to look more feminine voice feminization surgery is amazing it used to be awful and i would not have recommended it for anyone because like a third of people like lost their ability to speak it was so bad now there's like three guys that do it uh dr kim in south korea and dr haben and dr siegel i think is his name in boston they all do this vocal feminization minimally invasive surgery where effectively they take a person like my voice and they go in and they they cut off the vocal cord it's attachment pull it up tighten it and the net net effect of it is approximately this when you pull the vocal cords tight it increases the pitch now this makes me sound almost like kind of silly but compared to my normal voice it's a lot higher when done properly it is look it up on youtube i did include the video in here it's incredible uh yes and why eson voice center there's a girl there named jenny that uploaded her videos pre and post-op and it's it's just incredible incredible difference obviously breast augmentation tracheal shave shaving down the adam's apple buttock augmentation this is a problem oh my god is this a problem um again kind of a thing that's more seen in the african-american community than the caucasian and latina communities but they take basically industrial grade silicone and injected into their body and i see some nasty infections and complications related to this the slang term for it is a pumping party they will go to like a hotel and like someone will have this and they'll do these illicit injections and obviously an orchiectomy just removing the testicles so should we do this is it a thing that we should do um well we did once back in the 1800s to this person so lily was a intersex woman living at this time who identified as female and we put her on hormones transitioned her and then did a vaginoplasty and uterine transplant in 1929 1830 yeah that didn't go well we didn't know about any rejection drugs at that time she lived for like a month afterwards rejected the organ died of sepsis so the concept here though is at this time period there was people willing to provide these services these people but there was this level of demand that someone would go through this even we had very little experience doing it so in short these people are really desperate and they will do some crazy things to themselves in order to get access to hormones so just be aware of it if you see one of these patients at some point that like they might have gone through a lot to even get to the point of being able to see a doctor also in order to get the care that they want they can probably have diy'd or expose themselves to some really dangerous things i had a diyer the other day that was taking uh their sister's birth control which is ethanyl estradiol which is not a very effective thing for transitioning but we're taking mega doses of it like four five six pills at a time his sister was just filling it but not actually doing it so they were basically getting their birth control from them super risky thing to do but in short desperation will make people do crazy things moral of story safety first don't do anything they're going to hurt your patients what bad things can happen well i mean cancer heart attack stroke clots liver failure kidney failure osteoporosis seizures you know regret i guess in theory but i mean they happen to regular people too and in my patients using bioidentical hormones i don't see these happen like the levels where i should what's really interesting is i actually see them happen at a lower level in my transgender people than i do in my cisgender patients which is fascinating but regardless there is some risks or something you need to be aware of how often does it go bad five years and 1500 patients is now six years since i made this lecture um never had one adverse event not even one and i can stand here and say that because if i did you know it would come back to haunt me but i have not not even one i have three adverse events um that are not in major um and it's people who had the estrone ratio problem when i first discovered it and i fixed them their breast grew so fast in response to the changes that they got stretch marks none of them were mad none of them were mad at all but they would get some axillary stretch marks because the skin could not keep up with the breast growth so now when i make a switch like this in somebody i monitor the breasts for the next few months and if they get kind of red and irritated i back down their dosing to slow down the process to allow the skin time to to grow to fill in that space but i have literally had a patient go from like an a cup to a d cup in 12 months and they got axillary striae as a result so i'm very careful with that now that's probably the worst thing that i've done to anybody in all these years is it worth it sometimes it's not um some people have gender dysphoria and it's like meh yeah sometimes i wish i was a girl but like it's not enough that it's worth it they don't need to not all transgender people take hormones so we can still be transgender and not take hormones you don't have to transition to be transgender the act of being transgender is having gender dysphoria but not everybody is going to go through that process you can also be intersex and trans to be clear you can be both you do not they're they're separate constructs you can have klinefelter syndrome and identify as transgender that doesn't necessarily make you not trans to do that however some intersex people do not like to identify as transgender they view themselves separately depends on the patient just ask them how they feel all right let's talk about the preventative medicine stuff and office policies this is wrapping it up here so we'll get to the end as fast i can these are the people who give decent guidelines um they're where i would go if you have no idea what you're doing and you want to start from scratch that's what i did i learned these and then i kind of grew from there establishing a safe practice obviously educate yourself on these sort of issues you're doing that right now thank you assess the office environment be sensitive your patient experiences like my bathroom is unisex i don't have a male and female bathroom i have a gender-neutral bathroom have relevant appropriate health information um provide prep which we're going to talk about advertise yourself as lgbt friendly it's a mark you can give yourself on google you can literally mark boop trans-friendly space and lgbt friendly that's a thing you can do as a business train all staff to use culturally appropriate language my staff is really good about not misgendering people and my emr is designed specifically for that purpose we have preferred names everything shows up even though i have their legal name they're called by their preferred name every single time at my office actually we do a really unique thing where when you check in you don't give your name you give your initials is the probability of somebody having like the same initials like one like 16 000 or something like that it's very very unlikely um so