Gender Confirming Healthcare Across the Lifespan Dr. Tracey Wiese, APRN, FNP-BC, PMHNP-BC
What is gender confirming healthcare? Not just for trans clients Being aware of gender and sexuality concepts and spectrums Meeting the client where they are at Using the words the client is using Competency Open mindedness Compassion Awareness of intrinsic bias
General concepts Changing of sex/gender diversity occurs in other species Gender nonconforming Transsexual (subset of people seeking treatment) vs. Transgender (self identity) Gender queer/neutral/fluid Stealth health care Etiology is unknown Some review of twin studies (30% concordance in identical twins MtF (23% FtM)
Vocabulary discussion We will review these terms and discuss as a group Additional Discussion Questions: Why is it important to use the correct vocabulary? Doesn t all of this vocabulary make things more confusing?
Historical marginalization Historical marginalization of the LGBTQ community has led to individual, systemic and community oppression of this group of people
HISTORY Evidence of same sex relationships/love/sexual activity/gender diversity is documented in every culture These practices were either condemned or celebrated (Ancient Greece, Two Spirit, gender non conforming) Legal, financial, economic, familial, mental and physical health consequences of identifying as LGBTQ+
Implications Elder patients Individual, community, systemic bias Compounded trauma for many
Cultural humility: Alaska Native/American Indian Two-spirit Adopted in 1990 at the third annual spiritual gathering of lesbian, gay, bisexual, and transgender (LGBT) Natives Greater risk for adverse health outcomes than other Natives Multiple levels of boundary violations Geographic, familial, community, spiritual, colonial oppression Structural power inequities
Cultural humility: AN/AI Few existing studies particularly high risk for victimization relatively high rates of sexual orientation victimization (especially women) One study reporting AI/AN females having the highest rates of physical and sexual abuse and assault, both in childhood and adulthood
The point here is that this is a group of people who only recently are accessing healthcare without fear of legal, social and discrimination and for many regions and many people this is still occurring. If we are going to have positive outcomes for the population, we must be aware of this, and integrate this concern into our compassionate approach
Mental health and substance abuse
Higher rates of trauma than their straight peers bullying harassment traumatic loss intimate partner violence physical and sexual abuse traumatic forms of societal stigma, bias and rejection Poor competency amongst professionals (historically) leading to poor engagement ineffective treatment perpetuating the youth s trauma
33% attempting suicide in the previous year. 84% called names or had their safety threatened 45% (LGBTQ youth of color) experienced verbal harassment and/or physical assault 39% of LGB students and 55 percent of transgender students were shoved or pushed. 64% of LGBTQ students feel unsafe at school. 25-40% of homeless youth may identify as LGBTQ.
Social learning perspective age, gender, bisexuality, affiliation with gay culture, sexual minority stress, level of outness and HIV status of individuals and those in their social networks? It is likely that LGB individuals do not conform to the traditional norms? Transition later in life into, social roles that are incompatible with heavy substance use (e.g. marriage, parenthood)
Minority stress model LGB-specific stressors and elevated substance use. Being out to higher proportions of one s social network is related to higher substance use. Bisexual identity and/or behavior adds incremental risk MSM who are HIV+ or do not know their status report more polydrug use
Treatment interventions Most studies have used samples of gay/bisexual men Focus on drug use disorders None have examined LGB-specific protocols vs. non specific protocols cognitive-behavioral therapy LGB substance abusers do not require specialized treatment protocols Cultural competency is still a must
Treatment interventions contingency management motivational interviewing abstinence is not the goal of choice for many gay/bisexual men (possibly lesbian/bisexual women as well) Treatment targets Affiliation with gay culture Social roles r/t gender and age are different Perceived norms within the LGB culture Anxiety, shame, depression and/or isolation
This updated review does support that LGB individuals, particularly women, are at greater risk for alcohol and drug use disorders and related problems. Lesbians/bisexual women are drinking more than heterosexual women The findings for men continue to be mixed Bisexual identity and/or behavior further elevates the risk for substance abuse for both men and women.
