Clinical Case Discussions

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1 Clinical Case Discussions 9 th Floor: Sarah Eley, LICSW and Julie Thompson, PA-C 10 th Floor: Tim Cavanaugh, MD, Melissa Grieco-Waters, LICSW, and Lisa Moore, PhD, LICSW

2 Continuing Medical Education Disclosure Program Faculty: Sarah Eley, LICSW; Melissa Grieco-Waters, LICSW; Lisa Moore, Ph.D., LICSW; Tim Cavanaugh, MD; Julie Thompson, PA-C Current Position: Therapist, Fenway Health; Therapist, Fenway Health; Assistant Professor of Social Work and Family Studies, St. Olaf College, Minnesota; Medical Director, Trans Health Program, Fenway Health; Physician s Assistant, Fenway Health Disclosure: No relevant financial relationships. All hormone therapy for transgender people is off-label. It is the policy of The National LGBT Health Education Center, Fenway Health that all CME planning committee/faculty/authors/editors/staff disclose relationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.

3 Case 1: Description 42yo transgender woman who reports she always knew she was female. Married to a cisgender woman for four years, divorce was finalized 4 months ago. She investigated genderaffirming hormone therapy for several years, but had not sought hormone treatment due to marriage. She had sex with multiple cisgender male partners in the past 12 months and uses condoms all the time. Recently started spironolactone 25mg PO twice daily and estradiol transdermal patch ER 0.1mg/24 hours twice weekly. 3

4 Case 1: Questions 1. How would you educate this client about realistic expectations for hormonal gender affirmation? 2. What would your treatment plan be for hormone therapy in this client? 3. What considerations would you give to education and exploration of potential sexuality and sexual functioning changes due to hormone treatment effects? 4

5 Case 2: Description 67yo transfeminine person seeking gender-affirming hormone therapy. Uses he/him pronouns At 10yo he found out from his mother that he was born as a result of a violent rape and he found this very traumatic. He was raised in traditional religious household and underwent gay conversion therapy. A few lifetime sexual encounters with men, no significant romantic relationships until he met a cisgender gay man at the senior center this year. He is anxious about having romantic intimacy. His thought process at baseline is tangential, with loose associations. He believes he and his mother switched gender identities when he was a fetus and that he is therefore emotionally female. Under stress he sometimes has delusions and hallucinations: While caring for his brother, he had the sensation that he was ingesting semen and other bodily fluids off ground and believed he would develop an infection. While eating chicken with a friend, he believed she was calling him chicken. One remote psychotic episode several years ago, stabilized with antipsychotic medication. No current psychiatric medications. 5

6 Case 2: Questions 1. What would your treatment plan be for gender affirmation for this patient? 2. What information is important for diagnosis of gender dysphoria and for assessing hormone readiness? 3. What considerations do you have due to age that might be different if this person was 27 years old? 6

7 Case 3: Description 28yo transmasculine person who initiated social gender affirmation 18-20yo, had chest construction surgery at 22yo, and took testosterone from 22-25yo. After developing a beard, he stopped taking hormones and his beard growth persisted. Prior to starting hormones he had long periods of amenorrhea, and looking back he believes he likely had PCOS. No menstrual periods for the past 6 years. Pelvic ultrasound shows a thin endometrial stripe consistent with atrophy. He does not want any feminine sexual characteristics to develop, but he does want menses. He may want to have a pregnancy in the future. 7

8 Case 3: Questions 1. How do you support and council this person in his desire for biological children? 2. How do you work with a patient s goals that do not fit the social understanding of a binary paradigm? 8

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