1. No category

5/18/2015
TRANSGENDER
HEALTHCARE
Barry Zevin, MD
Conrad Wenzel, MSW
Disclosures
• Dr. Zevin is an employee of the San Francisco
Department of Public Health
• There are no other relevant financial or personal
relationships that could cause bias in this
presentation
• No medications used as feminizing / masculinizing
therapy for transgender patients are FDA
approved for this indication
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5/18/2015
Why Focus On Trans Healthcare?
The Lived Realities
• 56% reported
verbal harassment
in public places
• 61% experienced
physical assault
• 64% experienced
sexual assault
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5/18/2015
Nearly 4 times more
likely to have
household income of
less than $10,000
per year compared
to the general
population.

Health Conditions Associated with
Transgender Identity
• Hx of assault, victimization, abuse, discrimination
• Depression, Substance use disorders, Trauma, Suicidality
• HIV infection
• Barriers to healthcare / Discrimination in medical settings
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Prevalence
• 1:11,900 – 1:45,000 MTF 1:30,400 – 1:200.000 FTM
• Conventional prevalence based on presentation to
specialized centers
• .3% to 1.4% of the general population
• Based on community surveys
• % even higher if includes “ambivalent” gender
identities
• Numbers seen in healthcare settings rising
• At least 2000 seen in SFDPH settings over past 5 yrs
• Based on ICD-9 codes and “TG” marker in registration
Implications for HIV and Other
Prevention
• Are behavioral risks for HIV and other problems
concentrated in .01% who present for specialized
transition related care or spread through much much
larger trans* population?
• Risk in this population still imperfectly understood
• Discrimination appears to effect larger population
• African American and other minority populations at
higher risk
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5/18/2015
Access to care (NTDS)
Experienced refusal to provide care
Postpone care due to discrimination by
provider
Healthcare Discrimination
• 28% report harassment in medical settings
• 20.9% report healthcare providers used harsh or
abusive language
• 7.8% report health care professionals were
abusive or physically rough
• 2% reported violence in the doctor’s office
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5/18/2015
Healthcare Discrimination
• Patients will not disclose that they are
transgender if they feel unsafe. This can result in
compromised medical care.
• Ex: Doctors won’t offer pap screens if they don’t
know a person has a cervix or prostate exams if they
don’t know a person has a prostate
Access to care
50% of sample reported having to teach their medical
providers about transgender care
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5/18/2015
Health outcomes

HIV
• 2.64% reported having HIV, a rate 4 times high than the
general pop. at 0.6%
• HIV rates higher for transgender people who have had
experiences of homelessness than those who have not
(7.12% vs 1.97%)
Trans Responsive Care is Possible
(and not too difficult)
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5/18/2015
Know your patients’ legal protections
• The Gender Nondiscrimination Act , CA
• Discrimination illegal in housing, employment, and
public accommodations
• HIPAA
• transgender identity is protected health information
• Disclose is a violation of HIPAA
Know what’s covered
• Medi-cal: Since 2001 Medi-Cal prohibited from categorically
denying coverage for transgender people, including surgeries
• Medicare: covers medically necessary hormone therapy,
exclusion on surgery lifted 5/2014
• Other insurance in CA: Can’t discriminate if medically necessary
• VA: Covers everything except surgery
• Other states: various policies
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5/18/2015
How to Make The Clinic More Welcoming
Physical Environment
 Gender neutral bathrooms
 Visible and welcoming signage, magazines, posters
Intake Forms
 2 Part Question – Sex and Gender
 Option for legal name and name the person uses
 Place to designate Appropriate gender pronoun
How to Make The Clinic More Welcoming
 Protocol for navigating electronic health records and
the real live person
 Protocol for intervening when harassment or
discrimination occurs between clients/patients
 Ongoing transgender trainings for staff
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5/18/2015
Get Familiar with the Lingo
• Terms are always changing
• Paradox of definitions: both crucial and meaningless
• It’s ok not to know all aspects of how someone identifies in
order to treat them respectfully and give them good care
• Know why you’re asking
Genderbread Person
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Terms
Sexual orientation
Transgender
Cisgender / “Not transgender”
Gender Non-Conforming
Gender Galaxy
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Tips on Terms
• Transgender is an adjective, not a noun
• Ex: Gina is a transgender woman
Tom is a transgender man
• Ex: Gina is a transgender
Gina and Tom are transgenders
Gina and Tom are transgendered
Pronouns
• Honor the patient's preferred gender identity and use the pronouns and
terminology that the patient prefers.
