Evidence Based Care ofTransgender Patients
Spokane is Out
Evidence Based MedicineMeta AnalysisSystematic ReviewRandomized Controlled TrialCohort StudyCase StudyExpert Opinion
Strength of RecommendationTaxonomy (SORT)• Disease vs. Patient-Oriented Outcomes– Surrogate results (BP, Glucose, etc)– Vs...
Strength of Recommendation• A– Recommendation base don consistent and good-quality patient-oriented evidence• B– Recommend...
Goals• Introduction– Terminology, Pronouns– Gender vs. Sexual Orientation• Transgender Care & Scope of Family Medicine– Ev...
Goals: Healthy People• Harm reduction– Preventative care– Mental health– Substance abuse reduction• QOL maximization– Safe...
Gender vs. Sexual OrientationBoth are spectrums• Gender Identity: one’s sense of self as male, female orthird sex• Gender ...
Pronouns Matter• Intro to Gender Neutral/Gender VariantPronouns– Ze-She-He– Per-Him-Her– Mx-Mr-Ms-Mrs– Hersband-Husband• M...
We don’t live in a binary gender society anymore
Adolescents: Estimating GLBTQ+ Population• 2011 Youth Risk Behavior Survey (YRBS)• San Francisco School District middle sc...
Practice Recommendation:• ASK!– About gender identification– About sexual orientation– About bullying/violence (from peers...
When does gender change?• It’s a spectrum:– Lifestyle/Social– Hormone– Legal– Surgical• Some patients want all of the abov...
Things to Remember• A transgender patient’s body may haveelements, traits, or characteristics that do notconform to the pa...
How will I change my practice?• Honor the patient’s gender identity and use theterminology the patient prefers• New patien...
Transgender Hormone Therapy
Primary Care Protocols Project• Goal: Provide accurate, peer-reviewed medicalguidance for care of transgender pt• Why? IOM...
Assessing Readiness for Hormones• Only absolute contraindication to hormonetherapy is estrogen- or testosterone- sensitive...
Initiating Hormone Therapy• Baseline Labs:– MTF:• Estrogen: fasting lipids• Spironolactone: K+ and Cr• *remember that Cr c...
Initiating Hormone Therapy• Baseline Labs:– FTM:• Hemoglobin• LDL, HDL• Use Male reference values for testosterone(SOR A)–...
Hormone Administration• Goal: induce or maintain the physical and psychologicalcharacteristics of the sex that matches the...
Hormone Administration• MTF– Estrogen• SL, TD, Injectable are preferable to Oral due to avoiding firstpass liver metabolis...
Hormone Administration• MTF– Anti-Androgen• Spironolactone– Starting dose 100mg daily– May titrate up by 50mg a week to ma...
Hormone Administration• MTF– Progesterone risks not well studied, benefits notwell-characterized.• Nipple areola and libid...
Adjunct non-hormone therapy• MTF:– EMLA/lidocaine and oral analgesics prior to hairremoval procedures– Viagra/Cialis for s...
Hormone Administration• FTM– Testosterone recommended, in any form• IM/TD patch/TD Gel/SC Depo Implant (SOR B)• Gel prefer...
Hormone AdministrationIM injection testosterone allergy warnings:• Testosterone cypionate: suspended incottonseed oil• Tes...
Hormone Administration• FTM– Typically only 50mg testosterone needed to stopmonthly periods, rarely can use a progestin(SO...
Hormone Administration• FTM– Testosterone is not a contraceptive. FTM patients havingunprotected sex with fertile non-tran...
Long-term side effects of cros-sex hormones• Single center cross-sectional study• N= 100 transgender patients– post-sex re...
Practice Recommendation• To decrease cardiovascular morbidity, moreattention should be paid to decrease othercardiovascula...
Surgical Options• MTF:– Orchiectomy– Vaginoplasty (using penile tissue or colon graft)• Usually includes clitoro-labioplas...
