HEALTH CARE FOR TRANSGENDER PERSONS

Transcription

1 HEALTH CARE FOR TRANSGENDER PERSONS Tim Cavanaugh, MD Medical Director for the Trans Health Program Fenway Health 1

2 TRANSGENDER refers to a person who is born with the genetic traits of one gender but has the internalized identity of another gender The goal of treatment for transgender people is to improve their quality of life by facilitating their transition to a physical state that more closely represents their sense of themselves. 2

3 TRANSGENDER DEMOGRAPHICS Data from the Netherlands 1 in 11,900 males 1 in 30,400 females 3

4 TRANSGENDER DEMOGRAPHICS Massachusetts Behavioral Risk Factor Surveillance Survey (2007, 2009) 0.5% of population between ages California LGBT Tobacco Survey 0.1% of adult population Estimate in U.S. from the Williams Institute 0.3% of adults Approximately 700,000 people

5 ETIOLOGY OF TRANSGENDER Research into genetics, brain anatomy and function, hormonal influences, but, the fact is, we just don t know. Recent review of twin studies shows an approximate 30% concordance in MtF monozygotic twins and an approximate 23% concordance in FtM monozygotic twins (Diamond, 2013) fenwayhealth.org 5

6 ENDING STIGMA AND DISCRIMINATION From the National Transgender Discrimination Survey: Refusal of care: 19% reported being refused care due to their transgender or gender nonconforming status, with even higher numbers among people of color in the survey. Harassment and violence in medical settings: 28% of respondents were subjected to harassment in medical settings 2% were victims of violence in doctor s office Lack of provider knowledge: 50% of the sample reported having to teach their medical providers about transgender care.

7 ENDING STIGMA AND DISCRIMINATION: Many transgender people maintain their assigned gender role for fear of stigmatization Many don t discuss with caregivers MN Study: 45% did not inform family physician they were transgender

8 GENDER DYSPHORIA The discomfort or distress that is caused by a discrepancy between a person s gender identity and that person s sex assigned at birth with its associated gender role and secondary sex characteristics (Coleman, SOC, V 7 p168) The focus of health care engagement is alleviating the distress.

9 TERMINOLOGY: UNDERSTANDING TRANSITION OR AFFIRMATION The process of changing from living and being perceived as the gender assigned at birth according to the anatomical sex (M or F) to living and being perceived as the individual sees and understands themselves Goes beyond medical care with mental health, medical and surgical treatment, and includes social affirmation and legal changes. Many prefer the term gender affirmation or gender confirmation over transition

10 TRANSGENDER STANDARDS OF CARE 10

11 CROSS-SEX HORMONE THERAPY 2010 meta-analysis (Murad, et al) of studies on hormone therapy 80% with improvement in gender dysphoria 78% with improvement in psychological symptoms 80% improved quality of life 72% improved sexual functioning

12 FEMALE TO MALE TREATMENT OPTIONS Injectable Testosterone Testosterone Enanthate or Cypionate mg IM q 2 wks (20-22g x 1 ½ needles) Transdermal Testosterone Androderm TTS 2-8mg daily Topical testosterone Gels in packets and pumps, multiple formulations (Testim, Androgel) 5 to 10 gm applied topically daily Axiron 2% pump gel for axillary application 1 pump to each axilla daily Testosterone Pellet Testopel- implant 6-10 pellets q 3 to 6 months Buccal Testosterone Striant 30 mg buccal system q 12 hours 12

13 MASCULINIZING EFFECTS OF TESTOSTERONE Effect Onset (months) Maximum (years) Skin oiliness/acne Fat redistribution Cessation of Menses 2-6 Clitoral enlargement Vaginal atrophy Emotional changes Increased sex drive 13

14 MASCULINIZING EFFECTS OF TESTOSTERONE Effect Onset (months) Maximum (years) Deepening of voice Facial/Body Hair Growth Scalp Hair Loss 6-12 Increased Muscle Mass & Strength Coarser Skin/ Increased Sweating Weight Gain/Fluid Retention Mild Breast Atrophy Weakening of Tendons

15 RISKS OF TESTOSTERONE THERAPY Lower HDL and Elevated triglycerides Polycythemia Increased risk of sleep apnea Infertility Increased libido may cause issues in relationship Mood lability. Potential to destabilize schizophrenia, bipolar disorder, impulse control disorders Hepatotoxicity? Unknown effects on breast, endometrial, ovarian tissues 15

16 MALE TO FEMALE TREATMENT OPTIONS Oral Estrogens Estradiol (estrace) 2-6mg PO or SL daily(can be divided into BID dosing) Premarin (conjugated estrogens) mg PO daily (can be divided into BID dosing) Transdermal Estrogens Estradiol patch mg twice weekly Injectable Estrogens Estradiol valerate 5-20mg IM q2 weeks Estradiol cypionate 2-10mg IM weekly 16

17 MALE TO FEMALE TREATMENT OPTIONS Anti-androgens Spironolactone (aldactone) mg PO daily (can be divided into BID dosing) Finasteride (Proscar) 2.5-5mg PO daily Lupron Cyproterone acetate

