HIV, Hormones, Stress & Discrimination


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This case study focuses on the transgender population and the discrimination that they face in the medical community. It also focuses on nutrition and medications and how they play an part in the management of HIV.

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  • Now that we have a better understanding about HIV from Molly, I will like to continue on with an understudied population that has a very high prevalence of this chronic disease. There are many things that we as RD’s and future dietitians will be able to do for the trnasgender population to help understand the challenges that this community faces. The Transgender revolution is not new; I am sure most of us have recently heard in the news about Chaz Bono (originally Castity, the daughter of Sonny & Cher). It is these famous celebrity children, as well as the younger generation who are taking this issue into the media and bringing it mainstream in hopes of us all having a better understanding of who this community of people are, what their needs are and what we can do to help them in society, in public health and in the medical field. With this in mind, I would like to briefly go over a health report published by the the Institute of Medicine in March of this yea. This report acknowledged the lack of research that we have on the LGBT community and what needs to be done to improve the needs of these individuals. They have recognized that clinicians are faced with incomplete information about the health status of the lesbian, gay, Bi and Transgender population and acknowledge that each population has its own specific needs and concerns.
  • The Institute of Medicine, in their report states that a program will be created by the National Intistute of Health so that everyone is equally aware of all of the challenges that the Lesbian, Gay,Bisexua l& Transgender Population Faces. When doing research they will focus on 4 major things that will have to do with this community, the fourth being Transgender specific health needs. Along with the research that I have done-we also will focus on transgender specific health needs!
  • There presently is no reliable date on the number of transgender individuals in the US. As you may imagine, this is a hard statistic to measure.     
  • Because you may never know and it is quite amazing what hormones, hair dy, surgery and electrolysis can do-you must have the knowledge.
  • So some terminology – Transgender is an umbrella term that symbolizes how people self identify. It is a population of individuals whose identity differs from the gender assigned at birth.
  • It is crucial to understand how people self identify in order to build relationships.
  • My patient is presently a MTF transgender taking hormones, she has had breast augmentation.
  • HIV + due to long term relationship. The depression had no bearing on transgender status or her sexual identity.
  • These tests are very important with hormones as well as HIV
  • My assessment was based on an HIV positive woman since she has been on female hormones successfully for over one year (Deutsch, 2010)
  • My patient is presently on a hormone regime that consists of three forms of estrogen. The side effects include a fluctuation in weight, change in appetite, decreased bone calcium, an increase in TG, HDL and LDL.
  • In order to receive hormones and eventually have surgery, a transgender patient must be diagnosed as having a Gender Identity Disorder-not everyone wants to have a disorder and live with a label for the rest of their life.
  • A patient must be diagnosed from the mental health Diagnostic and Statistical Manual, known as the DSM ,as having a Gender Identity Disorder. Not everyone in the transgender community agrees with this mental health criteria. The American Psychiatric Association defines the criteria for GID as having evidence of the desire to be or the insistence to be one that is the other sex. This cross gender must show discomfort in their present senx and the inappropriate role of the assigned sex. With this in mind, please note that homosexuality was also in the DSM until 1974 and considered too a mental illness-it was then eliminated.
  • So since not everyone believes in having a mental diagnosis rule their life, there is a new program to empower and support the transgender in the community. My patient is currently enrolled in this program and I was fortunate enough to learn more about this program first hand while visiting Howard Brown Health Clinic. This program allows patients to make choices for them selves based on their own lives and their transitions. It is based on “informed consent”. The program involves 2 medical appointments and one psych-educatrional meeting and not everyone is guanteed hormones but as most other providers requires clients to demonstate “lived experiences” or “a letter” from a therapist, this is not needed here. One thing to keep in mind is that hormones are not provided free of charge, there are no clinics in Chicago that are able to give away hormones. This is one of the issues that needs to be understood as many transgender people are forced to get their hormones off the street which means bad drugs and dirty needles, ultimately this put them at a high risk for many diseases. The Howard Brown Clinic which is the largest LGBT clinic in the Midwest, believes that GID should be a diagnosis of Gender Incongruence which means that the physical body is not matching the body’s internal wishes desires, etc. And should be left out of the DSM all togther. The DSM is reevaluated every 15 years. I personally hope there will be a revision or even a deletion.