Surgical Options• FTM:– Bilateral Mastectomy/reudction– Hysterectomy/Oophorectomy– Metoidoplasty- construction of male app...
Preventative Medicine and Screening• Annual visit: MTF– Annual mammogram beginning at age 40-50depending on risk factors, ...
Preventative Medicine and Screening• Annual visit: FTM– Annual lipids >30 yo or if preexisting hyperlipidemia prior tostar...
Mental Health
Cultural Competency: Mental Health• Suicide is 3rd leading cause of death inadolecsents• Nonsuicidal self-harm occurs in 1...
Cultural Competency: Self Harm• Risk factors in LGBTQ+ Youth (n=246):– Birth gender equal– Used several inventories:• Hx o...
Cultural Competency: Self Harm• Risk factors in LGBTQ+ Youth (n=246):• Risk factors for Suicidal Ideation and Attemptswere...
Cultural Competency: Substance Abuse• Not universal, but LGBTQ+ use is moreprevalent than the general populaiton• New York...
Cultural Competency: Substance Abuse• 50% of transgender individuals delayed orfailed to seek treatment because ofanticipa...
Cultural Competency: Tobacco• LGBTQ+ individuals smoke at higher rates thanthe general population.– Systematic review of 4...
Cultural Competency: Tobacco• Minority stress• Association between smoking and sensation-seeking and impulsivity• Targeted...
Cultural Competency: Tobacco• Less access to Primary Care Physician• 2-3x less likely to have health insurance• PCP less l...
Cultural Competency: Tobacco• The Last Drag– Week 1: orientation and Pre-test• Pre-test: readiness to quit, stages of chan...
Cultural Competency: Tobacco• The Last Drag– CLASH (Coalition of Lavender Americans in San Francisco)– August 2005 to Janu...
How will it change my practice?• Ask about LGBTQ+ specific bullying andvictimization• Ask about Hopelessness• Ask about Pe...
Future: Aging LGBTQ+ Population• Many go back into the closet when they are inneed of assisted living, home nursing, hospi...
Future: LGBTQ+ Aging• Why come out as an elderly individual?• Retirement and/or death of a spouse bringson the feeling tha...
Future: LGBTQ+ Aging• It’s not uncommon or unusual for transgenderpatients to present for the first time to aphysician as ...
Questions?
Evidence Based Care of the Transgender Person
Evidence Based Care of the Transgender Person
Evidence Based Care of the Transgender Person
Evidence Based Care of the Transgender Person
Evidence Based Care of the Transgender Person
Evidence Based Care of the Transgender Person
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Evidence Based Care of the Transgender Person

  1. 1. Evidence Based Care ofTransgender Patients
  2. 2. Spokane is Out
  3. 3. Evidence Based MedicineMeta AnalysisSystematic ReviewRandomized Controlled TrialCohort StudyCase StudyExpert Opinion
  4. 4. Strength of RecommendationTaxonomy (SORT)• Disease vs. Patient-Oriented Outcomes– Surrogate results (BP, Glucose, etc)– Vs. quality measures that help patients live longeror better lives (Sx improvement, improved QOL)• Level of Evidence– Validity of a study base on assessment of design• Strength of Recommendation– Recommendation for clinical practice based onbody of evidence (usually more than one study)Mark Ebell, et al. Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approachto grading evidence in the Medical Literature. Am Fam Physician (Feb 1 2004): 69; 3, 548-556.
  5. 5. Strength of Recommendation• A– Recommendation base don consistent and good-quality patient-oriented evidence• B– Recommendation based on inconsistent or limitedquality patient-oriented evidence• C– Recommendation based on consensus, usualpractice, opinion, disease-oriented evidence, or caseseriesMark Ebell, et al. Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approachto grading evidence in the Medical Literature. Am Fam Physician (Feb 1 2004): 69; 3, 548-556.
