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In the U.S., approximately 1.4 million adults identify as transgender and the number of transgender people accessing healthcare for gender dysphoria and related treatments is on the rise. In this episode, Murat Altinay, MD discusses the neurological underpinnings and managing care for individuals with gender dysphoria.

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Gender Dysphoria

Podcast Transcript

Intro:  Neuro Pathways, a Cleveland Clinic podcast, exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD:  Gender dysphoria, the in congruence between assigned sex and expressed gender has existed in human society for thousands of years. But only recently has researched begun to examine its underpinnings and shed light on how to manage care for individuals with gender dysphoria. In today's episode of Neuro Pathways, we're discussing this research and its implication for today's medical practice. I'm your host Glen Stevens, a neurologist neuro-oncologist in Cleveland Clinic's Neurological Institute. I'm very pleased to have Dr. Murat Altinay join us for today's conversation. Dr. Altinay is a clinical psychiatrist who specializes in transgender mental health and mood disorders in Cleveland Clinic Center for Behavioral Health. Murat, welcome to Neuro Pathways.

Murat Altinay, MD:  Thanks for having me Glen.

Glen Stevens, DO, PhD:  And I'd like to say that certainly this is an area that we could all use more education and is certainly topical in today's environment. So Murat let's get started a little more broad. Can you educate me and our listeners on the role you play in the care of transgender individuals and what your typical practice is, is a psychiatrist at the Cleveland Clinic?

Murat Altinay, MD:  Sure. So as you mentioned briefly, so I have two subspecialties. So one area is mood disorders and neuromodulation. So I treat people with severe mood disorders, bipolar disorder and depression. And I use neuromodulation techniques such as DBS, DNS, and TMS to treat those conditions.

Then the second sub specialty is the LGBT mental health specifically in transgender mental health. So all of my practices are outpatient. So I am at main campus seeing patients in an outpatient clinic. With the LGBT health, I am primarily focused on transgender people who are in the process of transitioning from their biological gender, to their experience gender. And my role in that clinic, I wear different hats. So one hat is that I do clinical assessment from the psychiatric standpoint for their readiness, for the gender affirming treatments, such as hormonal treatments and surgeries. And also obtaining them with documentation such as recommendation letters for such surgeries. And then as a member of the LGBT team, I'm also a participant of the monthly meetings that we have. Also the quarterly meetings that we have with the larger group of providers. And most recently I've been awarded with a title of the head of LGBT mental health services at the Cleveland Clinic. So I have some administrative and some leadership roles in that area as well.

Glen Stevens, DO, PhD:  Good. So that we're all on the same footing, can you define gender dysphoria as you see it?

Murat Altinay, MD:  Gender dysphoria is a psychiatric diagnosis first of all. And it has a somewhat bumpy history in psychiatry. So the first time we ever see it in our diagnostic tool is the 1970s. And the first term that was coined in that aspect was transsexualism, which is something we don't use anymore. In DSM-IV, the title was changed to gender identity disorder, which was also a problematic title because it kind of insinuated that transgender people had a personality disorder, or there was something wrong with their identities, which obviously is not the case.

And in DSM-5, we finally get to the gender dysphoria aspect where the identity gets taken away from the description. And the focus is on the symptomatology of dysphoria, which means that the discomfort or the dysphoria that comes from the mismatch between the identified gender and the biological gender. Despite the fact that we call it gender dysphoria, a lot of people confuse, even sometimes psychiatrists actually confuse that with depression or anxiety. And there are some overlapping symptoms, but gender dysphoria is a completely separate diagnosis. And people, usually the dysphoric symptoms get better as they complete their transition. But if there's also an additional depression to it, then we treat the depression as well. So I want to make that distinction.

Glen Stevens, DO, PhD:  Good. Your team has done extensive work, identifying the biopsychosocial underpinnings of gender dysphoria. Can you talk us through some of your findings and research?

Murat Altinay, MD:  So before I talk about the neurological underpinnings, I also want to clarify a couple of terms because I'll be using them when I describe these things. So when it comes to transgender identity, we have to know three different terms. So the first term would be cisgender, which means non-transgender people. As in, I was born male and I identify as male, which makes me a cisgender person. And when it comes to transgender identity, we usually use the terms male to female transgender or female to male transgender, meaning the first word being the biological gender transition into the identified gender. So when it comes to the neurological underpinnings, we need to be familiar with the self body perception. So there are a lot of areas in the brain, some areas and networks, I should say, that are involved in self body perception, such as thee your right anterior parietal lobe, the temporoparietal junction, posterior cingulate, and so forth.

