HIV in Transgender Patients

HIV in Transgender Patients

Anita Radix, MD MPHAnita Radix, MD MPH

Callen Lorde Community Callen Lorde Community Health CenterHealth Center

Anita Radix, MD MPHAnita Radix, MD MPH

Callen Lorde Community Callen Lorde Community Health CenterHealth Center

Learning ObjectivesLearning Objectives

At the conclusion of this presentation, At the conclusion of this presentation, participants should be able to:participants should be able to:

•  •  Adapt and implement HIV prevention Adapt and implement HIV prevention strategies for persons of transgender strategies for persons of transgender experience experience • • Modify evaluation and treatment Modify evaluation and treatment approaches to ensure culturally approaches to ensure culturally competent delivery of HIV-related health competent delivery of HIV-related health services for your patientsservices for your patients

At the conclusion of this presentation, At the conclusion of this presentation, participants should be able to:participants should be able to:

•  •  Adapt and implement HIV prevention Adapt and implement HIV prevention strategies for persons of transgender strategies for persons of transgender experience experience • • Modify evaluation and treatment Modify evaluation and treatment approaches to ensure culturally approaches to ensure culturally competent delivery of HIV-related health competent delivery of HIV-related health services for your patientsservices for your patients

Off Label DisclosureOff Label Disclosure

This presentation will include discussion This presentation will include discussion of the following non-FDA-approved or of the following non-FDA-approved or investigational uses of products/devices:investigational uses of products/devices:

• • Cross gender hormone therapyCross gender hormone therapy

This presentation will include discussion This presentation will include discussion of the following non-FDA-approved or of the following non-FDA-approved or investigational uses of products/devices:investigational uses of products/devices:

• • Cross gender hormone therapyCross gender hormone therapy

CaseCase

27 y/o HIV-infected transgender (male-27 y/o HIV-infected transgender (male-to-female) woman transferring care to-female) woman transferring care from California. from California. •6 months ago CD4 420 cells/mm6 months ago CD4 420 cells/mm33 HIV HIV RNA level of 16,000 copies/ml.RNA level of 16,000 copies/ml.•ARV naïveARV naïve•PMH: HIV+ 2005, started CGHT at age PMH: HIV+ 2005, started CGHT at age 2020•Meds: spironolactone 100mg tid, Meds: spironolactone 100mg tid, Premarin 2.5mg bid Premarin 2.5mg bid

27 y/o HIV-infected transgender (male-27 y/o HIV-infected transgender (male-to-female) woman transferring care to-female) woman transferring care from California. from California. •6 months ago CD4 420 cells/mm6 months ago CD4 420 cells/mm33 HIV HIV RNA level of 16,000 copies/ml.RNA level of 16,000 copies/ml.•ARV naïveARV naïve•PMH: HIV+ 2005, started CGHT at age PMH: HIV+ 2005, started CGHT at age 2020•Meds: spironolactone 100mg tid, Meds: spironolactone 100mg tid, Premarin 2.5mg bid Premarin 2.5mg bid

The BasicsThe Basics

• Basic terminology - what does Basic terminology - what does transgender mean?transgender mean?

• Gender vs. sexual orientationGender vs. sexual orientation• What pronoun to useWhat pronoun to use• HIV & Primary care issuesHIV & Primary care issues• Risks/benefits hormone therapyRisks/benefits hormone therapy• Creating a welcoming spaceCreating a welcoming space

• Basic terminology - what does Basic terminology - what does transgender mean?transgender mean?

• Gender vs. sexual orientationGender vs. sexual orientation• What pronoun to useWhat pronoun to use• HIV & Primary care issuesHIV & Primary care issues• Risks/benefits hormone therapyRisks/benefits hormone therapy• Creating a welcoming spaceCreating a welcoming space

6

What is gender?What is gender?What is gender?What is gender?

