Transgenders; challenges to inclusiveness in Pakistan

1. LGBTQ HEALTH: WHO, WHAT, WHERE
AND WHY WE SHOULD CARE
LAURA C. HEIN PHD, RN, FAAN

2. OBJECTIVES
• Introduce you to LGBTQ terminology
• Discuss historical and contemporary health concerns of
the LGBTQ community
• Discuss facilitators and barriers to health
• Present current legal and regulatory standards related
to LGBTQ health with recommended practice protocols
• Is your facility compliant?

3. DEFINITIONS
• Gay, Lesbian
• Exclusive physical and emotional attraction to members of one’s
own sex
• Bisexual
• Physical and emotional attraction to members of both sexes
• Transgender (gender identity)
• A person who feels his or her body is not the sex it should be,
regardless of transformational hormone or surgical status
• Cis-Gender
• A person whose gender identity matches their sex at birth
LGBTIQ

4. • MtF = Male-to-Female (she) transwoman
• Born with male anatomy, female gender
• FtM = Female-to-Male (he) transman
• Born with female anatomy, male gender
LGBTIQ
Transgender
(gender identity)

5. • Intersex
• The vogue term for hermaphrodite. People born with
the sexual characteristics of both sexes
• Questioning
• People who suspect they might be LGBT, but are not
yet certain
• Queer
• Inclusive term of the LGBTIQ community
• Unique paradigm
Definitions LGBTIQ

7. PREVALENCE - 9 MILLION LGBT PEOPLE IN THE U.S.
Homosexual (gay/lesbian is preferred term)
• 3.4% self-identify as LGBT (Gates & Newport 2012)
• 1 in 5 - 20.8% of males in the U.S. reported either
homosexual behavior or homosexual attraction
since age 15 (Sell, Wells & Wypij, 1995)
• 17% of women and 6% of men have engaged in same-sex
behavior. However, 7% of women and 4% of men identify
as gay or bisexual (Copen et al. 2016).
Remember there are 320 million people in the U.S.

8. TRANSGENDER POPULATION SIZE
• ~1.4 million adults self-identify as trans in
the U.S.
• Crissman et al. 2017; Flores et al., 2016; Meerwijk & Sevelius,
2017

9. GENDER NON-CONFORMITY OR GENDER
DYSPHORIA
GENDER NON-
CONFORMITY
• the extent to which a person’s
gender identity, role, or
expression differs from the
cultural norms prescribed for
people of a particular sex
(IOM, 2011 definition)
GENDER DYSPHORIA
• discomfort or distress that is
caused by a discrepancy
between a person’s gender
identity and that person’s sex
assigned at birth (and the
associated gender role and/or
primary and secondary sex
characteristics) (WPATH, 2011)

10. TRANSGENDER HEALTH – YOUTH
• Protections under Title VII and Title IX of the Civil
Rights Act. Affirmed by DOJ filing in G.G. v.
Gloucester County School Board (2015). Case on
appeal to SCOTUS. Oral arguments Feb. 2017.
“There is a public interest in ensuring that all
students, including transgender students, have
the opportunity to learn in an environment free
of sex discrimination.” (DOJ)

11. TRANSGENDER HEALTH –
RESTROOM ACCESS
• April 8, 2015 – EEOC has ruled that an
employers refusal to allow a transgender
employee access to restrooms consistent with
his or her gender is sex discrimination under
Title VII.
• EEOC case: Lusardi v. AMRDEC

12. WHAT ABOUT SCHOOL? TITLE IX
• Title IX protects students, faculty and
employees from sex discrimination in any
federally funded education program or
activity.
• However… schools are still not safe.

13. EARLY SOCIAL TRANSITION
• Child lives as gender that matches their identity
• Trial run - name, attire, social roles at school, in community
• Reversible
• Family decision whether to disclose to others or not
• Approx. 25% of children who were assessed for gender
dysphoria grew up to be cis-gender gay vs. transgender.

14. CHILDREN AND YOUTH
• EARLY medical and mental health
services
• Family support is critical to positive health outcomes
• Puberty experienced congruent with gender (delay
until sure)
• Reduces need for later medical interventions
• Prevents unwanted sex characteristics (i.e.
breasts)
• Decreases stress, anxiety, depression

15. REPARATIVE THERAPY
• = Efforts to change the sexual orientation or gender
identity
• Condemned by all mainstream professional
organizations as harmful including the APA, AMA, Am
Acad of Pediatrics, AAN, ISPN etc.
• Related to depression, anxiety and suicide
• George Rekers (prof emeritus from USC SOM) –
published case where he conducted reparative
therapy. This is what he did….

