Gender-Affirming Healthcare Essentials: Hormones, Guidelines & Care

1. Transcare: Hormones and a Whole Lot Morethe basics of gender affirming healthcare • Lindsey Piper, WHNP • lindsey@mabelwadsworth.org • Sara Hayes, FNP • shayes@mainefamilyplanning.org

2. Who we are and why we do this

3. Confessions • We have no exciting financial disclosures to make. • A lot of this med stuff is off label • We really, really like doing transgender health care. • We really, really, really hope you will consider offering starting to offer transgender services

4. This presentation is for providers who want to provide hormone treatment for transgender people and just as important… • For those providers who are likely to have transgender patients in their practices, even if you don’t ever prescribe a single hormone for them.

5. About our audience…..

6. Trans 101….

8. Etiology of gender • Research into genetics, brain anatomy and function, hormonal influences, but, the fact is, we just don’t know.

9. Transgender • refers to a person who is born with the genetic traits of one gender but has the internalized identity of another gender • The goal of treatment for transgender people is to improve their quality of life by facilitating their transition to a physical state that more closely represents their sense of themselves.

10. Cisgender • TheOxford English Dictionary describes the word "cisgender" as an adjective and defines it as "Denoting or relating to a person whose self-identity conforms with the gender that corresponds to their biological sex; not transgender." 

11. DSM-V Diagnostic and Statistical Manual of Mental Disorders • December 2012, American Psychiatric Association formally announces that the diagnosis “Gender Identity Disorder” will be dropped and replaced with diagnosis “Gender Dysphoria”

12. Gender Dysphoria • The discomfort or distress that can be caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and secondary sex characteristics) Coleman, SOC, V 7 p168 • The focus of health care engagement is alleviating the distress.

14. Prevalence Estimates • Data from the Netherlands • 1 in 11,900 males • 1 in 30,400 females • Some researchers challenge these estimates and estimate that the prevalence is closer to 1/500 • Williams Institute (UCLA) estimates 0.3% of adult US population is transgender

15. US numbers • The Williams Institute, UCLA School of Law 2011

16. Maine LGBT #s estimated according to 2011 data

17. Transman F-M trans masculine • born female, transition to male • Transwoman M-F transfeminine • born male, transition to female • Gender Queer • Non binary • .

18. Providing HRT to trans folks …..

19. They are just hormones….

22. Who & how???

23. WPATH • “The medical provider who provides hormonal therapy need not be an endocrinologist but should become well-versed in the relevant medical and psychological aspects of treating persons with gender identity disorders”

24. Guidelines for care…. (not rules) • Check with Dr. Google • UCSF Center for Excellence for Transgender Health • Fenway Health • Mazzoni Center • There are lots of people who share their protocols and EVEN MORE WAYS OF DOING THINGS!

25. WPATH • The World Professional Association for Transgender Health, Inc., formerly the Harry Benjamin International Gender Dysphoria Association, Inc., is a professional organization devoted to the understanding and treatment of gender dysphoria. • WIKIPEDIA

26. WPATH SOC 2011 • This is the seventh version of the Standards of Care. The original SOC were published in 1979. Previous revisions occurred in 1980, 1981, 1990, 1998 and 2001. • “The previous versions of the SOC were always perceived to be about the things that a trans person must do to satisfy clinicians, this version is much more clearly about every aspect of what clinicians ought to do in order to properly serve their clients. That is a truly radical reversal . . . one that serves both parties very well.” • Christine Burns, SOC International Advisory Committee Member.

27. September 2011 WPATH Standards of Care • The criteria for hormone therapy are as follows: • Persistent, well-documented gender dysphoria; • Capacity to make a fully informed decision and to consent for treatment;

28. September 2011 WPATH Standards of Care • Age of majority in a given country (if younger, follow the Standards of Care outlined in section VI); • If significant medical or mental health concerns are present, they must be reasonably well controlled.

29. Standard vs. Informed Consent Model (WPATH SOC7) • Informed Consent Model • Standard • Initiation of hormone Rx after psychosocial assessment by “qualified mental health professional” • Psychotherapy not required • Experienced hormone prescribing medical provider may meet requirement • Rx initiated by prescribing provider based on: • Clinical judgment • Lack of contraindications • Pt. capacity to give informed consent • Informed consent

30. Requires healthcare provider to effectively communicate benefits, risks and alternatives of treatment to patient Requires healthcare provider to judge that the patient is able to understand and consent to the treatment Informed consent model does not preclude mental health care Recognizes that prescribing decision ultimately rests with clinical judgment of provider Informed consent is not equivalent to treatment on demand Informed Consent Model (Deutsch, 2012)

31. But before you prescribe a single estrogen pill or testosterone shot… • Do your homework…

32. Staff training and buy-in • Cultural competency • Maine Transnet training • Fenway • Providing Inclusive Services and Care for LGBT People: A Guide for Health Care Staff • https://www.lgbthealtheducation.org/publication/learning-guide/

33. Health history/intake for all patients • What is your gender? • Female Male •  M-F F-M • Genderqueer or not exclusively male or female • What gender were you assigned at birth? •  Female •  Male

34. Health history/intake for all patients • By what name do you like to be called? • What pronouns do you prefer? • Male • Female • Other • These should be determined before you see them.

35. Names and prounounsMATTER BIGTIME!!!!

36. Create and follow a protocol for noting preferred names, pronouns, mail, voice message instructions • EMR, friend or foe.

37. Before the first appt • Call center staff • Note in EMR, preferred name • MFP: info and admin packets • mainefamilyplanning.org/our-services/lgbtq-healthcare/

38. Meeting the transgender patient • Respect • Treat every patient as you would want to be treated • Deconstruct barriers to care – limit work for the patient in terms of # of appts, meetings, etc if not necessary • à Transgender pts often have a significant amt of knowledge about transitioning • Providing good medical care  -  pt does not need to jump through hoops, but appropriate medical care is #1 priority

39. Meeting the Transgender Patient • Meeting the patient where they are … gender expression, identity, readiness to come out, comfort with health care • Understanding previous experiences • Understanding pt’s supports and needs (family not accepting, homeless, financial issues, comes from far away, etc) • Share records with PCP? • Glma.org

40. Meeting the transgender patient • What questions are appropriate and necessary to this visit (establishing care vs physical vs urgent care visit) • How do you like to be addressed • Who are you having sex with?  Men, women, trans men, trans women • Have you been on medications in the past • Have you had any surgical modifications to your body  • Who are your supports

41. Initial Visits (40 minute) • Assess readiness for gender transition • Obtain history • Review risks and benefits of hormone therapy • Obtain informed consent ( review/not read to pt) • Order screening laboratory studies • Provide referrals – support groups

42. Initial Visit History • Review history of gender experience • Document prior hormone use • Obtain sexual history • Review patient goals • Address safety concerns • Expectations for transitioning…”look”

43. Initial Visit History • Assess social support system • Psychosocial hx • Mental health issues • Substance use/abuse • Trauma history ( may need much slower transitioning)

44. --------------------- History of Transgender Experience • Pronoun preference • Age when identified gender issues • Expectations for transitioning • Experience dressing/living as preferred gender • Legal name change done? • Legally changed "sex"?

47. --------------------- Documentation re hormone use • Past trans hormone rx? problems with it? • Need more info on hormones? • Hx sexual reassignment surgery? problems? • Need info on SRS? • Hx silicone injections?

48. --------------------- Social Support System • --------TRANS RELATED SUPPORT/COUNSELING • Supporters • Non supporters • Currently in a relationship/dating?......

49. --------------------- Patient goals • What kind of a “look” are you going for? • want to “blend in” • Want to keep hair • Don’t care about beard • Want to look more “butch” • androgenous Surgery goals?

50. --------------------- Patient Goals • -----------------FUTURE CHILDBEARING • Desire to have biological kids in future? • If yes, need to have a discussion about sperm/egg banking • Expensive, not covered by insurance • If they wait, there is no guarantee that they will be able to impregnate/conceive. • ? Delay transition til pregnancy achieved • Boston IVF