you give your initials and you're given an amiibo if you don't know what an amiibo is it's like a little nintendo figurine it could be like toad or bowser or any of those things and it's like hi you're towed then your chart is appended with toad and then when it's your time to come back they're not like hey uh will powers you're here for your you're here for your uh uh siemens sample because that's that's actually what happened to me um i went to give a semen sample because me and my wife are planning on having children soon there she is hi um and i wanted to make sure everything was okay before we attempted that process and so i went and i sat down in this room of fertility clinic with a bunch of women surrounding me and they called out my name and said it was time for me to give my semen sample and i was like i am not going to do this when i have my own practice and i don't so you get called back as toad or bowser or whatever and that's the name that's used to refer to you when not inside of an exam room safe zones obviously just make it seem like your practice is welcoming to these people not excluding having written and posted policies non-discrimination things like that are great intake forms okay so i went viral recently again off the same post it's been shared like seven thousand times and viewed by like a million people um over this complaint i had about an intake form that basically said gender and the patient was intersex and it was male and female and i was like okay not only should this say sex or sex assigned at birth it says gender and even that's still wrong because i can't assign this patient's non-binary in their intersex so i literally wrote it on the form like no patient is gender variant assigned female at birth intersex blah blah went viral you don't have to do that fanciness i mean literally if you just leave it blank so on my practice the intake says sex assigned at birth gender and then it's male female and then there's a checkbox with a blank next to it because if you're something else you just describe it there and that's it all you have to do is leave a blank when you leave a blank you're basically letting these people know hey there's a space here for you it's an open space where you can describe yourself do not give people check boxes it's so much easier to do a blank there's actually there's the form that's the one there's a good form sex at birth this is a chorus this is a cardiac test that i order sometimes and it here they want to know what your sex at birth is it stratifies your risk they also should ask whether they're on hormones because believe it or not your cardiovascular risk is more associated with the hormones than you take than the sexual at birth this is how i can describe gender to people um all of you have this you are all on this somewhere you identify as male female or somewhere in between um as much as tumbler would like to say that there are more than two genders there's basically two there's male and female and then there is everything in between as in male and female people who have that are non-binary that identify as sometimes male sometimes female gender fluid and then there's neither so when i describe like that water bottle what gender is it it's water it doesn't have one that's it that's what some people feel they don't really feel masculine or feminine they just sort of feel in the middle but there's not like these they always attack the the liberal media you know by saying like oh 58 genders attack apache i identify as a patchy helicopter like most ridiculous stuff it's really not the case human beings exist somewhere on the spectrum you can express yourself as feminine masculine or something else in between you are assigned at birth female male or intersex we went smack it on the butt and look at it and be like yup that's a whatever that's how it works um that doesn't necessarily mean your karyotype like i said i've already described you people who could be you hold it up and be like penis boy and in reality you're holding an xx fetus that has delicious syndrome physically attracted to you can be pan straight gay lesbian bisexual whatever you want attracted to men women people that are in between other genders people who are transgender you could be attracted to everybody except for trans men or everybody except for cis women and there are different gender and sexual identities that correspond to different things also emotional attraction is not always sexual attraction so some people find themselves like they'll they'll be bisexual but they really only is very common in our society you see a lot more acceptance of bisexuality in females than you do in males so subsequently you see a lot of females who are married have a boyfriend whatever and then hook up with a girl and they're bisexual but they say hetero-romantic whereas in the african-american culture there's something called the dl or the down low where it's very common to find young black men who have a girlfriend who then get hiv by engaging in you know msm and then they bring it home which is why african-american cisgender women is the largest rising group in terms of like proportion of hiv infections in the united states right now is the dl culture insurance you need to know the patient's current legal gender and you need to know their current legal name and that's what you use that is what you should submit always don't submit anything else if they change it submit that and sometimes they've legally changed their gender but haven't told their insurance yet so don't do it then either so you need to know what the situation is and we basically are constantly monitoring that with my patients that are transgender um insurance coding can be a real pain i have a transgender man that i have this problem with he was 30 and he has high risk sexual behavior and really needed a pap he'd never had one his whole life but transition 10 years ago has a male name male gender his insurance doesn't even know he's trans because he got this job recently and has completely legally changed everything and getting a pap smear on him was a real pain with the insurance because they're like not approved in men i'm like nope patient has cervix and they've rejected it again and so i basically got to get somebody on the phone and be like listen idiots this person still has a cervix and needs to be packed fluidity some people identify as different genders at different times in their life it changes for them over time it's a thing that they can be exposed to which can make them discover a new thing about themselves some people just feel more masculine and more feminine on one day it is very common in our the youngest culture right now like millennials and people younger than them to express gender fluidity as it becomes more accepted in culture transgender etiquette call person by their name it's not hard i told you my name's will call me will i didn't tell you what pronouns i prefer if you don't know you can more or less look at me and if my name's will probably assume that i use male pronouns if you say hey will uh go go hand that