8/17/2015. Objectives. Disclosures

Transcription

1 NPANY Annual Conference Niagara Falls, NY October 2015 Laura Markwick, DNP, FNP C Associate Professor Wegmans School of Nursing St Joh Fisher College Objectives The learner will gain an understanding of common terms used in the transgender culture. The learner will understand the process the transgender patient becomes involved with in regards to their sexual identity. The learner will understand basic information regarding hormone therapy and how it can affect a person. Disclosures I have nothing to disclose. Unfortunately, this is also often times the case with transgender patients. 1

2 Gender, Gender Expression, Gender Role Gender: The range of characteristics of men and women and masculinity and femininity assigned by society. Gender expression/gender role: The expression of masculinity or femininity by a person based on societal, cultural, and individual expectations. Gender identity: The part of a person s sexual identity with male, female, neither, or both. Genderqueer: Someone who does not identify with either male or female. They may identify with both, neither, or somewhere in between. Terminology Transgender umbrella term that includes anyone whose self identity, behavior, or anatomy falls outside of societal gender norms and expectations Transsexual a person whose gender identity is not congruent with their biological sex. They may or may not pursue hormonal or surgical treatment to bring congruency to their gender identity. Transmale Individual who was born a female but identifies with male and MAY have used hormonal and/or surgical treatment to become a male. Transfemale Individual who was born a male but identifies with female and MAY have used hormonal and/or surgical treatment to become a female. Terminology Two Spirit Native American term that refers to someone who identifies with both multiple genders. Cisgender: The state of not being transgender. Refers to people who identify with the sex that they were assigned at birth 2

3 What does it all mean? Must be aware of gender identity and biological sex in order to provide competent care and recommend appropriate care and measures for conditions specific to this population Barriers to healthcare for trans persons that cluster around four main issues: Reluctance to disclose Lack of provider Experience and resources Structural barriers Financial barriers Facts Incidence Range from 1:11,900 to 1:45,000 MTF Range from 1:30,400 to 1:200,000 FTM Lack of uniform collection of data Changed with ACA LGBT health care facts LGBT youth more likely to be homeless 2 3 times more likely to attempt suicide; Lesbians less likely to get preventative services for cancer; Lesbian and bisexual females are more likely to be overweight or obese; Gay men, especially those of color, at a higher risk of HIV and other STDs; LGBT highest rates of tobacco, alcohol, and drug use; Elderly: additional barriers to healthcare due to isolation and lack of social services and trained providers; Transgender high rate of HIV/STDs, victimization, mental health issues, and suicide. less likely to have health insurance 3

4 Healthy People 2020 Transgender Health Facts Access to Health Services Medical Provider discrimination, hostility, and insensitivity Lack of health insurance Lack of coverage for transgender specific services Lack of FDA approval for transgender hormonal therapy Healthy People 2020 Transgender Health Facts HIV HIV/AIDS prevention HIV testing HIV Treatment Immunization and Infectious Diseases Prevention Healthy People 2020 Transgender Health Facts Injury and Violence Prevention Violence and Murder prevention Mental Health and Mental Disorders Suicide prevention Mental health treatment 4

5 Healthy People 2020 Transgender Health Facts Public Health Infrastructure Need for training in transgender specific health care in US medical schools Need for improvements in data collection methods for public health information STD Prevention Healthy People 2020 Transgender Health Facts Substance Abuse Prevention Treatment Tobacco Use Need for tobacco cessation programs Gender Dysphoria in Children (302.6) (F64.2) A. A marked incongruence between one s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least 6 of the following (1 must be A1) 1. Strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one s assigned gender) 2. In boys (assigned gender), a strong preference for cross dressing or simulating female attire; or in girls (assigned gender) a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing. 3. Strong preference for cross gender roles in make believe play or fantasy play. 4. Strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender 5. Strong preference for playmates of the other gender 6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough and tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities. 7. Strong dislike of one s sexual anatomy 8. Strong desire for the primary and/or secondary sex characteristics that match one s experienced gender. 5

