Primary Care for the Transgender Patient

1. Primary Care for the Transgender Patient Cyril K. Goshima, M.D. Internal Medicine Assistant Clinical Professor of Medicine John A. Burns School of Medicine

2. Primary Care for the Transgender Patient • Basis of Talk • Definition • Barriers to Care • Standard of Care • Case Studies

3. Basis of Talk • Personal Experience • Lori Kohler, M.D. presentation to Pacific AIDS Education Training Center • “Medical Care of Transsexual Patients” Dr. Kathleen A. Oriel, M.D., Journal of the Gay & lesbian Medical Association, 2000

4. Definitions • Transsexual: refers to a person who is born with the genetic traits of one gender, but has the internalized identity of another gender • Transgender: Includes transsexuals, cross dressers, transvestites, biologically inter-sexed • Gender Identity Disorder Replaced Transsexualism in DSM-IV

5. Gender Identity Disorder Strong and persistent cross-gender identification Manifested by symptoms such as the desire to be treated as the other sex, passing as the other sex, the conviction that he or she has the typical symptoms of the other sex Persistent discomfort with his or her sex or sense of inappropriateness in their gender role

6. Gender Identity Disorder • No concurrent physical inter-sex condition • Disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning

7. Barriers to Care • Lack of Providers: provider ignorance • Lack of Clinical Research • Limited Medical Literature • Lack of Insurance Coverage for Treatments • Patient Issues: marginalized patients, social stigma

8. Standards of Care • Harry Benjamin International Gender Dysphoria Association – Published 6th Version of Standards of Care, February 2001 • www.tc.umn.edu/nlhome/m201/colem001/hbigda/ • Who was Harry Benjamin, M.D.? • Association made up of professionals from various fields of medicine

9. Readiness for Treatment • Past Puberty: 18 years of age • Demonstrate knowledge of social and medical risk and benefits of therapy • Real life experience for at least 3 months or psychotherapy for 3 months • Attempt made toward elimination of barriers to emotional well being and mental health

10. Treatments • Psychotherapy • Hormonal Therapy • Sexual Reassignment Surgery

11. Primary Care of Transgender Patients • Knowledge of standards of care • Risk and benefits of hormonal therapy • Psychosocial Support • Risk Assessment for HIV/STD • Age and gender specific health maintenance

12. Female to Male: Testosterone Therapy Reversible Changes • Cessation of menses • Increase libido, changes in sexual behavior • Increase in muscle mass • Redistribution of fat • Increase sweating, change in body odor • Weight gain, fluid redistribution • Prominence of veins, coarser skin • Acne • Mild Breast Atrophy • Emotional Changes

13. FTM: Risks of Testosterone Therapy • Changes in Lipids: Incr. HDL, Decr. TG • Insulin Resistance • Incr. Homocysteine Levels • Hepatotoxicity • Polycythemia • ? Effects on Breast, Endometrial, Ovarian Tissue • Incr. Risk of Sleep Apnea

14. FTM: Continuing Care • Legal Issues • Surgical Options: Mastectomy, Hysterectomy, Oophorectomy, Genital Reconstruction • Health Maintenance: PAP, Mammogram, Breast Exam • STD/HIV Screening • CAD risk

15. Male to Female: Estrogen Therapy • Breast Development • Redistribution of Fat • Softening of Skin • Loss of Erections • Testicular Atrophy • Decreased Upper Body Strength • Slowing or cessation of Scalp Hair Loss

16. MTF: Risk of Estrogen Therapy • Venous Thrombosis/Thromboembolism • Weight Gain • Decreased Libido • Drug to Drug Interactions • Increased BP • Decreased Glucose Tolerance • Gallbladder Disease • Benign Prolactinemia • ? Breast Cancer • Infertility

17. MTF: Spironolactone Therapy • Anti-androgen • Modest Breast Development • Softening of Facial & Body Hair • Maybe Able to Decrease Estrogen Dose • Risk: Incr. K, Decr. BP, Drug to Drug Interactions

18. MTF: Continuing Care • ASA Therapy • Topical Treatment for Hyperpigmentation • Hair Removal • STD/HIV Screening • DRE for Prostate Cancer, PSA • Breast Augmentation, Thyroid Cartilage reduction, Castration, Sexual Reassignment Surgery

19. Special ConsiderationsSFDPH Transgender Community Health Project • Employment Discrimination • Services not accessed due to fear of discrimination • Unprotected Sex Provide Sexual Validation and Increased Self Esteem • Incarceration • Increased STD • Suicide Attempts, Psychiatric Illnesses

20. Unanswered Questions • Long Term Effects of Hormonal Therapy • Benefits Outweigh the Risks • When to Adjust Hormonal Therapy and to What Levels

21. Case Studies • Case #1: DG, 56 y/o, MTF, Filipino, patient since 1983, estrogen therapy initially, none for many years, feminine appearing, employed full time as a chef, in long term relation with male, CAD on beta blocker, Lipitor

22. Case Studies • Case #2: PC, 26 y/o, MTF, Chinese/Cauc., Patient since 10/03, referred by psychologist for hormonal therapy, disheveled in T-Shirt and shorts, not feminine appearing, unemployed, never cross dressed, sex partners women, identifies as lesbian.

23. Case Studies • Case #3: EE, 30 y/o, FTM, Puerto Rican, Patient since 1999, works in hardware store, on Testosterone therapy with good masculinization with beard, mastectomy done, long term relationship with a woman.

24. Thank You Questions?