over there to him and you point at me and i go actually i prefer they them pronouns be like okay go hand that to them that's it that's all you have to do you made a mistake patient corrects you sorry i didn't know or sorry i didn't mean to say that correct yourself flame on you're not gonna be the first person to misgender a transgender patient that's like what happens to them literally all day through transition for years just don't be a jerk about it when you screw up you're like sorry i'll do better and then flame on i have since opening my new clinic seen uh 500 novel patients and approximately a thousand visits and i have misgendered two people twice i have done it and i almost never do it and in both situations i did it because their spouse did it and i mimic the spouse which is what i have trained my brain to do is if the spouse uses a particular pronoun i use that pronoun because i made the assumption that that's what they would prefer oops i was very wrong when i did that and i had to correct myself i went sorry i didn't mean to do that i just was mimicking your spouse odds are you're not the first person to misgender them respectfully ask someone how they'd like to be addressed ask appropriate questions if you don't know like you look at somebody and you're like like that south uh saturday night live skit it's pat you ever seen that okay like what's pat's gender like nobody ever really knows the solution to that entire skit would be like hey pat how do you want us to address you what pronouns do you prefer and if the person is not transgender they'll be like what huh and if they are any sort of gender anything variant they'll be like oh i prefer this and that's the end of the discussion be like oh never mind sorry i you know i was confused i just wanted to say you know i wanted to address you respectfully that's it just ask literally no one's gonna be mad about it and if they are they're the jerk not you because you're literally making an effort to be civil to somebody this is a thing um this is probably one of the more important slides in the entire thing if somebody comes in with a broken arm to the er and they're transgender it's of course because they're on spira or hormones it's the hormones that made their bones weak everything my patients come to me with literally everything because the really funny thing about transgender people a lot of people that are in medical field don't realize is that transgender people are people they're people and people get sick and things happen to them totally unrelated to that fact so i have green eyes and i have vision it's terrible we're talking like seven diopters negative that has nothing to do with the fact that my eyes are green i just have terrible astigmatism so i wear contacts they're like as thick of a dime because otherwise my glasses would look like coke bottles up here that has nothing to do with me being green eyed and most of the time when a transgender person presents your clinic with an earache or whatever it has nothing to do with their hormones please do not make this assumption it is very difficult for them to get medical care when everybody always just looks them says yup because of this because doctors don't understand what doing testosterone taking testosterone does to someone assigned female at birth so if they have an abdominal pain oh well that's one of my favorite ones if you're a transgender man and you go to the er with abdominal pain it's the only thing worse than a 20 to 30 year old cisgender female going to the er with abdominal pain is a transgender man doing it because they immediately assume that it's related to testosterone and you get the worst workup ever it just doesn't and i have had to deal with this where they've been like severely constipated and if anybody just shot an x-ray you would have seen the obvious constipation on x-ray but of course it's their ovaries causing them pain because of the testosterone they don't even ovulate you're on t for more than like two or three months at a therapy to deuce ovulation stops like you don't have a period just over zero anyways uh etiquette trans men will need a pat every three years as per acog guidelines if they're in that group um if they've not had top surgery they need mammograms trans women need a psa if they complain a nocturia a strong family history of prostate cancer over age 45. be an awesome allied provider remember these things i talked about do your homework don't forget your hippocratic oath you say you're going to take care of everybody no matter what i cite the example that i have this is really kind of interesting but i have five pedophiles as patients um one of which and what's really interesting is of the five of them four of them are women and the one that just got out of prison for molesting kids came to me and said i heard you'll take care of anybody i said yep i will i said well i just got out of prison for child molestation i've been in for three years and i want to never do that again please help me and so i basically what i ended up doing is i gave them a high dose of paxil which more or less shut down their libido completely because they had gone to therapy and everything else they still had this drive in their head they couldn't erase and so they came to me for help there is literally no reason to not take care of these people they need help it doesn't matter whether you don't agree with it or whether you don't mean obviously i don't agree with what this person did clearly that's why they were in prison but i would gladly help society and them by preventing that from happening again that can be extrapolated to pretty much anybody i have bodybuilders that come to me that have been juicing themselves for years that are like i'd like to get off the testosterone i i want to have kids with my wife and like they walk in like their neck is directly attached to their shoulder and i'm like okay um and i'm like when was the last time you used tren or anavar or danvar and the other and anabolic like horse steroids and they'd be like whoa last week and blood well my cool here's your clomid and i write them clomiphene just like i do for my transgender women to restore their testicular function and sometimes they come back and tell me they use trent again and i write them clomiphene again i'll never write them trend i'm never going to help someone hurt themselves but i will help mitigate the harm that you did to yourself even if it was stupid be an awesome airline provider um so how many of you show of hands made a mental note of the fact that i'm wearing a pink shirt you busted see i do this every time i give this lecture i wear a pink shirt the reason is because you have certain gender norms in your head that you associate with things blue for boys pink for girls you saw many people like half of you had like actual like no i wonder why i was wearing a pink shirt right yeah exactly how many of you assumed that i am a cisgender heterosexual man probably overwhelming majority you did because my wife's literally right there but i might not be i could be bisexual pansexual i could