So this will show that these areas were shown to represent the self body image in the brain. In addition to that, the default mode network and also the salience network, we're also networks that are involved in the self body image networks. So the studies show that there are some functional and structural differences in these networks and brain areas. And that's what the research really focuses on right now. So when we looked at the literature, there were some structural and functional differences between the transgender brain and the cisgender brain. So I categorize these changes as structural and functional, because they're a little bit different when it comes to which areas are affected. So when it comes to structural findings, they looked at post-mortem studies, they looked at some volume metrics studies, and they looked at some functional studies. So let's focus on the structural changes first.

The post-mortem studies, which focused on male to female transgender brain, found out that the volumes of transgender women were similar to that of cisgender females in certain areas, such as the central nucleus of the bed stria terminalis or interstitial nucleus of the anterior hypothalamus. So these are areas that are essential in sexual behaviors, and the fact that the transgender female brain resembles the cisgender brain was important. And then people also looked at some gray matter volumes and cortical thickness. And again, transgender brains showed similarities to the identified gender even before they started hormonal treatment. So these were some very important structural differences that were shown. Then when it comes to the functional findings, the FMRI findings of the transgender brain versus the cisgender brain, the self body image networks become very, very important because what was shown was that within the self body image networks, there was decreased connectivity in the transgender population compared to the cisgender population, showing that there was a problem, or there was an issue with body self -perception when it comes to transgenders understanding their own bodies.

And which was very, very important. And then the second functional studies looked at brain activation studies. So in these conditions, people were given certain tasks and the activation of the certain brain areas were looked at. And again, transgender people showed a lot of similarities to their identified gender as opposed to their biological gender.

So in light of all of these findings, we brought the concept of brain gender, because currently, when we are talking about gender, it is the common understanding is that your genitalia determines your gender. But what we're saying is that the brain actually is the main source when it comes to understanding your own gender and your gender identity. So we're bringing the term the brain gender, which can be different than your genitalia. So that's one concept. The second thing is when your brain doesn't match the body that you're in, you find yourself in this cognitive dissonance your entire life, right? So the external world is telling you that this is your gender, but your personal experience is different. So that creates a dissonance. And when you combine the brain gender and the dissonance, then that's how we get the gender dysphoria.

Glen Stevens, DO, PhD:  To go a little bit further. One of the advantages we have here is a 7-Tesla MRI. Have you found that helpful? Is it gleaned any new information?

Murat Altinay, MD:  We are in the process of developing some research studies in that area. So our team in mood disorders, we use the 7- Tesla and we find it very beneficial, but we haven't been able to use that for the transgender population just yet. But, there are some studies that we are working on, which might come into fruition in the near future. Yeah.

Glen Stevens, DO, PhD:  And I'm curious, are we seeing a younger presentation for gender dysphoria in your practice?

Murat Altinay, MD:  Yes and no. So my practice gets patients from all over the Midwest, to be honest with you. So I have patients from in the middle of nowhere, Ohio to some of the more urban parts of Cleveland. And I do get a lot of younger patients. Yes. And they also tend to be more open and expressive about their gender. But I also get 75 year olds who lived their lives in the closet for decades and are now just coming out to express their gender. So I see all kinds of patients.

Glen Stevens, DO, PhD:  Are there any unique neurologic correlations, consequences, phenotypes, with gender dysphoria patients that are unique?

Murat Altinay, MD:  Well, so I described some of the things earlier. So, there's the structural differences and the functional differences, but it is still very difficult to pinpoint what the unique difference is. Maybe I can talk about that here. So one of the biggest things that is missing, I think in the literature is to look at some specific gender dysphoria tasks and then look at brain activation and functionality. So that is really missing. For instance, if we can create a situation where patients feel dysphoric during the FMRI imaging and then look at the brain activation that would give us the most specific and unique findings of gender dysphoria, I think. But we're not there yet. And one thing I would like to be able to do is actually just that, to look at specific brain during a specific dysphoric condition.

Glen Stevens, DO, PhD:  While we've made strides in researching the underpinnings of gender dysphoria, individuals with gender dysphoria, still face significant barriers to healthcare. How are we currently managing these barriers and what complexities do providers and patients face?

Murat Altinay, MD:  Yeah, I mean, there are still many, many, many barriers when it comes to LGBT health care, especially transgender health. So to start, as you may remember from your own medical school experience, so the amount of time allocated to LGBT medical health is very, very limited. So I think currently the average medical student gets three to four hours of LGBT health in four years of medical school, which is obviously not enough. And it is resulting with new physicians coming into workforce without knowing what LGBT healthcare really is. So that creates one level of disparity. In addition to that, LGBT people or transgender people in general have low socioeconomic status, they have higher or bigger psychosocial stressors. And when that added to them, seeing physicians who are not very knowledgeable in this area, that creates a major issue and make them probably shy away from seeking healthcare, which is really important.