16. PUBERTY BLOCKING – GNRH
AGONISTS
• Ideally begun in Tanner 2 stage (early start of puberty).
• Can begin in Tanner 3-5 – goal is to stop puberty/
prevent secondary gender characteristics i.e. height,
breasts etc.
• GnRH Agonists - Leuprorelin; Triptorelin; Goserelin;
Histrelin implants
• Very expensive. Cost is between $500 and $1500 month.
• Insurance rarely covers this cost
• Effects are totally REVERSIBLE

17. IRREVERSIBLE HORMONE EFFECTS
• ESTROGEN
• Breast development
• Nipple enlargement
• Loss of erection
• Testicular atrophy
• ? sterility
• TESTOSTERONE
• Uterine atrophy
• Facial and body hair
• Deepened voice
• Clitoral enlargement
• ? sterility

18. FIRST DO NO HARM….
There is harm related to NOT intervening
• Suicide ~ 44%
• Depression
• Anxiety
• Homelessness
• ETOH, drug use
• Sex work
• HIV

19. OVERREPRESENTED HEALTH
PROBLEMS
• HIV/ AIDS
• Trauma/ Victimization
• Mental Health Concerns
• Addictions
• Is this because they’re LGBT? –or- because of the
context within which LGBT people must exist?

20. HIV/ AIDS
• A missing generation of gay men due to AIDS
• HIV+ the norm in some areas
• Homelessness/ poverty – survival sex
• Street hormones (trans)

21. TRAUMA/ VICTIMIZATION
• Parental abuse
• Increased prevalence of verbal and physical abuse and
heightened suicidal ideation among those who disclosed their
s.o. to their families
• Hate crimes

22. MENTAL HEALTH –
DEPRESSION & ANXIETY
Additional stress d/t image
management related to s.o./g.i.
• LGBT children often grow up in a
society that says that they should not
exist and/or should not act on their
feelings.
• These societal mores can be internalized =
internalized homophobia

23. DEPRESSION
• Prevalence of depression 17.2% higher than in U.S.
adult men in general
• Distress & depression associated w/:
• lack of a partner;
• not identifying as gay, queer, or homosexual;
• experiencing multiple episodes of antigay
violence in the previous 5 years; and
• very high levels of community alienation
Mills 2004

24. LGBT YOUTH VICTIMIZATION
• 25% of gay youth (16% lesbian) have been
threatened or injured with a weapon on school
property.
• 3x higher than hetero rate for boys; 4x higher than
hetero for girls.
• 13% gay (16% lesbian) youth didn’t go to school
because of safety issues (O’Malley, 2014)
• 3x the hetero rate
Sample was of YRBS HS students

25. MENTAL HEALTH - SUICIDE
• LGB youth = 30%
attempted suicide (double
the hetero rate)
• School bullying increased
the risk of suicide (Bouris et al,
2016)

26. TRANSGENDER SUICIDE
U.S. TRANS/GQ DATA
• 42% attempted
suicide
• Those who reported
moderate to severe
rejection by their
family were more
likely to attempt
suicide (OR 2.0 to 3.2

27. ADDICTIONS
• Young LGBT (most prevalent)
• Lesbian/ female Bi – principally ETOH
• Gay/ MtF Transgender –
• Ecstasy (and other Rave drugs)
• Risk = hyperthermia;
• Poppers (amyl nitrate) – enhanced
sexual experience
• Risk = an MI, priapism
Ecstacy: MDMA

28. CDC RECOMMENDATIONS FOR
SCHOOLS TO SUPPORT LGBTQ HEALTH
1. Identify “safe spaces”
2. Prohibit harassment and bullying
3. Facilitate access to health & psych providers not on school
property who are LGBTQ affirming
4. Encourage professional development on safety for all
students
5. Provide health education curricula with inclusive
terminology
Demisse et al., 2013

29. CASE 1
• A 15yo questioning female student presents to the school nurse
asking him to sponsor a Gay Straight Alliance (GSA) at their
school. The best school nurse answer:
A. “yes, of course I’ll sponsor a GSA”
B. “I’d like to but I’ll need to talk to the principal first”
C. “I think I’d like to talk to your parents first – we’ll be back in
touch”
D. “You really need to talk to our school psychologist about this”

30. SC CODE 59-32-30A(5)
LOCAL SCHOOL BOARDS TO IMPLEMENT COMPREHENSIVE
HEALTH EDUCATION PROGRAM; GUIDELINES AND
RESTRICTIONS
• (5) The program of instruction provided for in
this section may not include a discussion of
alternate sexual lifestyles from heterosexual
relationships including, but not limited to,
homosexual relationships except in the context
of instruction concerning sexually transmitted
diseases.