  6. 6. Goals• Introduction– Terminology, Pronouns– Gender vs. Sexual Orientation• Transgender Care & Scope of Family Medicine– Evidence Based Preventative Care– Evidence Based Hormonal Therapy• Evidence Based LGBTQ+ Mental Health– Culturally Competent approach to substance abuse– Suicide and Self Harm Risk
  7. 7. Goals: Healthy People• Harm reduction– Preventative care– Mental health– Substance abuse reduction• QOL maximization– Safe space– Hormone therapy– Patient-centered careHealthypeople.gov/2020/topicsobjectives2020/overview
  8. 8. Gender vs. Sexual OrientationBoth are spectrums• Gender Identity: one’s sense of self as male, female orthird sex• Gender Presentation: the expression of gender• Genderqueer: one who defies typical binary gender rolesand lives outside expected gender norms• Transgender: literally “across gender” or “beyond gender”• Transition: period of time when a transgender person islearning how to cross-live socially as a member of thegender category opposite their birth sex/natal gender• Sexual Orientation: sexual attraction tomales/females/transgender individuals, both, or noneItspronouncedmetrosexual.org; also at www.transhealth.ucsf.edu
  9. 9. Pronouns Matter• Intro to Gender Neutral/Gender VariantPronouns– Ze-She-He– Per-Him-Her– Mx-Mr-Ms-Mrs– Hersband-Husband• More can be found atitspronouncedmetrosexual.comitspronouncedmetrosexual.com
  10. 10. We don’t live in a binary gender society anymore
  11. 11. Adolescents: Estimating GLBTQ+ Population• 2011 Youth Risk Behavior Survey (YRBS)• San Francisco School District middle schools• 35,000 respondents aged 12-17– 12.1% reported being “unsure”– 3.8% middle school students identified themselves asLGBT– 1.3% identified as transgender• Growing body of data shows disproportionatelyhigh rates of harassment, bullying & violenceaimed at LGBT YouthJohn Shields, et al. Estimating Population Size and Demographic Characteristics of LGBTYouth in Middle School. Journal of Adolescent Health 52 (2013) 248-250.
  12. 12. Practice Recommendation:• ASK!– About gender identification– About sexual orientation– About bullying/violence (from peers OR family)– Teach that they are different– Allow as safe space for questioning(SOR C)Point toward resources (ex: Odyssey Youth Ctr,GSA in each high school in Spokane)
  13. 13. When does gender change?• It’s a spectrum:– Lifestyle/Social– Hormone– Legal– Surgical• Some patients want all of the above• Some want some of the above changes but notall- and it’s all ok.• Genderqueer patients may not desire anyhormone therapy or may desire fluctuatinghormone therapy
  14. 14. Things to Remember• A transgender patient’s body may haveelements, traits, or characteristics that do notconform to the patient’s gender identity.• For trans people, their anatomy does not definethem.• Do not define the person by their sex assigned atbirth• Provide usual prevention and screening for theanatomy that is present, regardless of theirgender identification(SOR C)Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  15. 15. How will I change my practice?• Honor the patient’s gender identity and use theterminology the patient prefers• New patient forms• EMR capability of “other” for gender• Unisex bathrooms• Letters to patients with desired pronouns• All are recommendations from the JointCommission(SOR C)The Joint Commission. Advancing Effective Communication, Cultural Competence, andPatient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT)Community: A Field Guide.
