Case Studies in Primary care Holistic care of Transgender and Gender-nonconforming People Katy Kropf DO Ohio University Heritage College of Osteopathic medicine pronouns she/her/hers kropf@ohio.edu
My Story: Dr. Katy Kropf cisgender female DO I started providing trans care in 2010 because a patient requested it. I continued to do it because I loved it. Soon I discovered there was a need here in Southeast Ohio (and West Virginia).
Clinical Resources World Professional Association of Transgender Health (WPATH) Standards of Care (SOC) version 7-2012. (VERSION 8 in process) wpath.org UCSF Center of Excellence for Transgender Health transhealth.ucsf.edu Fenway Institute http://www.lgbthealtheducation.org/topic/transgender-health/ Transline transline.zendesk.com Lyon-Martin Hormone Guide
What about you? Lets Talk! Who currently provides care to transgender / gender non-conforming individuals? Prescribing Hormones? Counseling/therapy support? Social work/case management? Surgical care? Specialist care? Legal support???? Please add your experiences to this conversation!
Holistic care what do we mean? What is wellness? A conscious, self-directed process that emphasizes and fosters physical, intellectual, emotional, spiritual, socioeconomic, and environmental well-being, in the evolution of achieving one s optimal personal and professional potential. Constitutes an approach to delivering health care that considers these multiple influences on a person's health and diverse modalities for treating and preventing disease
Holistic care what do we mean? Supporting their whole person: body-mind-spirit Accepting and non-judgmental care while still encouraging greater selfaffirmation and healthier choices Do your best to let their whole person show up Meeting people where they are at Where is there flexibility in guidelines and where do I need to draw more rigid boundaries for patient safety or my own practice ethics? Gender affirming care = life saving care
Harm Reduction 101 Alternatives to Suicide for Teens, Freaks and Other Outlaws Kate Bornstein
Case 1: Bill transgender female Bill, 24 year old assigned male at birth, identifies as transgender female. Desires to start feminizing hormones. Does not plan to present as female at this time. Uses he/him pronouns. Recovering opiate addict x 2 months. Desires to preserve fertility. Smokes 1 ppd.
Does not plan to present as female at this time Is this an issue? WPATH SOC 7 The criteria for hormone therapy are as follows: Persistent, well-documented gender dysphoria; Capacity to make a fully informed decision and to consent for treatment; Age of majority in a given country (if younger, follow the SOC outlined in section VI); If significant medical or mental health concerns are present, they must be reasonably well- controlled. NO MENTION of REQUIREMENT for Gender presentation to be congruent with gender Identity **see notes re: Surgery requirements
Recovering opiate addict x 2 months Is this an issue? What about active addiction? WPATH SOC 7 The criteria for hormone therapy are as follows: Persistent, well-documented gender dysphoria; Capacity to make a fully informed decision and to consent for treatment; Age of majority in a given country (if younger, follow the SOC outlined in section VI); If significant medical or mental health concerns are present, they must be reasonably well- controlled. As noted in section VII of the SOC, the presence of co-existing mental health concerns does not necessarily preclude access to feminizing/masculinizing hormones; rather, these concerns need to be managed prior to, or concurrent with, treatment of gender dysphoria.
Desires to preserve fertility Counseling about Fertility It is recommended that prior to transition all transgender persons be counseled on the effects of transition on their fertility as well as regarding options for fertility preservation and reproduction. - UCSF Center for Transgender Excellence Can trans individuals maintain or return to fertility?
