Coming Around: Parenting Lesbian, Gay, Bisexual, and Transgender Kids (20 page)

LESBIANS AND THE PATIENT-PHYSICIAN RELATIONSHIP

Lesbians are at a higher risk for gynecologic cancers. It is a myth that women who don’t have sex with men don’t need preventive screening. Many lesbians have a combination of risk factors (such as weight problems, smoking and being nulliparous or childless) that increase the chance of developing breast cancer. Add issues with gaining access to care and the result could be a delay in important medical interventions.

GAY MEN AND THE PATIENT-PHYSICIAN RELATIONSHIP

Gay men have a high prevalence of sexually transmitted diseases (STDs). Some STDs are curable, such as syphilis, gonorrhea and chlamydia. Some are not curable, such as hepatitis A, B and C and the human papillomavirus (HPV). For years, the prevalence of HIV in the gay population was trending down, but in recent years it has been increasing. While treatment for HIV has resulted in substantial improvements in the quality and length of life of those affected, there is still no cure.

Educate your child about safe sexual practices early and often. It’s the physician’s job to help. S/he should be able to discuss safe sex in a knowledgeable and comfortable manner with your son. Ask your son’s physician to explain his or her approach, first to you and then to your child. This allows you to evaluate the physician’s knowledge and attitude before s/he gives counsel to your child and also makes it possible for your child to have a private conversation with the doctor. This will help your child make the connection between sex and relationship and will promote safe sex. Anonymous sex is often risky sex.

When vaccines are available, take advantage of them. Men who have sex with men are at increased risk of contracting hepatitis A, B and C and HPV. Hepatitis is a serious liver disease that can ultimately lead to cirrhosis and liver cancer. Vaccines are available to prevent hepatitis A and B and they are recommended for gay adolescents. There is no vaccine to prevent hepatitis C; safe sex is the only means of prevention. In addition, new evidence suggests that boys and men
benefit from being immunized against HPV. The human papillomavirus can cause warts and also increases the risk of developing anal cancer. The HPV vaccine is available for both girls and boys. Most of the cancers caused by HPV affect women and for that reason, physicians are likely to advocate the strongest for the vaccination of girls. Men who have sex with men are at a higher risk for HPV-related cancers so gay male adolescents, in particular, benefit from vaccination.
⁵
If your child’s physician does not suggest the HPV vaccine, it is a good idea to bring up the subject.

Men do not see their primary care doctors as frequently as women do. Gay men are even less likely than heterosexual men to seek preventive care. I suggest that you get your adolescent off to a good start with self-care by identifying a culturally competent pediatrician/provider. Young men need to be screened for testicular cancer and they need to be shown how to do a testicular self-exam. Gay adolescents are at risk of avoiding this examination. A positive early experience with a primary care provider will enhance trust and establish a habit of preventive screening.

TRANSGENDER PERSONS AND THE PATIENT-PHYSICIAN RELATIONSHIP

Unfortunately, sometimes when they are young (because of parental rejection), or as adults (because of employment discrimination), transgender persons are often left without health insurance and without the money to pay for health care. One of the most important things a parent can do for a transgender child is to maintain connection. This is especially true in regard to access to health care. With healthcare reform, in some instances children may remain covered by their parents’ health care until the age of twenty-six.

Often, transgenders do not disclose important details of their health histories to their physicians. For instance, a transgender patient
might fear that disclosing a history of depression may result in failing to pass a psychological evaluation necessary for gender reassignment. Transgender patients may purposely exclude their histories of transition when visiting a new doctor, even many years after surgery. Perhaps this is due to a fear of rejection, stigmatization or negative past experiences with previous providers.

Failure to disclose important medical details can result in incomplete or inappropriate treatment. A lack of trust in a physician can also lead to dropping out of care. Parents of transgender youths can play an important role by establishing care with a pediatrician or primary care provider who is comfortable with gender identity issues, knowledgeable about transgender care and nonjudgmental toward transgender persons and those who seek gender reassignment.

Estrogen and antiandrogens are used in male-to-female hormonal reassignment and testosterone is used in female-to-male hormonal reassignment. Though these hormones are found in both men and women, hormone reassignment alters the balance to achieve the desired changes in secondary sexual characteristics.

Hormone therapy can have negative side effects. Estrogen can cause “blood clotting, high blood pressure, elevated blood sugar and water retention.” Antiandrogens can lead to “dehydration, low blood pressure and electrolyte disturbances.” Testosterone “carries the risk of liver damage.” Hormone reassignment is not considered a medical need and many transgender persons will try to bypass the healthcare system to obtain treatment. It is important that hormone reassignment occur under the supervision of a physician. Parents may consider providing financial support for hormone reassignment in order to ensure medical supervision.

Transgender persons are at increased risk for heart disease and cerebral vascular accidents (strokes) due to smoking, obesity, hormone treatment and lack of early and regular screening for hypertension and other disorders that contribute to these diseases. If a transgender male or female believes a health provider will ask him or her to stop taking hormones, the person may avoid care, even in the presence of
medical symptoms. Again, it is important for parents of transgender individuals to advocate for sensitive health care. When conflicts about treatment arise, they are best handled in the context of a trusting patient-physician relationship.

Medical checkups should include screenings for hormone-related cancer, such as breast cancer in transgender women, liver cancer in women and men and cancer of the reproductive organs in women and men. Without removal of such organs as the uterus, ovaries, breasts and prostate, transgender men and women are still at risk for developing cancer of these organs.

