Primary Care for Transgender Pa5ents. Objec5ves. Transgender 2/22/17. Charleston APRN Conference February 2017

Transcription

1 Primary Care for Transgender Pa5ents Charleston APRN Conference February 2017 Marty Player MD MS MUSC Department of Family Medicine Objec5ves Review terminology related to transgender people Review screening and primary care medical issues specific to transgender pa5ents Provide par5cipants informa5on and tools to help improve knowledge of and comfort with transgender pa5ents Transgender literally "across gender"; some5mes interpreted as "beyond gender a community- based term that describes a wide variety of cross- gender behaviors and iden55es. Not a diagnos5c term Does not imply a medical or psychological condi5on. 1

2 Barriers to Medical Care Geographic isola5on S5gma Lack of insurance coverage Lack of research and limited medical literature Limited training and knowledge of medical staff and providers Resources 2

3 Transgender Terminology Not all identify as transgender or use these terms We avoid attaching labels if not appropriate or comfortable. We ASK patients how they define themselves, and USE their preferred self-definitions and pronouns. Transgender-related terminology includes a wide variety of terms (and ever evolving and expanding) Terminology Quiz The classification of bodies according to the anatomy of the individual s reproductive system; described as male and female SEX 3

4 Social categories described as masculine and feminine GENDER The sense of oneself as male or female A person s internal experience of their own gender may or may not conform to conven5onal expecta5ons for their birth sex GENDER IDENTITY The outward presenta5on of one s gender, for example mannerisms, hairstyle, speech etc. MAY differ from their gender iden5ty GENDER EXPRESSION 4

5 A note on Gender Expression Most people who are NOT transgender dress and comport themselves in ways that reinforce their gender identity gender identity and gender expression are congruent Transgender people usually do the same- when possible Transitions require medical help May not feel safe Other Terms Female to Male, FTM, Trans man* person who is changing or has changed their body and/or lived gender role from a birth- assigned female to an affirmed male Male to Female, MTF, Trans woman* Change from birth assigned male to affirmed female *These terms have nothing to do with what people have or have not changed physically, hormones, surgery etc. Genderqueer Transexual not used as oden today Tranny slang term for transgender or transsexual. Some people find these highly offensive Avoid using 5

6 Mostly keep it simple Cis gender assigned sex and gender iden5ty are the same Trans gender assigned sex and gender iden5ty are different ASK pa5ents how they define themselves, and respect and USE their preferred self- defini5ons Iden5fica5on Patients may wish to be labeled 'Male' or 'Female based on gender identity/expression legal status registered with their insurance carrier. REMEMBER: none of this has anything to do with Sexual Orientation Trans affirming offices Knowledgeable staff Calling pa5ents Expanded and inclusive intake forms Gender neutral facili5es/bathrooms 6

7 Two- step Gender and Sex Ques5on What is your current gender iden1ty? Male Female Transgender Male/Transman/FTM Transgender Female/Transwoman/MTF Addi5onal category (please specify): Decline to answer What sex were you assigned at birth? Female Male Decline to answer May also ask which pronoun they prefer Relax and take it easy You already know 90+% of what you need to know for primary care of trans patients Two major principles: 1. MOST healthcare for transgender people has nothing to do with being trans 2. Healthcare and screening is based on the anatomy present (and hormone status) 7

8 Medical Care Recommenda5ons Published transgender-specific level 1 evidence is essentially non-existent. No long-term, prospective studies for most transgenderspecific health issues preventive care recommendations based primarily on expert opinion Data collection weaknesses further impacting the marginalization of transgender people lack of researcher access to the population, lack of cohesive community networks within the population, disagreement with terminology used to refer to the population Transgender Care Guidelines extrapola5on from studies based on non- transgender popula5ons adapted findings from the few long- term cross- sex hormonal assessments done in the Netherlands by Gooren, et al. combined with their own clinical experience Center for Excellence for Transgender Health UCSF Medical Advisory Board Developed care guidelines using AAFP SOR taxonomy 8