Transfeminine fertility (MTF) research suggests that prolonged estrogen exposure of the testes has been associated with testicular damage. Restoration of spermatogenesis following extended estrogen treatment, however, has not been well studied. The most successful option for fertility preservation for transgender women is cryopreservation of sperm prior to initiation of hormone therapy. -UCSF Center of Excellence for Transgender Health
Transmasculine fertility (FTM) The effect of prolonged treatment with exogenous testosterone on ovarian function is unclear. Testosterone therapy usually leads to anovulatory state and amenorrhea. This is usually reversible upon discontinuation of testosterone therapy, and pregnancies have been reported in transmen following prolonged testosterone treatment. Fertility preservation options for transgender men include oocyte cryopreservation, embryo cryopreservation, and ovarian tissue cryopreservation. -UCSF Center of Excellence for Transgender Health
Smokes 1 PPD Tobacco use in combination with estrogen therapy is associated with an increased risk of Venous Thromboembolism. All transgender women who smoke should be counselled on tobacco risks and cessation options at every visit. Many transgender women may be unable or unwilling to quit smoking; this should not represent an absolute contraindication to estrogen therapy. After an in depth and careful informed consent discussion, it is reasonable to prescribe estrogen using a harm reduction approach, with a preferred route of transdermal estrogen. -UCSF Center of Excellence for Transgender Health
Case 2 Josh transgender Male Josh, 56 year old transgender male; he/him pronouns; 10 years on Testosterone (started at age 46) Last pap was 10 years ago Still has breast tissue; never had mammo Mother recently diagnosed with breast cancer
Preventive Care and Screening Screen the tissues (body parts) that patient has and per appropriate Guidelines** ** I most often use USPSTF United States Preventive Services Task Force Can we make accommodations????
Pap screening Recommend routine guidelines: Every 5 years for age >30 with HPV testing Every 3 years age 21-30 with reflex HPV testing What are the challenges of pap testing in Transmasculine people? FTM patients had over ten times higher odds of having an inadequate Pap after adjusting for age, race, and body mass index - Peitzmeier SM, J Gen Intern Med. 2014 May;29(5):778-84. Encourage HPV vaccination
Pap screening Josh, 56 year old transgender male; 10 years on Testosterone (started at age 46) Last pap was 10 years ago He is due for a pap! Ideally every 5 years with co-testing.
Slide from: Primary Care and Preventive Health Needs of Transgender Patients Julie Thompson, PA-C Co-Medical Director for Transgender Health Fenway Health
Breast Cancer Screening UCSF Center for Excellence After age 50 AND After 5-10 years of feminizing hormone use Interval of every 1-2 years - UCSF http://transhealth.ucsf.edu/trans?page=guidelines-breast-cancer-women Endocrine Society Guidelines 2017 Guideline 4.5. We suggest that transgender females with no known increased risk of breast cancer follow breast-screening guidelines recommended for those designated female at birth. (2 ) - https://academic.oup.com/jcem/article/102/11/3869/4157558#99603362
Patient Handouts
Transmasculine (FTM): Initial Visit EHR Template Discussed Consent model of hormone initiation and though while counseling is not required, I do recommend getting counseling support during the transition process. Handouts given covering the basics of hormones and expected changes and side effects - including time-frame of changes, permanent and reversible changes. Consent form given for patient to review before next visit. Discussed that future fertility cannot be guaranteed after hormones and encouraged consideration of egg-harvesting and freezing. Fertility handout given. Discussed that testosterone treatment not considered sufficient birth control if patient is with partner who produces sperm. Also reviewed handout on Athens-area support services, including counsellors. Initial questions answered and will have patient return to discuss any further questions before starting hormones.
Transfeminine (MTF): Hormone Initiation EHR Template Estradiol and spironolactone initiated today. We discussed that there is an increased risk of blood clots on estrogen and to watch for signs of blood clot including knots, pain, and/or swelling in legs; chest pain, shortness of breath in lungs. We discussed that smoking, injuries/accidents/procedures can increase risk of blood clots. If symptoms occur to seek medical attention. Discussed risks of elevated potassium on spironolactone and that we will check potassium levels 10-14 days after each dose adjustment. Discussed that elevated potassium levels can cause cardiac arrhythmias and is a serious concern. All questions answered.
Other Topics Approval seeking Dysfunctional personal relationships Homelessness Hair loss (Rogaine) Purchasing Internet hormones (Cyproterone acetate) OTC Supplements with hormone activity Injection into testicles method used in India for sterilizing dogs Pt. desires to stop hormones due to challenges with employment and social acceptance Many more.
Resources Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People. Version 7, 2012. World Professional Association for Transgender Health Primary Care and Preventive Health Needs of Transgender Patients. Julie Thompson, PA-C Co-Medical Director for Transgender Health Fenway Health UCSF Center of Excellence For Transgender Health. transhealth.ucsf.edu Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline academic.oup.com/jcem/article/102/11/3869/4157558
Questions? Discussion? Thank You! Katy kropf kropf@ohio.edu