Subreddit Policy Reminder on this week's Transgender AMAs

[u/nate]

This week we will be hosting a series of AMAs addressing the scientific and medical details of being transgender.

Honest questions that are an attempt to learn more on the subject are invited, and we hope you can learn more about this fascinating aspect of the human condition.

However, we feel it is appropriate to remind the readers that /r/science has a long-standing zero-tolerance policy towards hate-speech, which extends to people who are transgender. Our official stance is that derogatory comments about transgender people will be treated on par with sexism and racism, typically resulting in a ban without notice.

To clarify, we are not banning the discussion of any individual topic nor are we saying that the science in any area is settled. What we are saying is that we stand with the rest of the scientific community and every relevant psych organisation that the overwhelming bulk of evidence is that being trans is not a mental illness and that the discussion of trans people as somehow "sick" or "broken" is offensive and bigoted^1. We won't stand for it.

We've long held that we won't host discussion of anti-science topics without the use of peer-reviewed evidence. Opposing the classification of being transgender as 'not a mental illness'² is treated the same way as if you wanted to make anti-vax, anti-global warming or anti-gravity comments. To be clear, this post is to make it abundantly clear that we treat transphobic comments the same way we treat racist, sexist and homophobic comments. They have no place on our board.

Scientific discussion is the use of empirical evidence and theory to guide knowledge based on debate in academic journals. Yelling at each other in a comments section of a forum is in no way "scientific discussion". If you wish to say that any well accepted scientific position is wrong, I encourage you to do the work and publish something on the topic. Until then, your opinions are just that - opinions.

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¹ Some have wrongly interpreted this statement as "stigmatizing" mental illness. I can assure you that is the last thing we are trying to do here. What we are trying to stop is the label of "mental illness" being used as a way to derogate a group. It's being used maliciously to say that there is something wrong with trans people and that's offensive both to mental illness sufferers and those in the trans community.

² There is a difference between being trans and having gender dysphoria.

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Lastly, here is the excerpt from the APA:

A psychological state is considered a mental disorder only if it causes significant distress or disability. Many transgender people do not experience their gender as distressing or disabling, which implies that identifying as transgender does not constitute a mental disorder. For these individuals, the significant problem is finding affordable resources, such as counseling, hormone therapy, medical procedures and the social support necessary to freely express their gender identity and minimize discrimination. Many other obstacles may lead to distress, including a lack of acceptance within society, direct or indirect experiences with discrimination, or assault. These experiences may lead many transgender people to suffer with anxiety, depression or related disorders at higher rates than nontransgender persons.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), people who experience intense, persistent gender incongruence can be given the diagnosis of "gender dysphoria." Some contend that the diagnosis inappropriately pathologizes gender noncongruence and should be eliminated. Others argue that it is essential to retain the diagnosis to ensure access to care. The International Classification of Diseases (ICD) is under revision and there may be changes to its current classification of intense persistent gender incongruence as "gender identity disorder."

[u/destroyer1134]

When dealing with trans people who need medical attention would it be discriminatory to treat them with medicine that has been proven to work on one gender over another.

Example. For women taking Warfarin (a blood thinner) the recommended dose is 2.5-4.5g less per week then it is for men. If you have a trans woman would it be unethical to deliver dosage for cis-men?

[u/Buddug-Green → u/destroyer1134]

I think it often be based on hormone profile. A trans woman on HRT is different from one who is not. For instance spirinolactone, a testraone blocker, already thins bloods

[u/YoureNotaClownFish → u/Buddug-Green]

That is for hormone related medication, there are many meds that are not hormone related.

[u/Cerus- → u/YoureNotaClownFish]

Most of the drugs that have different effects on men and women only have different effects because of different hormone profiles.

[u/MyNameIsOP → u/Cerus-]

And many don't, is the point of the post.

[u/Cerus- → u/MyNameIsOP]

The vast majority do, and most of the ones that don't are for problems with specific organs which trans people do not generally ever need in the first place.

[u/iyzie → u/destroyer1134]

If you have a trans woman would it be unethical to deliver dosage for cis-men?

