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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. Read the full story: http://sc-ctsi.org/index.php/news-dev/researchers-share-how-they-work-with-community-members-to-address-critica Learn more about SC CTSI at USC and CHLA: http://sc-ctsi.org/
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Slide #1
The Cardiovascular & Metabolic Health of Transgender Persons:
Implications in Primary Care
The Cardiovascular & Metabolic Health of Transgender Persons:
Implications in Primary Care
PI - Madeline B. Deutsch, MDDirector
Transgender Health ProgramLA Gay & Lesbian Center
Assistant Clinical ProfessorUCSF Department of Family & Community Medicine
PI - Madeline B. Deutsch, MDDirector
Transgender Health ProgramLA Gay & Lesbian Center
Assistant Clinical ProfessorUCSF Department of Family & Community Medicine
Slide #2
Study 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)
Slide #3
Funding• CTSI – In kind funds (lab costs, incentives,
CASI equipment)• LAGLC – In kind PI time, overall project
support and management• CCALAC – 50% Research Navigator• CHLA – In kind co-investigator time
Slide #4
Background and Significance
• Body of research on transgender people is severely limited
• 2011 report from the IOM recommends funding research in all areas of transgender health
Slide #5
Trans Research –Why Important?
• 50% of transgender patients report having to 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 curriculae include content on transition-related care– Obedin-Mailver et al JAMA Sept 7, 2011
Slide #6
Transgender Care – Why Important?
• Hormone therapy reduces anxiety, depression and improves social functioning & QOL
• Surgery improves global functioning and quality of life
Newfield 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.
Slide #7
Primary Aim
1) Collect metabolic and cardiovascular parameters on transgender patients before and after 6 months of cross-sex hormones
2) Collect information on transgender patient attitudes about primary care
Slide #8
Secondary Aims
• Develop infrastructure for future transgender research at the study site
• Test feasibility of conducting community-based transgender research and subsequent translation into clinical practice
• Explore research collaborations between the multiple involved institutions
Slide #9
Study Site (LA Gay & Lesbian Center)
• Oldest and largest (by budget) LGBT organization in the world
• Federally Qualified Health Center (Lookalike) & Ryan White Grantee
• Existing research programs focused primarily on HIV
• Transgender Health Program census = approx 500 individuals
Slide #10
Methods• Collect baseline and 6 month metabolic
data• Baseline and 6 month survey of attitudes
about primary care• Subjects receive covered lab costs and
$25 gift card incentives at enrollment and again at completion
• Planned N determined by budget (75)• Retention efforts include reminder calls &
texts
Slide #11
Study Population
• 18 years of age or older• Patient registered in LAGLC Transgender Health
Program• No prior cross-sex hormone treatment (csHT)• Intend to begin csHT• Transgender identified• No contraindication to csHT• Sequential patients enrolled
Slide #12
Initial Results
• 57 sequential patients enrolled– 34 FTM, 23 MTF
• Reasons for under-enrollment– Front office/scheduling difficulties– Shifting patient demographics (higher
percentage of new-to-LAGLC patients coming from another clinic already on hormones)
– Enrollment closed in January 2013 in order to allow completion of study within projected time frame of August 2013
Slide #13
White
Black
Native H
awain
Asian
Americ
an India
n
Oth
er 0
5
10
15
20
25
3027
3
0
31
0
Race Breakdown for FTM (N=34)
White
Black
Native H
awain
Asian
Americ
an India
n
Oth
er 0
5
10
15
20
25
30
18
1 1 2 0 1
Race breakdown for MTF (N=23)
Slide #14
Hispanic 32%
Non-Hispanic
68%
Ethnicity breakdown for FTM (N=34)
Hispanic45%
Non-Hispanic
55%
Ethnicity Breakdown for MTF(N=23)
Slide #15
18-25 26-35 36-45 46-55 >550
2
4
6
8
10
12
14
16
18
20
18
11
5
00
12
6
1
3
1
Age Distribution for FTM and MTF
FTMMTF
# o
f P
ati
en
ts
Slide #16
FTM MTF
BP Systolic
Mean ±SD 119.8±13.3 130.8±15.3
Median 120.0 130.0
BP Diastolic
Mean ±SD 74.1±10.9 77.6±12.1
Median 73.0 77.0
Height
Mean ±SD 65.2±3.3 68.3±4
Median 65.0 68.0
Weight
Mean ±SD 183.1±56.1 174.8±55
Median 173.0 153.0
Waist Circumference
Mean ±SD 98.9±19.9 92.5±17.8
Median 96.0 86.0
BMI
Mean ±SD 30±8.4 25.9±5.8
Median 69.6 5.8
Slide #17
FTM MTF Cholesterol Total Mean ±SD 175.8±31.6 177.9±29.5Median 172.5 186.5HDL
Mean ±SD 60±16.9 53.2±17.6Median 57.0 53.0LDL (Calc) Mean ±SD 95.5±26.7 100.7±26.8Median 92.0 109.5Triglycerides Mean ±SD 102±94.3 130.5±120.4Median 79.0 88.0
Estradiol Mean ±SD 109.4±65.8 32.4±22.4Median 141.9 28.9
Testosterone , Total Mean ±SD 38.8±17.8 410.7±192.9Median 35.5 399.0Testosterone , Free Mean ±SD 0.8±0.5 11.6±5.5Median 0.7 11.4
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
Slide #19
Very Likely Likely Somewhat Likely
Unlikely Very Unlikely0%
5%
10%
15%
20%
25%
30%
25%
18%
23%
28%
7%
How likely are you to see a primary care provider for routine care?
Slide #20
Anxiety
about g
oing to
the d
octor
No health
insu
rance
Distance
/ Tra
nsporta
tion is
sues
Difficu
lt to g
et an a
ppointm
ent
Healthca
re is
not a
prio
rity
for m
e right n
ow
0%
10%
20%
30%
40%
50%
60%
24%
12%
50%
21%
12%
15%
6%
18%
9%
27%
Barriers that may exist to accessing Care
Slide #21
Very Important75%
Somewhat Important23%
Neither important nor unimportant
2%
How important is it for you to recieve medical care of any kind at an LGBT-
oriented clinic?
Slide #22
Very Important16%
Somewhat Important25%Neither important nor
unimportant47%
Somewhat unimportant2%
Very Unimportant9%
How important is it for you to have a primary care provider who is trans-
gender themself?
Slide #23
Much more com-fortable
44%
Somewhat more comfortable
26%
Does not make a dif-ference
30%
Does having a transgender medical provider make you feel more or less comfortable in the health-
care setting?
Slide #24
Very Likely Likely Somewhat Likely
Unlikely Very Unlikely0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
77%
18%
4% 2% 0%
How likely is it that you would make future changes to your lifestyle, diet or exercise routine
if recommended to do so by your provider?
Slide #25
Study - Next Steps
• Complete 6 month exit visits• Conduct rigorous data analysis in
collaboration with CTSI• Prepare and submit manuscripts for
publication
Slide #26
Lessons Learned
• More resources needed to support scheduling of study patients (front office)
• Areas for improvement in EMR data abstraction at study site
• Collaborative, community based research appears to feasible in the study of transgender patients