6 Gender Dysphoria in Children (302.6) (F64.2) B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning Specify if: With a disorder of sex development (a congenital adrenogenital disorder such as congenital adrenal hyperplasia or androgen insensitivity syndrome Gender dysphoria in Adolescents and Adults A marked incongruence between one s experience/expressed gender and assigned gender, or at least 6 months duration, as manifested by at least two of the following: 1. Marked incongruence between one s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics) 2. Strong desire to be rid of one s primary and/or secondary sex characteristics because of a marked incongruence with one s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) 3. Strong desire for the primary and/or secondary sex characteristics of the other gender 4. Strong desire to be of the other gender (or some alternative gender different from one s assigned gender) 5. Strong desire to be treated as the other gender (or some alternative gender different from one s assigned gender) 6. Strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one s assigned gender) Gender dysphoria in Adolescents and Adults B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if: With a disorder of sex development (a congenital adrenogenital disorder such as congenital adrenal hyperplasia or androgen insensitivity syndrome Specify if: Posttransition: the individual has transitioned to full time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross sex medical procedure or tx regimen namely regular cross sex hormone tx or gender reassignment surgery confirming the desired gender (ex. penectomy, vaginoplasty, mastectomy, phalloplasty) 6

7 Intake questions How do you identify your sexual orientation, gay/lesbian, straight, bisexual? Are you sexually active? Do you practice safe sex at all times? Are you monogamous or do you have multiple partners? Have you been tested for HIV and other sexually transmitted diseases? What were the results? Would you describe your gender as male, female, transgendered, other gendered? If transgender or other gender Do you have a preferred name that I can use? Are your medical records and insurance under your preferred name? Are you taking any medications or hormones at this time or in the past? Have you had any gender affirming surgical procedures? Do you have a supportive community and/or family? Intake questions Do you ever feel that your sexual orientation or gender identity has a negative impact on your sense of self esteem or could be related to feelings of depression, isolation, or thoughts of self harm? Have you encountered discrimination or sexual or physical abuse related to your expressed gender or sexual orientation? Are there any questions you want to ask me about these issues or is there anything you want to share with me related to your sexual orientation or gender identity? Transgender process Counseling Hormone Therapy Surgery 7

8 Counseling Important for patient to receive counseling Potential permanent changes with surgery Internal and external conflict/stress Hormone Therapy Physical Effects FTM MTF Deepening of voice Breast growth (variable) Clitoral enlargement (variable) Decreased erective function Growth of facial and body hair Decreased testicular size Cessation of menses Increased percentage of body fat compared to muscle mass Atrophy of breast tissue Decreased percentage of body fat compared to muscle mass Hormone Therapy FTM Oral Testosterone undecanoate (only available outside US) mg/day Parenteral Testosterone enanthate or cypionate mg/week or mg/2 weeks Testosterone undecanoate (only available outside US) 1000 mg/12 weeks Transdermal Testosterone 1% gel g/day Testosterone patch mg/day MTF Anti-androgen Spironolactone mg/day (up to 400 mg) Cyproterone acetate (only available outside US) GnRH agonists mg/day 3.75 mg subcutaneous monthly Oral Estrogen Oral conjugated estrogens mg/day Oral 17-beta estradiol 2-6 mg/day Parenteral Estradiol valerate or cypionate 5-20 mg IM/2 weeks or 2-10 mg IM/week Transdermal Estradiol patch mg/2x week 8

9 FTM MTF Likely risk Polycythemia Venous thromboembolic disease Weight gain Gallstones Risk Associated with Hormone Therapy Acne Elevated liver enzymes Androgenic alopecia (balding) Weight gain Sleep apnea Hypertriglyceridemia CVD (if additional risk factors present) Possible increased risk Elevated liver enzymes HTN Hyperlipidemia Hyperprolactinemia or prolactinoma Destabilization of certain psychiatric disorders Type 2 DM (if additional risk factors present) CVD (if additional risk factors present) HTN (if additional risk factors present) Type 2 DM No increased risk or inconclusive evidence Loss of bone density Breast Cancer Breast Cancer Cervical Cancer Ovarian Cancer Uterine Cancer Special Considerations Cardiovascular Cardiovascular Monitoring BP, Estrogen may increase BP Testosterone may increase risk, especially in setting of risk factors Lipid panel Testosterone decreases HDL, variably effects LDL and TRI IM admin may worsen, transdermal better Underlying risk factors increased risk PCOS, dyslipidemia Estrogen may markedly increase TRI, increase risk pancreatitis, CV events Different modes of administration will have different effects; Transdermal will decrease this effect; best for those with preexisting lipid disorder Special Considerations Cardiovascular Testosterone can cause significant weight gain (>10%), mostly in abdomen Estrogen increases risk of CV events in pts > 50 with underlying risk factors; Additional Progestin use may increase this risk further Venous thromboembolism monitoring Risk increased pts over 40 smokers highly sedentary obese underlying thrombophilic disorders. additional use of third generation progestins Risk decreased with transdermal administration of estradiaol recommended for pts at higher risk of VTE Erythrocytosis (Hct>50%) (FTM) Dose and administration dependent, 44% with injection 3 18% with transdermal testosterone Potassium Monitor if MTF and taking spironolactone 9