  • Organs must always be screened, the prostate is usually present in MTF. MTF transsexuals should receive annual pelvic examinations following vaginoplasty, but there no evidence to suggest that they would benefit from vaginal cytological screening in most cases. However, if the glans penis has been retained as a neocervix, cytological examination of the neocervix is a reasonable practice. Also, clients need to be aggressively counseled on smoking cessation, maintaining a health weight, consuming a healthy diet and regular exercise.
  • Excess hair growth, loss of breast tissue, clitorial overdevelopment
  • Vagionoplasty creates a vagina from the male genatalia saving the sensitive nerve tissue. Breast Augmentation is quite popular with many male to female transgenders. Facial feminization surgery brings the males face closer to shape and size in many cases, this is not the term used to incorporate hair electrolysis, that would be another procedure that may need to be taken care of from whatever the hormones leave behind. Chest reconstruction – removal of breast tissue to create a male physique.Phalloplasy creates a penis from artificial means. In Metiodioplasty, the clitoris is overdeveloped through the use of hormones and thus made into a small penis.
  • When we are assessing transgender individuals we need to pay close attention to their physical appearance as well as their diet recalls. Many transgender individuals may increase their intake to help increase their size or vise versa. Many transgender struggle with body image attractiveness and self esteem and food intake is something that they can control. They also have barriers when it comes to physical activity since they have issues with gender specific restrooms, changing rooms, going out in public for exercise and avoiding ridicule. When assessing needs, after one year of successful hormone therapy, fatfree mass is beginning to decrease or increase so the new gender may be used. Never overlook the need for a FTM as the needs have now increased with the increase in muscle mass.
  • In an assessment of nutritional status done on Transgender in India, the research showed that based on BMI classification status of the World Health Organization, 15 % of the subjects studied were underweight, 63% were ideal and 20% were overweight. 2% were obese due to their hormones. The community as a whole lacked a healthy lifestyle pattern. Their mean intake was below the mena standard value. Their emotions had a big impact on their food consumption. Overall nutrition education plays a vital role in improving their standards of living. Also I wanted to note that this research complemented my patient as well as far as lack of nutrients, emotions and skipping meals.
  • The rates among transgender individuals, according to the CDC, is between 14 - 69% with the highest being MTF sex workers.
  • The high prevalence is due to a myriad of challenges that increase the rate of HIV among the transgender population. There is a lack of HIV education that is transgender appropriate, as well as prevention activities. There is the lack of knowledge from medical providers about caring for this population so many choose not to get medical help. There is also discrimination from providers about caring for this population, things such as exclusion from services such as drug rehab programs, as well as continually verbal harrassment & mistreatment). Social isolation plays a large role in the increased risk. Many transgender men and women are rejected from their peers and family as well as isolated from the G, L, B community (They feel they are traders), due to this they lack social support which leads to low self esteem which indeed increases the risk for sex work, substance abuse and overall decrease in safe sex practices. The increased stigma and discrimination that this community faces puts that at an increased risk for more behavioral risks.
  • Many of these increased behaviors are unprotected sex, especially when they first come out-they are looking for that sexual freedom, this leads to multiple casual partners. Please note that many transgender male and female find it very hard to find a mate to make a commitment, and may end up with numerous partners. Of course there is prostitution in this population as well as IV drug use, street hormones and silicone pumping to increase cheeks, lips buttocks, etc. Many MTF have pumping parties, which may lead to dangers of a less than clean environment and dirty needles.