Cross gender hormone replacement therapy
HRT Psychotherapy is not a requirement General Tips Age of majority Informed consent Medical conditions are reasonably well controlled
Medical history Coronary artery disease DVT/PE Embolic stroke Liver disease Pituitary adenoma Uncontrolled hypertension Uncontrolled diabetes Breast or uterine cancer Erythrocytosis Smoking status/desire to quit Mental health history Social history Family history Medications Allergies Substance use Gender identity history Gender dysphoria history Suicidal thoughts/attempts/self harm
Healthcare maintenance PPD status Immunization history Breast exam Testicular exam Pelvic exam HIV status and risk assessment > 50 colon cancer screening
Female to male cross gender hormone replacement therapy
FtM: medications Enanthate or Cypionate testosterone suspensions Pellets Rogaine or Finasteride for baldness Progesterone (prior to T to cessate menses) Bioidenticals are okay to use
Ftm: medications Testosterone patch/androderm Testosterone gel/androgel, Testim Applying testosterone to the clitoris Vaginal atrophy may need treatment: Estrogen (e-ring or topical) Refractory uterine bleeding in patients without gyn abnormalities: GnRH agonists
o Transition Symptom o Initial o Full o Skin o 1-6 mos o 1-2 y o Fat o 1-6 m o 2-5 y o Menses o 2-6 m o o Clitoral enlargement o 3-6 m o 1-2 y o Vaginal Atrophy o 3-6 m o 1-2 y o Emotions o o o Increased Sex Drive o o o Voice Changes o 3-12 m o 1-2 years o Hair o 6-12 m o 4-5 y o Muscle o 6-12 m o 2-5 years o Coarse Skin o o o Weight Gain o o o Breast Atrophy o o
FtM: Risks odecreased HDL oincrease Triglycerides oincrease homocysteine ohepatotoxicity opolycythemia oincreased risk of sleep apnea ounknown effects on breast, endometrial and ovarian tissue oinsulin resistance oinfertility ochronic pelvic pain omental health
FtM: ongoing care Check hormone levels at 2-12 weeks after start, then every 6-12 months CBC, Lipid Panel, Liver Enzymes, Renal Panel, Fasting Glucose, Screen for PCOS if indicated (a quarter of FtM patients have PCOS) Estradiol, you do not need to check this unless there is menstrual bleeding, but it should be less than 50. Testosterone (total) level should be between 350-700
FtM: ongoing care 2010 was the first case of endometrial hypoplasia thought to be related to HRT WPATH no longer recommends a hysto/oophorectomy after 5 years of hormones Even post op, still need annual chest exam (1 reported case of breast cancer) Increased obesity, poor lipid profile, potential increase in hematocrit Increased smoking rates Slightly higher Type II DM, however, this was usually diagnosed prior to hormones Increased incidence of PCOS like changes of the ovaries after exposure to testosterone Insulin sensitivity PAP per natal female guidelines
Male to female cross gender hormone replacement therapy
MtF: medications Estradiol/Estrace Premarin Transdermal Estrogen Preferred if over 45, hx of DVT or CV risk factors, Injectable (no data showing this is a faster transition) Uses: hypertrophy of the breasts, impotence, redistribution of fat, testicular atrophy, reversal of androgenic hair loss, loss of body hair, softening of skin Risks: CVA, DVT, PE, depression, gallbladder disease, GI upset, HA, hepatitis, hypercalcemia, hyperlipidemia, hypertension, impotence, loss of libido, mood changes, pituitary adenoma, sterilization
MtF: medications Antiandrogens Uses: decrease alopecia, impotence, thinning and decrease of body and facial hair, hypertrophy of the breasts Side effects: ataxia (s), GI upset, HA, hirsuitism, hyperkalemia (s), hyponatremia (s) hypotension (s), mood changes, anemia (f), hot flashes (f), loss of libido, rash (f), Testosterone elevation (not clinically significant) (f, d),
MtF: Ongoing care Estrogen is a strong synthesizer of prolactin, so screen the prolactin level <25 okay 25-40 Check for other sources of estrogen, monitor >40 Decrease dose by half and check again in 6-8 weeks >100 STOP, recheck 6-8 weeks If elevation continues, get an MRI Same labs, add prolactin
MtF: Ongoing care Before menopause, estradiol levels are widely variable throughout the menstrual cycle: Mid-follicular phase: 27-123 pg/ml Periovulatory: 96-436 pg/ml Mid-luteal phase: 49-294 pg/ml Postmenopausal: 0-40 pg/ml Increase risk of cardiovascular events in year 1 Increase risk of pulmonary embolism in year 1 Increase risk of cardiovascular events with conjugated estrogen which is NOT used in this type of hormone therapy Transdermal estrogen is the safest for pulmonary embolism and CV risk