9 Transgender- related prac5ce using the following grade defini5ons and nota5on to indicate strength of recommenda5ons Hormone readiness and administration 60 years of off-label use for trans patients in Europe and the US Not all trans patients will want hormone therapy Guidelines do not require an endocrinologist initiate/continue hormones; can be a trained primary care physician The only absolute medical contra-indication to estrogen or testosterone therapy is an estrogen- or testosterone-sensitive cancer. Hormone treatment Hormone treatments are one of the easiest parts FTM Testosterone up to normal male dose Dose that masculinizes and stops menses is enough MTF More difficult because must suppress testosterone production to get best results Anti-androgen(s) Estrogens 9

10 Baseline Labs and Hormone therapy Transwomen fasting lipid panel (if on oral estrogen). If taking spironolactone, then include potassium and creatinine). Estrogen levels - Use F reference values for transwomen taking estrogens. LFTs not essential due to newer estrogen preparations Monitor prolactin level if elevated stop or reduce estrogen (not anti-androgen) Transmen Hemoglobin, LDL/HDL. Use M reference values for transmen taking testosterone. (Grade C) Testosterone Therapy - FTM Permanent changes Increased facial and body hair Deeper voice Male panern baldness Clitoral enlargement Reversible changes Cessation of menses Increased libido Increased muscle mass/strength Redistribution of fat Increased sweating/change body odor Weight gain /fluid retention Prominence of veins/coarser skin Acne Mild breast atrophy FTM considera5ons Testosterone reduces fer5lity but is not contracep5on! Testosterone cream in aquaphor for clitoral enlargement Estrogen vaginal cream for atrophy 10

11 MTF Estrogens at high dose 3-5x normal replacement doses Estrogen Supresses Testosterone! An5- Androgen Spironolactone Orchiectomy Results variable Age at star5ng is important ader 40 less change noted Breast Development Effects of Estrogen Redistribution of body fat Softening of skin Loss of erections Testicular atrophy Decreased upper body strength Slowing or cessation of scalp hair loss Spironolactone therapy Therapeu5c effects Modest breast development Hyperkalemia Risks Sodening of facial and body hair Hypotension Drug Interac5ons 11

12 MTF treatments MTF over 40 ASA 81mg therapy May use transdermal estradiol to reduce VTE risk Hydroquinone topical treatment for pigmentation caused by estrogen therapy Hair Removal Eflornithine cream Electrolysis Laser hair removal Role for Primary Care Assess patient comfort with transition Review medication use Assess social impact of transition Assess masculinization/ feminization Discuss family issues Monitor mood cycles Counsel regarding sexual activity Discuss legal issues / name change Review surgical options / plans Continue Health Care Maintenance Assess CAD risk Cancer Screening Screen transgender people who have not used cross- sex hormones or had gender- affirming surgery using the same criteria and risk parameters as for persons of their natal sex. 12

13 MTF Breast Cancer Screening Breast augmenta5on is not considered to increase risk Transwomen (MTF), past or current hormone use: Prostate: PSA is falsely low in androgen- deficient sepng, even in presence of cancer; only consider PSA screening in high risk pa5ents. (Grade C) Follow USPSTF guidelines Transwomen (Male to female) Pap smears in neovaginas are not indicated; neovagina is lined with kera5nized epithelium and cannot be evaluated with a Pap smear. May perform periodic visual inspec5on with a speculum If STI is suspected, do a culture swab, not PCR. Neovaginal walls are usually skin, not mucosa; Follow standard screening recommenda5ons for other cancers 13