have been a trans man i actually had a really interesting case yesterday where i had a guy who i the intake form from my office lists uh you know you have a partner are you married yes is your what what sex was your spouse assigned at birth and they were female so i read that i was like okay blah blah and i sat down with this guy who identifies as bisexual and he's going on preps like as they're non-monogamous they're polyamorous and they have sex with other people and i was like cool okay well here's the situation blah blah blah and i said and your wife is your wife active with men women or both he's like well my husband actually and i was like what you aren't femaling from like yeah he's a trans man i was like oh okay and i actually got burned on my own form because i literally didn't have a way of describing and i will now the sex assigned at birth and then the gender of your partner because it matters because in that regard i have to think about does the person they have sex with have a penis or a vagina do they need certain vaccinations um this is pretty dry and i'm going to breeze through most of it because i'm going to tell you right now the answer to nearly every preventative medicine thing you can think of is screen prenatal sex if you have the parts you do the thing you're supposed to do for those parts if you have breasts you need mammograms if you have a prostate you need psas that's how this works this is all available and there's on the back of uh in the back desk back there there's my cards and there's a powerpoint presentation that's linked to my website and also the dr will powers facebook page which you can download this whenever you want so i'm going to tear through it really fast because i'm running out of time and i want to make sure you guys don't get held too late um current past hormone use if you have a neo vagina that is made of anything but colon you do not need to pap it it's stratified squamous epithelium if you have a colonic vagina from a choloplasty you need to pap it because it's columnar epithelium and it gets cancer if you have the organ screen prenatal female rules for cervical cancer breast cancer or uterine cancer if you have it you do what you would do anyways for cardiovascular disease screen prenatal sex consider that hormones might increase lipids screen lipids there's really not a whole lot of other things you need to do cardiovascular disease again pretty much same thing taking estrogen respect to lipids transgender people who have not used cross-sex hormones require the same screening criterias persons of their natal sex if you identify as transgender but you have done nothing about it you haven't taken anything you just get screened as to what you were assigned at birth being transgender is not a license to not eat well i often see my transgender women not exercising because they don't want to get buff because they view that as a masculine trait i see my transgender men gaining weight so they can be more blocky to try and hide some of their breast tissue effectively they have a belly like they flatten themselves down with a binder clothing you need to know that this thing exists it's called an stp or a stand to pee free tom makes the most of them there's a number of different things if your patient uses this they need to clean it every day or they get some really really nasty utis they basically suction cup it or glue it onto the front of the vagina and then they can stand and urinate through it as you can see this is the same human wearing bras and wearing binders these things can be really tight i do what's called the powers four finger tests well at least i call it that someday someone else besides me will call it that um but basically i take four fingers and i go like this and i put it on the side of the patient so you don't do it on the front where it's all dysphoric and weird you go over here where there's actually the greatest amount of impulse tightness from the binder which is squeezing their chest to flatten them down and if it causes them like if when you put your fingers in there they collapse onto each other you cannot keep them in a row it's too tight because effectively that's enough force to squish the rib cage down which does cause considerable problems over time and i've seen i mean the the saddest part is that they end up getting top surgery eventually and then they have what i call reverse muffin top so because they have literally squeezed their chest for so many years all their organs get forced down into the abdomen below the height of where the ribs are so they kind of blew out this way and then their top is completely flat and masculine looking after mastectomy so they look ridiculous and it's because of many years of doing this make sure you monitor this in your patients you'll see forms um in patients early in transition that have no breasts that want to they will use these sometimes they'll wear a thing that's their i have one patient that wears things are the size of beach balls i'm like are you serious and they're heavy they must weigh 40 pounds and i can see back pain associated with them because if you're not if you haven't had these on your chest for years and they're only on some of the time your musculature is not designed for this you know uh center of gravity being moved forward and they get back issues mental health being transgender is not a mental illness but transgender people have mental illness more than general population screen them be more attentive to it musculoskeletal health pretty much the same uh if you have estrogen you need d and calcium transgender women get osteoporosis they get it more when you do a crappy job of prescribing them hormones they don't have a high enough dose i see it a lot and people have been on like a pittance of oral estrogen for a long time um you can do same pulmonary screening basically in the same as you would um getting people to quit smoking telling them that like hrt is really risky use with smoking which it is um is a great way to quit get somebody to quit motivates them like oh if i quit smoking i can go on hrt and i do that same with hiv come on in for your hiv treatment while you're here i'll treat you for hormones and i literally get them to come for that reason every three months because they're really coming for their hormones that's why they're showing up but i'm treating their hiv while i'm at it and i'm effectively when their viral load goes to zero i remove them as a node from the community when the w the world health organization says if your viral load is undetectable you cannot transmit the virus period unprotected or not so these people that i have properly treated are no longer nodes in the community infecting other people don't assume the sexual orientation of transgender patients also it changes like a lot my very first transgender patient was a young trans man who i started on testosterone who identified as a lesbian came out as a trans man and now is a gay trans man they're gay and they stay gay um anecdotally if you come to me as a female to male and you show up like my name is