  • We must understand that there are no prevention interventions for transgender individuals. There is lack of research and the lack of knowledge from the medical field which is a major concern for this community. The World Health Organization defines ‘health’ as a “state of complete physical, mental, emotional, and social well-being and not merely the absence of disease or Infirmity but from my research sexual orientation appears to play a large role in the lack of care of this community. Medical schools do not train in LGBT health care needs aside from HIV education and a fraction of hours on homosexuality. Aside from the physicians we need to keep in mind that not all people are honest about their sexual history which makes it hard for any physician to form an open and honest relationship as it does take both parties.
  • Isolated from families. Transgender people are often denied medical care or mistreated by health care providers who are biased or who don't understand transgender issues. 
  • There are many things that inequities and discrimination from families can lead to . Isolation leads to being homeless which can then lead to loss of a job, which leads to lack of insurance, which leads to poor health status and lack of care. Homeless also leads to lack of proper nutrition which may lead to poor health status and may have an impact on medications if they are still being taken. In the end, the poor health status, both mentally and physically will lead to risky behaviors because the individual is feeling isolated and ill and does not have many cares.
  • When referring, go that extra mile to let the dietitian know how the patient prefers to be addressed. The little things go along way. All these things will make the patient more compfortable, which will lead to better medical access and better overall health.
  • Lastly-To Angelique, my friend, who helped me better understand the transgender population with an open heart and mind. She has shared her most intimate disappointments and triumphs with me and gave me the passion to learn and want to share the many challenges she faces. For this I love and thank her!
  • HIV, Hormones, Stress & Discrimination

    1. 1. HIV, Hormones, Stress & Discrimination: Assessment &Education with Transgender Patients TARA JEANINE OLIVA DIETETIC INTERN BENEDICTINE UNIVERSITY, SPRING 2011
    2. 2. IntroductionAccording to the IOM Clinicians are faced with incomplete information about the health status of the LGBT population. Each population has its own specific health needs and concerns. Researchers face numerous challenges in understanding each populations including a lack of data. Institute of Medicine,( March 2011)
    3. 3. Introduction Continued For better understanding, the NIH needs to create an ample training program to raise awareness of health issues that the LGBT community is faced with. The most pressing issues to focus on are:  1. Demographic research  2. Social Influences  3. Intervention Research  4. Transgender specific health needs Institute Of Medicine,( March 2011)
    4. 4. Prevalence of Transgender There is no reliable data on the number of transgender individuals in the United States.Center for Disease Control and Prevention (2011)
    5. 5. You never know, you must have knowledge
    6. 6. Terminology
    7. 7. Terminology Natal sex: Identified sex at birth Gender: psychological, social & cultural aspects of female & male. Transgender: a self selected term used to describe an identity that transcend gender norms; an umbrella term. Transition: a process from being perceived as one gender to another gender.  Through : Name change or /and Hormones and/or Surgery Transsexual: a medical term used to describe a transgender individual who has sought formal or informal medical intervention. Alegria, (2011)
    8. 8. Other terminology MTF :Male to Female, FTM(female to male), transman (FTM), transwomen (MTF), Drag: someone who wears clothing of another gender, often involving the presentation of exaggerated, stereotypical gender characteristics. Gender Queer: a term used by some people who may or may not fit on the spectrum of trans or be labeled as trans, but who identify their gender or orientation to be in-between or outside the binary gender. Cross Dresser: a person who, on occasion wears clothing considered typical for another gender, but does not necessarily desire to change their gender.Alegria, (2011)Howard Brown (n.d.)