• Linked to not only patient feeling welcome, but provider comfort.
• Understand the importance
• Visual cues misleading with clients in transition or people who are fluid
• Focus is on not on offending client, not provider comfort
• “Ask, Practice, apologize if you misstep, Do better next time rinse and
repeat.”
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5/18/2015
More Best Practices
•
Don’t try to guess or ask about a person’s “real gender” – who they are is who they
tell you they are
•
Don’t discuss your beliefs about whether or not a person “passes”
•
Stay focused on the issue that brought the patient in
•
Don’t ask about a person’s body parts unless its clinically necessary
A Note About Transgender Medical Care
• Anatomy ≠ Identity
• Transgender specific care can include: hormones
and surgery
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5/18/2015
GUIDELINES FOR
TRANSGENDER
MEDICAL CARE
Possible Topics
•
Hormone Therapy
Informed Consent
Dosing and Monitoring
• Patient Education
• Interactions
•
•
•
Health Promotion / Disease Prevention
HIV, STD, Sexual Violence Prevention
Routine Health Maintenance
• Special Issues – Sexual functioning, fertility, tucking and binding, silicone and pumping
• Cancer Screening
•
•
•
Surgery Preparation and Aftercare
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Gender Spectrum and Gender Dysphoria
• WPATH SOC 7th version “Standards of Care for the Health of
Transsexual, Transgender, and Gender Nonconforming
People.”
• Gender expression and gender identity occur on spectrum
• Strong evidence against
binary conception of gender
• Diversity not pathology
• Gender dysphoria in DSMV
• Gender identity disorder (DSM IV) still used as billing code
etc.
Natural History of Gender Dysphoria
• Consequences of untreated gender dysphoria
• Suicidality / suicide
• Neglect of health and healthcare needs
• Resorting to black market or unscrupulous MD’s
• Unmonitored hormone therapy with adverse effects
• High risk sexual behavior
• Substance use
• HIV and other infectious diseases
• Vulnerability to victimization
• Attempts at self surgery or surgery by
unscrupulous providers
• Silicone and other injections “pumping parties”
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5/18/2015
Harm related to treatment vs harm related
to not treating
Possible Harms related to treating
• Possible adverse effects of hormones or surgery
• Irreversible effects that will later be regretted
• Clinician being over-concerned with gender
presentation and neglecting other areas of health
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Possible Harms Related to Not Treating
• Continued misery and suffering related to being
unable to express gender identity
• Continued suicidality, depression, substance use,
victimization, etc.
• Continued vulnerability to HIV, STD’s, etc.