Background information Terminology

Background information Terminology

Gender vs. SexGender vs. Sex

TraditionalTraditional• Gender is binary (M/F)Gender is binary (M/F)

• Synonymous with sex (chromosomes, Synonymous with sex (chromosomes,

genitalia)genitalia)

NewNew• Gender is a spectrumGender is a spectrum

• Defined by several criteriaDefined by several criteria

• Separate from sexSeparate from sex

TraditionalTraditional• Gender is binary (M/F)Gender is binary (M/F)

• Synonymous with sex (chromosomes, Synonymous with sex (chromosomes,

genitalia)genitalia)

NewNew• Gender is a spectrumGender is a spectrum

• Defined by several criteriaDefined by several criteria

• Separate from sexSeparate from sex

GenderGender

Return

Trans-terminologyTrans-terminology

•TransgenderTransgender• umbrella term used to group the many gender umbrella term used to group the many gender

different communitiesdifferent communities• people who transcend typical gender people who transcend typical gender

paradigmsparadigms•TranssexualTranssexual• biological men and women whose gender biological men and women whose gender

identity most closely matches the other identity most closely matches the other gendergender• Sometimes used to describe persons who Sometimes used to describe persons who

have undergone genital surgeryhave undergone genital surgery

•TransgenderTransgender• umbrella term used to group the many gender umbrella term used to group the many gender

different communitiesdifferent communities• people who transcend typical gender people who transcend typical gender

paradigmsparadigms•TranssexualTranssexual• biological men and women whose gender biological men and women whose gender

identity most closely matches the other identity most closely matches the other gendergender• Sometimes used to describe persons who Sometimes used to describe persons who

have undergone genital surgeryhave undergone genital surgery

TransitionTransition• The process from living and The process from living and

being perceived as the being perceived as the

gender assigned at birth gender assigned at birth

according to the anatomical according to the anatomical

sex (M or F) to living and sex (M or F) to living and

being perceived as the being perceived as the

individual sees and individual sees and

understands themselvesunderstands themselves

TransitionTransition• The process from living and The process from living and

being perceived as the being perceived as the

gender assigned at birth gender assigned at birth

according to the anatomical according to the anatomical

sex (M or F) to living and sex (M or F) to living and

being perceived as the being perceived as the

individual sees and individual sees and

understands themselvesunderstands themselves

Trans-terminologyTrans-terminology

Common terms to describe transition:Common terms to describe transition:

• MTF, male-to-female (trans women)MTF, male-to-female (trans women)

• FTM, female-to-male (trans men)FTM, female-to-male (trans men)

Common terms to describe transition:Common terms to describe transition:

• MTF, male-to-female (trans women)MTF, male-to-female (trans women)

• FTM, female-to-male (trans men)FTM, female-to-male (trans men)

Trans-terminologyTrans-terminology

• Gender Dysphoria (DSM III) or Gender Gender Dysphoria (DSM III) or Gender

Identity Disorder (DSM IV)Identity Disorder (DSM IV)• Often perceived as pathologizingOften perceived as pathologizing

• DSM-V revising definition to Gender DSM-V revising definition to Gender

Incongruence (APA, 2010)Incongruence (APA, 2010)

• Sex Reassignment Surgery (SRS) or Sex Reassignment Surgery (SRS) or

Gender Confirming Surgery (GCS)Gender Confirming Surgery (GCS)

• Gender Dysphoria (DSM III) or Gender Gender Dysphoria (DSM III) or Gender

Identity Disorder (DSM IV)Identity Disorder (DSM IV)• Often perceived as pathologizingOften perceived as pathologizing

• DSM-V revising definition to Gender DSM-V revising definition to Gender

Incongruence (APA, 2010)Incongruence (APA, 2010)

• Sex Reassignment Surgery (SRS) or Sex Reassignment Surgery (SRS) or

Gender Confirming Surgery (GCS)Gender Confirming Surgery (GCS)

Medical TermsMedical Terms

Sexual OrientationSexual Orientation

• Part of, but not the same as, gender Part of, but not the same as, gender

identityidentity• Trans-women attracted to men and trans-men Trans-women attracted to men and trans-men

attracted to women may identify as attracted to women may identify as

heterosexualheterosexual

• Trans-women attracted to women may identify Trans-women attracted to women may identify

as lesbianas lesbian

• Trans-men attracted to men may identify as gayTrans-men attracted to men may identify as gay

• Part of, but not the same as, gender Part of, but not the same as, gender

identityidentity• Trans-women attracted to men and trans-men Trans-women attracted to men and trans-men

attracted to women may identify as attracted to women may identify as

heterosexualheterosexual

• Trans-women attracted to women may identify Trans-women attracted to women may identify

as lesbianas lesbian

• Trans-men attracted to men may identify as gayTrans-men attracted to men may identify as gay

• How do I know which pronoun to How do I know which pronoun to

use?use?• Ask politelyAsk politely

• What’s the presenting gender?What’s the presenting gender?

• Echo the language you hear; listen for Echo the language you hear; listen for

new pronouns (hir, zie, s/he)new pronouns (hir, zie, s/he)

• Make an effort to use the correct Make an effort to use the correct

pronoun consistentlypronoun consistently

• How do I know which pronoun to How do I know which pronoun to

use?use?• Ask politelyAsk politely

• What’s the presenting gender?What’s the presenting gender?

• Echo the language you hear; listen for Echo the language you hear; listen for

new pronouns (hir, zie, s/he)new pronouns (hir, zie, s/he)

• Make an effort to use the correct Make an effort to use the correct

pronoun consistentlypronoun consistently

What is the Correct Pronoun?What is the Correct Pronoun?

Transgender EpidemiologyTransgender Epidemiology

DemographicsDemographics

No reliable data: No reliable data:

Prevalence rates of MTF transsexualismPrevalence rates of MTF transsexualism• 1:500 – 1:20001:500 – 1:200011 • 1/11,900, based on medical/surgical 1/11,900, based on medical/surgical

treatmenttreatment22 • 1:2,900 surgical treatment1:2,900 surgical treatment33 • Transgender prevalence higherTransgender prevalence higher

No reliable data: No reliable data:

Prevalence rates of MTF transsexualismPrevalence rates of MTF transsexualism• 1:500 – 1:20001:500 – 1:200011 • 1/11,900, based on medical/surgical 1/11,900, based on medical/surgical

treatmenttreatment22 • 1:2,900 surgical treatment1:2,900 surgical treatment33 • Transgender prevalence higherTransgender prevalence higher

HIV PrevalenceHIV Prevalence

• No national surveillance data No national surveillance data • Transwomen designated as MSMTranswomen designated as MSM• Meta-analysis - HIV prevalence estimated at 11.8 Meta-analysis - HIV prevalence estimated at 11.8

(self report) to 27.7% (confirmed) among MTF(self report) to 27.7% (confirmed) among MTF44

• Higher rates among transgender sex workers - Higher rates among transgender sex workers - 68%68%55

• African American MTFs 41-63%African American MTFs 41-63%6,76,7

• HIV prevalence in transgender men was found to HIV prevalence in transgender men was found to be 3% in Washington, DC be 3% in Washington, DC 88 and 2% in San and 2% in San FranciscoFrancisco77

• No national surveillance data No national surveillance data • Transwomen designated as MSMTranswomen designated as MSM• Meta-analysis - HIV prevalence estimated at 11.8 Meta-analysis - HIV prevalence estimated at 11.8

(self report) to 27.7% (confirmed) among MTF(self report) to 27.7% (confirmed) among MTF44

• Higher rates among transgender sex workers - Higher rates among transgender sex workers - 68%68%55

• African American MTFs 41-63%African American MTFs 41-63%6,76,7

• HIV prevalence in transgender men was found to HIV prevalence in transgender men was found to be 3% in Washington, DC be 3% in Washington, DC 88 and 2% in San and 2% in San FranciscoFrancisco77

HIV IncidenceHIV Incidence

• High HIV incidence 3.4-7.8% per 100 High HIV incidence 3.4-7.8% per 100 person-yearsperson-years9,109,10

• African American transwomen African American transwomen 18.118.1%% per 100 person-yearsper 100 person-years1010

• High HIV incidence 3.4-7.8% per 100 High HIV incidence 3.4-7.8% per 100 person-yearsperson-years9,109,10

• African American transwomen African American transwomen 18.118.1%% per 100 person-yearsper 100 person-years1010

Predictors of HIV infectionamong Transgender WomenPredictors of HIV infection

among Transgender Women

• African-American race African-American race 5,75,7

• SyphilisSyphilis55

• High number of sex partnersHigh number of sex partners77

• Less than high school educationLess than high school education77

• History of sex workHistory of sex work88

• UnemploymentUnemployment88

• African-American race African-American race 5,75,7

• SyphilisSyphilis55

• High number of sex partnersHigh number of sex partners77

• Less than high school educationLess than high school education77

• History of sex workHistory of sex work88

• UnemploymentUnemployment88

Return

Transphobia – an irrational fear of Transphobia – an irrational fear of

gender-different people leading to gender-different people leading to

systematic discriminationsystematic discrimination

Transphobia – an irrational fear of Transphobia – an irrational fear of

gender-different people leading to gender-different people leading to

systematic discriminationsystematic discrimination

Tyra Hunter (1970-1995)Died in Washington DC after paramedics withdrew treatment at scene of car accident.

Robert Eads (1945-1999)Care for ovarian cancer delayed for one year because more than two dozen doctors refused to treat him.

Brandon Teena (1972-1993)Raped and murdered by John Lotter and Marvin Nissen after they discovered he was anatomically female.

Initial AssessmentMedical History

Initial AssessmentMedical History

Ask about:Ask about:• Hormone use, dose, duration, obtained Hormone use, dose, duration, obtained

“on the street” or prescription“on the street” or prescription• Silicone injections, pump partiesSilicone injections, pump parties• Needles for injection (shared)Needles for injection (shared)• Psychosocial issues: depression, PTSD, Psychosocial issues: depression, PTSD,

support network, employment, sex support network, employment, sex work and substance usework and substance use

Ask about:Ask about:• Hormone use, dose, duration, obtained Hormone use, dose, duration, obtained

“on the street” or prescription“on the street” or prescription• Silicone injections, pump partiesSilicone injections, pump parties• Needles for injection (shared)Needles for injection (shared)• Psychosocial issues: depression, PTSD, Psychosocial issues: depression, PTSD,

support network, employment, sex support network, employment, sex work and substance usework and substance use

Initial AssessmentExam

Initial AssessmentExam

Keep in mind:Keep in mind:•Transgender patients may have had previous Transgender patients may have had previous negative healthcare experiencesnegative healthcare experiences•Developing trust and rapport may take longer than Developing trust and rapport may take longer than you are used toyou are used to•Avoid genital and rectal exams on first visit, if Avoid genital and rectal exams on first visit, if possible. possible. •Be sensitive to disassociation from genitalsBe sensitive to disassociation from genitals•Discuss choice of language to describe anatomy Discuss choice of language to describe anatomy Avoid using “pre-op” and “postop”Avoid using “pre-op” and “postop”

Keep in mind:Keep in mind:•Transgender patients may have had previous Transgender patients may have had previous negative healthcare experiencesnegative healthcare experiences•Developing trust and rapport may take longer than Developing trust and rapport may take longer than you are used toyou are used to•Avoid genital and rectal exams on first visit, if Avoid genital and rectal exams on first visit, if possible. possible. •Be sensitive to disassociation from genitalsBe sensitive to disassociation from genitals•Discuss choice of language to describe anatomy Discuss choice of language to describe anatomy Avoid using “pre-op” and “postop”Avoid using “pre-op” and “postop”

Initial AssessmentCounseling

Initial AssessmentCounseling

• Counseling on minimizing modifiable Counseling on minimizing modifiable

risk factorsrisk factors• Smoking cessationSmoking cessation

• Alcohol and drug use harm reductionAlcohol and drug use harm reduction

• STI preventionSTI prevention

• Needle use and sharingNeedle use and sharing

• Silicone useSilicone use

• Counseling on minimizing modifiable Counseling on minimizing modifiable

risk factorsrisk factors• Smoking cessationSmoking cessation

• Alcohol and drug use harm reductionAlcohol and drug use harm reduction

• STI preventionSTI prevention

• Needle use and sharingNeedle use and sharing

• Silicone useSilicone use

SiliconeSilicone

• >25% of transgender women inject silicone >25% of transgender women inject silicone to create “feminine” appearanceto create “feminine” appearance44

• May be industrial grade and mixed with May be industrial grade and mixed with paraffin or cooking oilparaffin or cooking oil

• Pump Parties - venue for sharing and Pump Parties - venue for sharing and injecting siliconeinjecting silicone• Risks – pulmonary embolism, ARDS, local Risks – pulmonary embolism, ARDS, local

infections, disfigurement, Hepatitis C, HIVinfections, disfigurement, Hepatitis C, HIV

• >25% of transgender women inject silicone >25% of transgender women inject silicone to create “feminine” appearanceto create “feminine” appearance44

• May be industrial grade and mixed with May be industrial grade and mixed with paraffin or cooking oilparaffin or cooking oil

• Pump Parties - venue for sharing and Pump Parties - venue for sharing and injecting siliconeinjecting silicone• Risks – pulmonary embolism, ARDS, local Risks – pulmonary embolism, ARDS, local

infections, disfigurement, Hepatitis C, HIVinfections, disfigurement, Hepatitis C, HIV

Case cont.Case cont.

• Labs: CD4 count of 322 cells/mmLabs: CD4 count of 322 cells/mm33 and an and an HIV RNA level of 82,000 copies/ml.HIV RNA level of 82,000 copies/ml.

• She is interested in antiretroviral therapy She is interested in antiretroviral therapy and there are no major concerns with and there are no major concerns with adherence. Genotype is fully sensitive.adherence. Genotype is fully sensitive.

• What about interactions with her CGHT What about interactions with her CGHT (Premarin 2.5mg BID, spironolactone (Premarin 2.5mg BID, spironolactone 100mg TID)?100mg TID)?

• Labs: CD4 count of 322 cells/mmLabs: CD4 count of 322 cells/mm33 and an and an HIV RNA level of 82,000 copies/ml.HIV RNA level of 82,000 copies/ml.

• She is interested in antiretroviral therapy She is interested in antiretroviral therapy and there are no major concerns with and there are no major concerns with adherence. Genotype is fully sensitive.adherence. Genotype is fully sensitive.

• What about interactions with her CGHT What about interactions with her CGHT (Premarin 2.5mg BID, spironolactone (Premarin 2.5mg BID, spironolactone 100mg TID)?100mg TID)?

HIV Medications That HIV Medications That IncreaseIncrease Estradiol and Ethinyl Estradiol and Ethinyl Estradiol LevelsEstradiol Levels

HIV Medications That HIV Medications That DecreaseDecrease Estradiol and Ethinyl Estradiol and Ethinyl Estradiol LevelsEstradiol Levels

amprenavir (Agenerase)amprenavir (Agenerase) atazanavir/ritonaviratazanavir/ritonavir

atazanavir (Reyataz) ↑ 48%atazanavir (Reyataz) ↑ 48% darunavir/ritonavir (Prezista) ↓44%darunavir/ritonavir (Prezista) ↓44%

delavirdine (Rescriptor)delavirdine (Rescriptor) fosamprenavir/ritonavir (Lexiva) fosamprenavir/ritonavir (Lexiva) ↓37%↓37%

efavirenz (Sustiva) ↑ 37%efavirenz (Sustiva) ↑ 37% lopinavir/ritonavir (Kaletra) ↓ 42%lopinavir/ritonavir (Kaletra) ↓ 42%

etravirine (Intelence) ↑22%etravirine (Intelence) ↑22% nelfinavir (Viracept)nelfinavir (Viracept)

fosamprenavir (Lexiva)fosamprenavir (Lexiva) nevirapine (Viramune) ↓20%nevirapine (Viramune) ↓20%

indinavir (Crixivan)indinavir (Crixivan) ritonavir (Norvir)ritonavir (Norvir)

saquinavir (Invirase)saquinavir (Invirase) tipranivir (Aptivus)tipranivir (Aptivus)

Ethinyl estradiol may decrease levels of: amprenavir (Agenerase), fosamprenavir (Lexiva) Selzentry (Maraviroc) – no significant effect on ethinyl estradiol levels

DHHS, 2009

Adherence Adherence

• Lower adherence rates noted among HIV+ Lower adherence rates noted among HIV+ MTF MTF 1212

• Negative provider interactionsNegative provider interactions• Perceived negative effects of ARVs on hormonesPerceived negative effects of ARVs on hormones• Selling ARVs to purchase hormonesSelling ARVs to purchase hormones

• Psychosocial Psychosocial 4,5,8,124,5,8,12

• ↑↑ Homelessness Homelessness • ↑↑ Unemployment Unemployment • ↑↑ Substance useSubstance use• ↑↑ Incarceration Incarceration • ↑↑ Social isolation Social isolation

• Lower adherence rates noted among HIV+ Lower adherence rates noted among HIV+ MTF MTF 1212

• Negative provider interactionsNegative provider interactions• Perceived negative effects of ARVs on hormonesPerceived negative effects of ARVs on hormones• Selling ARVs to purchase hormonesSelling ARVs to purchase hormones

• Psychosocial Psychosocial 4,5,8,124,5,8,12

• ↑↑ Homelessness Homelessness • ↑↑ Unemployment Unemployment • ↑↑ Substance useSubstance use• ↑↑ Incarceration Incarceration • ↑↑ Social isolation Social isolation

What hormones are used and What hormones are used and what do they do?what do they do?What hormones are used and What hormones are used and what do they do?what do they do?