    9. 9. Patient Information
    10. 10. Patient Information Gender: MTF (male anatomy at present, w/hormones) Age: 40 Ethnicity: Caucasian Height: 5’10” Weight: 182# (78kg) Wt Change: 27# gain in 5 years Usual Body Weight: 150-155 # ( as a male) IBW: F = 150# % IBW = 120% Deutsch, M.(2010) BMI: 26.1 ABW: 158#
    11. 11. Patient Information Current diagnoses: HIV+, severe depression o HIV+ = diagnosed 2005 o Depression: Childhood Symptoms: depression
    12. 12. Patient Information Medical tests planned: lipid panel, blood glucose, continuous CBC, estradiol levels, mammogram. Previous Surgery: Breast Implants Surgery Planned: vaginoplasty.Jenner, C.O. (2010)
    13. 13. Assessment of Nutrition Needs Using the literature and ABW Harris Benedict (stress 1.3) o 1931 kcals per day 1.0-1.4 grams protein/kg for maintenance o 72 g-101g per day MVI(Coyne-Meyer, K., &Trombley, L., 2004)
    14. 14. Hormones & Surgeries
    15. 15. Hormone Therapy Premarin .625 BID o Conjugated estrogen Estraderm Transdermal: system patches Delestrogen shot 40 mg o Increased or decreased weight, appetite changes, decreased Ca+ bone loss, increase Ca+, increased TG, Increase HDL, Increased LDL
    16. 16. It is a Catch 22…..
    17. 17. Gender Identity Disorder Diagnosis in the DSMA. evidence of a strong and persistent gross-gender identification, which is the desire to be, or the insistence that one is of the other sex.B. This cross-gender identification must not merely be a desire for any perceived cultural advantages of being the other sex. there must also be evidence of persistent discomfort about one’s assigned sex or a sense of inappropriateness in the gender role of that sex
    18. 18. Criteria for Hormones & Surgery  Psychiatric Evaluation before surgery or hormones (A mental health diagnosis rules their life?)  Diagnoses of Gender Identity Disorder  Thinc: Trans Hormones-Informed Consent (@Howard Brown)p://
    19. 19. Hormones MTF Estrogens Effects:  SofterSkin  Reduced testicular volume  Decreased erectile function  Decreased hair growth  Decreased libido  Enlargement of nipples  Testosterone to female levels Labs: free testosterone, fasting chemistry panel, fasting lipid panel, CBC, estradiol levels, PSA, Pap (if vagina), mammogram Algeria, (2011)
    20. 20. Hormones FTM Androgen effects:  Deepening of voice  Increased aggression  Increased libido  Cessation of menses  Hirtuism  Clitorial growth  Breast atrophy  Redistribution of fat  Laryngeal prominence Labs: Fasting lipid profile, liver function tests, CBC, pap smear, mammogram (breast tissue present)Alegria, (2011)
    21. 21. Surgeries MTF o Vaginoplasty o Augmentation o Facial Feminization o Electrolysis FTM o Chest reconstruction o Hysterectomy o Penis construction (phalloplasty) o Metoidioplasty (creation of penis from clitoris)
    23. 23. Diet & Appearance Trans persons may use food to help with their physical appearance  Overeating to increase size  Calorie Restriction New gender after one year of successful hormone therapy  Increase for FTM  Do not overlook their needs Deutsch, 2010 Vancouver Coastal Health, 2010
    24. 24. The Literature Lack healthy lifestyle pattern Mean nutrient intake below standard value Eat more or skip meals  Lead to malnutrition  Obesity Emotions had impact on food consumption  Rejection  Racism  Lack of medical health care The literature complements the patientSivakami, PL & Veena, K.V. (January, 2011)
    25. 25. HIV And Transgender
    26. 26. Rates among transgender Estimated HIV infection rates among specific transgender populations range from 14-69%. Highest among MTF sex workers Center for Disease Control and prevention (2011)
    27. 27. Prevalence of HIV High Rate of HIV+o Lack of HIV educationo Lack of medical accesso SES – social isolationo Mental Health concernso Stresso Many barriers **LEAD TO ↑ RISKY BEHAVIORS
    28. 28. Behavioral Risks for HIVo Unprotected receptive anal intercourseo Multiple casual partnerso Sex worko IV drug/street hormoneso Herbst, J.H. (2008)
    29. 29. Lack of education of HIV/AIDS o Providers lack adequate knowledge to care for patients. o Do not lend themselves to “caring” environments. o Do not understand their needso Lack any formal education of this population o May see this population as having a diagnosed “Gender Identity Disordero Butler, R. (2010)
