Providing Primary Care for Gender-Diverse Clients Seaway Valley Community Health Centre June 30 th, 2016 Jennifer Douek, Jordan Zaitzow
Introductions Jennifer Douek, MD Jordan Zaitzow, MSW
Faculty / Presenter Disclosure Faculty: Jordan Zaitzow, Trans Health Connection Coordinator, Rainbow Health Ontario I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device, or communications organization Relationship with commercial interests: None
Faculty / Presenter Disclosure Faculty: Jennifer Douek, MD I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device, or communications organization Relationship with commercial interests: None
Disclosure of Commercial Support No commercial support
Not Applicable Mitigating Potential Bias
Setting the Space CREATING A SUPPORTIVE LEARNING ENVIRONMENT STEP UP, STEP BACK CONFIDENTIALITY RESPECTFUL QUESTIONS/DISAGREEMENTS WELCOME! SHARE TOOLS NOT STORIES All art by Elisha Lim: www.elishalim.com
Agenda Introductions What is trans health? Assessment Feminizing Hormones, Primary Care Masculinizing Hormones, Primary Care Evaluations and Questions
Rainbow Health Ontario (RHO) www.rainbowhealthontario.ca
Trans Health Connection Increasing the capacity of Ontario s primary health care system to provide high-quality, comprehensive care to trans communities through training, education, mentorship, resources, networking, and increasing access.
Locations * Peterborough * Cambridge / KW * Windsor * London * Ottawa * St. Catharines, Niagara * Scarborough * Thunder Bay * Oshawa, Ajax * Toronto * Guelph * Halton * Orillia * Hamilton * Cornwall * Sudbury Site of Trans Health Training
Trans Mentorship Group Dynamic opportunity for connection General advice intended to guide clinicians in practice Weekly teleconference with trainers in various disciplines Guest speaker sessions on topical issues
Introductions Name What You Do and Where You Work Your OWN gender: Share a story about gender in your family. If your gender was an object, what would it be?
Definitions and Terminology
Who are Gender Diverse People? EXTREMELY simply put. People whose - Gender identity - Gender expression - Gender transition Differs from what is expected.
Gender Identity: - Deeply intrinsicly felt sense of self (how you feel) - How would you describe it? - E.g. I am a woman, man, boy, etc. Gender Expression: - Boyish? Sporty? Feminine? Fancy? Dapper? - Masculine? Feminine? Fluid? Indescribable? Sex Assigned at Birth: - When you were born, what did the doctor say? Sexually Attracted to: - Who do you build sexual connection with? Romantically/Emotionally Attracted to: - Who do you build romantic and emotional relationships with?
Who are Trans People in Ontario? 50% live in poverty 30% straight 20% Both or Neither (Non-binary) 45% Masculine, 35% Feminine 27% parents 70% live outside Toronto - TransPULSE, 2010
Barriers to Care Trans PULSE 20% have been denied hormone prescription 21% avoided emergency room care when they needed it as a result of being trans 14% have used hormones not prescribed to them - Trans PULSE, 2011
Risks of Providing Treatment (For the Provider): Turn to the person sitting next to you and discuss: What are the common barriers to providing hormone treatment?
Turn to a different person and ask: What are the risks of not treating a trans patient looking to access hormone treatment?
Transition and Advocacy - Trans PULSE, 2012
Primary Care Providers Barriers to Treating Do we have the knowledge? Evidence, guidelines Do we have supports? Colleagues, experts, community Is it within our scope? Can we diagnose and prescribe What are the risks of harm? Of treating & not treating Do we have the time? To assess & manage
Primary Care Guidelines and Protocols Sherbourne Guidelines and Protocols (revised 2015) WPATH Standards of Care, www.wpath.org Vancouver Coastal Health (revised 2015) Centre of Excellence for Transgender Health (UCSF)
Who Can Prescribe Hormones? In Ontario: Family Doctors can prescribe estrogen and testosterone testosterone blockers testosterone Nurse Practitioners can prescribe estrogen testosterone blockers
Case 1: Accessing Medical Supports
Case 1: Accessing Medical Supports Things to think about: New Client, Supportive Family, 16y/o No issues in health history, looking to start hormones. What are some questions you would want to ask Mackenzie regarding gender identity, today? What are some non-medical considerations for support? (intake, welcoming environment, staff training, etc) Can you imagine Mackenzie seeking support at your clinic today? What would happen? Where do you feel confident? Where would you need more support?
