Providing Transgender- Affirming Primary Care By Allison Fox, FNP, RN, BA and Margot Presley, FNP, MN-RN, BA, DNP-S Lecture Objectives Care Coverage in OR and the US Best-practice customer service Hormones: Readiness, Informed Consent, Initiation and Monitoring Health Maintenance & Lifespan Considerations Referrals for surgery and gender non-conforming children and adolescents Overview of OHP Coverage and Medicaid Landscape in the US 1
11 States Include Transition Related Care in Medicaid (Transgender Law Center, 2016) Turning Point In Oregon: 2012 Insurance Division Bulletin 2012-1 Expanded the Oregon Equality Act of 2008: A health insurer may not deny or limit coverage or deny a claim for a procedure provided for GI/GD* if the same procedure is allowed in the treatment of another non-gi/gd- related condition. STAY UP TO DATE WITH WHAT OHP COVERS (Insurance Division, 2012) BRO PUBLISHES FAQ SHEETS OHP Coverage: Gender Dysphoria ICD-10 In 2015, Oregon Health Plan expanded coverage for transition-related medical care Puberty suppression in adolescents (Tanner stage 2) Gender-affirming hormones in adolescents and adults Top/Chest surgeries (feminizing and masculinizing) Bottom/genital gender confirmation surgeries + necessary hair removal (FamilyCare Health Provider Toolkit, 2015) 2
Basic Customer Service Principles in Working with Trans Patients 3
Gender-Affirming Clinic Processes Gather and Use Pertinent Patient Data Collect sexual orientation and gender identity (SOGI) info at intake Follow guidelines for verbiage (Deutsch et al., 2013) Sex Assigned at Birth Current Gender Identity Insurance gender marker Put info in a helpful place in EMR (banner, flag) Create a protocol for noting correct names, pronouns, in EMR, letters and voice message instructions Collaborate with your friends in IT Most Importantly: Create a Positive Space Hormones: Readiness, Informed Consent, Initiation and Monitoring 4
Assessing Readiness Gender Dysphoria replaces gender identity disorder in DSM V To diagnose GD- there must be: gender identity is not congruent with gender assigned at birth desire to live or be treated as the other gender strong conviction that one has feelings and reactions typical of the other gender must be present for at least 6 months DSM notes GD is not in itself a mental disorder Informed Consent No longer need a MH letter! Like any informed consent: make sure patient understands, risks, alternatives, unknowns, limitations, risks of not treating WPATH, 7th version Informed Consent Fenway Health Email me: foxal@ohsu.edu take time to read them over- they can be long reiterate important topics, things that can t be changed, fertility, T doesn t prevent pregnancy, estrogen can carry higher risk for blood clot 5
Initiating Hormones Know your resources! UCSF Transgender guidelines Initiating Hormones Endocrine Society, 2009 Initiating Hormones: UCSF, feminizing 6
Initiating Hormones: UCSF, masculizing Monitoring Hormones: UCSF Goal Estrogen level: <200 pg/ml Goal Testosterone level: <55 ng/dl Monitoring Hormones: UCSF Goal Testosterone Level: no higher than 700 7
Health Maintenance & Lifespan Considerations Collecting a Health History Obtain a thorough medical, mental health, and surgical history Ask about previous preventive screenings Document anatomy inventory If already on hormone therapy, request pt records that include baseline labs Preventive Care and Screening Nat l screening guidelines for organ systems unaffected by hormone therapy are appropriate for trans patients Vision, dental, dermatology, lung cancer Adapting nat l guidelines to trans patients is difficult w/o sufficient evidence: cardiovascular bone health hormone sensitive cancers (WPATH, 2007) 8
Slide 24 1 reword this slide Margot Presley,
Cardiovascular Risk and HT CV risk is similar for transmen (female at birth) on testosterone compared to cisgender women Evidence regarding transwomen (male at birth) taking estrogen is less clear Some studies find increased morbidity and mortality from MI and stroke compared with cisgender men (UCSF Primary Care Protocol, 2016) Cardiovascular Risk and HT Calculating Risk: Currently there is no guidance on whether to use natal sex or affirmed gender in risk calculators Depends on age at which hormones are begun, total length of exposure Providers may use the risk calculator for the natal sex, affirmed gender, or an average of the two Reducing Risk: For trans women with CV risk factors or established CVD, using the transdermal route of estrogen may be preferred due to lower rates of VTE and lack of associated changes in lipid profile or markers of coagulation (UCSF Primary Care Protocol, 2016) Diabetes Screening Recommendations for DM screening in trans patients (regardless of hormone status) do not differ from current national guidelines Weak evidence about hormones and insulin resistance Estrogen may increase resistance Testosterone may decrease resistance Young people who seek out healthcare for hormone therapy Opportunity to provide comprehensive primary care and identify risk factors/disease (obesity, PCOS, metabolic syndrome, impaired fasting glucose, or diabetes) (UCSF Primary Care Protocol, 2016) 9