  16. 16. Transgender Hormone Therapy
  17. 17. Primary Care Protocols Project• Goal: Provide accurate, peer-reviewed medicalguidance for care of transgender pt• Why? IOM Report 2011 “The Health of LGBTPeople”– High levels of joblessness and poverty– Lack of health insurance– Both private and public health care plans severelylimit transgender access to surgeryMarvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  18. 18. Assessing Readiness for Hormones• Only absolute contraindication to hormonetherapy is estrogen- or testosterone- sensitivecancer• Informed consent is key.– Patient-centered outcomes vs. disease-centeredoutcomes– Obesity, CV disease, dyslipidemia, hepatitis, HIVare all conditions that should not precludetreatment insetting of informed consent(SOR C)Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  19. 19. Initiating Hormone Therapy• Baseline Labs:– MTF:• Estrogen: fasting lipids• Spironolactone: K+ and Cr• *remember that Cr clearance is based on muscle mass• The standard of testing LFTs is based on older studies with methodologicalflaws, using formulations which are no longer prescribed (ethinyl estradiol),and NOT controlling for alcohol and Hepatitis B/C– Follow up labs:• K if changing dose of spironolactone, then annual• Only check testosterone if not virilizing or stopping menses after 6 mo• No need to check estrogen levels• Prolactin screening once at 1-2 years after starting hormones– Other labs testing based on specific PMH, FHx, age and sexual orsubstance abuse risk factorsMarvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  20. 20. Initiating Hormone Therapy• Baseline Labs:– FTM:• Hemoglobin• LDL, HDL• Use Male reference values for testosterone(SOR A)–Follow up labs if on hormones:•Testosterone level after 6 months on stable regimen or ifexperiencing anxiety/aggression side effects–Hg/Hct Q6-12 mo (use male reference range)Other labs testing based on specific PMH, FHx, age andsexual or substance abuse risk factorsMarvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  21. 21. Hormone Administration• Goal: induce or maintain the physical and psychologicalcharacteristics of the sex that matches the patient’sgender identity• Cross-sex hormone administration is currently an off-label use ofboth estrogens and androgens• Is recommended for treatment of gender dysphoria• ICD-9: “Hormone imbalance in transgender individual”• Most medical problems that arise in transgenderpatients are NOT secondary to hormone use.• Discuss Fertility with ALL patients considering hormonetherapy.(SOR C)Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  22. 22. Hormone Administration• MTF– Estrogen• SL, TD, Injectable are preferable to Oral due to avoiding firstpass liver metabolism (SOR B)• Dosing:– SL: 1-4mg estradiol a day– TD: 100-200 mcg estradiol a day– IM/SC: 10-20 mg estradiol valerate Q1-2 weeks» max 2 years (SOR C)– Over 35 yo/Smokers: risk of thromboembolic dz(SOR B)– After gonadectomy: cut pre-surgical dose in half thentitrate to effect (SOR C)Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  23. 23. Hormone Administration• MTF– Anti-Androgen• Spironolactone– Starting dose 100mg daily– May titrate up by 50mg a week to max of 400mg daily– Advise taking all at once in am over divided dosing to avoiddiuretic effect interrupting sleep– Check K when starting and when titrating then Q6 mo(SOR C)• Finesteride– Adjunct for significant unwanted male pattern baldness– 1-5mg daily(SOR C)Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  24. 24. Hormone Administration• MTF– Progesterone risks not well studied, benefits notwell-characterized.• Nipple areola and libido benefits• 5-10 mg oral medroxyprogesterone daily• Depo-Provera 150mg IM Q3 mo for 2-3 years• Risk of weight gain and depression• Women’s Health Initiative: Oral Medroxyprogesteroneincreases CV disease, whereas IM may minimizeadditional risk (SOR B, C respectively)Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  25. 25. Adjunct non-hormone therapy• MTF:– EMLA/lidocaine and oral analgesics prior to hairremoval procedures– Viagra/Cialis for sexual dysfunction• Both:– Voice/Speech Therapy– Surgical referral if desiredMarvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  26. 26. Hormone Administration• FTM– Testosterone recommended, in any form• IM/TD patch/TD Gel/SC Depo Implant (SOR B)• Gel preferred for patient with polycythemia SE• Starting dose:– 50-200mg IM Q 2 weeks; alt: 100mg IM Q Week– Dosing can be changed Q7-10 days– Max dose 250mg Q2 weeks, as excess testosterone converts toestrogen (SOR C)– Avoiding excessive peaks and troughs ideal for avoidingemotional reaction, esp in pt with PTSD– Testosterone should not be withheld forhyperlipidemia (SOR C)Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  27. 27. Hormone AdministrationIM injection testosterone allergy warnings:• Testosterone cypionate: suspended incottonseed oil• Testosterone enanthate: suspended in sesameoil• Sustanon (Europe/Canada) suspended inpeanut oil