    30. 30. Health Disparities
    31. 31. Discrimination Affects Healtho Families : isolationo Employers : loss of job, loss of health insuranceo Homelessness: lack of support system, increased risk of HIV.o Healthcare: uncaring environment, unknowledgeable staff, lack of careo Williamson, (2010)
    32. 32. Homeless Lack of unemployment homeless insurance Lack of meds TRANSGENDER Lack of nutrition Lack of medical care Risky Poor health statusBehaviors Operario, D & Nemato, T. (2010)
    34. 34. Howard Brown Health Center Howard Brown exists to eliminate the disparities in health care experienced by lesbian, gay, bisexual and transgendered people through research, education and the provision of services that promote health and wellness.o Medical centero Behavioral Serviceso Youth Serviceso Fund raising eventso Substance abuse programso Many, many, moreo
    35. 35. TWISTATrans Women Informing Sister Trans Women on AIDS TWISTA is a group designed to celebrate the strength and resiliency of transgender women of color (ages 16-24) Support to deal with struggles like harassment, relationships, and health.o Role modelso Love and supporto Educationo Sponsored through Howard Brown –Chicago
    36. 36. Community Interventions AIDS Foundation of Chicago o Supportive Housing o Food pantries, soup kitchens, and meal programs o Prevention Events o Syringe Programs o Medication Programs o Advocacy o Grantmaking
    37. 37. What Can We Do? Proper gender on questionnaires Proper pronoun/proper name Gender neutral restrooms Work as a multidisciplinary team, know your part Understand hormones/ART interactions Understand eating disorders/refer if necessary Know the risks in this community Know your patient, do not make assumptions. Create a caring environment
    38. 38. Angelique
    39. 39. Works Cited Butler, R. (2010)An assessment of lesbian, gay, bisexual, and transgender curriculum infusion in U.S. medical schools. Retrieved on May 05, 2011 from Center for Disease Control and Prevention. (2011) HIV in the United States. Retrieved from May 4, 2011 from Coyne-Meyers, K., & Trombley, L. (2004). A review of nutrition in Human Immunodeficiency Virus infection in the era of highly active antiretroviral therapy. Nutrition in Clinical Practice, 19, 340-355. Deutsch, M. (2010). Primary care for transgender patients. Proceedings of the 13th Annual Clinical Conference for the Ryan White HIV/AIDS Program, Health Communities.(2011) Gender Identity Disorder. Retrieved on May 06, 2011 from Herbst, J.H. (2008). Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A system review. AIDS and Behavior, 12(1), 1-17. Howard Brown Health Center Publication. (2009) TWISTA Institute of omedicine of the national Acadamies. (March, 2011). The health of lesbian, gay, bisexual and transgender People; Building a foundation for better understanding. Retrieved on April 15, 2011 from Lesbian-Gay-Bisexual-and-Transgender-People.aspx. Jenner, C.O. (2010). Transsexual primary care. Journal of the American Academy of Nurse Practitioners, 22(8), 403-408.
    40. 40. Works Cited• Jenner, C.O. (2010). Transsexual primary care. Journal of the American Academy of Nurse Practitioners, 22(8), 403-408.• Lawrence A. (2001) Vaginal Neoplasia in a Male-to-Female Transsexual: Case Report, Review of the Literature, and Recommendations for Cytological Screening. International Journal of Transgender.5,(1).• Nerad, J., et al. (2003). General nutrition management in patients with Human Immunodeficiency Virus. Clinical Infectious Diseases, 36(2), S52- 62• Operario, D. & Tooru, N. (Dec 15, 2010) HIV in Transgender Communities: Syndemic dynamics and a need for multicomponent interventions. Journal of Acquired Immune Deficiency Syndromes, 55, p 91-93. Pribram, V. (2010). Nutrition and HIV. Singapore: Blackwell Publishing Ltd Willliamson, C. (2010). Providing care to transgender persons: A clinical approach to primary care, hormones, and HIV management. Journal of the Association of Nurses in AIDS Care, 21(3), 221-229 Vancouver Coastal Health. (2011) Transcare medical issues. Retrievedd on May 5, 2011 from