The Plight of Transgender People Seeking Basic Medical Care


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Men and women who have gone through gender reassignment have all the typical medical needs as well as some that are specific to transgender people. Yet most physicians are uncertain about treatment options for transgender people. In this SC CTSI-supported study, Maddie Deutsch, MD, director of Transgender Health Care at the Los Angeles Gay & Lesbian Center, is collecting cardiovascular and metabolic data following cross-sex hormone therapy, as well as data on attitudes and other issues.

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The Plight of Transgender People Seeking Basic Medical Care

  1. 1. Slide #1The Cardiovascular & MetabolicHealth of Transgender Persons:Implications in Primary CarePI - Madeline B. Deutsch, MDDirectorTransgender Health ProgramLA Gay & Lesbian CenterAssistant Clinical ProfessorUCSF Department of Family & Community Medicine
  2. 2. Slide #2Study Team• Madeline Deutsch, MD – PI– LA Gay & Lesbian Center• Vipra Bhakri, MPH - Research Navigator– Comm. Clinics Assoc of LA County• Katrina Kubicek, PhD – Collaborator– USC CTSI• JoAnna Olson, MD – Co-Investigator– CHLA• Special thanks to Marvin Belzer, MD(CHLA)
  3. 3. Slide #3Funding• CTSI – In kind funds (lab costs, incentives,CASI equipment)• LAGLC – In kind PI time, overall projectsupport and management• CCALAC – 50% Research Navigator• CHLA – In kind co-investigator time
  4. 4. Slide #4Background and Significance• Body of research on transgender people isseverely limited• 2011 report from the IOM recommendsfunding research in all areas oftransgender health
  5. 5. Slide #5Trans Research –WhyImportant?• 50% of transgender patients report havingto teach their health provider about care– National Transgender Discrimination Survey 2011• 11% report being refused care outright– State of Transgender California 2009• Only 30% of medical school curriculaeinclude content on transition-related care– Obedin-Mailver et al JAMA Sept 7, 2011
  6. 6. Slide #6Transgender Care – WhyImportant?• Hormone therapy reduces anxiety,depression and improves socialfunctioning & QOL• Surgery improves global functioning andquality of lifeNewfield E, Hart S, Dibble S, Kohler L. Quality of Life Research. 2006 Jun 7;15(9):1447–57.Gómez-Gil E, Zubiaurre-Elorza L, Esteva I, Guillamon A, Godás T, Cruz Almaraz M, et al.Psychoneuroendocrinology [Internet]. 2011 [cited 2012 Dec 10];Meier SLC, Fitzgerald KM, Pardo ST, Babcock J. Journal of Gay & Lesbian Mental Health.2011;15(3):281–99.
  7. 7. Slide #7Primary Aim1) Collect metabolic and cardiovascularparameters on transgender patients beforeand after 6 months of cross-sex hormones2) Collect information on transgender patientattitudes about primary care
  8. 8. Slide #8Secondary Aims• Develop infrastructure for futuretransgender research at the study site• Test feasibility of conducting community-based transgender research andsubsequent translation into clinicalpractice• Explore research collaborations betweenthe multiple involved institutions
  9. 9. Slide #9Study Site (LA Gay & LesbianCenter)• Oldest and largest (by budget) LGBTorganization in the world• Federally Qualified Health Center(Lookalike) & Ryan White Grantee• Existing research programs focusedprimarily on HIV• Transgender Health Program census =approx 500 individuals
  10. 10. Slide #10Methods• Collect baseline and 6 month metabolicdata• Baseline and 6 month survey of attitudesabout primary care• Subjects receive covered lab costs and$25 gift card incentives at enrollment andagain at completion• Planned N determined by budget (75)• Retention efforts include reminder calls &texts