So those are the main issues that we're seeing with the LGBT healthcare in general. In addition to that, there is also an argument that we are overly medicalizing, the transgender care, because in order for a transgender person to transition, they have to have letters from psychiatrists and psychologists. And they have to be on hormones for at least a year in order to get any kind of gender affirming surgery. And then if you add up all of the other barriers, it takes a transgender person years, if not a decade, to actually complete a transition. So, all of these things create a lot of barriers for this population.

And I think one thing you mentioned in that question was what can we do or what do we do to help with these barriers? So I think what I'm personally, or my team is trying to do is to expand our services. For instance, we have a big presence in Lakewood Family Health Center, but we're going to expand that to some local clinics as well. We're trying our best to educate medical students and fellows and trainees. I give grand rounds and go and talk to some other non-physician staff in other departments, because it was brought to my attention that places like Taussig for instance, was having some issues with dealing with transgender people in the sense that asking the right questions at the right time when it comes to cancer disparities. And of course, increasing visibility. So a podcast like this, for instance, I think is a great tool for people like me to gain some visibility when it comes to LGBT health.

Glen Stevens, DO, PhD:  And what percentage of people out there would have gender dysphoria?

Murat Altinay, MD:  It is difficult to say, I don't think there is any clear data, but obviously in the Western world and in European countries, the documentation of these things is a little bit better. So when I look at the data, so in Europe and the US it's around 1 in 1000%, so that's where it is. But in most of the world, these things are not really captured adequately. So it is difficult to say, to be honest.

Glen Stevens, DO, PhD:  And I'm just curious, are there other psychiatrists in the institution that do this, or are you the lone ranger?

Murat Altinay, MD:  So in the adult psychiatry world, it is me. And we recently got a nurse practitioner who is working with me, but in child psychiatry, we have another psychiatrist. So in total we have three mental health providers, two in adult world, and one in peds psychiatry.

Glen Stevens, DO, PhD:  And is there increased risk of suicidality in gender dysphoria patients?

Murat Altinay, MD:  Sure. So traditionally there was this concept of LGBT people or transgender people with dysphoria having higher rates of suicide risk and depression, anxiety risk. So it is true that the risk and the co-morbidities or the dysphoria levels are higher. But when you look at the data in more detail, you find out that these are the case when people don't have access to transition specific care. Or when they cannot get the help that they need. Once they get in the right system and once they start transitioning, all of these issues get better. So I guess, the traditional concept of LGBT people always have a high risk of suicide is not that accurate. I think that becomes the reality when people cannot get what they need when it comes to expressing or living their own gender.

Glen Stevens, DO, PhD:  So if I see a transgender patient, is there anything specific that I should address with them as an neurologic patient?

Murat Altinay, MD:  So I think in general, my biggest recommendation for physicians, medical students, non-physician staff is to avoid assumptions. And don't shy away from asking questions. For instance, if you see somebody who appears to look like a male in front of you, but if you don't ask about their surgical status, their gender identity, you might actually miss somebody who may appear masculine from outside, but could still have uterus and be at risk for uterine cancer, right.

And making assumptions and not asking the right questions would lead to mistakes. And you can also lose the trust in the doctor, patient relationship. But my biggest recommendation for any clinician or anybody who interacts with transgender people is to be able to preface the questions by saying, okay, I'm going to ask you some sensitive questions right now and it's going to help me understand you better as a human. And it'll also prevent me from making assumptions. So when you preface something like that, my experience has been that transgender people open up to you and they don't get offended by those questions. But if you make assumptions and make mistakes, then the actual problems really start because then you missed the opportunity to form that relationship with the patient, then you can actually make mistakes in your clinical diagnoses too. So that will be the biggest and the most important take home message from this I think.

Glen Stevens, DO, PhD:  Well, Murat, I would like to thank you for joining me today. It's been very educational. It's always exciting to learn how the field of psychiatry is changing and emerging. And how we can take better care of our patients. So once again, thank you for joining us today.

Murat Altinay, MD:  Oh, it was my pleasure. Thank you so much for having me.

Outro: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our consult QD website. That's or follow us on Twitter @CleClinicMD, all one word and thank you for listening.

Neuro Pathways

Neuro Pathways

A Cleveland Clinic podcast for medical professionals exploring the latest research discoveries and clinical advances in the fields of neurology and neurosurgery. Learn how the landscape for treating conditions of the brain, spine and nervous system is changing from experts in Cleveland Clinic's Neurological Institute.

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