• Clinician undervaluing of gender concerns may be
retraumatizing
• Continued mistrust of the healthcare system
Implications for HIV Prevention
• Ability to provide hormones in primary care setting
can increase engagement in care
• Risk in this population still imperfectly understood
• Discrimination appears to effect larger population
•African American and other minority
populations at higher risk
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5/18/2015
Hormone Therapy
Standard vs. Informed Consent Model (WPATH SOC7)
•
•
•
•
•
Standard
Informed consent model
Initiation of hormone Rx after
psychosocial assessment by
“qualified mental health
professional”
Recommendation for team
care or collaborative model
Psychotherapy not required
Experienced hormone
prescribing medical provider
may meet requirement
Informed consent
•
Rx initiated by prescribing MD
• Based on clinical judgment
• Lack of contraindications
• Pt. capacity to give informed
consent
• Informed consent
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Informed Consent Model
• Ethical construct familiar to healthcare providers
• Widely and successfully used in multiple settings
• Requires healthcare provider to effectively communicate benefits,
risks and alternatives of treatment to patient
• Requires healthcare provider to judge that the patient is able to
understand and consent to the treatment
• WPATH SOC7 states protocols using informed consent model are
consistent with SOC7
• Informed consent model does not preclude mental health care
• Recognizes that prescribing decision ultimately rests with clinical
judgment of provider
•
Informed consent is not equivalent to treatment on demand
(Deutsch, 2012)
Hormone Therapy
• Feminizing /masculinizing hormone therapy is
medically necessary for many
• Goals of therapy vary
• Relief of gender dysphoria may occur with varying
doses and various degrees of transition
• Outcomes of hormone therapy have been very
successful
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General approach to prescribing
• Most effective
when collaboration with patient, other
involved clinicians, and prescriber
• Educate patients that not everyone who is gender non-
conforming requires hormone therapy
• Assess and discuss possible benefits of hormone therapy
• Assess and discuss possible harms of hormone therapy
General approach to prescribing
• Acknowledge limits of knowledge
• Patients make different decisions and have different feelings about
body changes at different stages in life
• we are more cautious about giving
treatment that causes irreversible
changes
• Balance benefits with possible harms from patient’s point of view
• Assure patient is making informed decision and is able to give
consent
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Hormone Therapy
• Various regimens proposed and used based on experience
• European and American regimens differ
• 3 theories of hormone therapy
• Attempt to recreate hormone milieu of opposite gender
• Attempt to recreate hormone milieu of puberty for opposite
gender
• Customize to values and goals of individual patient and
assess by subjective response
Hormone Therapy: patient and physician
values and goals
• Lower dose
• Longer time to same changes?
• Less adverse effects?
• Dose dependent effects vs idiosyncratic vulnerabilities
• Less risk of irreversible unwanted changes
• Higher dose
• More rapid changes and complete changes?
• Less risk of patient using illicit hormones
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Feminizing hormone therapy
• Anti-androgens
• Estrogens
Anti-androgens
•
GnRH agonists
• Especially useful for blocking puberty in children
• Expensive
• Not covered on many formularies
•
Spironlactone
• Widely used in USA
• Inhibits testosterone production
• Inhibits androgen binding
•
Cyproterone acetate (progestin widely used in Europe not available in US)
•
Finesteride, etc (may be useful adjunct or when others contraindicated not
available)
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Feminizing Hormone Therapy
Anti-androgens - Spironolactone
• Gender Related Effects
• ↓ facial and body hair growth
• ↓ progression of male pattern baldness
• ↓ libido
• ↓ erections
• Mild breast growth (irreversible)
Feminizing Hormone Therapy
Anti-androgens - Spironolactone
• Adverse effects
• Mild diuretic
• Hyperkalemia(potentially
life threatening)
• High risk when combined with ACEI, ARB
• High risk for patients with kidney disease
• ↓libido, ↓erections
• Risk of osteoporosis if used in long term without
estrogen
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Feminizing Hormone Therapy
Anti-androgens - Spironolactone
• Mood, Behavioral, & Sexual Effects
• Effects of lowering testosterone vary widely
• Decreased libido & erections are desirable for some
patients and undesirable for others – ask!