10 Special Considerations Liver Liver Testosterone and estrogen Transient elevation in liver enzymes, and rarely hepatotoxicity Estrogen increases risk of cholelithiasis and subsequent cholecystectomy Special consideration Endocrine Monitoring for DM Testosterone can decrease insulin sensitivity Feminizing hormone tx, particularly estrogen, increases the risk of Type II DM Monitor hormone levels Prolactin levels Estrogen increases risk of hyperprolactinemia in first year of treatment High dose estrogen may promote clinical appearance of preexisting but clinically unapparent prolactinoma Hormone levels Special Considerations Cancer Mammography MTF Annual >50 with > 5 yrs hormone tx BMI >35 + family hx No hormone use, not recommended unless other known risk factors (Klinefelter syndrome) FTM Annual Reduction mammoplasty or no surgery, or preoperative >40 Yearly chest wall/axillary exam if bilat mastectomy Cervical Cancer Screening according to natal guidelines if cervix remains Prostate Cancer Screening according to natal guidelines 10

11 Special Consideration Psychological Depression Suicide PTSD Eating disorders Anxiety Substance abuse Note: hormone tx results in less psych sx than non tx counterparts Desired effect Testosterone May increase risk of hypomanic, manic, or psychotic symptoms in person with predisposition; dose dependent or with supraphysiologic blood levels Special Consideration MS FTM and MTF BMD prior to testosterone if at risk for OP; otherwise start at age 60 or earlier if sex hormones consistently low FTM Testosterone maintains or increases BMD prior to oophorectomy, in the first 3 years of tx Increased risk of BMD loss after oophorectomy if testosterone tx is interrupted or insufficient Special Considerations Other STD Increased risk of STD s due to high risk behaviors Impaired fertility Libido Estrogen decrease Testosterone increase Skin/hair/nails Testosterone acne, androgenic alopecia Estrogen decrease nocturnal erections, variable impact on sexually stimulated erections 11

12 Surgery FTM Breast reduction Bilat Mastectomy Top Surgery MTF Breast Augmentation Implants Lipofilling Surgery FTM Hysterectomy Balpingo oophorectomy Phalloplasty MTF Orchiectomy Vaginoplasty Health Care Maintenance screening to consider Male to female with a prostate Female to male osteoporosis Male to female osteoporosis Cholesterol screening HDL male norms or female norms? Mammograms Pap smears Lab values reference ranges should they be reported based on sex identity or gender identity? Recommendations on website Centers for Excellence Transgender Healthcare UCSF 12

13 10 Things Transgender person should discuss with PCP Access to Healthcare Health History Hormones Cardiovascular Health Cancer STD/Safe Sex Alcohol and tobacco Depression Silicone Injections Fitness: Diet, and Exercise Adapting Care Important points to remember Use correct pronoun that conforms with gender identity; inappropriate to put preferred name or pronoun in quotation marks Try to provide context for questions and apologize for unintentionally offending someone by questions or assumptions Ongoing monitoring Follow up Monthly until stable Every 3 months Every 6 12 months Labwork Patient specific Screening Patient specific See guidelines 13

14 Responsibilities of hormone prescribing provider Perform initial evaluation Pt s physical transition goals Health history PE Risk assessment Labs Discuss expected effects of of medications Risks/benefits Reproduction issues Confirm pt has capacity to understand and make decisions Provide ongoing monitoring Communicate as needed with healthcare team (MH, Surgeon, specialists) If needed, provide written statement regarding hormone therapy to prevent difficulties with police or law enforcement Questions? 14