helga i'm here to transition like they're already heavily masculine facial hair they don't change they generally stay the same but the ones that are like five foot to five foot three pixie like 110 pound soaking wet human with very feminine facial features they're attracted only to women when they come in and then they're attracted only to men a year later i've seen it happen an astronomical amount with transgender women it's more of a slow gradual shift if they're attracted to men at the start they stay that way generally speaking if they're attracted to women at the start or the the colloquial term is trans being a transgender woman lesbian um they're attracted to women only at the start they tend to shift a little bit towards bisexuality over time a variable amount with estrogen exposure depends on the human but it's something you need to be aware of because if somebody's previously been attracted only to women and you're not screening them or vaccinating them for hep b according to cdc guidelines and their behaviors change from hormones you need to know about that so i usually ask my patients their sexual orientation at least once a year if not more often providers for care for transgender people should enhance their hiv expertise for reasons i already said use a gloved finger appropriate speculum be nice when you're doing exams of people don't do unnecessary genital exams don't ask a transgender person whether or not they've had the surgery unless you need to know because they have a gynecological complaint like unless it's relevant to your care for them you don't need to ask them things if a transgender person comes in and sees you in the er for acute otitis media it doesn't matter that they're transgender you would not be like oh so i noticed that you're black or oh so i hear you have an accent you must be british like and it's not things that you would just bring up to people like you wouldn't start talking to them about what's it like being british well you would be taking care of your patient so when you start asking them these questions about transgender things it can be very insulting and demeaning to somebody because they feel like they're only viewed in that lens so if i were trans i would be like will the trans guy instead of will the doctor who loves cats and is into bitcoin and video games and bicycling and blah blah who's also trans people often get ped like pigeon holed in that identity silicone injections we already talked about pumping parties this is a thing you just got to keep an eye out for especially in the gluteal area and along the hips and saddlebag region substance use is considerably increased in the entire lgbt population with transgender people actually not being the worst lesbians tend to be the worst for smoking alcohol with gay men everybody has a distribution that they end up in but transgender people are kind of in the middle when it comes to the lgbt community for substance abuse still still almost double though the stray population thyroid screening same thing vaccinations there are certain things you need to do based on who they have sex with so what parts do you have and who do you have sex with treat them accordingly for that homelessness is incredibly high the tragedy discrimination survey reveals a 19 homeless rate i'd say at least 10 to 20 my patients currently are homeless i try and help them with that problem on a regular basis but it's very difficult hiv and aids already talked about transgender women of color have a hiv positivity rate of 56 57 actually as of this year i should update the slide it's pretty bad so you should write them this this is a drug that exists i want to jump up and down so i can show how excited i am about it you should write this drug anyone can write this drug in any specialty anywhere it's called truvada also known as prep soon it will be replaced by a newer farm called the scovi but the short and narrow is that this drug when taken every single day as prescribed makes you pretty much immune to hiv it protects you against nothing else and i see a ton of other std infections in the people on this drug because they feel like it's like a license to go out and do whatever the hell they want unprotected so i constantly seeing syphilis and gonorrhea and really weird infections in these people saw cankeroid a couple years ago totally serious but it is so effective that in like half a million people who have taken it there's been two infections two two and of those two both of them had when they tested their hair had serum levels under what would be considered uh therapeutic they were only taking it a couple times a week so like taken perf there has never been a documented case somebody taking the drug right with proper serum levels that pop that positive from it is that effective and you can get it from for free and gilead has all these things you can do to help them get it for free and most insurances will pay for it so just write it you need an hiv test on them before because if you give them this drug excuse me and they're already hiv positive you screw up nucleosides you literally wreck the whole class so don't do that but if they're hiv negative within a week of the time you're gonna write them the drug you write it for them every three months you check them again you monitor their liver and kidney enzymes make sure everything's okay for those who prescribe hrt we're getting the real end now we've got three slides left um do or do not there is no try if you're gonna do this for somebody and prescribe them hrt you do it or you don't please stop being the doctors that are sending me these people who've been on a pittance of estrogen in a tiny dose of spyro for years even if you're going to do the wpath method at least do it right where they're like afraid like here's two milligrams of estrogen a day and 25 a spyro and they like the patients don't know they think that'll work so they spend five to ten years of their life like languishing away and transgender hell stuck in between two genders in society where they don't fit in and they feel totally out of place don't do this either do it or don't or send them to me i'm i welcome the competitors i i'm overwhelmed i literally can't see them at the rate that they're coming in right now we had 23 new patient calls today i i'm gonna have to stop soon and say i'm full that's it and i opened three months ago that's how i have that's let me make that clear i open on february 25th and i've seen over 500 novel humans since that time that's the rate at which people are flowing into my practice so like i welcome other people to do this make good use of the time you get so i almost died a little while ago and i'll talk about it but yeah this is how long you have left to live just so you know something you should be aware of make sure you spend your time right you're doing things that you find rewarding but this applies to transgender people because a lot of them feel like they didn't get to actually live their lives until they're finally out so be aware of this this is literally how long you have left to live and