• Mood and energy may drop but be offset by satisfaction
with effects
Feminizing Hormone Therapy
Anti-androgens - Spironolactone
• Limitations
• Minimal feminization
• No effect on facial or other bone structure
• Can’t reduce amount of hair follicles
• Interactions
• ACEI, ARBS, digoxin, other K+ sparing diuretics
• No interaction with tobacco
• Danger with street drug use that results in
dehydration
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Feminizing Hormone Therapy – Estrogens
• 17β-Estradiol (oral, sub-lingual, injectable,
transdermal, etc) – many brand names
• Conjugated equine estrogens (aka Premarin, aka
horse estrogen)
• Ethinyl estradiol (no longer used for feminization
due to increased risk of thrombosis)
Estrogens - Gender Related Effects
• Breast development (irreversible)
• Redistribution of body fat (partly reversible)
• Softening of skin
• Suppression
•
of testosterone production
Requires higher doses when used alone
• Improved
mood
• Shrinkage of testes (partly reversible)
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5/18/2015
Estrogens – mood, behavioral, & sexual effects
• Mood swings / “moodiness”
• ↓libido
• many people describe feeling more comfortable or desirable
sexually
• Emotional changes especially when starting or
stopping or changing dose
• ↓ in sexually stimulated erections
• Changes in sexual interest / orientation
Estrogens – Adverse Effects
• Thrombosis
• Most serious and dreaded adverse effect
• Not common
• Life threatening
• Increased risk of deep vein thrombosis and
pulmonary embolism
• Specific known risk factors
• Other thrombotic conditions rare but increased
• Stroke, heart attack, retinal vein or artery, others
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Estrogens - Common Adverse effects
• ↑ weight,
• Adverse changes in lipid levels
• ↑ in prolactin levels
• nausea / vomiting,
• migraine / headache,
• melasma (skin darkening),
• skin irritation from estradiol patches
Estrogens - Less Common Adverse Effects
• ↑ risk of cardiovascular events in those over age 50 with other
cardiovascular risk factors
•
especially those taking progesterones in addition to estrogens
• transient liver enzyme abnormalities,
• ↑ risk of gallbladder stones,
• ↑ risk of diabetes mellitus
•
particularly in those with family history or other risk factors
• ↑ in blood pressure
•
note spironolactone reduces blood pressure
• Impaired fertility
• Regret of irreversible changes
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Estrogens - rare or plausible but have
not been observed
• liver damage
• Prolactinoma
•
•
•
Estrogens clearly exacerbate pre-existing adenoma
Open question as to whether estrogens cause adenoma
Usual endocrine issues due to microadenoma not relevant for transgender
patients
• permanent sterility
• ↑ risk of breast cancer
•
compared to men never exposed to estrogen
• ↑ risk meningioma
Estrogens
•Limitations
• Degree of breast growth, fat redistribution, skin
softening, etc very variable
• Breast growth rarely greater than B cup and structure
of chest remains male
• Generally most changes in younger people, least in
older people
• Height, basic body structure, facial structure don’t
change
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Estrogens
•Interactions
• Estradiol Interactions with other medications not well
studied at these doses
• No important interactions with HIV medications or
other commonly used medications for other chronic
diseases
• Cigarettes increase metabolism and decrease
effectiveness of estrogens
• Cigarettes increase risk of DVT and other
cardiovascular risks
10 things to know about feminizing
hormone therapy
1.
More isn’t always better / less isn’t always better
2.
Importance of smoking cessation
3.
Psychological benefit may be more than physical changes
4.
Hormone therapy cannot get rid of hair follicles
5.
Decision to start, continue, or increase hormones must
include benefits, risk of adverse effects, and risk related to
what will happen if a person does not get it
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10 things to know about feminizing
hormone therapy
6.
Estrogen is not toxic to the liver or kidneys with very rare exceptions
7.
Counsel patients on fertility impairment and offer sperm banking to
interested patients prior to starting therapy
8.
Patches or shots may be the safest for many patients over 40 or with
other health issues
9.
Ask about sexual functioning and expectations about erections before
start or change
10.
