Photo: Sharon Kilgannon

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2 Photo: Sharon Kilgannon

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8 Photo: Paul Grace

9 Photo: Marie Claire

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11 of trans and gender variant people have a non-binary gender identity McNeil et al. (2012) Trans Mental Health Study 2012, GIRES

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13 Dmitry Nikolaev / Adobe Stock

14 0.1-1% Unselected population studies in Netherlands, Belgium, USA, New Zealand and UK Typically small study samples relative to the population Much higher than studies conducted in healthcare settings Kuyper L, Wijsen C.(2014) Arch Sex Behav 43(2): UK Equality and Human Rights Commission, 2012 Gates et al. (2011) UCLA: The Williams Institute.

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17 Photo Andrey Popov / Adobe Stock

18 Global meta analysis of HIV prevalence 19% HIV prevalence in trans women (Odds Ratio 49) Baral S et al. (2013) Lancet Inf Dis. 13(3)

19 Baral et al. Lancet Inf. Dis Volume 13, Issue 3, 2013,

20 Global meta analysis of HIV prevalence 19% HIV prevalence in trans women (Odds Ratio 49) Rates of Syphilis, Gonorrhoea, Chlamydia In trans women higher or comparable to MSM Baral S et al. (2013) Lancet Inf Dis. 13(3) Fernandez F. et al. (2015) Sex Transm Infect 91: Leon SR. et al. BMJ Open 2016 Jan 6;6(1):e008245

21 Count Me In Too Study Brighton % never had STI screen vs. 24% non-trans group More likely to feel that local sexual health information and services was not appropriate to their sexual practices Browne, K. & Lim, J. (2008). Count Me In Too: Additional FIndings Report - Trans People. Brighton.

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23 Photo weedezign / Adobe Stock

24 The Clinic Setting Waiting areas, Toilets etc Documentation / IT systems Registration proformas, EPR, National Reporting

25 2 Stage gender question What is your current gender? Male, Female, Trans Male, Trans Female, Non-Binary, Other (please specify), Prefer not to say What gender were you assigned at birth? Male, Female, Prefer not to say

26 Photo Monkey Business Images / Shutterstock.com

27 Preferred Pronoun (He / She / They etc) I d like to make some notes about what we talk about today, what pronoun would you like me to use for you?

28 Be sensitive to genital dysphoria Ask about preferred terminology Are there any words you would like me to use for specific body parts when we talk about your tests? Be specific / avoid euphemisms

29 Hormone treatment (if any) Obtaining from NHS, Private, Internet, Friends? Mental health, drug and alcohol use Sexual violence, non-consensual sex, sex work Psychosexual issues

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31 Is an examination required? Self taken swabs / urine may be fine STI screening: Screen for the anatomy not the gender Think beyond STIs

32 Trans Women Genital surgery (if any) what type, when, where? Complications / revision surgery Vulval sensation / sexual function Dilating - frequency / size / depth / pain / any recent changes

33 Speculum examination Examination using proctoscope may be preferred Can be inserted by the patient (similar to dilator)

34 Vaginoplasty Skin lined vagina (Majority of cases) Penile / Peno-scrotal inversion, Skin grafting Mucosal lined vagina Colovaginoplasty recto-sigmoid / caecum

35 Vaginoplasty Skin lined vagina (Majority of cases) Penile / Peno-scrotal inversion, Skin grafting Mucosal lined vagina Colovaginoplasty recto-sigmoid / caecum Influences risk of infections and potential complications

36 Is a vulvovaginal swab sufficient to screen for CT / GC? Skin lined vagina - Possibly sub-optimal sampling - Urethra main focus of infection - Add Urine NAAT Mucosal lined vagina - Likely to be adequate for screening - Microscopy / screening as for rectal specimens

37 Normal post-vaginoplasty microscopy appearance Cornified squamous epithelial cells Mixed gram +ve / gram ve flora (very variable morphology) Image from Weyers et al. (2009) BMC Micro 9:102

38 Other Issues Overgranulation Presents with bleeding after sex / dilating Treated with chemical cautery (silver nitrate) / laser Intra-vaginal hair regrowth Vulval pain / dysaesthesia / sensory loss Rarer conditions: (Seek specialist help) Introital / vaginal stenosis, prolapse, fistulae, perforation, diversion colitis (Colovaginoplasty)

39 Trans Male Examination Normal to see clitoral hypertrophy testosterone effect Speculum exam often more uncomfortable Increased muscle tone due to testosterone Reduced vaginal secretions

40 Trans Men Phalloplasty / Metaidioplasty Involves multiple surgeries significant complication risk Complication rate higher if urethra formed (stricture / fistulas) Vagina not always removed introitus may be narrowed Seek specialist advice if suspect surgical complications

41 Other Issues Vaginitis / atrophic changes Change in vaginal epithelia ph elevated, parabasal cells, inflammatory exudate PV bleeding Exclude endometrial hyperplasia Nambiar et al. Sex Transm Infect 2015;91:A12 doi: Post phalloplasty issues: Urethral strictures fistula, dysaesthesia / pain, Erectile implant issues

42 In all trans patients Don t forget extragenital (pharyngeal / rectal) testing HIV / Syphilis / Hepatitis screening Hep B vaccination

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44 Trans men not on cervical screening programme once gender registered as male Cervical sampling more uncomfortable 10x more likely inadequate cytology 1 Testosterone associated atrophic or metaplastic changes in the cervix 1. Peitzmeier, S. et al. J Gen Intern Med May;29(5):778-84

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46 Trans men / non-binary identified having receptive vaginal sex should be offered contraception advice Testosterone treatment does not guarantee anovulation Non-hormonal methods LNG IUS (Mirena) may be helpful in accelerating amenorrhoea

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48 iprex Study Subanalysis Randomised controlled trial of Truvada PrEP 339 trans women randomised in study post hoc subgroup analysis done More likely to have (compared to MSM) Lower educational level, condomless anal sex, recent concomitant STIs, transactional sex, cocaine and meth use Deutsch M. et al. Lancet HIV Dec;2(12):e512-9.

49 iprex Study Subanalysis 11 seroconversions in treated group, 10 in placebo (ITT analysis) None of those who seroconverted had protective drug levels All trans women were less likely to have protective levels on random testing than MSM group Deutsch M. et al. Lancet HIV Dec;2(12):e512-9.

50 iprex Study Subanalysis Drug Drug Interaction? No evidence for this so far 1 1. Deutsch M. et al. Lancet HIV Dec;2(12):e

51 Treatment Adherence Patients not taking PrEP effectively Concerns about effect on hormones Poor group specific education and promotion

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57 Clinic T - Claude Nicol Centre Tamara Woodroffe Ali Parnell cliniq 56 Dean St., London Michelle Ross Aedan Wolton Dr. Laura Mitchell The Laurels Gender Identity Clinic Dr Jane Hussey City Hospitals Sunderland NHS Trust Terence Higgins Trust Brighton LGBT HIP Brighton Trans Alliance

58 Contact Other Links: GIRES: Center of Excellence for Transgender Health (USA): THT: