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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.
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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
Our mission is to increase access to comprehensive, effective, and affirming healthcare services for trans and gender-variant communities.
Project Inception • 18-month grant: The California Endowment • 9-member Medical Advisory Board
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 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 • Literature review & gap analysis • Draft protocol • Review meetings with Medical Advisory Board • Protocol launch April 2011 • www.transhealth.ucsf.edu
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 • 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
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
Terminology • Transition • Social • Medical • Surgical • Cisgender • “Cis” means “same” in Latin • People who are not trans are cisgender
Terminology • Lesbian transgender woman • MTF, attracted to women • Gay transgender man • FTM, attracted to men
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 • 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? • Hormones • Surgery • Chest • Genital • Facial • Other
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? 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? • Cross-Sex Hormone Therapy affects • Skin/hair/nails • Subcutaneous and facial fat • Odors • Breasts • Body fat • Genitals • Mind • Voice
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 If you have an organ, it must be screened
Case #1 • 32 y/o MTF transgender person referred by mental health for initiation of cross-sex HRT
Case #1 • Take a history • Med & SurgHx • Meds • Social history • Support system • Desires, goals, time frames • Baseline labwork • K+, Lipids, ? LFT, ? FSBG
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 #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 • 23 y/o FTM transgender person seeks initiation of cross-sex HRT
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 #2 • Clinical progress monitoring • Induction of amenorrhea • Voice, clitoral, body hair and oil changes • F/u schedule and other needs similar to MTF
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 #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 & Screening • Breast • FTM • MTF
Cancer Risk & Screening • Breast • FTM • MTF • Cervix & Anus
Cancer Risk & Screening • Breast • FTM • MTF • Cervix & Anus • Ovarian
Cancer Risk & Screening • Breast • FTM • MTF • Cervix & Anus • Ovarian • Prostate
Cancer Risk & Screening • Breast • FTM • MTF • Cervix & Anus • Ovarian • Prostate • Uterus
Cancer Risk & Screening • Breast • FTM • MTF • Cervix & Anus • Ovarian • Prostate • Uterus • Pituitary
Cancer Risk & Screening • Breast • FTM • MTF • Cervix & Anus • Ovarian • Prostate • Uterus • Pituitary • Everything else
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
24 MTF15 FTM Cross – sectional study