  28. 28. Hormone Administration• FTM– Typically only 50mg testosterone needed to stopmonthly periods, rarely can use a progestin(SOR C).• Anticipate it taking 2-3 months– For male pattern baldness: finasteride or mioxidil (butfinasteride will decrease masculinization effects esp.clitoromegaly)– For undesired significantly increased libido: low doseSSRIs– For greater clitoromegaly: topical testosterone onclitoris (subtract that amount from total dose)Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  29. 29. Hormone Administration• FTM– Testosterone is not a contraceptive. FTM patients havingunprotected sex with fertile non-trans males are at risk forpregnancy if they have patent tubes and a uterus.– Some may desire pregnancy– Options:• Mirena IUD (progesterone effect is local not systemic)• Endometrial ablation• Hysterectomy– AVOID: Nexplanon, OCPs, TD Estrogen patch, etc.– In non-mensturating FTM, try NOT to use vaginal estrogenMarvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  30. 30. Long-term side effects of cros-sex hormones• Single center cross-sectional study• N= 100 transgender patients– post-sex reassignment surgery– Average 10 yr hormone therapy• Outcomes:– FTM did not experience an increase in CV events,hormone-related cancers, or osteoporosis– 25% of MTF experienced a thromboembolic event– 6% of MTF experienced other CV SE after avg 11.3yr– Many MTF experienced osteoporosis– MTF: No reports of hormone-related cancerWierckx K, et al. Long-term evaluation of cross-sex hormone treatment in transsexualpersons. Journal of Sex Med. 2012 Oct;9 (10): 2641-51. Epub 2012 Aug 20.
  31. 31. Practice Recommendation• To decrease cardiovascular morbidity, moreattention should be paid to decrease othercardiovascular risk factors during hormonetherapy management in MTF patients(SOR C)Wierckx K, et al. Long-term evaluation of cross-sex hormone treatment in transsexualpersons. Journal of Sex Med. 2012 Oct;9 (10): 2641-51. Epub 2012 Aug 20.
  32. 32. Surgical Options• MTF:– Orchiectomy– Vaginoplasty (using penile tissue or colon graft)• Usually includes clitoro-labioplasty to create an erogenouslysensitive clitoris and labia minora/majora• Colon grafts do not require serial dilation and are self-lubricating– Penectomy– Breast Augmentation– Reduction Thyrochrondroplasty– Voice surgery– Facial FeminizationMarvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  33. 33. Surgical Options• FTM:– Bilateral Mastectomy/reudction– Hysterectomy/Oophorectomy– Metoidoplasty- construction of male appearinggenitalia from testosterone-enlarged clitoris– Phalloplasty– Scrotoplasty– Urethroplasty– VaginectomyMarvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  34. 34. Preventative Medicine and Screening• Annual visit: MTF– Annual mammogram beginning at age 40-50depending on risk factors, length of estrogen use,family history (SOR C)– Annual rectal exam +/- PSA age 50, depending onpersonal Hx and risk factors– USPSTF: PSA not useful if patient is on estrogen(SOR B)– Colonoscopy at age 50, depending on personal Hxand FHX, risk factorsMarvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  35. 35. Preventative Medicine and Screening• Annual visit: FTM– Annual lipids >30 yo or if preexisting hyperlipidemia prior tostarting testosterone– Annual mammogram beginning at age 40-50, depending on riskfactors, FHx, and presence of breast tissue.– Palpate chest if pt has had mastectomy– Bimanual pelvic exam Q1-2 years (SOR C)– Pap Q2-3 years based on current recommendations if has cervix– Pelvic U/S for new bleeding, if still has uterus/ovaries– TSH Q1-2 years or based on sx/preexisting thyroid dz– DEXA Scan at 5-10 years after beginning testotserone(SOR B)Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center.Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
  36. 36. Mental Health
  37. 37. Cultural Competency: Mental Health• Suicide is 3rd leading cause of death inadolecsents• Nonsuicidal self-harm occurs in 13-45% ofteens• 17% of U.S. teens endorsed Suicidal Ideationover a 12 month period• LGBTQ+ are at independent increased risk,increased bullying victimization and stressRichard T. Liu, PhD, Brian Mustanski, PhD. Suicidal Ideation and Self-Harm in Lesbian, Gay,Bisexual, and Transgender Youth, Am J Prev Med 2012;42(3):221-228.