Gender Confirming Hormone TherapyGender Confirming Hormone Therapy

EstrogensEstrogens Conjugated Estrogens : 1.25-10mg po qd or divided as bidConjugated Estrogens : 1.25-10mg po qd or divided as bid

Estradiol: 2Estradiol: 2-8 mg-8 mg po qd or divided as bidpo qd or divided as bid

Estradiol Patch : 0.1-0.3mg q3-7 daysEstradiol Patch : 0.1-0.3mg q3-7 days

EstradiolEstradiol Valerate injection : 20-60mg IM q2wksValerate injection : 20-60mg IM q2wks

• Ethinyl estradiol (OCP) Ethinyl estradiol (OCP) 50-10050-100g qdg qd

Anti-androgenAnti-androgen Spironolactone 100-400mg daily, divided dosesSpironolactone 100-400mg daily, divided doses Finasteride 1-5mg po dailyFinasteride 1-5mg po daily Cyproterone Acetate (Androcur) Cyproterone Acetate (Androcur) 5-5--reductase inhibitors: -reductase inhibitors:

• Finasteride: 1-5mg daily; Dutasteride: 0.5mg dailyFinasteride: 1-5mg daily; Dutasteride: 0.5mg daily

• Flutamide (Eulexin) 50-750mg dailyFlutamide (Eulexin) 50-750mg daily

EstrogensEstrogens Conjugated Estrogens : 1.25-10mg po qd or divided as bidConjugated Estrogens : 1.25-10mg po qd or divided as bid

Estradiol: 2Estradiol: 2-8 mg-8 mg po qd or divided as bidpo qd or divided as bid

Estradiol Patch : 0.1-0.3mg q3-7 daysEstradiol Patch : 0.1-0.3mg q3-7 days

EstradiolEstradiol Valerate injection : 20-60mg IM q2wksValerate injection : 20-60mg IM q2wks

• Ethinyl estradiol (OCP) Ethinyl estradiol (OCP) 50-10050-100g qdg qd

Anti-androgenAnti-androgen Spironolactone 100-400mg daily, divided dosesSpironolactone 100-400mg daily, divided doses Finasteride 1-5mg po dailyFinasteride 1-5mg po daily Cyproterone Acetate (Androcur) Cyproterone Acetate (Androcur) 5-5--reductase inhibitors: -reductase inhibitors:

• Finasteride: 1-5mg daily; Dutasteride: 0.5mg dailyFinasteride: 1-5mg daily; Dutasteride: 0.5mg daily

• Flutamide (Eulexin) 50-750mg dailyFlutamide (Eulexin) 50-750mg daily

Adverse Effects of Hormone Therapy

Adverse Effects of Hormone Therapy

Risks (anecdotal): Risks (anecdotal):

• Thromboembolism Thromboembolism

• Increased risk of breast cancer?Increased risk of breast cancer?

• Hyperprolactinemia/pituitary adenomaHyperprolactinemia/pituitary adenoma

• HepatotoxicityHepatotoxicity

• Cardiovascular risk?Cardiovascular risk?

• InfertilityInfertility

• Anxiety/depressionAnxiety/depression

• GallstonesGallstones

• HypertensionHypertension

Risks (anecdotal): Risks (anecdotal):

• Thromboembolism Thromboembolism

• Increased risk of breast cancer?Increased risk of breast cancer?

• Hyperprolactinemia/pituitary adenomaHyperprolactinemia/pituitary adenoma

• HepatotoxicityHepatotoxicity

• Cardiovascular risk?Cardiovascular risk?

• InfertilityInfertility

• Anxiety/depressionAnxiety/depression

• GallstonesGallstones

• HypertensionHypertension

Safety of Hormone TherapySafety of Hormone Therapy

• Very few published studies of long-term Very few published studies of long-term

safety of MTF or FTM regimenssafety of MTF or FTM regimens

• Prospective study from The NetherlandsProspective study from The Netherlands 1313

• 30 years follow-up 2236 MTF, and 876 FTM. 30 years follow-up 2236 MTF, and 876 FTM.