Some Aspects of Transition Social Medical Surgical Transition is an individual pathway. Surgeries, hormones, and presentation do not make you more or less trans, or more or less of a man/woman.
DIAGNOSIS: Gender Dysphoria, DSM V A A marked incongruence between one s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following: 1. A 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. A 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. A strong desire for the primary and/or secondary sex characteristics of the other gender
DIAGNOSIS: Gender Dysphoria, DSM V 4. A strong desire to be of the other gender (or some alternative gender different from one s assigned gender) 5. A strong desire to be treated as the other gender (or some alternative gender different from one s assigned gender) 6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one s assigned gender) B The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning
Or More Simply Gender Dysphoria refers to the distress which occurs when Gender identity doesn t fit with the gender assigned at birth One s sense of self does not match one s body One is not being acknowledged in the world as one s true gender.
Checklist 1. Meets Gender Dysphoria diagnosis criteria Yes ( ) No ( ) 2. Medical contraindications explored Yes ( ) No ( ) 3. Psychiatric morbidity Yes ( ) No ( ) List: 4. Targeted physical, as appropriate Yes ( ) No ( ) 5. Blood work Yes ( ) No ( ) 6. If smoker, smoking cessation discussion Yes ( ) No ( )
Checklist 7. Discussed contraception/fertility Yes ( ) No ( ) 8. Supports in place to assist with Yes ( ) No ( ) transitioning 9. Good understanding of the risks, side Yes ( ) No ( ) effects, and expected benefits of hormones 10. Consent signed Yes ( ) No ( )
Task Breakdown One: General medical intake Initial discussion of gender history Old records from previous health care provider if new patient Two: More detailed gender history Explore supports, reactions
Task Breakdown Three: periodic health review, age appropriate screening and targeted physical exam based upon any issues identified in the history and functional inquiry Blood pressure and basic labs Paps suggested but not necessary Four: Expected physical changes with hormones Side effects and risks associated with hormone treatment Give consent form for patient to review and sign
Task Breakdown Five: Review risks of treatment Obtain consent Choose initial hormone regimen with client Art by Lee Hicks, Both/And, 2011
Gender Focused Health History General History Family history with particular attention to: history of cancer (breast, prostate, reproductive organs), clotting disorders, cardiovascular disease, diabetes, hypertension, mental illness Past medications (hormones) Psychosocial supports/stresses (family, work etc) Sexual history: sexual orientation, risks related to STIs, sexual function
Gender Focused Health History Gender Identity How would you describe it? How do you feel about it? Gender Expression Perception of others How do you feel most comfortable expressing your gender? How would you change your appearance if you could? How do other people see you? How do you wish they saw you? Sexuality How does your sexuality interact with your gendered sense of yourself? Based on the BC Guidelines: Potential Areas of Inquiry - Transgender Identity Development
Gender Focused Health History Support Resources Do people in your life know you are trans? Do you know other trans people? What is your relationship to trans communities? Hormones Why now? What do you want them to change? What will happen if change isn t as hoped? Three most common gender dysphoric times: starting school, puberty, dating Based on the BC Guidelines: Potential Areas of Inquiry - Transgender Identity Development
Psychosocial Preparedness Social supports Work/ school/ community Partner/ family/ children Economic/workplace Emotional readiness Mental health Do you know of resources available locally?
Taking a Gender History Things to think about: Try and document questions you would ask about their gender history. What questions do you have for Aria? Where are you confused or unclear or needing more information? Imagine Aria is coming in and they haven t started hormones yet. How would you proceed? What feelings come up for you? Fear? Confusion? Excitement? How does that impact your practice?
Taking a Gender History
Taking a Gender History 1. What comes up for you when you watch this video? 2. What if Aria was not yet on hormones but looking to start. What questions would you have for Aria? How would you structure your questions around gender history? 3. Where do you feel confident? 4. Where do you feel like you need more support/information?
Hormones What do you already know about prescribing hormones?
