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![Important Footnote
• “In selected circumstances, it can be
acceptable to provide hormones to
patients who have not fulfilled criterion 3
[RLE or psychotherapy] – for example, to
facilitate the provision of monitored
therapy using hormones of known quality,
as an alternative to black-market or
unsupervised hormone use.”](https://image.slidesharecdn.com/aidsclinicalrounds07102015blumenthal-150728143822-lva1-app6892/75/Free-to-Be-You-and-Me-Providing-Culturally-Sensitive-Patient-Care-to-Transgender-Individuals-23-2048.jpg)
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Free to Be You and Me: Providing Culturally-Sensitive Patient Care to Transgender Individuals
The UC San Diego Antiviral Research Center hosts weekly presentations focused on current research and clinical practices for various infectious diseases, including HIV and issues surrounding transgender health care. The document discusses the significant challenges transgender individuals face regarding access to health care, economic insecurity, and the high prevalence of HIV within their communities. It emphasizes the need for culturally-sensitive medical practices and support systems to improve health outcomes for transgender individuals.
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Free to Be You and Me: Providing Culturally-Sensitive Patient Care to Transgender Individuals
- 1. The UC SanDiego AntiViral Research Center sponsors weekly presentations by infectious disease clinicians, physicians and researchers. The goal of these presentations is to provide the most current research, clinical practices and trends in HIV, HBV, HCV, TB and other infectious diseases of global significance. The slides from the AIDS Clinical Rounds presentation that you are about to view are intended for the educational purposes of our audience. They may not be used for other purposes without the presenter’s express permission. AIDS CLINICAL ROUNDS
- 2. Free To BeYou and Me: Providing Culturally-Sensitive Patient Care to Transgender Individuals Jill Blumenthal, M.D. AIDS Rounds July 10, 2015
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- 4. Terms of self-description • FTM, F2M, FtM, FM, Transman, Transgender man, Transsexual man, ManMTF • MTF, M2F, MtF, MF, Transwoman, Transgender woman, Transsexual woman, WomanTwo-Spirit • Androgyne, Tranny, Boi, Tranz, Gender queer, Third gender, Non-gendered, Bigendered, Trannyboy, Gender fluid, Polygender, Transgenderist…
- 5. Prevalence of Transgenderism • Receiving Hormones (Netherlands) • 1:11,990 MTF • 1:30,400 FTM • Completed SRS (Belgium) • 1:12,900 MTF • 1:33,800 FTM Moore J Clin Endocrinol Metab 2003
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- 7. Pathogenesis Theory • Region ofthe bed nucleus of the stria terminalis (region known for sex and anxiety responses), MTF transgenders have a female-normal size while FTM have a male-normal size (Zhou Nature 1995) • Later research found a decrease in the somatostatin neurons, similar to biologic women in MTF transgenders and the opposite is true for FTM transgenders (Kruijver J Clin Endo Metab 2000) • Study of 24 MTF transgenders not yet treated with hormone therapy studied via MRI, significantly larger volume of gray matter in right putamen compared to men (Luders NeuroImage 2009) • Conclusion: transsexualism associated with distinct cerebral pattern
- 8. The Effects ofAnti-Transgender Bias are Numerous and Profound -Discrimination -Poverty -Suicide -Homelessness -Violence -Harrassment -Sex work -HIV
- 9. “I was kickedout of my house and out of college when I was 18. I became a street hooker, thief, drug abuser, and drug dealer. When I reflect back, it’s a miracle that I survived. I had so many close calls. I could have been murdered, committed suicide, contracted AIDS, or fatally overdosed.”