  11. 11. Slide #11Study Population• 18 years of age or older• Patient registered in LAGLC Transgender HealthProgram• No prior cross-sex hormone treatment (csHT)• Intend to begin csHT• Transgender identified• No contraindication to csHT• Sequential patients enrolled
  12. 12. Slide #12Initial Results• 57 sequential patients enrolled– 34 FTM, 23 MTF• Reasons for under-enrollment– Front office/scheduling difficulties– Shifting patient demographics (higherpercentage of new-to-LAGLC patients comingfrom another clinic already on hormones)– Enrollment closed in January 2013 in order toallow completion of study within projectedtime frame of August 2013
  13. 13. Slide #132730310051015202530Race Breakdown for FTM(N=34)181 1 2 0 1051015202530Race breakdown for MTF (N=23)
  14. 14. Slide #14Hispanic32%Non-Hispanic68%Ethnicity breakdown for FTM(N=34)Hispanic45%Non-Hispanic55%Ethnicity Breakdown for MTF(N=23)
  15. 15. Slide #1518115001261310246810121416182018-25 26-35 36-45 46-55 >55#ofPatients Age Distribution for FTM and MTFFTMMTF
  16. 16. Slide #16FTM MTFBP SystolicMean ±SD 119.8±13.3 130.8±15.3Median 120.0 130.0BP DiastolicMean ±SD 74.1±10.9 77.6±12.1Median 73.0 77.0HeightMean ±SD 65.2±3.3 68.3±4Median 65.0 68.0WeightMean ±SD 183.1±56.1 174.8±55Median 173.0 153.0Waist CircumferenceMean ±SD 98.9±19.9 92.5±17.8Median 96.0 86.0BMIMean ±SD 30±8.4 25.9±5.8Median 69.6 5.8
  17. 17. Slide #17FTM MTFCholesterol TotalMean ±SD 175.8±31.6 177.9±29.5Median 172.5 186.5HDLMean ±SD 60±16.9 53.2±17.6Median 57.0 53.0LDL (Calc)Mean ±SD 95.5±26.7 100.7±26.8Median 92.0 109.5TriglyceridesMean ±SD 102±94.3 130.5±120.4Median 79.0 88.0EstradiolMean ±SD 109.4±65.8 32.4±22.4Median 141.9 28.9Testosterone , TotalMean ±SD 38.8±17.8 410.7±192.9Median 35.5 399.0Testosterone , FreeMean ±SD 0.8±0.5 11.6±5.5Median 0.7 11.4
  18. 18. Slide #18< 3 mths21%3-6 mths23%6-12 mths14%12-18 mths16%18-24 mths7%2-3 yrs3%> 3 yrs16%Time since last routine primary care visit
  19. 19. Slide #1925%18%23%28%7%0%5%10%15%20%25%30%Very Likely Likely Somewhat Likely Unlikely Very UnlikelyHow likely are you to see a primary care providerfor routine care?
  20. 20. Slide #2024%12%50%21%12%15%6%18%9%27%0%10%20%30%40%50%60%Barriers that may exist to accessing Care
  21. 21. Slide #21Very Important75%SomewhatImportant23%Neither importantnor unimportant2%How important is it for you to recievemedical care of any kind at an LGBT-oriented clinic?
  22. 22. Slide #22Very Important16%SomewhatImportant26%Neither importantnor unimportant47%Somewhatunimportant2%Very Unimportant9%How important is it for you to have aprimary care provider who is transgenderthemself?
  23. 23. Slide #23Much morecomfortable44%Somewhat morecomfortable26%Does not make adifference30%Somewhat lesscomfortable0%Much lesscomfortable0%Does having a transgender medical provider makeyou feel more or less comfortable in the healthcaresetting?
  24. 24. Slide #2477%18%4% 2% 0%0%10%20%30%40%50%60%70%80%90%Very Likely Likely Somewhat Likely Unlikely Very UnlikelyHow likely is it that you would make futurechanges to your lifestyle, diet or exercise routineif recommended to do so by your provider?
  25. 25. Slide #25Study - Next Steps• Complete 6 month exit visits• Conduct rigorous data analysis incollaboration with CTSI• Prepare and submit manuscripts forpublication
  26. 26. Slide #26Lessons Learned• More resources needed to supportscheduling of study patients (front office)• Areas for improvement in EMR dataabstraction at study site• Collaborative, community based researchappears to feasible in the study oftransgender patients