Feminine Spectrum
Suppression of Androgens 2 anti-androgen medications commonly used: Spironolactone (Aldactone) Cyproterone (Androcur)
Suppression of Androgens Other options: GnRH analogs - Leuprolide (Lupron), Buserelin (Suprefact) Non-steroidal anti-androgens (Flutamide) Finasteride (Proscar) Anti-androgens decrease the dosage of estrogen needed to suppress testosterone
Anti-Androgens Spironolactone Diuretic Acts in the kidneys: blocks aldosterone Reduces the action of testosterone; acts as an androgen receptor blocker May not totally suppress blood levels because testosterone still made Effective, affordable
Anti-Androgens Cyproterone Also blocks androgen receptors Suppresses LH, reduces testosterone conversion to DHT More expensive, effective May affect mood
Anti-Androgens Spironolactone Cyproterone Starting Dose 50 100 mg OD 50 mg OD Maximum Dose 200 mg BID 100 mg OD Cost* (4 weeks) $16.56 a -$40.58 b $32.98 c -$101.92 d
Estrogens Oral Conjugated equine estrogen (CES, Premarin) Estrace (Estradiol) Transdermal Injectable Estraderm / Estradot Less risk of DVT/PE or increase of TG s consider in women> 40 or those with elevated CV or thrombosis risk avoids first pass effect through liver Estrogen Valerate, available through compounding pharmacies Avoids first pass effect through the liver Creams, Gels
Progesterone? New SHC Protocols has consent form Risk of cardiovascular disease, depression, weight gain Much debate in professional communities re benefits for MTF clients However, continues to be demand
Effects and Expected Time Course of Feminizing Hormones. WPATH Standards of Care, Version 7. Effect Expected Onset Expected Maximum Effect Body Fat Redistribution 3-6 Months 2-5 years Decrease Muscle Mass/Strength 3-6 Months 1-2 years Softening of Skin/Decreased Oiliness 3-6 Months Unknown Decreased Libido 1-3 Months 1-2 Years Decreased Spontaneous Erections 1-3 Months 3-6 Months Breast Growth 3-6 Months 2-3 Years Decreased Testicular Volume 3-6 Months 2-3 Years Decreased Sperm Production Variable Variable Thin/Slow Growth of Body Hair 6-12 months >3 Years Male Pattern Baldness No Regrowth, Loss Stops 1-3 Months 1-2 Years
Irreversible vs. Reversible Irreversible Breast Development May or May Not Reverse - Fertility Reversible Softening of skin Muscle / fat distribution Decreased libido Hair growth
Estrogen Doses Conjugated Estrogen Starting Dose Maximum Dose Cost (4 weeks) 0.625mg OD 1.25mg OD $20.01 Estradiol (oral) 1-2mg OD 4mg OD $18.53- $40.14 Estradiol (transdermal patch) 0.1mg OD/ apply patch 2x/week 0.2mg OD/ apply patch 2x/week $29.97- $69.95 Estradiol valerate injectable) (IM) 10mg q 2/52 10mg q 1/52 $14.20- $28.40
Inquiry MTF Monitoring How are you feeling? Side effects Physical Changes Change in libido and/ or erections - Shifts in emotional landscape Cece McDonald, 2012 Blood work including hormone levels
MTF Monitoring continued Targeted physical examination as directed by history Blood pressure DVT and liver exam if client presents with HX
Primary Care Screening Osteoporosis may be an increased risk. BMD, Calcium and Vit D recommended. Mammograms inconclusive evidence but likely beneficial if >50yo, especially if >5 years of estrogen. Of high personal importance. Prostate Exam likely still necessary (consider reduced risk with androgen deprivation) Genital / Pelvic PAP not likely necessary See appendix D in protocols
Recommended Blood Work Test Baseline 1 mo 3 mo 6 mo 12 mo CBC X X X X X ALT/AST a X X X X X Creatinine/ Lytes/ Urea b X X X X X Fasting Glucose X X LDL/HDL/TG X X X Testosterone (+/- Estradiol) X X X X X Prolactin c X X X X X LH d X X Other Hep ABC
Masculinizing Spectrum
Effects and Expected Time Course of Masculinizing Hormones. WPATH Standards of Care, Version 7, 2011. Estimates represent published and unpublished clinical observations. Effect Expected Onset Expected Maximum Effect Skin Oiliness/Acne 1-6 Months 1-2 Years Facial/Body Hair Growth 3-6 Months 3-5 Years Scalp Hair Loss >12 Months Variable Increased Muscle Mass/Strength 6-12 Months 2-5 Years Body Fat Redistribution 3-6 Months 2-5 Years Cessation of Menses 2-6 Months n/a Clitoral Enlargement 3-6 Months 1-2 Years Vaginal Atrophy 3-6 Months 1-2 Years Deepened Voice 3-12 Months 1-2 Years