if if you're over 75 well then good for you about me um i went to pitt studied neuroscience chemistry i studied universidad de carlos de madrid in espanol i'm fluent in spanish i lived in madrid for a while i went to licom i did my residency downtown at wayne county health authority and then i'm bored in family medicine i specialize in lgbt care i have a cool office in farmington hills called powers family medicine this is the brother of the world record cat phoenix there is an arcade machine i have in my lobby my office is super chill um i'm going to talk to you about this really quick and then i'm going to be done so on november 12 2017 i woke up my wife was at work rounding in the hospital and my house was on fire and i tried to put it out and i couldn't so what i did is i grabbed the fire mask that i had prepared for this eventuality and i ran around searching the upstairs as long as i could um for my cats uh two weeks before the fire they had been uh announced the guinness world record holders and we've been on good morning america like tv shows and like well not physically on that one but we're on pickler and ben and like channel 4 and all this other stuff like flying around the country with them appearing on tv shows so i hunted for them as long as i could um until i the fire mask actually separated out and i breathe in a whole bunch of smoke and i collapsed and i passed out and i almost died i got pretty mangled windows blew out glass cuts all over the face i didn't work for over a year and all this was because i didn't have enough fire extinguishers um i maybe i could have fought it if i had more i don't know but we weren't prepared enough we had just recently moved into this house we just got married and so we just we weren't ready and what it was was a massage chair that my old boss gave me he didn't want it at the office anymore i've been there for years we took it home i loved it it was great i had it in the living room it was plugged in but off and it just decided to burst into flames and when i woke up the seat of the chair had flames coming out of it this wide around that were like this high and i couldn't put it out i tried in short they all died i almost died and i lost everything i've ever owned in my entire life aside from my cell phone and the clothes i had on at the time because i'd used it to call 9-1-1 if you don't know uh when you call 9-1-1 your phone locks out so the cats had trackers on their necks tile trackers that i used to page them to find where they are and when i attempted to do that i couldn't open the app because i was in 9-1-1 mode and my phone was locked out so just if you ever call 9-1-1 be aware that it is the only thing you can do with your phone while you are in 9-1-1 mode that is a law i didn't know that but unfortunately it made it on me unable to track them and set the alarms off because i would have heard them even in the smoke and been able to find the sound to get to them but i couldn't do that so in short be prepared this is the brother of arcturus the world's tallest cat this is phoenix arcturus powers so arcturus is arcturus aldebaran powers you can google them and they're there there's a bazillion articles about this whole thing um where our family was famous and then infamous within a one month time frame but phoenix comes to the office on mondays and tuesdays and is the therapy cat there and on wednesdays thursdays and fridays polaris goes who's the bengal cat and they were in the pictures earlier they're also in the pamphlets back you see the smaller bengal cat and he's a savannah he's an african circle hybrid if you ever want to get the latest version of this lecture you can do it here i always publish it here and there's a link to it on powersfamilymedicine.com that's it any questions and to be clear um i treat transgender people i treat hiv i treat the polyamorous community i treat the bdsm community specifically the detroit house of pain um i'm probably their primary provider because i these people come to me and they get hurt doing stuff you can ask me literally anything and i will not be phased by it i assure you i've heard more interesting questions than anything you could possibly dream up so knock yourselves out so i see about maybe two to three a week i have probably well a lot of them have aged out i have like 100 that i've seen i probably have like 50 right now a lot of them are now 18 19 they've aged out during the time that i've been seeing them i don't start like i said young kids on hormones there's such a media like you know that we're say chopping off the penises of young boys who identify as transgender it's not true we're not doing it we don't do surgery on anybody so they're 18. um jazz is a very rare case they done at 17 and a half but we don't do that there's no need to do that you just block the kid i mean you could do this in any family practice internal matter like anywhere you don't have to be i'm not an endocrinologist i do endocrinology all day long but i'm a family practice doctor sometimes i treat sinus infections and other crap that happen to these same people but you can do whatever you want to do with your own practice but yeah i have i see kids but i primarily block them when they hit pubertal age then we start the process of doing hormones assuming they have gone through sufficient psychiatric and gender clearance at that point i will not allow kids to do informed consent so because i mean you're a kid you can't give informed consent that's the nature of being a minor even if the parent says it's okay you still have to go to psych nothing after all that really um how do you convince your male to female trans patients to use the topical testosterone on their penises yeah i'm going to um so how do i convince my transgender women to put topical testosterone on the penis when that is literally the opposite of what they would normally want to do i have it was not something i could have done three or four years ago in this community i have developed a reputation for being the guy i get better results than everyone else my patients do better and i have safer and novel ways of doing it so when i asked people to start sticking progesterone capsules up their butt a shocking number of them said it was okay and they do it so in that regard i tell them hey this is going to be safe and i monitor them too it's not like i don't just give them the t and then i don't monitor the level i will draw a level on them a few weeks after they're on the therapy they i generally use 0.5 which is like a third of androgel on the penis once a week sometimes twice a week and then i gradually like three to till we get to the point where the tissue is like happy and functioning again but i almost exclusively use it people either having pain or difficulty they want erectile function that can't i can always get anybody erectile function like i have a compounding pharmacy that makes me quad mix which is an injectable that's a combination of different things that basically like you could you could stick it into a corpse and it would get an erection i specifically actually