• MTF: ethinyl estradiol, 6–8% increase venous MTF: ethinyl estradiol, 6–8% increase venous

thrombosisthrombosis

• Very few published studies of long-term Very few published studies of long-term

safety of MTF or FTM regimenssafety of MTF or FTM regimens

• Prospective study from The NetherlandsProspective study from The Netherlands 1313

• 30 years follow-up 2236 MTF, and 876 FTM. 30 years follow-up 2236 MTF, and 876 FTM.

• MTF: ethinyl estradiol, 6–8% increase venous MTF: ethinyl estradiol, 6–8% increase venous

thrombosisthrombosis

Appropriate Follow-upAppropriate Follow-up

• Routine screening on all organs as Routine screening on all organs as

long as they are present:long as they are present:

• Testicular and prostate examTesticular and prostate exam

• Pap smearPap smear

• Breast exams and mammogramsBreast exams and mammograms

[Evidence level C, consensus opinion]

• Routine screening on all organs as Routine screening on all organs as

long as they are present:long as they are present:

• Testicular and prostate examTesticular and prostate exam

• Pap smearPap smear

• Breast exams and mammogramsBreast exams and mammograms

[Evidence level C, consensus opinion]

Appropriate Follow-upAppropriate Follow-up

• Periodic laboratory testing:Periodic laboratory testing:• MTF - q6-12 mos: fasting glucose, lipid MTF - q6-12 mos: fasting glucose, lipid

profile, liver function, prolactin; as needed: profile, liver function, prolactin; as needed:

testosterone, potassium, hemoglobintestosterone, potassium, hemoglobin

• FTM - q6-12 mos: fasting lipids, liver FTM - q6-12 mos: fasting lipids, liver

function, hemoglobinfunction, hemoglobin

[Evidence level C, expert opinion]

• Periodic laboratory testing:Periodic laboratory testing:• MTF - q6-12 mos: fasting glucose, lipid MTF - q6-12 mos: fasting glucose, lipid

profile, liver function, prolactin; as needed: profile, liver function, prolactin; as needed:

testosterone, potassium, hemoglobintestosterone, potassium, hemoglobin

• FTM - q6-12 mos: fasting lipids, liver FTM - q6-12 mos: fasting lipids, liver

function, hemoglobinfunction, hemoglobin

[Evidence level C, expert opinion]

STI ScreeningSTI Screening

• Assess the risk of STI’s for all transfemale Assess the risk of STI’s for all transfemale patientspatients

• Offer Hepatitis B immunizationOffer Hepatitis B immunization• Screen at least annually* (3-6 months for Screen at least annually* (3-6 months for

highest risk) forhighest risk) for• Syphilis Syphilis • Urethral & rectal Urethral & rectal N. gonorrheoeae N. gonorrheoeae and and C. C.

trachomatistrachomatis testing testing

[Evidence level C, expert opinion]

*MTFs who have sex with men

• Assess the risk of STI’s for all transfemale Assess the risk of STI’s for all transfemale patientspatients

• Offer Hepatitis B immunizationOffer Hepatitis B immunization• Screen at least annually* (3-6 months for Screen at least annually* (3-6 months for

highest risk) forhighest risk) for• Syphilis Syphilis • Urethral & rectal Urethral & rectal N. gonorrheoeae N. gonorrheoeae and and C. C.

trachomatistrachomatis testing testing

[Evidence level C, expert opinion]

*MTFs who have sex with men

Creating a Welcoming SpaceCreating a Welcoming Space

• Use language that is sensitive to Use language that is sensitive to transgender identitiestransgender identities

• Trans-sensitive intake forms – allow clients Trans-sensitive intake forms – allow clients write in their genderwrite in their gender

• Become familiar with the gender pronoun Become familiar with the gender pronoun your patient prefersyour patient prefers

• Cultural competency training for staffCultural competency training for staff• Have trans-sensitive brochures, prevention Have trans-sensitive brochures, prevention

information availableinformation available• Be familiar with local resources available to Be familiar with local resources available to

assist with name/gender changeassist with name/gender change

• Use language that is sensitive to Use language that is sensitive to transgender identitiestransgender identities

• Trans-sensitive intake forms – allow clients Trans-sensitive intake forms – allow clients write in their genderwrite in their gender

• Become familiar with the gender pronoun Become familiar with the gender pronoun your patient prefersyour patient prefers

• Cultural competency training for staffCultural competency training for staff• Have trans-sensitive brochures, prevention Have trans-sensitive brochures, prevention

information availableinformation available• Be familiar with local resources available to Be familiar with local resources available to

assist with name/gender changeassist with name/gender change

Thank you!