  38. 38. Cultural Competency: Self Harm• Risk factors in LGBTQ+ Youth (n=246):– Birth gender equal– Used several inventories:• Hx of Suicidal Ideation: Brief Symptom Inventory (BSI-18)• Self Harm: ARBA computerized self-administered interview designed foradolescents• Baseline Impulsivity: Barratt Impulsiveness Scale (BIS-11)• Sensation Seeking: brief Sensation seeking Scale (BSSS)• Gender Nonconformity (Boyhood Gender Conformity scale)• History of Attempted SuicideHopelessness Scale for Children (originally designed for use w/ethnic-minority youth)10 item measure (D’Augelli)– 2.5 fold increased risk for self harm• Social Support (MSPSS= Multidimensional Scale of Percieved Social Support)Richard T. Liu, PhD, Brian Mustanski, PhD. Suicidal Ideation and Self-Harm in Lesbian, Gay,Bisexual, and Transgender Youth, Am J Prev Med 2012;42(3):221-228.
  39. 39. Cultural Competency: Self Harm• Risk factors in LGBTQ+ Youth (n=246):• Risk factors for Suicidal Ideation and Attemptswere INDEPENDENT from risk factors for selfharm.• Suicidal Ideation and Self Harm behaviors wereNOT connected.• Increased Risk of Suicidal Ideation/Attempt:• Hx of Suicidal Ideation & Baseline Impulsivity:Richard T. Liu, PhD, Brian Mustanski, PhD. Suicidal Ideation and Self-Harm in Lesbian, Gay,Bisexual, and Transgender Youth, Am J Prev Med 2012;42(3):221-228.
  40. 40. Cultural Competency: Substance Abuse• Not universal, but LGBTQ+ use is moreprevalent than the general populaiton• New York Transgender Project:– Heavy alcohol use: 60.4%– Marijuana: 40%– Cocaine 21%– Stimulants 3.9%– Opiates 3.5%• Higher in younger MTF Transgender peopleLarry A. Nuttbrock PhD (2012): Culturally Competent Substance Abuse Treatmetn withTransgender Persons, Journal of Addictive Diseases, 31:3, 236-241.
  41. 41. Cultural Competency: Substance Abuse• 50% of transgender individuals delayed orfailed to seek treatment because ofanticipated maltreatment• Less than 5% of substance abuse counselorshave received transgender education• Afraid of “outing” side effects from combininghormone therapy with abused drugs (esp.alcohol)• Gender abuse as trigger for relapseLarry A. Nuttbrock PhD (2012): Culturally Competent Substance Abuse Treatmetn withTransgender Persons, Journal of Addictive Diseases, 31:3, 236-241.
  42. 42. Cultural Competency: Tobacco• LGBTQ+ individuals smoke at higher rates thanthe general population.– Systematic review of 42 studies (Lee, Griffin & Melvin2009).– Even higher in bisexual individuals who don’t identifywith LGBT community/label– Am Lung Assoc 2010 Six state Health Surveys (CA):• Men: 19% heterosexual to 26.5% gay, 29.5% bisexual• Women: 11.5% heterosexual to 22.3% lesbian, 30.9%bisexual• Few Transgender studies, but est. 30%• LGBTQ+ Youth age 13-24: 63% (n=500)Michelle Eliason PhD, et al. The Last Drag: An Evaluation of an LGBT-Specific SmokingIntervention. Journal of Homosexuality, (2012) 59:6, 864-878.