have a quadriplegic patient who's completely paralyzed and uses it and it works and him and his wife can have intercourse as a result so there's always ways around it so to speak but with the topical testosterone i i tell them to do it and that it will be okay and they believe me and thus far i haven't heard anybody with it and nor regrown any beards because it's a pretty wimpy testosterone but it really does do the job is i have a lot to say about lee khan um lawrence family got stuck with me leecom um was a tremendous education i have to say that they prepared me better for boards and other places than pretty much any other medical school out there with the things that they did however they are a totalitarian dictatorship and it is a miserable place to go to medical school it was a complete we we often me and my wife joke we sing that song as a rihanna we found love in a hopeless place so yeah we met over a dead body but yeah elite com was brutal don't get me wrong um but they they do do a tremendous job of educating their students i cannot fault them for the education i got it wasn't any fun but it was a great education yeah i just could you speak a little bit more on just the process of going against the norm and experimenting with these things that i mean that sounds like it's really possible yeah so um so the patient and the sort of the the oh my god i want to say patient the um the person asked me um what it's like to go against the norm and that the kind of process and how that feels to do that and admittedly it was not a thing that happened overnight it's sort of a gradual process like the frog in the boiling water um i started to notice things that i was like huh this worked better than that or and then i had a lot of i spend a lot of time online i'm very active on reddit um much to the sugar into my wife but basically i i uh i spent a lot of time talking on transgender forums two transgender people and a lot of them are diy-ers in other parts of the world and they gave me their labs and results and other stuff and information that was basically me i call it my anecdata because it's like like an unofficial study but i aggregated a tremendous amount of attic data and started to realize that things didn't have to be the way that they were and then over the span of many years like i discovered the estrone thing first but when i discovered the estrone thing i was still writing spyra then i started to switch to the bit glutamine then i started to realize i could use progesterone as a blocker like each thing was incremental so it wasn't like one day i woke up and said i've invented the powers method it really was just a gradual way of doing it over time um but i was i should have published it already i was about to publish it um right before the fire um but it was destroyed all my research was destroyed in the fire and to be totally honest i was very mentally ill for a long time after the fire and i was terminated for my job they knew that and they didn't look like i was coming back basically and so they terminated me and i therefore lost access to all those patient records and all the research material i had on my laptop at work i never got back so i've had to completely start over from scratch and so i'm hoping by the end of summer to get the very first publication the estron one done and out there and then once i like right now i'm the guy in michigan that's how a lot of these doctors refer to me as i have people from all over the world send me messages sometimes doctors are like i tried what you did it's incredible it's so much better thank you so much and then i have people that are like the head of endocrinology at the maine gender gender clinic for the nhs in england is basically of the opinion that i'm a complete idiot and that's okay i'm totally fine with that that's also what they told the guy who discovered helicobacter pylori they told him he was a total idiot he was wrong and then he drank the dish himself and then he got a nobel prize so like depends but he was laughed at he was literally laughed at and so these people they can feel whatever they want to feel about what i do but yet i have a lot of satisfied customers i haven't hurt anybody i've had zero complications and if you look at my face i'm the highest ranked family doctor in the state of michigan um i have basically over 140 reviews now and they are all five star except for one single one star review from an anti-vaxx mom who's mad that i wouldn't see their trans kid because they think that the kid is uh trans because of vaccines and i yeah i know um i know what are you gonna do um but the worst part is that i treat aids patients i have actual people with aids that sit in my lobby like legitimate aids like on azithromycin on drugs bactrim to prevent them from dying of aids i can't have your measles kid next oh i had an actual measles case i'm one of i'm one of the doctors that had one i had one of my one of my patients i can't tell you i was about to tell you information about them and i can um one of my patients who may or may not fall into this group was exposed to one of the jewish kids at one of those centers downtown and then developed 105 fever and a rash and the whole thing and didn't go to the hospital for like two days they were like i'll get better so they finally came in we were like oh my god this is measles so we sent them to the hospital and they tested positive for measles which is nuts and uh long story short we'd like call like every single person in the clinic at that time period and make sure that they had all been vaccinated and get a booster does anyone within a two-hour time frame of their exposure there was this whole protocol i had to follow but yeah so that that happened too so i guess you know you go against the grain you're gonna have to deal with some of that sort of stuff but i'm patient i'll uh it's gonna be a war of attrition because what's happening is that the people are seeing my methods this powerpoint has been downloaded like a quarter million times it went viral off so i made this after the fire full disclosure i was very mentally ill and i wasn't sure how much longer i was going to be around and i had lost everything and so i had put all this time and effort into this research and i never got to publish it and i couldn't do it officially then i wasn't even working or anything and access to no patient data i had nothing that i could write it with so i basically made this and i released it online so that in the event i died it would be available to the public so that eventually other people would discover it because i'd like to think that someone else would come to this conclusion on their own but yet estrone and all these other things have been known since like the late 90s and yet no one has done this yet so i i would say that no matter who you are or whatever field of medicine you're in don't discount yourself and your own intuition and clinical experience because you can absolutely advance medicine to make discoveries and things that i never would have imagined that i could have done just by sheer luck