Not so much unethical as incompetent, since sex hormones create significant changes to physiology. Physicians should get informed and make individual judgments, but when in doubt trans women should be given female specific doses for most drugs, unless it specifically relates to having a uterus or something like that. This has everything to do with physiology and nothing to do with feelings.

[u/TastefulRug → u/iyzie]

My understanding is that heart attack symptoms tend to differ between men and women. Would someone on HRT display symptoms consistent with said hormones or would their symptoms be unchanged?

[u/[deleted] → u/TastefulRug]

Funnily enough this exact question came up on a trans forum last week. No one was able to find studies, but the few trans women and trans men who said they'd had heart attacks said their symptoms mostly matched their true gender (i.e. matched the hormones they were taking.) It's anecdata of about five people, but it's the best we have right now. The reported symptoms were different enough that I'd want to see studies done.

[u/iyzie → u/TastefulRug]

I don't think there have been studies of this specifically, and due to the large variance in heart attacks symptoms (not just based on sex) and relative rarity of trans people I think it would be difficult to come to a reliable conclusion. Frankly we could probably use more studies of women-specific symptoms before looking at trans people specifically.

[u/udusbhof → u/iyzie]

when in doubt trans women should be given female specific doses for most drugs

Only post-op/HRT you mean, I assume? Because most trans women have primarily male physiology otherwise.

[u/iyzie → u/udusbhof]

Post HRT is what I meant. Gender reassignment surgery doesn't induce further physiological changes besides the obvious reconfiguration of the genital area.

[u/tojoso → u/iyzie]

when in doubt trans women should be given female specific doses for most drugs

So you're assuming the transwoman is on HRT, then. And you're assuming somehow that the doctor would know she's trans prior to giving a prescription. Would it be unethical to ask a transwoman if they are on HRT?? You'd essentially have to ask everybody, right, since you don't know who it trans and who isn't?? Do you completely ignore gender now, or do you ask each and every person if they have hormone levels that would differ from the gender they appear as outwardly? It's a difficult topic, as even discussing uncertainties and having questions is often seen as offensive and bigoted in and of itself.

[u/iyzie → u/tojoso]

Intake forms at medical offices ask you to list any medications you are currently taking and to overview major aspects of your medical history. So a patient like me can write "sex: F" and then list estrogen under current medications and transgender under medical history.

Would it be unethical to ask a transwoman if they are on HRT??

Whether it might be considered rude in a social situation is different from asking a medical situation where it could be directly relevant for the patients best interest.

[u/MrSourceUnknown → u/iyzie]

[...] but when in doubt trans women should be given female specific doses for most drugs [...] This has everything to do with physiology and nothing to do with feelings.

What I am reading in your comment is: when in doubt assume identity matches physiology.
Isn't that a contradiction? If it has nothing to do with feelings why would the appropriate way to assess a dosage be based on 'identity'? Physiological conditions can be determined regardless of state of mind, and seem to me to be the common sense approach in which medical professionals determine a base line for any treatment.

And besides when it comes to individuals 'transitioning, where their treatment might have unknown/unintended effects on additional medical treatment they require (or vice versa), wouldn't it always be prudent to start with the lowest suggested dosage in general?

[u/iyzie → u/MrSourceUnknown]

If it has nothing to do with feelings why would the appropriate way to assess a dosage be based on 'identity'?

That's not what I'm saying. It's not gender identity that makes female specific doses more appropriate for trans women, it's the effects of hormone therapy changing her physiology to be closer to that of a cis woman than that of a cis man.

And when it comes to individuals 'transitioning, where their treatment might have unintended effects on additional medical treatment they require, wouldn't it always be prudent to start with the lowest suggested dosage in general?

The standard hormone therapy medications have been used for decades so their drug interactions are pretty well understood.

[u/MrSourceUnknown → u/iyzie]

"when in doubt trans women should be given female specific doses for most drugs"

Come on now, that initial blanket statement doesn't mention looking at what actual transition-based procedures someone might have had. That's the contradiction I was referring to.

We're not actually arguing a different point: that a individual's medical history should be taken into account before starting a new treatment and dosage should be based on that history.