- 10. Economic Insecurity • ~15% oftransgender people are unemployed • 1/3 make < $10,000/year • 2/3 make < $25,000/year • 20% have unstable housing • Increased reliance on street economies including sex work • Majority of homeless shelters, if they accept transpeople, house according to assigned sex Grant, National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
- 11. Access to HealthCare Findings from the National Transgender Discrimination Survey Report 2011 on health and health care ! 19% reported no health insurance ! High levels of postponing medical care when sick or injured due to discrimination (28%) or inability to afford it (48%) ! Significant hurdles to accessing health care reported, including: ! Refusal of care: 19% of our sample reported being refused care due to transgender or gender non-conforming status (higher numbers among people of color in the survey) ! Harassment and violence in medical settings: 28% subjected to harassment in medical settings and 2% were victims of violence in doctor’s offices ! Lack of provider knowledge: 50% reported having to teach their medical providers about transgender care Grant, National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
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- 13. Harm Reduction • Lifetimerisk (in US) that a transgender person will be murdered: 1:12* (Average US risk: 1:18,000) • 41% of respondents from NTDSR reported attempting suicide compared to 1.6% of the general population • unemployment, low income, and sexual and physical assault significant risk factors • Access to care can increase “passing” • Passing for marginalized transpeople is safety *HRC: Transgender Basics!
- 14. The Problem ofHIV ! Transgender communities are among the groups at highest risk for HIV infection. ! In 2010, the highest percentage of newly identified HIV+ test results was among transgender people (2.1%) ! Black (4%) and Hispanic (3%) transgender women represent highest percentage of new positive infections ! In NYC from 2007-2011, 191 new diagnoses of HIV infection among transgender people, 99% of which were among transgender women. ! A review of studies of HIV in countries with data available for transgender people estimated that HIV prevalence for transgender women was nearly 50 times as high as for other adults of reproductive age. ! Information is lacking http://www.cdc.gov/hiv/risk/transgender/
- 15. Prevention Challenges ! Identifyingtransgender people within current data systems can be challenging. ! There are MANY behaviors and factors that contribute to high risk of HIV infection ! Discrimination and social stigma can hinder access to education, employment, and housing opportunities. ! may help explain why transgender people who experience significant economic difficulties often pursue high-risk activities including sex work to meet basic survival needs. ! Transgender men’s sexual health has been understudied. ! Health care provider insensitivity to identity or sexuality can be a barrier for individuals seeking health care. http://www.cdc.gov/hiv/risk/transgender/
- 16. Alignment “I’m the Onethat I want” -Margaret Cho
- 17. The First Question(s) • Whodo you want to be? • What do you like to be called? (preferred pronoun) • How do you want to live? • How do you want to get there? • Who are you going to tell and when?
- 18. NOT the FirstQuestions • Do you want hormones? • Are you planning to have surgery? • Do you want to change your name?
- 19. 5 Year Plan • Gender transition is a journey not a destination • Realistic expectations: • Body (hormones, surgery) • “Out” (work, family, friends) • Legal (DMV, name, gender) • Risks (hormones, surgery)
- 20. Transgender-Friendly Clinic ! Publicityand educational materials should use inclusive language ! Intake forms should allow patients to self-identify ! Collect sexual orientation and gender identity info as well as chosen name and preferred pronoun. ! Preferred name and pronoun should be visible to staff who interact with the patient ! Keep health interview focused on patient’s needs ! Conduct the physical exam that acknowledges patient’s gender identity but also educates patient on preventive health screening based on anatomy ! DO NOT assume all transpatients want to follow set of predetermined set of steps for transitioning
- 21. Goal is tochange physical appearance to maximize consistency between physical and internal gender identity Endocrine Therapy
- 22. HBIGDA – 'Standardsof Care' (V.6) • Requirements: • 18 yo • Knowledge of hormone effects • Either 3 month Real Life Experience (RLE) OR psychotherapy (usually at least 3 months) • Readiness: • Further “consolidation” of gender identity during psychotherapy or RLE • Progress in mastering other psych problems (improvements in sociopathy, substance abuse, suicidality, etc.) • Likely to take hormones in responsible manner
- 23. Important Footnote • “Inselected circumstances, it can be acceptable to provide hormones to patients who have not fulfilled criterion 3 [RLE or psychotherapy] – for example, to facilitate the provision of monitored therapy using hormones of known quality, as an alternative to black-market or unsupervised hormone use.”
