Kelly Washburn, AGNP-C

TRANS* HEALTHCARE IN PRIMARY CARE

This speaker has no financial or other conflicts of interest to report.

DISCLOSURES 2017

¡  Define culturally appropriate terms used when discussing transgender and gender non-conforming (GNC) individuals.

¡  Review pre-hormone counseling using the model of informed consent.

¡  Identify the medications, including their methods of action, used for feminizing and masculinizing hormone regimens.

¡  Demonstrate the difference in the medication management of cross gender hormone therapy in older adults.

OBJECTIVES

¡  1948- Endocrinologist Dr. Harry Benjamin pioneered cross gender hormone therapy with a transfemale child.

¡  1952- Christine Jorgensen, a transwoman, became internationally known as the first woman in the US to have undergone gender affirming surgery.

¡  1966- First Gender Clinic opened at Johns Hopkins Medical Center.

¡  1969- The Stonewall riots, led by transwomen of color Marcia P. Johnson and Sylvia Rivera, initiated the modern day fight for LGBTQ rights in the US.

¡  1979- WPATH (World Professional Association for Transgender Health) published the first Standards for Care.

¡  1980- Transexualism was introduced the DSM III (which was later changed to Gender Identity Disorder and is now listed as Gender Dysphoria)

TRANSGENDER HEALTH HISTORY IN THE UNITED STATES

¡  28% of trans* individuals have postponed medically necessary care when sick or injured.

¡  33% of trans* individuals have delayed or forgone preventative medical care.

¡  50% of trans* individuals have to teach their providers about transgender care.

Office policies to Consider -Document preferred name and pronouns in EHR. -Add gender identity/expression in non-discrimination policy. -Gender neutral bathrooms. -Annual trainings for staff. -Train new staff within 30 days of hire.

THE IMPORTANCE OF FRONT LINE STAFF

¡  Center for Excellence for Transgender Health Primary Care Protocols: www.transhealth.ucsf.edu

¡  Trans Care BC- Transgender Health Information Page: http://transhealth.phsa.ca

¡ World Professional Association for Transgender Health Standards of care: www.wpath.org

¡  Endocrine Treatment for Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinic Practice Guidelines: www.endocrine.org/guidelines-and-clinical-practice/clinical-practice-guidelines

¡  The Fenway Guide to LGBT Health, American College of Physicians: available on amazon

GUIDELINES

¡  Irreversible: -breast tissue enlargement - loss of testicular volume ¡  Reversible: -body fat redistribution -softening of skin -decreased muscle mass -decreased libido - loss of spontaneous erections - increased prolactin level

¡  Does not af fect: -pitch of the voice -size of laryngeal prominence -growth of facial hair ¡  Risks: -thromboembolic events -heart disease -migraine -elevated liver enzymes -choleithiasis -prolacinoma -glactorrhea

FIRST VISIT: PRE-HORMONE COUNSELING

FEMINIZING ESTROGEN

¡  Spironolactone Benefits: -increased breast tissue growth -reduced male pattern baldness Possible risks: hypotension, hyperkalemia   ¡  5-alpha reductase inhibitors- Finasteride/Dultasteride Benefits: -alternative to spiro -additional for persistent hair loss Possible risks: inadequate testosterone suppression ¡  Progesterone *No well -designed studies regarding the role of progesterone in feminization*

Benefits: -anecdotal report of breast/areolar development Possible risks: depression, weight gain, headache

FIRST VISIT: PRE-HORMONE COUNSELING

FEMINIZING

Center of Excellence for Transgender Health. (2016). Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People (M. Deutsch, Ed.). http://transhealth.ucsf.edu/trans?page=guidelines-home

¡  Prior to initiation: UCSF: BUN/Cr/K+, lipids, (consider A1c) Additional: CBC, CMP, prolactin, testosterone, estradiol ¡  3-6-12months s/p initiation: UCSF: BUN/Cr/K+, estradiol (not at 12mo), total testosterone, SHBG, albumin Additional: CMP ¡  Annually: UCSF: BUN/Cr/K+ Additional: CBC, CMP, lipids, testosterone, estradiol

SECOND VISIT: REVIEW LABS AND INITIATE HORMONES

¡  Hormone therapy is not an adequate form of bir th control ¡  Unknown long term effect of hormones on fertil ity

§  Sperm banking and egg harvesting options ¡  Discuss risks for discrimination/harassment/violence and the

need for a strong support system

¡  Prioritize mental health care

¡  Consume whole foods and exercise “Patient verbalized understanding of above information and provided consent to initiate treatment.”

ADDITIONAL COUNSELING BEFORE STARTING HORMONES

¡  I rreversible: -body hair growth -male pattern baldness -deepening of the voice -c l i toral enlargement ¡  Reversible: -acne -coarse skin -mood changes - increased l ibido - redistr ibution of body fat - increased muscle mass -amenorrhea -vaginal dryness

¡  Does not af fect: -he ight -hand/foot s ize

¡  Risks: -polycythemia -elevated l iver enzymes -hear t disease ¡  Finasteride/Minoxidi l : For use in those experiencing male pattern baldness

FIRST VISIT: PRE-HORMONE COUNSELING

MASCULINIZING TESTOSTERONE

Center of Excellence for Transgender Health. (2016). Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People (M. Deutsch, Ed.). http://transhealth.ucsf.edu/trans?page=guidelines-home

¡  Prior to initiation: UCSF: lipids, A1c, H&H Additional: CBC, CMP, lipids, testosterone, estradiol ¡  3-6-12months s/p initiation: UCSF: total testosterone, SHBG, albumin, H&H Additional: CBC, CMP, lipids ¡  Annually: UCSF: H&H Additionally: CBC, CMP, lipids, testosterone

SECOND VISIT: REVIEW LABS AND INITIATE HORMONES

¡ Mammogram ¡  Pap smear ¡  PSA ¡  Colonoscopy ¡  DEXA ¡  A1c Screening ¡  Blood pressure/Cholesterol screening ¡  STI Screenings (consider throat and rectal GC/CT)

IF YOU’VE GOT IT- CHECK IT: ROUTINE HEALTH MAINTENANCE

¡  Ask the patient what words they use to describe their bodies §  E.g. Referring to genitals as “my junk” or not feeling comfortable with

traditionally anatomical terms such as testes

¡  Only examine individual if medically necessary ¡  Consider binding- auscultate over clothes if possible

¡  Avoid the use of gowns/the need to undress (eg. During a pelvic exam, allow the patient to be dressed from the waist up)

¡  Genital exams should only be performed per patient request or for cancer screenings

PHYSICAL EXAM

Specific to transgender populations: ¡  Feminizing vaginoplasty ¡  Masculinizing phalloplasty / scrotoplasty ¡  Metaoidioplasty (cl itoral release/enlargement, may include urethral

lengthening ¡  Masculinizing chest surgery ("top" surgery) ¡  Facial feminization procedures ¡  Reduction thyrochondroplasty (tracheal carti lege shave) ¡  Voice surgery Not specific to transgender populations: ¡  Augmentation mammoplasty ¡  Hysterectomy / oopherectomy ¡  Orchiectomy ¡  Vaginectomy Other interventions: include facial hair removal, voice modification, genital tucking and packing, and chest binding.

SURGERIES

¡  Comorbid mental illness (e.g. schizophrenia)

¡  68yo transwoman with hypertension looking to start hormones

¡  Transmale individual with vaginal bleeding while on testosterone

¡  Elevated H&H on routine labs

¡  Transwoman over the age of 51yo on estrogen

CASE STUDIES TO CONSIDER

¡  Center of Excel lence for Transgender Heal th . (2016, June 6) . Guidel ines for the

Pr imar y and Gender - Af f i rming Care of Transgender and Gender Nonbinar y People (M. Deutsch, Ed. ) . Retr ieved September 1 , 2017, f rom http ://transheal th .ucsf .edu/trans?page=guidel ines -home

¡  Close, C . (Ed. ) . (n .d . ) . The Myth of Trans Regrets . Retr ieved September 1 , 2017, f rom http ://www.transstudent .org/transregrets

¡  De Guerre , M. (2017, March 09) . T imel ine : Transgender Through Histor y - Doc Zone - CBC-T V ( J . B lokland, Ed. ) . Retr ieved September 1 , 2017, f rom http ://www.cbc.ca/doczone/features/t imel ine - t ransgender - through-h istor y

¡  Nat ional LGBT Heal th Educat ion Center. (n .d . ) . Af f i rmat ive Care for Transgender and Gender Non-Conforming People : Best Pract ices for Front -L ine Heal th Care Staf f . Retr ieved September 1 , 2017, f rom http ://www. lgbtheal theducat ion.org/wp-content/uploads/13-017_TransBestPract icesforFront l ineStaf f_v6_02-19-13_FINAL.pdf

¡  Pan, L . , & Moore, A . (n .d . ) . The Gender Unicorn. Retr ieved September 1 , 2017, f rom http ://www.transstudent .org/gender

¡  Pan, L . (n .d . ) . Homelessness . Retr ieved September 1 , 2017, f rom http ://www.transstudent .org/homelessness

¡  Pan, L . (n .d . ) . Why Trans People Need More V is ib i l i ty. Retr ieved September 1 , 2017, f rom http ://www.transstudent .org/transv is ib i l i ty

¡  The Wor ld Profess ional Associat ion for Transgender Heal th . (2001) . Standards of Care for the Heal th of Transsexual , Transgender, and Gender Nonconforming People . Retr ieved September 1 , 2017, f rom http ://www.wpath.org/s i te_page.cfm?pk_associat ion_webpage_menu=1351&pk_associat ion_webpage=3926

REFERENCES

Kelly Washburn, MSN, AGNP-C

Thank you for your time and dedication to the trans*

communities

KellyWashburnNP@gmail.com