my own stupidity one thing i discovered by accidentally clicking the wrong lab and i got a result back that was like astronomical and i'm like oh my god oh i didn't order that oh i did order that but then i studied it and figured out why it happened so i mean that's the concept i guess sort of a vague answer to your overall question but anybody else yeah um oh hell yeah i mean that's just being a man so we know that transgender men um so repeat the question um do i see increased aggression in my my ftm patients on testosterone transgender men commit crimes uh pretty much on parity with cis men i mean if that's an argument for testosterone they're you know that like so to speak men are wired differently i've never heard one but i constantly have them come in and be like i'm so angry all the time and i'm so horny and hungry and raw and that's just the nature of tea like they i've had transgender men come and crying apologize to me for what society does to men i know i'm not me too movement right now right like imagine that like they literally this has happened to me like no less than 10 times apology i'm dr powers i'm so sorry now that i know what it's like to have lived life as both a woman and a man it's just so wrong what society does to men and how they how they treat us and how and i'm like uh-huh tell me more about that but in reality it is absolutely a thing they see increased sex drive increased aggression they commit crimes like i said equal to that of cis men it's a thing you have to watch for and it's like something i warn them for particularly i have problems where when the sexual orientation flips and they're already in a long-term relationship cause a lot of relationship discord and when you have that like me club me angry it's like in your brain like that id that intrinsic like way of functioning and you have not been raised to be a gentleman girls are not raised in society not to hit their brother they just hit the guy like that's why we see women slap men but you don't see men like deck women in society on the regular it's just not an acceptable cultural thing girls can hit a boy but guys can't hit a girl well if you've been raised that you basically are not held to that standard your whole life and then now you're filled with rage and testosterone you don't have the societal conditioning to behave as a gentleman and i have absolutely seen them commit crimes get in trouble with the law relationship violence like yes to answer your question yes you have to monitor for it and you back down their tdos if it happens some people i i generally let my trans men run between about 700 and 900 which is effectively where i was at peak physical like fitness when i rode for pitt's crew team back in the day i was carved at a marble and that's what my testosterone was i had like 900 and so i'm like that's what would be normal for a young healthy man as they get a little older i let them run a little lower that kind of following would be like you know 500 600 range down to 400. especially if they fully masculinize like they're totally maxed out there really isn't any need to keep them running that high or as i say running that hot almost like you're rubbing the engine um but effectively yeah i mean it's a thing you have to monitor and adjust accordingly based on the patient's behaviors and reported issues nope so yeah that's pretty much it um so to repeat the question do we have an association do we work together me and the other providers i know all of them i can tell you them right now like they're patricia smith alzahili um the u of m's gender services center bishop randolph i think who else off the top of my head does it they're used uncle diddles used to do it sikorsky who's a doctor that's been on trial a lot for various reasons but he doesn't have a dea anymore so he doesn't write testosterone so i just absorbed hundreds of his patients it just came over to me um but yeah so they're they're all doing their own thing uh they're all following the w path method more or less um a couple people do some slight variances u of m doesn't prescribe progesterone period just no the answer is no you get spiro and estrogen that's it that's what you get at u of m that's their rule that's how they do it and so yet while while we kind of punt patients around to each other as people get frustrated with one provider or another i've tended to aggregate more than i've lost apparently because my methods are different and i'm willing to do things for people other people aren't but there is no major medical society besides the w path which you can belong to which i did belong to back in the day and i no longer never renew my membership because i don't agree with what they do um but i at least how often am i sitting in bed answering emails or being on reddit more than my wife would like replying to doctors from all over the planet that send me random messages yeah i mean i'll respond to pretty much anybody if you hit me up on the internet you ask me a question i'll give you advice i won't tell you like what you should personally do i'll never give personal medical advice somebody i haven't examined they're like for a similar patient yes your estrone of 4000 and your estrodial of 200 is a problem i would have corrected this in my clinic because a lot of patients are finding out about my theories and then getting their own labs run at like any lab test now you can go to like websites and order these labs and they're like being told by u of m that what they're doing is fine they then go to the lab they find out their s drone is astronomical and then they come to me and they're like so that happens a lot and whether they're from u of m or from ucsf or washington or texas i have patients that fly in from like everywhere so far we've seen people from alaska hawaii washington california texas we had a patient drive all day from maine and then drive back the same day which is pretty crazy but at least once or twice a week i have a patient that either flew in to see me or drove from an incredibly long distance sometimes a lot more than that the first couple weeks it was nuts it was like every other patient was from like a totally other state because they just can't find the care that's my point of like if you guys are going to do this it's i i literally feel like field of dreams like if you build it they will come like i did not intend to do this i just had one and two and then four and then i became like the hold and call field of the transgender population like catching them in the rye like as they come to me because there's just so many of them i can't catch them all i can't i need help i do this to try and be like hi help me there are too many they need help they need care some people are driving to me from astronomical distances that's ridiculous they should be able to go to their family doctor get this done it's like it's not that complicated it's really not no no anybody else nothing juicy yet come on all right cool thanks i will hang around afterwards if anybody wants to ask me anything you didn't feel like asking in front of 30 other people