Irreversible vs. Reversible Changes Irreversible Deeper voice Androgenic Alopecia May or May not reverse Clitoromegaly Body / facial hair Fertility Reversible Menstruation Fat / muscle / skin changes will reverse
Androgens Injectable Testosterone Enanthate (Delatestryl) Testosterone Cypionate (Depo-Testosterone) Patch Androderm Gel Androgel Oral Oustide the XY: Queer, Brown Masculinity. www.afropunk.com
Testosterone Enanthate (IM) Testosterone Cypionate (IM) Testosterone (transdermal) Patch Testosterone Gel (transdermal) Testosterone Gel (transdermal, axillary) Starting Dose Max Dose Cost per Unit Approx. Cost for 4 Weeks 50mg q week or 100mg q 2 weeks 100mg q week or 200mg q 2 weeks $69.03 per vial (each vial contains 200mg/ ml x 5mL = 1000mg $43.31 per vial (each vial contains 100mg/mL x 10mL = 1000mg 2.5-5mg OD 5-10MG OD $159.27 / 60 x 2.5mg OR 30 x 5mg patches 2.5 5g OD (2-4 pumps, equivalent to 25-50 mg testosterone) 1.5-3mL OD (1-2 pumps, equivalent to 30-60 mg testosterone) 5-10g OD (4-8 pumps, equivalent to 50-100 mg testosterone) 3-4.5mL (2-3 pumps, equivalent to 60-90 mg testosterone $85.90 / 30 x 2.5g sachets, $147.29 / 30 x 5g sachets, $167.55 / 2 pump bottles $13.81 - $ 27.60 $8.66 - $ 17.32 $74.33 - $297.30 Sachets $80.17 - $274.94 Bottles $78.19 - $312.76 $166.89 / pump bottle $77.88 - $233.65
FTM Monitoring Inquiry Side effects Menstrual Emotional/transitional Blood work including hormone levels STI considerations Physical exam Weight/height pap & pelvic, breast exams Liver Counselling
Test Baseline 1 Month 3 Months 6 Months 12 Months CBC X X X X X ALT/AST a X X X X X Fasting Glucose X X X LD/HDL/TG X X X Testosterone X X X X X LH b X X Other Hep A, B, C, pregnancy test
Primary Care Screening Osteoporosis may be an increased risk, mostly associated with poor adherence to hormone regimens after surgery. BMD, Calcium and Vit D recommended. Mammograms routine screening, if chest surgery chest exam and possible ultrasound Genital / Pelvic routine PAP screening, only after hysto if high grade dysplasia See appendix F in protocols
Precautions These are not necessarily contraindications to hormones, rather points of consideration for best steps forward: Addiction Uncontrolled or undiagnosed serious psychiatric disorder Obesity and smoking Wish to preserve fertility
Risks of Hormone Therapy With Estrogen: Risk Likely Increased Risk Possible Increased Risk No/not sure VTE, Gallstones, Elevated liver enzymes, Weight gain, Trigs, Vascular disease Hypertension, Hyperprolactinemia, DM 2 Breast cancer
Risks of Hormone Therapy With Testosterone: Risk Likely Increased Risk Possible Increased Risk No/not sure Polycythemia, Weight gain, Acne, Male pattern baldness, Sleep apnea Elevated liver enzymes, lipids, Hypertension, DM 2, Exacerbation mood, Vascular disease Bone density loss, Breast, Cx, Uterus, Ovarian cancer
Preventative Health Care What we Do in Primary Care For Cis Patients For Trans Patients Disease Prevention Health Promotion Screening Sexual Health Personal Safety Immunizations Focus on organs present Focus on organs present
Ways You Can Be Involved Trans*Specific Care Trans*Supportive Care
Expectations Change can happen slowly Unique degree and rate of change Age (more slowly after 40yo) # hormone receptors Sensitivity Some things do not change Body type Bone size Hands and feet Genetics
Psychosocial Assessment / Counselling Self perception Body image Side effects of medication Mood changes/thought content Lifestyle Identifying and discussing sexual risk factors
Counselling Follow-Up How transitioning is going? what are your feelings/experiences around transitioning? Are you out at work and out with family? How s that going? If binding/tucking: are safe techniques being used?
Evaluation THANK YOU Please fill out the evaluation forms Comments, suggestions and questions welcome