Bone Health Trans people (regardless of natal sex) should begin bone density screening at age 65 Screening in ages 50-64 should be considered for those with risk factors for osteoporosis Transwomen (male at birth): low T use after gonadectomy, androgen blockers w/o adequate estrogen, GnRH analogues w/o hormones Transmen (female at birth): oophorectormy before age 45 w/o optimal hormone replacement No studies determine whether to use natal sex or affirmed gender for assessment of osteoporosis, e.g., FRAX tool Case by case basis considering age of hormone initiation (before or after peak bone mass) and length of exposure (UCSF Primary Care Protocol, 2016) Bone Health Trans patients (regardless of natal sex) who have undergone gonadectomy and have a history of at least 5 years without hormone replacement should also be considered for bone density testing Prevention: Vit D supplementation, weight bearing exercise, adequate calcium intake, smoking cessation, and moderate alcohol intake (UCSF Primary Care Protocol, 2016) HIV and STIs Trans patients should undergo universal HIV screening consistent with recommendations for the general public Effective risk assessment (for HIV and other STIs) requires the ability to obtain an accurate sexual history that includes anatomy-specific sexual behavior Condoms and PReP encouraged for prevention There are no known drug-drug interactions or contraindications between concomitant use of PReP and gender affirming hormones (UCSF Primary Care Protocol, 2016) 10
Slide 28 2 reword slide about Frax and give example of hormonal mileu Margot Presley,
Suggested Questions for Sexual Health History (Fenwway Health) Are you having sex? How many sex partners have you had in the past year? Who are you having sex with? (including anatomy and gender of partners) What types of sex are you having? What parts of your anatomy do you use for sex? How do you protect yourself from STIs? (How often do you use condoms/barriers? Any use of PrEP?) What STIs have you had in the past, if any? When were you last tested for STIs? Has your partner(s) ever been diagnosed with any STIs? Do you use alcohol or any drugs when you have sex? Do you exchange sex for money, drugs, or a place to stay? Approach to STI Specimen Collection and Exam Chaperoned Trauma-Informed Approach: Greet patients while they are dressed Explain what you plan to do and why Provide information, choices, and decision-making ability Offer self-collection of specimen Self-collected vaginal and rectal swabs and urine specimens have equivalent sens/spec to providercollected samples for gonorrhea, chlamydia, and trichomonas Self-insertion of speculum (UCSF Primary Care Protocol, 2016) 11
Fertility and Reproduction It is recommended that prior to transition all transgender people be counseled on the effects of transition on their fertility and options for fertility preservation and reproduction. Hormone therapy is not a contraception. Any person with gonads who engages in sexual activity that can lead to pregnancy should be counseled about contraception. (UCSF Primary Care Protocol, 2016) Cancer Screening If an individual has a particular body part or organ and otherwise meets criteria for screening based on risk factors or symptoms, screening should proceed regardless of hormone use. (UCSF Primary Care Protocol, 2016) (UCSF Primary Care Protocol, 2016) Breast Cancer Transwomen: Screening mammography criteria: patient age of 50+ AND 5-10 years of feminizing hormone use Every 2 years Risk score calculators (e.g. GAIL method) may be unreliable. Obtain thorough family history. Transmen: Transmen w/o bilateral mastectomy or with breast reduction should undergo screening according to current guidelines for ciswomen Evaluation of palpable lesion may require MRI or u/s No evidence to guide screening in transmen who underwent complete mastectomy (no breast tissue remaining) Obtain good surgical history (UCSF Primary Care Protocol, 2016) 12