18 MALE TO FEMALE TREATMENT OPTIONS Progestins???? Benefit on breast development Risk of worsening depression Weight gain associated with increased risk of cardiovascular events and breast cancer in WHI Formulations: * Depo-Provera 150 mg IM q 3 months Provera 2.5 to 10 mg PO daily* Prometrium 100 mg 200 mg po daily* 18

19 FEMINIZING EFFECTS OF ESTROGENS & ANTIANDROGENS Effect Onset (months) Maximum (months) Decreased Libido Decreased Spontaneous Erections Breast Growth Decreased Testicular Volume Decreased Sperm Production Unknown Unknown Redistribution of Body Fat Decrease in Muscle Mass Softening of Skin 3-6 Unknown Decreased Terminal Hair 6-12 >36 NOTE: Possible slowing or cessation of scalp hair loss, but no regrowth No change in voice 19

20 RISKS OF ESTROGEN THERAPY Venous thrombosis/thromboembolism Weight gain Depression Decreased libido Hypertriglyceridemia ( but increased HDL) Elevated blood pressure Decreased insulin sensitivity Gallbladder disease Benign pituitary prolactinoma Infertility Breast cancer(?) 20

21 CHALLENGES RELATED TO CSHT How do we best manage persons who do not identify on a gender binary? Limited study data on the effects of different hormone formulations and dosing regimens No large US patient cohort

22 FULL HORMONAL MASCULINIZATION OR FEMINIZATION OCCURS OVER WHAT PERIOD OF TIME? 1. 6 to 12 months 2. 3 to 5 years months to 2 years 4. Never really occurs 5. Full is a subjective term that denigrates the desires and goals of individual trans persons 0% 0% 0% 0% 0%

23 GENDER AFFIRMATION SURGERY (GAS) SEX REASSIGNMENT SURGERY (SRS) GENITAL RECONSTRUCTION SURGERY (GRS) Surgery has proven to be an effective intervention for the patient with gender dysphoria. Patient satisfaction following surgery is high (Lawrence 2003), and reduction of gender dysphoria following surgery has psychological and social benefits. As with any surgery, the quality of care provided before, during, and after surgery has a significant impact on patient outcomes. Insurance coverage historically has been difficult to obtain.

24 SURGICAL OPTIONS FOR TRANS MEN Mastectomy with masculine chest reconstruction Hysterectomy and oophorectomy Genital reconstruction Phalloplasty Metoidioplasty

25 SURGICAL OPTIONS FOR TRANS WOMEN Augmentatin Mammoplasty Vaginoplasty Orchiectomy without Vaginoplasty Penectomy without Vaginoplasty Tracheal shave Facial Feminizing Surgery Vocal Cord Surgery to elevate voice pitch Lipoplasty of waist/ Augmentation of hips and buttocks 25

26 DIVERSE UTILIZATION OF SURGERY: FEMINIZING PROCEDURES MtF Breast Augmentation MtF Vaginoplasty Don't Want 28% Don't Want 20% Want Someday 54% Have Had 18% Want Someday 60% Have Had 20% Source: Grant et al., 2010:

27 DIVERSE UTILIZATION OF SURGERY: MASCULINIZING PROCEDURES FtM Chest Reconstruction Don't Want 8% FtM Hysterectomy Don't Want 23% Want Some -day 51% Have Had 41% Want Some -day 57% Have Had 20% Source: Grant et al., 2010:

28 DIVERSE UTILIZATION OF SURGERY: MASCULINIZING PROCEDURES FtM Metoidioplasty FtM Phalloplasty Want Some -day 52% Don't Want 45% Have Had 3% Have Had 2% Want Some -day 26% Don't Want 72% Source: Grant et al., 2010:

29 CHALLENGES RELATED TO SURGERY Patient expectations regarding surgery are often unrealistic and patients may need extra expert counseling on this to avoid poor outcomes Special counseling for patients in recovery re need for and use of potentially addictive or addiction triggering medications during and after surgery Triggering with BZD s and opioids plus disappointment that surgery did not fix every problem may cause relapse

30 GENDER AFFIRMING SURGERY IS: 1. Expensive and often not covered by insurance 2. A goal of all trans-identified persons 3. Fraught with complications and with high rates of dissatisfaction 4. Effective at treating gender dysphoria 5. B and C 6. A and D 0% 0% 0% 0% 0% 0%

31 HEALTH OUTCOMES 2011 review of Dutch patient cohort: 50% higher mortality rate in MtF individuals compared to general population No increase in mortality in FtM individuals 31

32 THE INCREASED MORTALITY IN TRANSWOMEN WAS DUE TO: 1. Heart attacks and strokes 2. HIV complications 3. Suicide 4. Diabetic complications 5. Substance use and overdose 6. Surgical deaths 0% 0% 0% 0% 0% 0%

33 HEALTH OUTCOMES Most of the increase in mortality was due to higher rates of suicide, drug-related deaths and AIDS

34 HIV PREVALENCE HIV infection: Average rate about 27% in studies done on MtF populations. Death rate due to AIDS is 30 times higher. 34