14 Cancer screening Transmen: Breast cancer: annual chest wall/axillary exam; mammography as for natal females (not needed following chest reconstruc5on, but consider if only a reduc5on was performed). Cervical cancer (uterus/cervix remain intact): follow Pap guidelines for natal females; may defer if no history of genital sexual ac5vity; inform pathologist of current or prior testosterone use (cervical atrophy can mimic dysplasia) Fenway Health - Boston healthcare facility serving the LGBT community in analyzed Pap test results from 233 FTM and 3625 female pa5ents between 2006 and FTM pa5ents were more likely to have an inadequate Pap mul5ple inadequate tests delayed follow- up tes5ng five 5mes longer than female pa5ents. Extreme care with gynecologic exams 5me when extreme emo5onal conflict between self- percep5ons and physical anatomy are heightened because of physical touch HPV tes5ng offers alterna5ve screening 14

15 Cardiovascular Disease Transwomen planning to start feminizing hormones within 1-3 years: bring SBP 130 Hg DBP 90 mm Hg bring LDL to 135 mg/dl Transwomen currently taking estrogen: monitor for cardiac events/symptoms, especially during the first 1-2 years of hormone therapy in pa5ent at high risk use transdermal estrogen, reduce estrogen dose, and omit proges5n use Trans- men not currently taking testosterone: screen and treat hyperlipidemia as with non- transgender pa5ents. Trans- men planning to start masculinizing hormones within 1-3 years: try to bring systolic pressure to 130 mm Hg and diastolic pressure to 90 mm Hg, and bring LDL to 135 mg/dl (3.5 mmol/l) Diabetes Transwomen currently taking estrogen: consider annual fas5ng glucose test, esp. if family history of diabetes and/or > 12 pounds weight gain. Treat diabetes according to guidelines for non- transgender pa5ents Consider decreasing estrogen if glucose is difficult to control or pa5ent is unable to lose weight. 15

16 Bone Health - Osteoporosis Transwomen, post- orchiectomy: To prevent osteoporosis either maintain estrogen therapy or consider combina5on of calcium/vitamin D supplementa5on and bisphosphonate consider bone density screening for agonadal pa5ents who have been off estrogen for over 5 years. (Grade A, B, C) Bone Health - Osteoporosis Transmen: Consider bone density screening if age > 60 and if taking testosterone for < 5-10 years if taking testosterone for > 5-10 years, consider at age 50+ recommend supplemental calcium and vitamin D in accordance with current osteoporosis preven5on guidelines HIV and STI screening The USPSTF recommends that clinicians screen for HIV infec5on in adolescents and adults aged 15 to 65 years Grade A High risk more frequently (which is??) Every 6 months, annually Higher risk of HIV among transpeople 16

17 STI Screening Assess Drug use Needle sharing (drugs or hormones) Previous STIs Current sexual activities (specifically) Consider HepB/C, GC, Chlamydia, syphilis testing q 6-12 months Pre- exposure Prophylaxis (PreP) Prevent HIV transmission in any high- risk person Truvada (emtricitabine/tenofovir) shown to reduce the risk of HIV infec5on in people who are at high risk by up to 92% Kaiser Permanente Medical Center in SF men, followed 32 months 99% MSM No new HIV cases Mental health Depression Anxiety Substance use Screening for alcohol, tobacco and drug use 17

18 Insurance and Legal Protec5on Varies by state, town, city, plan etc Plans offered through Medicaid, Medicare, or the state/ federal health insurance Marketplaces (ACA), categorical exclusions based on gender iden5ty are now prohibited. Some states explicitly ban transgender exclusions in health plans: Cali, Colorado, Conn, DC, Illinois, Mass, Nevada, NY, Oregon, Vermont, and Washington State. Medicare Medicare covers rou5ne preven5ve care regardless of gender markers. May be ini5al confusion based on gender marker with the carrier Medicare covers medically necessary hormone therapy Medicare covers medically necessary sex reassignment surgery Exclusion eliminated May 2014 Coding Gender iden5ty disorder Trans- sexualism NOS Hormone deficiency Estrogen deficiency Testosterone deficiency

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