Prostate and Testicular Cancers Screening for prostate cancer in transwomen should be made based on guidelines for cismen. Removal of gonads + estrogen likely reduces risk for prostate cancer and benign prostatic hypertrophy PSA less relevant If testing PSA of transwomen with low T, may be appropriate to reduce the ULN to 1.0ng/ml If prostate exam is indicated: Via neovagina or DRE Routine testicular cancer screening is not recommended in cismen and there is no evidence to screen in transwomen. Transwomen adherent to therapeutic doses of estrogen plus an androgen blocker who have persistent testosterone elevations should be evaluated for testicular tumors by physical exam and labs. (UCSF Primary Care Protocol, 2016) Cervical Cancer Cervical cancer screening for transmen follows recommendations for ciswomen as endorsed by the ACS, WHO, and USPSTF. Transmen have lower rates of screening Inadequate screening is linked to the barriers trans patients face in accessing culturally sensitive care Trauma-informed approach to exam Use non-gendered, culturally sensitive language Remember testosterone effects on vaginal tissue (atrophy-use extra lube, smaller speculum) (UCSF Primary Care Protocol, 2016) Some evidence to support self-collection Review of 18 studies with 5441 participants found self-swab to be as sensitive as provider collected sample (Petignat, Faltin, Bruchim, Tramèr, Franco, & Coutlée, 2007) Mental Health Three primary MH needs in trans care: 1. Exploration of gender identity. 2. Coming out and social transition. 3. General mental health issues, possibly unrelated to gender identity (routine screening for depression, GAD, SA). Primary care providers who are experienced in working with transgender patients may feel comfortable initiating hormone therapies without an initial mental health assessment using an informed consent model. (UCSF Primary Care Protocol, 2016) 13
Brief overview of surgical referral Surgery Referral OHP Requirements: Cross-sex hormone therapy for 12 months Top surgery: one letter from a mental health provider Bottom surgery: two letters from mental health providers Pearls: Letter templates available online (Transline and OHP Provider Tool Kit) Start referral process early wait lists can be months long + time for hair removal Discuss access to post-op care OHSU Currently Offers: Chest surgery (FTM and MTF) Facial feminization surgery Oophorectomy/hysterectomy Orchiectomy Metoidioplasty Vaginoplasty Phalloplasty (summer/fall 2016) 14
Surgery Referral Chest Surgery: Juliana Hansen, MD @ OHSU Hema Thakar, MD @ Legacy Facial Feminization: Myrian Loyo Li, MD @ OHSU Jens Berli, MD @ OHSU Bottom Surgery/Gender Confirming Surgeries: Daniel Dugi, MD @ OHSU (orchi, vaginoplasty, metoidioplasty, later this year: phalloplasty) Jens Berli, MD @ OHSU (phalloplasty) Bottom/Genital Surgery Male-to-Female: Orchiectomy, Vaginoplasty Female-to-Male: Metoidioplasty, Phalloplasty Post-operative satisfaction generally high, low incidence of regret (<4%) Slides adapted from Dr. Dugi s lecture Orchiectomy Surgical removal of testicles Benefit: stop spironolactone, any dysphoria related to testes Risk: loss of fertiliy potential, loss of endogenous sex hormone Outpatient procedure 15
Vaginoplasty Goals: removal of male external genitalia, natural appearing external female genitalia, sensate clitoris, vagina for receptive intercourse. Does not remove prostate Most are penile inversion: use of penile, scrotal and perineal skin to create vagina, clitoris and vulva Sigmoid vaginoplasty: usually revision Need permanent hair removal: scrotum, perineum, base of penis 5-7 day stay in hospital, foley cath 1-2 wks, post operative edema normal Complications: wound healing, loss of vaginal depth/width (need for long term dilation), cosmetic dissatisfaction, fistula >90% satisfied, and 85% achieve orgasm post op Metoidioplasty Clitoris as analog of penis: grows with testosterone exposure Release of suspensory ligament of clitoris and mobilization of clitoris, lengthening of urethra Goals: stand to void, male genital appearance Not likely to allow penetrative intercourse No change in clitoral sensation May be followed by phalloplasty Ideal for slender patients/near ideal body weight Mean length after release 5.6 cm (microphallus) Hospital stay 2-3 days, suprapubic cath 3 wks Rate stricture/fistula 6% Metoidioplasty 16
Metoidioplasty Metoidioplasty 17
Phalloplasty Multiple techniques Goals: appearance of normal penis, ability to stand to urinate, maintain erogenous sensation, penetrative intercourse Radial forearm free flap: thin supple skin, potentially sensate however has donor site scar Hospital stay 5-7 days, suprapubic cath ~3 wks Implant for stiffening Complications: wound, minor (common), urethral (40-80%), implant (40-60%) Radial forearm free flap phalloplasty Radial forearm free flap phalloplasty 18