- 24. Hormones Benefits: Decreased DepressiveSymptoms and Suicidality • Suicidality 20% pre and 1-2% post (Lundstrom B, Acta Psych Scand 1984) • PreTx Suicide attempts: 19% FTM, 24% MTF. PostTx: 0% FTM, 6% MTF (2% were still in tx) (Kuiper M Arch Sex Behav 1988) • Decrease in suicidality and depressive symptoms (Rehman J, Arch Sex Behav 1999)
- 25. Hormone Benefits: Improvementsin Self-Esteem and Emotional Well-being • No longer dysphoric at followup with increased social functioning. • Self-esteem, social dominance, and extroversion significantly increased. • Controlled trial of SRS: improvement in social activity and sexual function. Cohen-Kettenis P, American Acad of Child and Adol Psych 1997; Mate-Kole C, Brit J of Psychiatry 1990 !
- 26. Goals of overalltreatment- MTF • Feminine body habitus, features, voice, mannerisms • Improved mood, well-being, sense of self as a woman • Societal and self perception as a woman • Can't easily undo the results of androgens ! often need more than just hormones to “pass”
- 27. Estrogen Risks • Waterretention • DVT *20 fold increased risk • Diabetes • Liver disease • Cholesterol • Hyperprolactinemia • Regrets (<1% in most studies) • Obesity • Mood swings (or worse) • Sleep apnea • Sterility • Cholelithiasis • Cancer (breast and prostate! Med Clin (Barcelona) 1999!
- 28. Relative Contraindications • Severediastolic hypertension • Heart disease • History of blood clots • History of stroke • Liver disease • Kidney problems • Severe headaches • Seizure disorder • Poorly controlled diabetes • Family history of breast cancer • TOBACCO USE • Obesity • High cholesterol!
- 29. • What isthe most effective one? • What is best for my goals? • Will the effects be different for the different forms? What hormones should I take?
- 30. Estrogen: Pill orShot or Patch? ! Pill ! Estradiol ! Premarin ! Shot ! Estradiol ! Patch ! Estrogen is estrogen… ! Pick what works “best” for your patient ! Try to transition from oral to IM or patch if >40yo
- 31. Estrogen Dosing ! Everyoneis different ! Try to keep expectations realistic based on age and family history ! Follow 5 year plan ! Start low, go slow: “Don’t over water the plants” ! Dosing regimens: ! Oral: Estradiol 2-6mg/d ! Transdermal: Estradiol patch 0.1-0.4mg twice weekly ! Parental: Estradiol valerate 5-20mg every 1-2 weeks IM Endocrine Society Clinical Practice Guidelines 2009 !
- 32. MTF Monitoring ! Baseline:PSA, Lipids, LFTs, CBC, TSH ! Q3-6 months (pre-op): LFTs, serum estradiol (<200pg/ ml), serum testosterone (<55ng/dl), lipids, prolactin (<20 ng/mL), K+ if on spironolactone, breast exams ! Q3-6 months (post-op): LFTs, serum estradiol (<200pg/ ml), lipids, prolactin (<20 nl/mL), breast exams, DEXA if >50 yo Endocrine Society Clinical Practice Guidelines 2009
- 33. Other Monitoring ! Eatingdisorders (Int J Eat Disord 2002 Dec; 32(4):473-8) ! STDs/HIV (CDC, HIV Among Transgender People 2011) ! Recommend every 6 month testing ! Street drug use ! Socioeconomic problems
- 34. Surgery: MTF • Chestsurgery • Orchiectomy • Vaginoplasty/Labiaplasty • Clitoroplasty • Liposuction • Silicone • Hair Removal Methods
- 35. Non-estrogens ! Finasteride ! Wanthair on head ! Prostate problems ! Spironolactone ! ?Breast growth ! Don’t want hair on my face ! Diuretic ! Progesterone ! ?Moving fat around
- 36. Goals of overalltreatment- FTM • The goal of treatment is to stop menses and induce virilization, including a male pattern of sexual hair, male physical contours and clitoral enlargement. • The principal hormonal treatment is a testosterone preparation. • Although the objective is to reduce female secondary sex characteristics as much as possible, complete elimination is rare.