Changes related to any particular hormone or dose may take 3 months
or longer to be noticeable
Masculinizing Therapy: Testosterone
• Injectable
• Patch
• Gel or solution
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Testosterone – gender related effects
• Cessation of menses
• Voice change to a male range (irreversible)
• ↑hair growth on face, chest, extremities (irreversible)
• ↑muscular mass & strength (partly reversible)
• Redistribution of body fat (partly reversible)
• Clitoral enlargement (irreversible)
Testosterone – mood, behavioral, &
sexual effects
• More contentment,
• Greater extroversion
• Less somatization
• ↓ in affective intensity
• ↑ libido
• Changes in sexual interest / orientation
•
Increased risk behavior for STD’s, HIV in population that may not
have received HIV prevention services
• Exaggerated mood changes at beginning and end of
dosing for injected testosterone
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Testosterone – Common Adverse effects
• ↑ weight,
• oily skin,
members to
testosterone with gel
• acne,
•
• vaginal atrophy,
• male pattern baldness,
• emotional changes,
• ↓ HDL cholesterol
level,
• skin irritation with
patch
• Exposure of family
Unwanted
masculinization in
female partner or kids
• Sweating
• Snoring
• Insomnia
• Reduced fertility
(partly reversible)
Testosterone – Less common adverse effects
• peripheral edema
• ↑ blood pressure
• erythrocytosis
• transiently abnormal liver
enzymes
• dyslipidemia
• obstructive sleep apnea
•
•
increased aggressiveness
•
Not common, when occurs
predictable in pts with previous hx of
poor impulse control
•
skin ulceration with patch
•
Regret of irreversible effects
skin irritation with gels
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Testosterone - rare or plausible but have
not been observed
•
•
•
•
•
•
HTN
liver dysfunction
↑ risk of cardiovascular disease
↑ risk of breast cancer
↑ risk of endometrial hyperplasia
↑ risk of ovarian cancer
Testosterone
• Limitations
• No effect on height
• No effect on breast size or composition
• Clitoral growth not adequate for insertive
intercourse
• Interactions
• Possible interactions with warfarin
• Decrease need for glucose lowering in
diabetics
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5/18/2015
10 things to know about masculinizing
hormone therapy
1.
Importance of smoking cessation
2.
Facial / body hair growth, voice deepening may occur quickly
even at low doses and is irreversible
3.
Male pattern baldness may occur quickly and is irreversible
4.
Almost everyone can be taught to self inject testosterone but
everyone needs to be taught
5.
Libido can increase and sexual attractions can change with
start of testosterone (think adolescent boys)
10 things to know about masculinizing
hormone therapy
6.
If patients have mood swings on every 2 weeks injectable testosterone
may be helped by changing to every week (at ½ dose) or patch or gel
7.
Testosterone usually does not cause rage, aggression, or violence (even
in high doses)
8.
Counsel regarding loss of fertility and possibility of ova banking
9.
Uterine bleeding after being on a stable testosterone dose requires a
medical work up
10.
Testosterone is not a reliable contraceptive and other methods are
required if patients are having vaginal sex with cisgender men
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5/18/2015
Transgender Surgeries
• What is covered
• How do we get it covered
Covered Surgeries (HSF, Medi-Cal)
• Mastectomy w/ chest
• Orchiectomy
reconstruction
• Hysterectomy/
salpingo-oophrectormy
• Vaginectomy/colpocleisis
• Metoidioplasty
• Phalloplasty with Penile
Implant
• Scrotoplasty
• Urethral reconstruction
• Penectomy
• Vaginoplasty
• Clitoroplasty
• Labiaplasty
• Feminizing mammoplasty
• Genital Hair Removal pre-
vaginoplasty/phalloplasty
•
Not Covered: facial feminization, body
contouring, tracheal shave, facial hair removal*
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Dr. Curtis Crane
Healthy SF and Medi-Cal
Metoidioplasty, Vaginoplasty, Phalloplasty
SF General Hospital
Orchiectomy & Hysterectomy: surgery staff
Chest and breast surgeries and revisions: Dr.