31. CASE 2
• 30yo transman who initiated social gender affirmation 5 years
ago, chest construction at 25yo, testosterone from 25-28yo. He
grew a beard and stopped taking T. Beard growth persisted. No
menstruation for 5 years. He would like the option to become
pregnant in the future because he wants children but has legal
concerns related to adoption. As the NP you first:
A. Conduct an exam and draw labs
B. Conduct an exam, draw labs and refer to endocrinology
C. Conduct an exam, draw labs and refer to GYN

32. YOUR PATIENT WANTS TO
TRANSITION – NOW WHAT?
1. Google “WPATH
Guidelines”
2. Refer to a Psych NP
or other mental
health provider
3. Start hormone
therapy
www.wpath.org
The pdf is free

33. RESEARCH ON HORMONES – IS IT
SAFE?
FTM
• No increase in CAD found in
876 FTM pts (Gooren, 200)
MTF
• Increased risk of CAD at
high doses.
• Increased risk of CA at low
doses
• If prior MI – PO estradiol
does not incr. or decr. risk
for further emboli

34. WPATH Standards of Care
The criteria for hormone therapy are as follows:
• Persistent, well-documented gender dysphoria;
• Capacity to make a fully informed decision and
to consent for treatment;
• Age of majority in a given country (if younger,
follow the Standards of Care outlined in section
VI);
• If significant medical or mental health concerns
are present, they must be reasonably well
controlled

35. HORMONES FTM - OPTIONS
• Injectable Testosterone
• Testosterone Enanthate or Cypionate 100-200 mg IM q 2 wks (20 -22g x 1 ½”
needles)
• Transdermal Testosterone
• Androderm TTS 2-8mg daily
• Topical testosterone gels in packets and pumps, multiple formulations (Testim,
Androgel) 5 to 10 gm (50 to 100 mg of testosterone) applied topically daily
• Axiron 2% pump gel for axillary application 1 pump to each axilla daily
• Testosterone Pellet
• Testopel- implant 6-10 pellets q 3 to 6 months
• Buccal Testosterone
• Striant 30 mg buccal system q 12 hours
Rx information taken from
Cavanaugh 2016

36. TESTOSTERONE
RISKS
•  HDL 
triglycerites
•  insulin resistance
•  sleep apnea
• Infertility
• Mental health
changes
MONITORING
• Baseline CBC, CMP, lipids,
renal panel, fasting
glucose
• 3 month, then Q 6-12 mo
• CBC, liver enzymes,
serum testosterone
• Q 6-12 mo
• Lipid profile, HbA1c

37. HORMONES MTF OPTIONS
• Oral Estrogen
• Estradiol (estrace) 2-6mg PO or SL daily(can be divided into BID dosing)
• Premarin (conjugated estrogens) 1.25-10mg PO daily (can be divided into BID dosing)
• Transdermal estrogen (preferred for 40yo)
• Estradiol patch 0.1-0.4mg twice weekly
• Injectable Estrogens [NOTE – shortage right now]
• Estradiol valerate5-20mg IM q2 weeks
• Estradiol cypionate2-10mg IM weekly
• Antiandrogens
• Spironolactone (aldactone) 50-400mg PO daily (can be divided into BID dosing)
• Finasteride (Proscar) 2.5-5mg PO daily
• Progestins – increase breast development, but CV risk, weight gain &
depression

38. MTF – ESTROGEN
RISKS
• CAD weight triglycerides
• libido glucose tolerance
• Gallbladder ds
• Infertility
• Mental health changes
• Spronolactone carries risks of
hypotension, hyperkalemia
and renal insufficiency
MONITORING
• Baseline – CBC, CMP, lipids,
renal, fasting glucose,
testosterone, prolactin
• 6mo. – serum testosterone &
estradiol
• If on spironolactone
• 1 mo. then 3mo. – lipids, lytes,
creatinine, glucose

39. MTF SURGICAL OPTIONS (~30%)
• Removal of scrotum & penis
• Creation of vagina, labia, clitoris
& mons
• Breast augmentation
• Tracheal shave
• Facial feminization
• Brow
• nose
Taken from Schechter 2017 p.37

40. FTM SURGICAL OPTIONS (~30%)
• Phalloplasty with
urethral reconstruction
& creation of scrotum
(uncommon)
• Chest reconstruction

41. STAGED SURGERIES
• Genital FtM
• Tissue removal from
donor site
• Urethral reconstruction
• Implant prosthesis
• Chest Contouring FtM
• Mastectomy
• Revision of prior surgery
to decrease scarring and
remove arm flaps

42. YOU’RE AN ORG LEADER/ MANAGER
WHAT CAN YOU DO?
• Know the law and standards related to LGBTQ
patients
• Train your staff – receptionist to CNO
• Work on the culture of your organization to
make it safe.

