transgender health issues what physicians need to know n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Transgender Health Issues: What Physicians Need to Know PowerPoint Presentation
Download Presentation
Transgender Health Issues: What Physicians Need to Know

Loading in 2 Seconds...

play fullscreen
1 / 73

Transgender Health Issues: What Physicians Need to Know - PowerPoint PPT Presentation


  • 168 Views
  • Uploaded on

Transgender Health Issues: What Physicians Need to Know. Featuring UCSF’s Protocols. Introduction. Jamison Green, PhD Manager, Primary Care Protocols UCSF Center of Excellence for Transgender Health.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Transgender Health Issues: What Physicians Need to Know' - brilliant


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
introduction

Introduction

Jamison Green, PhD

Manager, Primary Care Protocols

UCSF Center of Excellence for Transgender Health

slide3

Our mission is to increase access to comprehensive, effective, and affirming healthcare services for trans and gender-variant communities.

project inception
Project Inception
  • 18-month grant: The California Endowment
  • 9-member Medical Advisory Board
project goal
Project Goal
  • Inform & empower primary care providers
  • Create a concise, yet comprehensive transgender primary care protocol
  • Center of Excellence Web site and in-person trainings
medical advisory board
Medical Advisory Board

Jennifer Vanderleest MD, MSPH

Dan Karasic, MD

R. Nick Gorton, MD

James Franicevich, NP

Marvin E. Belzer, MD, FACP, FSAM

Marvin E. Belzer, MD, FACP, FSAM

Lori Kohler, MD

Maddie Deutsch, MD

Jennifer Hastings, MD

Jennifer Burnett, MS, MD, FAAFP

project plan
Project Plan
  • Literature review & gap analysis
  • Draft protocol
  • Review meetings with Medical Advisory Board
  • Protocol launch April 2011
  • www.transhealth.ucsf.edu
caring for transgender patients

Caring for Transgender Patients

Madeline B. Deutsch, MD

Director Transgender Health ProgramLA Gay & Lesbian Center

Chair, Medical Advisory BoardUCSF Center of Excellence for Transgender Health

terminology
Terminology
  • Transgender (Trans)
    • Umbrella term for gender-variant people
  • Transsexual
    • Older, more clinical term for people who use hormones or surgery to live fully as “opposite” sex
  • Cross Dresser / Transvestite
  • Drag Queen/King
terminology1
Terminology
  • FTM / Trans Man / Trans-masculine
    • Female-to-Male
    • Female Assigned at Birth (FAAB)
  • MTF / Trans Woman / Trans-feminine
    • Male-to-Female
    • Male Assigned at Birth (MAAB)
  • GenderQueer
    • Range of identities which lie outside binary
terminology2
Terminology
  • Transition
    • Social
    • Medical
    • Surgical
  • Cisgender
    • “Cis” means “same” in Latin
    • People who are not trans are cisgender
terminology3
Terminology
  • Lesbian transgender woman
    • MTF, attracted to women
  • Gay transgender man
    • FTM, attracted to men
big picture
Big Picture
  • Historical considerations in trans health
  • World Professional Association for Transgender Health Standards of Care
    • WPATH.org
  • Diagnostic coding
    • ICD-9, 10
    • DSM –IV, 5
prevalence
Prevalence
  • European data showing 1:10,000-30,000 has many methodological flaws
  • Williams Institute (UCLA) estimates 0.3% of adult US population is transgender
    • How many people are lesbian, gay, bisexual, and transgender?; Gates GJ April 2011; Accessed online law.ucla.edu/WilliamsInstitute
what do transgender people want from a medical provider
What Do Transgender People Want from a Medical Provider?
  • Hormones
  • Surgery
    • Chest
    • Genital
    • Facial
    • Other
what do transgender people need
What do Transgender People Need?

Care that is covered/paid for

Accepting administrative and clinic staff

Welcoming and inclusive clinic environment

Open-mindedness of others to not only accept, but incorporate their bodies’ differences into everyday medical care

Primary, preventive, sexual healthcare, just like everyone else

what can healthcare workers do
What can healthcare workers do?

If unsure, ask patient for preferred name & pronoun

Avoid assumptions about anatomy

Transgender people may have complex feelings about gowns, changing, etc.

Not all transgender people are obviously transgender

Not all transgender people fit the same mold

what can hormones do
What Can Hormones Do?
  • Cross-Sex Hormone Therapy affects
    • Skin/hair/nails
    • Subcutaneous and facial fat
    • Odors
    • Breasts
    • Body fat
    • Genitals
    • Mind
    • Voice
primary care1
Primary Care
  • Blood pressure
  • Cholesterol, weight, diabetes
  • Cancer screening
  • Bone health
  • Nutrition
  • Depression, mental health
  • HIV, STIs, Hepatitis
  • Substance abuse
  • Domestic violence
  • Silicone
preventive screening
Preventive Screening