Some providers are uncomfortable with treating such cancers in transgender people and transgender people may avoid examinations of the parts of their bodies that they reject. As a result, these cancers may spread before detection because of a lack of preventive screening. Parents of a transgender youth need to help their child deal with the dissonance s/he may feel about obtaining preventive care when that care exposes the child to gender-based examinations that conflict with gender identity. Communicating feelings is the first step to managing them. Parental support and the support of an understanding and skilled health provider can make a big difference.

Transgender youths who leave home are less likely to find employment and are more likely to resort to prostitution in order to survive. This puts them at high risk for HIV and other sexually transmitted diseases. Other transgender youths may put themselves at risk for unsafe sex due to discrimination, which inspires hopelessness and may lead to other types of self-destructive behavior. Furthermore, in the midst of all a transgender individual endures, concerns associated with unsafe sex may seem trivial. Parents can accentuate the importance of safe sexual practices.

Transgender people often experience rejection and depression, leading to high incidences of alcohol abuse. The introduction of sex
hormones combined with alcohol abuse increases the risk of liver damage. Tobacco use is high in this group, utilized especially for suppressing appetite in an effort to lose weight. Tobacco use increases the risk of heart attacks and cerebral vascular accidents, especially when combined with administered estrogen or testosterone. If your child is transgender, talk with him or her about the increased dangers associated with combining tobacco and alcohol use with hormone reassignment. Make an arrangement to support hormone reassignment financially in exchange for your child’s alcohol or tobacco moderation or abstinence. In the case of addiction, seek treatment for your child as early as possible with a culturally competent medical professional.

Some transgender women use injectable silicone in an attempt to feminize their appearances. The silicone is often administered at “pumping parties” by non-medical persons. Silicone administered in this manner is prone to “migrate in the tissues and cause disfigurement” in the future and “is usually not medical-grade material and may contain contaminants.” In addition, needle sharing has resulted in the spread of hepatitis. As your child enters adolescence, you will lose the ability to monitor his or her every action. What you can do is stay educated on the possible risks and share the information with your child so s/he can make better choices.

Many transgender people work long hours to support their transitions, so exercise and healthy nutrition may not be priorities. For transgender women, exercise that promotes healthy bones and musculature may be avoided for fear of bulking up and appearing more masculine. Exercise is good for everyone and maintaining good health “prior to sex reassignment will reduce a person’s operative risk and promote faster recovery.” Tell your transgender child that you want him or her, above all, to stay healthy and help him or her find ways to make health a priority.

Mike’s Story

Seventeen-year-old Mike was effeminate. As early as grade school, Mike began saying that he wished he were a girl. His parents were not surprised when he told them that he was transgender. After coming out, he experimented with eyeliner and mascara. Then he began discussing the idea of starting hormone therapy. His parents were anxious and frightened.

Mike has been constant in regard to his gender orientation. By taking on some of the social signals of femininity, he began to come out to the world. Coming out is different for transgender youths, because they have less control. Gays can conceal their sexual orientation to some people while being open about it with others. For instance, if a gay couple is holding hands and approaches a group of people whom they know to be aggressive toward homosexuals, they can stop holding hands and pass as heterosexuals. While this can feel cowardly, it is not. There is a time and place to take a stand and the time and the place need to be self-chosen rather than imposed by others.

Transgender individuals aren’t afforded this choice. Once they take on the outward appearances of their felt genders, they take on risk. About half of all transgender individuals report experiencing physical assault due to their gender identity, with more assaults occurring to transgender females (male transitioned to female). I encouraged Mike’s parents to have an open discussion with him about how people at school and in general were responding to his wearing makeup. I asked if anyone had harassed him about his gender orientation and I asked Mike to make a deal to talk with his parents right away if anyone threatened him or made him feel threatened. I also encouraged the parents to discuss Mike’s gender orientation with his primary teachers, his coach, his principal, etc., to get their assurance that Mike would be treated with respect.

Mike was considering hormone therapy, which would help to align his felt gender with his appearance by increasing breast size, altering the fat-to-muscle ratio and suppressing the growth of facial hair.

Mike’s gender orientation wasn’t solidified, at least not to his parents. Mike had been dealing with this all his life, every day, but his parents were just coming to terms with the strength of Mike’s conviction. It was natural for
them to harbor the hope that Mike’s gender dysphoria would vanish—that one morning he would wake up feeling like a young man and be spared the hardships of being transgender. When it becomes clear that this is not going to happen, fear can set in. Mike’s parents needed to reach out for support and to talk with parents who had children at various stages of transition. Mike and his parents also needed to meet with a physician trained in providing hormone reassignment. If a well-regarded specialty center were in the area, it could offer a wide range of useful resources, including support groups for both Mike and his parents.

Besides getting the facts about transition, Mike’s parents had to come to terms with losing a son and gaining a daughter. As Mike underwent hormone therapy, he began to look different and sound different from the son they raised. “She” had a new name, different from the one they’d chosen for “him.” “She” had a new body, different from the one “he” was born with. In this case, parental grief should not be written off as a form of bias. While Mike’s biological gender was a torment to him, it was not a torment to his parents—it was part of their beloved child’s identity. Still, it was necessary for them to accept Michelle with open arms. Failure to make the shift would likely have resulted in unconscious distancing from Michelle, and that would have been the greater loss. On the other hand, letting go of Mike and joining in the transformation allowed for several benefits to emerge.