MtF Ongoing Care What about Progestin? Increase cardiovascular events and breast cancer risk No evidence for breast growth Weight gain and depression as side effects Depo 150 mg IM q 3 m Provera 2.5-10mg daily Prometrum 100-200 mg daily Consider dosing 10 days a month cyclically or PO form to minimize risk Hydroquinone for hyperpigmentation MtF > 40 years old Should be taking a daily aspirin Should switch to topical hormones to decrease the risk of embolism and stroke
International medications Testoserone undecanoate oral 160-240 mg/d Dihydrotestosterone 10% cream applied topically to clitoris 20mg TID Cyproterone Acetate 50-150 mg/day oral an antiandrogen
Managing lab abnormalities Anemia < 11 Hgb + taking flutamide, d/c the flutamide and it should bounce back, if continues, get full anemia workup Erythrocytosis, r/o other causes such as polycythemia vera, hematocrit should be < 45, if > 52, decrease T switch to TD delivery Elevated LFTs if over 3 x upper limit or 2x baseline if chronically elevated, d/c hormones while workup is done,
Surgery: requirements Persistent and well documented gender dysphoria Capacity to make a fully informed decision Age of majority Reasonably well controlled medical conditions Well controlled mental health conditions 12 months of hormone therapy as preferred gender, unless hormones are not clinically indicated Insurance requirements
Surgery: types of surgeries FTM Hysterectomy and salpingooophorectomy Metoidoplasty* Phalloplasty* Male chest construction MTF Orchiectomy Vaginoplasty* Female chest construction
Other therapies Voice and communication therapy Surgery
MtF Primary care MtF still need vaginal exams Yeast is not usually an issue for a neovagina, but complex BV can be, treat with Clindamycin or amoxicillin Vaginal hygiene Use soap and water douche, or just warm water Mammograms are needed for over the age of 50 with hormones for 5 years for all patients regardless of gender Risk of breast cancer increases if also on progestin Androgen antagonists may falsely lower PSA, there may be protective effect, however Orchiectomy before the age of 40
MtF Primary care Aspirin daily if smoking and/or over 45 years old Bone density (mixed results in research) Increase in osteopenia/osteoporosis, but still less than natal women Bone density screen if > 60 years old and off of estrogen x 5 years High CV mortality rate in Transwomen than the general population Factors: (estrogen type, smoking status, obesity, baseline CV health) Risk for PE/DVT decreases after 1 year, all but 1 person in research was on ethinyl estradiol More US studies are starting, increase access to treatment for adolescents
MtF Primary care 50% higher mortality rate in MtF than FtM higher rates of AIDS, high risk sexual behaviors FtM still have high risk sexual behaviors, usually not as high risk as MtF patients HIV prevalence in US 28% 34 x more likely to acquire HIV than gen pop (MtF) In one study 62% of young trans women met criteria for taking PrEP, and most trans individuals are not served by existing MSM services https://www.cdc.gov/hiv/pdf/library/factsheets/prep101-consumer-info.pdf
MtF Ongoing management Some patients will want to use their penis for sex, so you can lower the dose of the androgen blocker or estrogen to help with obtaining and maintaining an erection Increased risk of gallbladder disease Hormone levels are decreased by seizure medication, steroids Hormone levels are increased by Zoloft (sertraline), anti-yeast medication, antibiotics, grapefruit, Paxil Lipids/Lytes. Creatinine and glucose every year Prolactin annually for 3 years Serum estradiol (do we need this?, maybe not always) up to about 200 (400-800). After 1-2 years, you only need annual visits
Ongoing management Suicide deaths are 6x higher than the gen pop Access to hormones and surgery reduces the general risks and mental health risks as well Increased substance abuse, 1/3 of transgender patients with hx of IV drug use Health Care Maintenance Treat the anatomy that is present
references Callen Lorde Community Health Center (2012). Protocols for the provision of cross gender hormone therapy. Accessed from www.tmeltzer.com The American College of Obstetricians and Gynecologists. Committee on Health Care for Underserved Women (2011) Heath care for transgender individuals (Committee Opinion)/ Number 512, December 2011. The National Child Trauma Stress Network. (2006). Trauma amoung lesbian, gay, bisexual, transgender or questioning youth. Culture and Trauma Brief: 1(2). The National Child Trauma Stress Network (unknown). LGBTQ Issues and Child Trauma. A Resource List. Accessed at nctsn.org on September 1, 2017. TransTalks Webinars. National LGBT Health Education Center. Accessed and watched on August 1 st, 2016. World Professional Association of Transgender Health. (2017). The Standards of Care: Version 7. Accessed from www.wpath.org on September 1, 2017.