Esther Kim
For Anthem patients:
Genital surgery with Dr. Maurice Garcia at UCSF
Dr. Marci Bowers
Medi-Cal
Vaginoplasty
Coming in 2016: All surgeries available at SFGH?
A note about Medicare
• Currently there is no pathway for coverage for
vaginoplasty, phalloplasty, or metoidioplasty for
patients with Medicare coverage
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Patient criteria for surgery
• 18 years or older
• 12 continuous months on hormones (unless hormones are
contraindicated or not desired by patient)
• Surgery referrals require the following:
• 2 psychosocial assessments & referral letters
•
(1 assessment for Chest Reconstruction / Breast
Augmentation)
• Medical evaluation form
• Medical history and physical exam with med list
How to support patient while waiting
• Opportunity for patients to work on further
stabilizing medical conditions, housing, mental
health, reduction of substance use, saving money
for supplies
• Start hair removal 6-9 months before
vaginoplasty and phalloplasty
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Aftercare Considerations
• Safe and clean place to recover
• Medical Respite available in some areas
• Transportation
• Paratransit / Medical Taxi
• Support system
• IHHS, Health at Home
• Meals
• Project Open Hand
• Medical Supplies
• Some supplies covered by Medi-Cal
VAGINOPLASTY
Common Complications and Clinical
Considerations
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Normal Healing
Discharge
•
Vaginal discharge that is brownish yellow is normal in first 4-6
weeks after surgery
Urine
•
Blood in urine and at opening of urethra is generally normal,
up to 6 weeks
Swelling
•
Some swelling is normal, 4-6 weeks
Early Complications After Vaginoplasty
• Granulation tissue
• Infection
• Hematoma
• Urinary stenosis
• Fistula
• Wound breakdown or necrosis
• Pain, neuropathic pain, phantom sensation
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Granulation tissue
• Usually 1st few weeks after surgery
• Patient is usually still following up with surgeon
• Can be treated with silver nitrate sticks
Infection
•
Blanching erythema, fever, nausea and vomiting, or urinary frequency or urgency
would be the most common signs of infection
•
Wound infection
•
UTI
•
Respiratory
•
Neo-Vaginal Discharge / Infection
•
•
GC / CT possible but unusual
BV type bacteria common but unclear if benefit to treat
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Urinary Problems
•Stenosis
•Fistula
•Spraying, Change in stream is normal
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Wound breakdown or necrosis
• Generally Obvious
• Non-dissolving (dissolving)sutures – ok to clip
Depression / Anxiety
• Usually responds to support
• May need more care
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Late Complications
• Vaginal Stenosis
• Pain
• Numbness or neuropathic symptoms
• Anorgasmia
What Do I Do When Patient Has a Complication
• Encourage patient to follow up with surgeon
• Some complications can be treated in primary
care settings
• Contact surgeon to consult
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Routine Health Maintenance for Trans* People
Preventative Services
•
Cancer Screening
•
Base on Anatomy
•
•
Pap smears for transmen with cervix – consider alternative options to speculum exam
Breast Cancer Screening
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5/18/2015
Cigarette Addiction
• Motivation to quit is high in population
• High desire to stay healthy
• Many hormone protocols do not allow initiation or escalation of
dose without smoking cessation
• Success rate for smoking cessation has been very
high Motivational interviewing is used
• Expert counseling is offered
• Adjunctive medications are used
• Relapse prevention is stressed
• It is possible and desirable to work on smoking even if other
substance use or MH disorders are still active or severe
Resources
•
World Professional Association for Transgender Health http://www.wpath.org/
•
SFDPH Transgender Health Services
http://www.sfdph.org/transgenderhealthservices
•
UCSF Center of Excellence for Transgender Health http://transhealth.ucsf.edu/
•
Transline project- health.org/transline
•
Vancouver Coastal Health transhealth.vch.ca
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