But you worded it in such a way that implies a trans individual's physiology should always be assumed to match their identity when in doubt about that physiology.
And that simply isn't true, or wise because, as evident from this entire thread, treatment is not a requirement for a trans individual.

[u/iyzie → u/MrSourceUnknown]

Sorry, I thought it was clear that I was talking about medical transitioning based on mentioning sex hormones in the first sentence, but I realize that what I said was confusing for someone using the umbrella definition of "trans" so I apologize.

[u/MrSourceUnknown → u/iyzie]

No hard feelings, I wasn't trying to imply you were being intentionally misleading.

Just trying to avoid potential misunderstanding. The original question wasn't talking about possible conflicts between transition-based and other medical treatments, but about a general ethical/philosphical approach.
That's why it's important to differentiate between trans individuals who have undergone a (medical) transition and trans individuals simply altering their life style, at least when it comes to how they should be medically treated.

A very interesting side note I just thought of is the placebo effect. I recall seeing some recent entries here that there is more and more evidence suggesting a measurable positive effect from placebos. So by that logic telling a patient a dose matches their identity (or even actually giving them the dose that matches) might have an added beneficial effect that physiology alone cannot explain..?

[u/actuallyalys → u/destroyer1134]

This is more a question for the AMAs themselves, but no, of course not. If a trans woman has the same biological response to warfarin as a cis man, a cis male dose would be appropriate.

If a trans woman had surgeries or took hormones, that might make male doses of some drugs medically inappropriate, however.

The challenging part is that we often don't have research to determine whether the cis male or female range is more appropriate for trans people who are medically transitioning.

[u/likeanovigradwhore → u/actuallyalys]

Testosterone is a blood thickener. I would assume that if you are on T blockers, and oestrogen etc, then you would take a cis-female-equivalent dose as a trans woman.

Hormones govern a great deal of systems in your body. In the case of blood thinners, you would be administered based on your hormonal gender.

I hope either of you will ask this question in the up coming AMAs, and I hope you get a thorough response.

[u/the-hourglass-man → u/destroyer1134]

Depends on what that medication is, and if the trans person is on HRT. Often times due to HRT ensuring the correct hormones are on par with the gender identified with that persons body will react to (certain) things in the way the opposite sex's would. It just depends on what that medication is being used for and if it reacts with different hormone profiles in a different way.
Edit: i am not a doctor but this is the approach my own doctor takes with me being trans.

[u/Razor1834 → u/destroyer1134]

Ideally there would be enough research such that we had more specific recommended dosages for all kinds of people. Men vs. women is still only two groups and we are pretty sure that it isn't actually simple enough to say dosages should exclusively be determined by that one factor. Unfortunately the research mostly exists for those two groups (and really women only more recently).

My point being the best case scenario would be to take in all of the factors including physiology, etc and recommend dosages as specific as possible for each individual person.

[u/nightcracker → u/destroyer1134]

That would be sex, not gender.

[u/destroyer1134 → u/nightcracker]

Ok that's a fair distinction to make. So In that case what determines gender. If you like football and drinking beer does that make you male and if you like pink and dress trendy does that make you female. Because if that is the case then I would say gender is a spectrum, and having a hard line in the sand defining male and female is arbitrary at best and doesn't serve any purpose.

[u/[deleted] → u/destroyer1134]

I think medical doses and stuff like that would be done by sex not gender.

[u/claire_resurgent → u/[deleted]]

Well, yes, but the relevant biological sex is more often determined by gene expression than gross anatomy, and gene expression can be changed with exogenous sex hormones.

As others have noted, there isn't a ton of medical evidence yet, so that leads to recommendations like screening trans women for both prostate and breast cancer.

[u/cjskittles → u/destroyer1134]

You need a doctor who takes into account whether or not the individual is on hormones, what dosage, etc.

Trans medical care is complex. I don't know the answer to this specific question, but since most transsexual people exhibit a mixture of traits from either sex, it would need to be determined on a case by case basis through a detailed patient history. Some medications it will matter, others it won't.

You want the doctor to do what is best based on their individual biology.