- 37. Testosterone Dosing ! Sameprinciple: Everyone is different ! Follow 5 year plan ! Dosing regimens: ! Parental: testosterone cypionate 100-200mg IM every 1-2 weeks ! Transdermal: 1% gel 2.5-10g/d or patch 2.5-7.5 mg/d ! Oral: testosterone undecanoate (not available in US) Endocrine Society Clinical Practice Guidelines 2009
- 38. Beneficial effects of‘T’ - FTM • Beard growth • Other body hair growth • Voice deepening – starts early, and just like changes in adolescent male's voices • Change of body habitus (muscle and fat) • Clitoromegaly (3-8cm, average 5cm per 2-3 years) • Cessation of menses • Decreases fertility for bi/gay transmen (unknown efficacy) • Enhanced libido
- 39. FTM Monitoring ! Baseline:CBC, Lipids, LFTs ! Q3-6 months (pre-op): LFTs, Hct <50%, serum testosterone (goal 300-1000 ng/dL), serum estradiol <50 pg/mL (measure in first 6 months), lipids, pap smear, mammogram ! Q3-6 months (post-op): LFTs, Hct <50%, serum testosterone, lipids, DEXA if >50 yo Endocrine Society Clinical Practice Guidelines 2009
- 40. ‘Adverse effects of“T”- FTM • Androgenic alopecia • 'Other' hair growth • Acne • CV (lipids, glucose metabolism, BP) • Polycythemia • Enhanced Libido (?)
- 41. Adverse effects of‘T’- FTM (cont) • Bone Density ! Ca++/D • No Δ cervical cancer risk... Unless fewer paps • Ovarian effects ! PCOS morphology ! Infertility ! Risk of ovarian cancer???? • Possible increased risk of endometrial cancer ! Transmen = Post menopausal UCSF, Center of Excellence for Transgender Health, Primary Care Protocol for Trans- gender Patient Care 2011
- 42.
- 43. Surgery: FTM ! Chestsurgery ! Breast reduction ! Chest reconstruction ! TAH/BSO ! Penis ! Metoidioplasty/Metaoidoplasty (meto/meta) ! Phalloplasty ! Urethroplasty ! Scrotoplasty
- 44. Surgery: A caveat ! Completion of surgery (or desire for surgery) does NOT determine gender identity ! Not every trans patient wants surgery (but many do) ! Many cannot afford the surgery they would want to get if they could ! Passing does not determine gender identity
- 45. Structural Problems ! Dependencyon medico-legal validation ! Gender marker and name changes ! Of those who have transitioned gender, 21% able to update all of their IDs and records with their new gender ! Sex segregated facilities ! Criminal and Juvenile Justice ! Employment and housing discrimination ! Insurance and access to health care
- 46. .Some solutions? • CADrivers License Change – DL328 • Medi-Cal pays for hormones and (theoretically) pays for surgery • California AB 1586 “Insurance Gender Non- Discrimination Act” (1/1/2006) • Coverage cannot be denied a trans patient by insurers based only upon their transgender status • Doesn't (necessarily) mean insurers must pay for SRS – just they can't deny care provided other patients
- 47. Progress! ! Affordable CareAct ! Anti-bullying efforts ! National HIV/AIDS Strategy ! Research RFAs ! Visibility in popular culture
- 48. Marlo Thomas saidit best… Come with me, take my hand, and we'll live In a land where the river runs free In a land through the green country In a land to a shining sea And you and me are free to be you and me
- 49.
- 50. Acknowledgements ! The amazingpatients at the Tuesday and Thursday Night Clinic at Family Health Center who truly humble me ! Davey Smith ! Cathy Logan ! Anthony Johnson