35 HIV PREVALENCE San Francisco details: 1997 MTF 137/392 (35%) HIV+ 65% aware of status prior to study, 20% learned their status through study, 15% failed to return 50% were not receiving HIV related medical care 65/104 (63%) African Americans HIV+ FTM 2/123 (2%) HIV+ San Francisco 2010 (respondent driven sampling) N=314 transfemales, 40% HIV+, only 3% were unrecognized Risk of HIV higher in all non-white, adjusted odds ration highest (30) for African Americans Among HIV+: 87% have ever seen a doc for care. 71% have ever taken meds. 65% are currently taking meds (Clements-Nolle, Marx, Guzman, & Katz, 2001) (Rapues, et.al. 2013

36 Transmen & HIV Risk Clements-Nolle et al., 2001: 392 transwomen and 123 transmen. HIV prevalence for transwomen = 35% HIV prevalence for transmen = 2%. 50% of the transmen in this study identified as gay or bisexual men > 60% of all the transmen reported previous unprotected vaginal sex with a non-trans man. 27% reported unprotected anal sex with a nontrans man. Lower prevalence maybe an issue of lower screening and under-reporting.

37 NATIONAL TRANSGENDER DISCRIMINATION SURVEY self-reported incidence of HIV infection 2.64% overall 4.28% of trans women 15.3% of self-identified sex workers 24.9% of black trans women and 10.9% of Latina trans women Rate of 0.6% in the general population

38 PREVENTION ISSUES Complex and numerous causes of increased risk Previous and ongoing trauma stands out as significant risk factor and clinically challenging 38-60% past experiences of physical violence 27-46% victims of sexual assault Most violence attributable to gender identity or expression (Testa et al., 2012)

39 DEPRESSION AND SUICIDE Suicide rates: In some surveys, up to 40% of transgender/gender variant individual report having attempted suicide. Suicide deaths 6 times higher than general population in Dutch cohort. Suicidal ideation rates as high as 64% A 2009 NYC Metro survey of 571 transwomen found a lifetime history of suicidal thinking of approximately 53%, suicidal planning of approximately 35%, and attempted suicide rate of 28 35% 39

40 DEPRESSION AND SUICIDE A 2009 study of 515 transgender individuals in San Francisco found that depression approaches 62% in trans women and 55% in trans men NYC metropolitan area survey found that 52 54% of trans women have a lifetime history of major depression 40

41 SUBSTANCE ABUSE The Transgender Community Health Project sampled 392 trans women and 123 trans men finding that 23% have a history of substance use treatment cannabis 90% cocaine 66%, LSD 52%, crack cocaine 48% heroin 24%. One-third of the sample had used injection drugs, not including hormones, in the past Various studies have shown 26 to 62% percent prevalence of substance use disorders in transwomen 41

42 YOUTH, HOUSING STATUS AND SUBSTANCES USE Substance Homeless Youth on the Street Homeless Youth in Shelters Non- Homeless Tobacco 81% 71% 49% Alcohol 81% 67% 57% Marijuana 75% 52% 23% Crack Cocaine 26% 8% 1.4% Intravenous Drugs 17% 4% 1% Other Drugs (stimulants, hallucinogens, inhalants) 55% 34% 16%

43 SUBSTANCE ABUSE The rate of drug-related deaths in MtF was 13 times higher than that of the general population in the Dutch cohort. 43

44 Transwomen & PrEP Project Life Skills: Kuhns, transwomen age enrolled in an on-going HIV prevention intervention Analyzed factors associated with PrEP indication 62% met criteria for PrEP PrEP interest, number of recent anal sex partners, But only 5 % reported ever taking PrEP lower collective self-esteem scores Despite HIGH indication, there is LOW awareness!

45 iprex Trial New analysis of previous study identified 339 trans women in iprex: Deutsch, et al. Lancet, Nov. 5, 2015 Compared with MSM, transwomen had lower drug levels in their blood and were less likely to take PrEP on a daily basis. None of the 11 transwomen who seroconverted in the randomized trial had detectable blood drug levels. While MSM who reported sexual practices with the highest risk of contracting HIV were more likely to have drug detected in their blood the opposite was true for trans women.

46 Transgender Women and PrEP: What We Know and What We Still Need to Know National Center for Innovation in HIV Briefing: Dec 1, 2015 PrEP is effective in reducing the risk of HIV among MSM, heterosexual men and women, and people who inject drugs. More research is needed to show that PrEP is effective for preventing HIV among transwomen engaging in anal sex with men. Research is needed to better understand the interaction between PrEP and hormones. Potential impact on ability of PrEP to build up sufficiently in rectal tissue. In the meantime, PrEP is a preventive option that transwomen should consider with their medical providers!

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48 RESOURCES Injustice at Every Turn: A Report of the National Transgender Discrimination Survey WPATH SOC v.7 are%20v7%20-%202011%20wpath.pdf UCSF Center of Excellence for Transgender Health