  43. 43. Cultural Competency: Tobacco• Minority stress• Association between smoking and sensation-seeking and impulsivity• Targeted marketing by tobacco industry- 1990– Free giveaways at gay bars– Funding LGBT organizations and events– Increased advertisements in LGBT publications• Community normalizationMichelle Eliason PhD, et al. The Last Drag: An Evaluation of an LGBT-Specific SmokingIntervention. Journal of Homosexuality, (2012) 59:6, 864-878.
  44. 44. Cultural Competency: Tobacco• Less access to Primary Care Physician• 2-3x less likely to have health insurance• PCP less likely to ask their LGBT patients if theysmoked than their heterosexual patientsIrony:• 8 week intervention with nicotinepatch, bupropion, and counseling: abstinencerates at end of intervention were identicalbetween Gay and Heterosexual men• The Last Drag classes (lastdrag.org)Michelle Eliason PhD, et al. The Last Drag: An Evaluation of an LGBT-Specific SmokingIntervention. Journal of Homosexuality, (2012) 59:6, 864-878.
  45. 45. Cultural Competency: Tobacco• The Last Drag– Week 1: orientation and Pre-test• Pre-test: readiness to quit, stages of change model– Week 2: Plan to quit smoking: process and tools– Week 3: Quit night• 2 days later: Becoming a nonsmoker and peer support– Week 4: Staying smoke-free: Short-term– Week 5: Staying smoke-free: Long-term– Week 6: Post-test and celebrationMichelle Eliason PhD, et al. The Last Drag: An Evaluation of an LGBT-Specific SmokingIntervention. Journal of Homosexuality, (2012) 59:6, 864-878.
  46. 46. Cultural Competency: Tobacco• The Last Drag– CLASH (Coalition of Lavender Americans in San Francisco)– August 2005 to January 2010– 19 program offerings– 371 LGBT Smokers, age 21-78; 73% male– 29% only went to one class -> n=233– Nonsmokers at end of class: 59%– Nonsmokers at 6 months: 36%– Rates lower for trans and ethnic minoritiesMichelle Eliason PhD, et al. The Last Drag: An Evaluation of an LGBT-Specific SmokingIntervention. Journal of Homosexuality, (2012) 59:6, 864-878.
  47. 47. How will it change my practice?• Ask about LGBTQ+ specific bullying andvictimization• Ask about Hopelessness• Ask about Perceived Social Support• Ask about substance abuse• Tobacco cessation• Ask about fears
  48. 48. Future: Aging LGBTQ+ Population• Many go back into the closet when they are inneed of assisted living, home nursing, hospice• It gets better campaign• Barriers: Health, Isolation, Income– Lack of culturally competent caregivers– Stigma: born in an era of strict gender roles– Lack of insurance– Successful careers while in the closetRandi Ettner and Kevan Wylie. Psychological and social adjustment in older transsexual people.Maturitas, November 2012 226-229.
  49. 49. Future: LGBTQ+ Aging• Why come out as an elderly individual?• Retirement and/or death of a spouse bringson the feeling that “life is short”• “Who am I?” comes back up• “Will I die never having lived lifeauthentically?”• Age related changes can bring on humor, selfdistance, and honestyMark Ebell, et al. Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approachto grading evidence in the Medical Literature. Am Fam Physician (Feb 1 2004): 69; 3, 548-556.
  50. 50. Future: LGBTQ+ Aging• It’s not uncommon or unusual for transgenderpatients to present for the first time to aphysician as transgender in their 60-80’s• Hormone therapy and/or surgical therapy canstill improve QOL and is still appropriate in theelderly (SOR C)• Cases of Elderly individuals desiring to starttransitioning with hormones, surgery or bothMark Ebell, et al. Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approachto grading evidence in the Medical Literature. Am Fam Physician (Feb 1 2004): 69; 3, 548-556.
  51. 51. Questions?
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