1. Olyslager F, Conway L. On the Calculation of the Prevalence of Transsexualism. WPATH 20th 1. Olyslager F, Conway L. On the Calculation of the Prevalence of Transsexualism. WPATH 20th International Symposium. Chicago, Illinois, 2007.International Symposium. Chicago, Illinois, 2007.

2. Bakker, A, et al. (1993) The prevalence of transsexualism in the Netherlands 2. Bakker, A, et al. (1993) The prevalence of transsexualism in the Netherlands Acta Psychiatrica Scandinavica Volume 87 Issue 4, Pages 237 - 238, Pages 237 - 238

3. Tsoi WF.The prevalence of transsexualism in Singapore. Acta Psychiatr Scand. 1988 Oct;78(4):501-4.3. Tsoi WF.The prevalence of transsexualism in Singapore. Acta Psychiatr Scand. 1988 Oct;78(4):501-4.4. Herbst, J., et al. (2007). Estimating HIV prevalence and risk behaviors of transgender persons in the 4. Herbst, J., et al. (2007). Estimating HIV prevalence and risk behaviors of transgender persons in the

United States: A systematic review. AIDS and Behavior.United States: A systematic review. AIDS and Behavior.5. Elifson, K., et al. Male transvestite prostitutes and HIV risk. (1993 Feb). American Journal of Public 5. Elifson, K., et al. Male transvestite prostitutes and HIV risk. (1993 Feb). American Journal of Public

Health;83(2):260-2.Health;83(2):260-2.6. Nemoto, T., et al. (2004) HIV risk behaviors among male-to-female transgender persons of color in San 6. Nemoto, T., et al. (2004) HIV risk behaviors among male-to-female transgender persons of color in San

Francisco. American Journal of Public Health;94 (7):1193-1199.Francisco. American Journal of Public Health;94 (7):1193-1199.7. Clements-Nolle, K et al (2001) HIV prevalence, risk behaviors, health care use, and mental health status 7. Clements-Nolle, K et al (2001) HIV prevalence, risk behaviors, health care use, and mental health status

of transgender persons: implications for public health intervention. (2001 Jun). American Journal of of transgender persons: implications for public health intervention. (2001 Jun). American Journal of Public Health.;91(6):915-21.Public Health.;91(6):915-21.

8. Xavier, J.M. (2000). The Washington, DC. Transgender Needs Assessment Survey Final Report for Phase 8. Xavier, J.M. (2000). The Washington, DC. Transgender Needs Assessment Survey Final Report for Phase Two. Washington, DC: Administration for HIV/AIDS of the District of Columbia. at: Two. Washington, DC: Administration for HIV/AIDS of the District of Columbia. at: http://www.gender.org/

9. Simon, P., et al. HIV prevalence and incidence among male-to-female transsexuals receiving HIV 9. Simon, P., et al. HIV prevalence and incidence among male-to-female transsexuals receiving HIV prevention services in Los Angeles County. (2000 Dec). AIDS, 14, 2953-2955.prevention services in Los Angeles County. (2000 Dec). AIDS, 14, 2953-2955.

10. Kellogg, 2001) Kellogg, T., Incidence of human immunodeficiency virus among male-to-female 10. Kellogg, 2001) Kellogg, T., Incidence of human immunodeficiency virus among male-to-female transgendered persons in San Francisco. (2001 Dec). Journal of Acquired Immune Deficiency transgendered persons in San Francisco. (2001 Dec). Journal of Acquired Immune Deficiency Syndromes;28(4):380-4.Syndromes;28(4):380-4.

11. DHHS 2009 http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.11. DHHS 2009 http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.12. 12. Sevelius, J et al. Antiretroviral Therapy Adherence among transgender women living with HIV.(2010) , J et al. Antiretroviral Therapy Adherence among transgender women living with HIV.(2010)

JANAC JANAC 21(3):256-264(3):256-26413. Gooren, L. Long-Term Treatment of Transsexuals with Cross-Sex Hormones: Extensive Personal 13. Gooren, L. Long-Term Treatment of Transsexuals with Cross-Sex Hormones: Extensive Personal

Experience. (2007) J. Clin. Endocrinol. Metab. 93:19-25 Experience. (2007) J. Clin. Endocrinol. Metab. 93:19-25

References