If you have an organ,

it must be screened

case 1
Case #1
  • 32 y/o MTF transgender person referred by mental health for initiation of cross-sex HRT
case 11
Case #1
  • Take a history
    • Med & SurgHx
    • Meds
    • Social history
      • Support system
    • Desires, goals, time frames
  • Baseline labwork
    • K+, Lipids, ? LFT, ? FSBG
case 12
Case #1
  • Estrogen
    • Transdermal 100-200mcg patches
    • Sublingual/Oral 2mg bid
    • Intramuscular/Subcutaneous 10-20mg q wk-2wks
  • Testosterone blockade
    • Spironolactone 25-200mg divided bid
    • 5-alpha reductase inhibitors
  • Progestagens
    • Breast/body
    • Medroxyprogesterone 5-10mg poqhs
case 13
Case #1
  • Clinical progress monitoring
    • Loss of erections/ejaculate
    • Reduced body hair, skin changes, fat redistrib
    • Breast budding/progress
    • F/u at 4-8 wks, then 3-6 mos, then q yr
  • Ongoing coordinated care
    • Case management
    • Articulation with mental health
    • Community resources and referrals
    • Support system (family/community/friends)
case 2
Case #2
  • 23 y/o FTM transgender person seeks initiation of cross-sex HRT
case 21
Case #2
  • Testosterone
    • Intramuscular / Subcutaneous 50-100mg/wk
    • Transdermal 5-10mg/day
    • Topical 2.5-10g/day
  • “Side effects” – acne, dyslipidemias
  • Mood, diet, lifestyle
case 22
Case #2
  • Clinical progress monitoring
    • Induction of amenorrhea
    • Voice, clitoral, body hair and oil changes
  • F/u schedule and other needs similar to MTF
case 23
Case #2
  • Pelvic health in FTM
    • Pap screening based on sexual history/risks, prior paps, patient willingness to allow
    • Bimanual exam every other year to assess uterine and ovarian health?
case 24
Case #2
  • Self-referred (i.e., no mental health “letter”)
    • Informed consent model

Deutsch MB; Use of the Informed Consent Model in the Provision of Cross-Sex Hormone Therapy: A Survey of the Practices of Selected Clinics; Int J Transgenderism; 13:1-7, 2012

cancer risk screening1
Cancer Risk & Screening
  • Breast
    • FTM
    • MTF
  • Cervix & Anus
cancer risk screening2
Cancer Risk & Screening
  • Breast
    • FTM
    • MTF
  • Cervix & Anus
  • Ovarian
cancer risk screening3
Cancer Risk & Screening
  • Breast
    • FTM
    • MTF
  • Cervix & Anus
  • Ovarian
  • Prostate
cancer risk screening4
Cancer Risk & Screening
  • Breast
    • FTM
    • MTF
  • Cervix & Anus
  • Ovarian
  • Prostate
  • Uterus
cancer risk screening5
Cancer Risk & Screening
  • Breast
    • FTM
    • MTF
  • Cervix & Anus
  • Ovarian
  • Prostate
  • Uterus
  • Pituitary
cancer risk screening6
Cancer Risk & Screening
  • Breast
    • FTM
    • MTF
  • Cervix & Anus
  • Ovarian
  • Prostate
  • Uterus
  • Pituitary
  • Everything else
long term outcomes1
Long Term Outcomes
  • 996 MTF and 365 FTM f/u over an average of 18.5 yrs csHT
  • Includes prior and current users of ethinylestradiol, known to be thrombogenic
  • Current use mix of EE, transdermalestradiol, IM testosterone
slide49

24 MTF15 FTM

Cross – sectional study

hiv and hrt surgery
HIV and HRT/Surgery
  • ART effects on estrogen levels
  • Renal effects of spironolactone and tenofovir
  • Unethical to deny surgery (or hormones) on the basis of HIV status
  • Do not hold treatment hostage
  • DO use treatment as an opportunity to initiate and encourage continued care
approach to coding fiscal issues
Approach to coding & fiscal issues
  • Preferred vs. legal gender/pronouns
  • Anatomical mismatches
    • Prostate in a woman
    • Cervix in a man
  • Creative coding
    • Endocrine disorder not otherwise specified
    • Obesity
    • Hyperlipidemia
    • Gonadal dysfunction
quality of life outcomes
Quality of Life Outcomes
  • Hormone therapy reduces anxiety, depression and improves social functioning
  • Surgery improves global functioning and quality of life
  • Regret rates are extremely low
  • Malpractice risk effectively non-existent
wpath and the soc s
WPATH and the SOC’s
  • World Professional Association for Transgender Health Standards of Care for the Health of Transgender, Transsexual and Gender Nonconforming People, Seventh Version
  • Released in 2011
  • Flexible, individualized approach
  • www.wpath.org
additional references
Additional References
  • Vancouver Guidelines
    • Transhealth.vch.ca
  • Very rational, complete set of guidelines
  • WPATH version 6 vs. 7, Informed Consent
  • Suggest that cross gender care belongs in a primary care setting, rather than endocrinology
additional references1
Additional References
  • Providing Care to Transgender Persons: A Clinical Approach to Primary Care, Hormones and HIV Management
    • Williamson C; J Assoc Nurs AIDS Care, 2010(21) 221-229
additional references2
Additional References
  • A Long-Term Follow-Up Study of Mortality in Transsexuals Receiving Treatment With Cross-Sex Hormones
    • Gooren LJ; Eur J Endocrinol, 2011 Apr;164(4):635-42
additional references3
Additional References
  • Care of Transsexual Persons
    • Gooren LJ, New Engl J Med 2011, (16) 1251-1257
  • Management of the Transgender Adolescent
    • Olson J, Forbes C, Belzer M, Arch PediatrAdolesc Med. 2011;165(2):171-176
slide73

www.transhealth.ucsf.edu

“Like” us on Facebook!

www.facebook.com/transhealth