43. • The patient-centered communication standards
for Hospitals (CAMH).
• Elements of performance 28 and 29 under
RI.01.01.01, require access to a support person
and non-discrimination of care.
The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and FamilyCentered Care
for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide. Oak Brook, IL, Oct. 2011.
LGBTFieldGuide.pdf.
Joint Commission Standards (2011)

44. RI.01.01.01 ELEMENT 29
“No longer considered to be simply a patient’s
right, effective communication is now accepted
as an essential component of quality care and
patient safety.”

45. HOSPITAL VISITATION
• January 2010 Centers for Medicare and
Medicaid Services (CMS) regulation required
hospitals to permit patients to designate
visitors & prohibits discrimination in
visitation based on so/gi. 42 C.F.R. §
482.13
• Compliance with requirements for Medicare Conditions
of Participation (CoPs)

46. HOSPITAL VISITATION
• July 2011 Joint Commission standard – prohibition
on discrimination based on orientation or gender
identity.
• “Prohibit discrimination based on age, race,
ethnicity, religion, culture, language, physical or
mental disability, socioeconomic status, sex,
sexual orientation, and gender identity or
expression.” RI.01.01.01 EP29 (p.48 of Joint
Commission LGBT doc).

47. CMS – EQUAL COVERAGE TO CARE IN
THE SAME NURSING HOME AS A
SPOUSE
• Aug. 29, 2013 - CMS announced the guarantee
of Medicare coverage applies to ALL spouses
regardless of sexual orientation.
• Prior to this same-sex spouses with Medicare Advantage plans
were not eligible to live in the same nursing home as their
spouse.

48. FMLA
• All spouses are now covered under FMLA if the employer is FMLA
covered. (3/15 injunction against same sex spouses dissolved by
SCOTUS Obergefell ruling)
FMLA may be used for
• The birth of a child, adoption or foster parent;
• To care for a spouse, son, daughter, or parent who has a serious
health condition;
• For a serious health condition that makes the employee unable to
perform the essential functions of his or her job; or
• For any qualifying exigency arising out of the fact that a spouse, son,
daughter, or parent is a military member on covered active duty or
call to covered active duty status.
http://www.dol.gov/whd/regs/compliance/whdfs28.pdf

49. AFFORDABLE CARE ACT
• Section 1557 – Civil Rights provisions
of the Act.
• Applies civil rights protections to the Health
Insurance Marketplace created by the ACA –
and includes LGBT people

50. ACA & PREVENTIVE CARE
May 2015 DOL Guidance on the ACA
confirms
• Plans cannot limit sex-specific preventive
services by gender identity. If a provider
orders the service it is considered
appropriate.
http://www.dol.gov/ebsa/faqs/faq-aca26.html

51. THE LAW
SC ANTI- TRANSGENDER BILL
• S.1203 defeated May 4, 2016
TITLE IX - EDUCATION
• Grimm v. Glouchester
(2015)
• Appealed to SCOTUS
• Administrative
guidance
TITLE VII - EEOC
• Macy v. Holder (EEOC, 2012) –
gender non-conformity = gender.

52. HOW DO I FIND AN
AFFIRMING PROVIDER?
GLMA.org
• Then click on: Resources – For Patients – Find a
Provider
• A searchable provider directory (location, specialty,
transition care etc.).
Provider Directory at the Harriet Hancock LGBT
Center

53. RESOURCES
Locally
• Harriet Hancock LGBT Center
• IRIS = LGBT group on campus
Nationally
• The Trevor Project – suicide hotline for LGBT youth www.thetrevorproject.org 1-
866-488-7386
• Trans Lifeline http://www.translifeline.org 1-877-565-8860
Providers GLMA.org
https://glmaimpak.networkats.com/members_online_new/members/dir_provider.
asp

54. HOW CAN AN LGBT PERSON KNOW IF
SOMEONE IS SAFE TO TALK TO?
• Go with your instincts
• If you get a bad vibe from someone – trust your instincts and get
out of there.
• Look for these symbols

55. WHAT WE CAN DO AS NURSES
• Be Authentic
• Encourage Authenticity in others
• Share
• Be flexible, scootch over a little, share the bench ≈ share the power

56. LAURA C. HEIN PHD, RN, FAAN
HEIN@SC.EDU