Criteria for puberty suppression and adolescent referrals Criteria for Puberty Suppression (WPATH SoC, 2011) Working with Children and Adolescents GI develops early, may socially transition prior to puberty Medical transition: Puberty suppression can start at Tanner Stage 2 with or followed by gender-affirming hormones Lupron/Lueprolide 7.5mg IM monthly most common regimen GnRH Agonist (turns off pulsatile action to stim LH & FSH) Consult with pediatric endocrinology Portland-based Pediatric Trans* Specialists: OHSU Kara Connelly, MD & Lindsey Nicol, MD and Trans Active Gender Center Legacy Trans Clinic Karin Selva, MD & Valerie Tobin, PMHNP Engage parents, assist w/ social support, collaborate with MH (OHSU Trans Health Program, 2015; UCSF Protocol: Youth Considerations, 2015) 19
Resources & Conferences Trans* Healthcare Resources Prescribing Guidelines & Support UCSF Center of Excellence for Transgender Health Primary Care Protocol http://transhealth.ucsf.edu/trans?page=protocol-00-00 International Endocrine Society Guideline http://press.endocrine.org/doi/pdf/10.1210/jc.2009-0345 OHP Provider Tool Kit http://www.healthshareoregon.org/for-providers/providerresources/provider%20tool%20kit%20v4.pdf Project Health: Transline http://project-health.org/transline/ WPATH Standards of Care http://www.org/site_home.cfm Trans* Education and Advocacy National LGBT Health Education Center (a lot of free webinars on working with trans* patients) http://www.lgbthealtheducation.org/training/on-demand-webinars/ TransActive Gender Center (Youth Organization) http://www.transactiveonline.org/index.php Gay & Lesbian Alliance Against Defamation (GLAAD) An Ally s Guide to Terminology http://www.glaad.org/2011/07/28/an-allys-guide-to-terminology-talking-about-lgbt-peopleequality National Center for Transgender Equality (has IDs Document Center and more) http://www.transequality.org Conferences LGBTQ Meaningful Care Conference Portland, OR Biannual spring conference http://oregonlgbtqhealth.org/mcc National Transgender Health Summit Oakland, CA Biannual conference http://transhealth.ucsf.edu/summit National Transgender HIV Testing Day (First Annual 4/18/16) Toolkit Available Philadelphia Trans Health Conference Philadelphia, PA 15th Annual Conference June 9-11, 2016 https://www.mazzonicenter.org/trans-health 20
References Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J.,... & Monstrey, S. (2012). Standards of care for the health of transsexual, transgender, and gendernonconforming people, version 7.International Journal of Transgenderism, 13(4), 165-232. Retrieved from http://www.tandfonline.com/doi/abs/10.1080/15532739.2011.700873 Deutsch, M. B., Green, J., Keatley, J., Mayer, G., Hastings, J., Hall, A. M.,... & Fennie, K. (2013). Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group. Journal of the American Medical Informatics Association, 20(4), 700-703. FamilyCare Health. (2015). Trans health provider tool kit. [pdf]. Retrieved from https://www.familycareinc.org/images/uploads/entries/trans_health_provider_tool_kit.pdf Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K.,... & Coyne-Beasley, T. (2015). Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. American journal of public health, 105(12), e60-e76. Retrieved from http://eds.b.ebscohost.com.liboff.ohsu.edu/ehost/pdfviewer/pdfviewer?sid=f8a0818e-3179-47e1-b296-ddb35fe29027%40sessionmgr112&vid=0&hid=108 Hembree, W. C., Cohen-Kettenis, P., Delemarre-van de Waal, H. A., Gooren, L. J., Meyer III, W. J., Spack, N. P.,... & Montori, V. M. (2009). Endocrine treatment of transsexual References, cont d Legacy Health. (n.d.) Transgender clinic. Retrieved from http://www.legacyhealth.org/healthservices-and-information/health-services/for-children-a-z/diabetes-and-endocrine/transgenderclinic.aspx Oregon Department of Consumer and Business Services. (2012, December 19). Oregon insurance division bulletin ins 2012-1. Retrieved from http://www.oregon.gov/dcbs/insurance/legal/bulletins/documents/bulletin2012-01.pdf Oregon Health & Science University. (n.d.) Transgender health program. Retrieved from https://www.ohsu.edu/xd/health/services/diversity-and-inclusion/culture-specificservices/transgender-program/index.cfm Petignat, P., Faltin, D. L., Bruchim, I., Tramèr, M. R., Franco, E. L., & Coutlée, F. (2007). Are self-collected samples comparable to physician-collected cervical specimens for human papillomavirus DNA testing? A systematic review and meta-analysis. Gynecologic oncology, 105(2), 530-535. Transgender Law Center. (n.d.). Healthcare laws and policies. Retrieved on May 16, 2016 from http://transgenderlawcenter.org/equalitymap Transline. (2012). Summary tables labs and hormone doses. [pdf]. Retrieved from https://transline.zendesk.com/entries/21714071-summary-tables-labs-and-hormone-doses University of California, San Francisco. (2016). Center of excellence for transgender h lth i t l f t d ti t R t i d f THANK YOU! Contact Us: Allison Fox, FNP-C foxal@ohsu.edu Margot Presley, FNP-C presley@ohsu.edu 21