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Transgender Health Issues: What Physicians Need to Know

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

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  1. Transgender Health Issues: What Physicians Need to Know Featuring UCSF’s Protocols

  2. Introduction Jamison Green, PhD Manager, Primary Care Protocols UCSF Center of Excellence for Transgender Health

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

  4. Health Disparities

  5. Project Inception • 18-month grant: The California Endowment • 9-member Medical Advisory Board

  6. 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

  7. 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

  8. Project Plan • Literature review & gap analysis • Draft protocol • Review meetings with Medical Advisory Board • Protocol launch April 2011 • www.transhealth.ucsf.edu

  9. 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

  10. 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

  11. 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

  12. Terminology • Transition • Social • Medical • Surgical • Cisgender • “Cis” means “same” in Latin • People who are not trans are cisgender

  13. Terminology • Lesbian transgender woman • MTF, attracted to women • Gay transgender man • FTM, attracted to men

  14. 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

  15. 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

  16. What Do Transgender People Want from a Medical Provider? • Hormones • Surgery • Chest • Genital • Facial • Other

  17. 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

  18. 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

  19. What Can Hormones Do? • Cross-Sex Hormone Therapy affects • Skin/hair/nails • Subcutaneous and facial fat • Odors • Breasts • Body fat • Genitals • Mind • Voice

  20. Primary Care ?

  21. Primary Care • Blood pressure • Cholesterol, weight, diabetes • Cancer screening • Bone health • Nutrition • Depression, mental health • HIV, STIs, Hepatitis • Substance abuse • Domestic violence • Silicone

  22. Preventive Screening If you have an organ, it must be screened

  23. Case #1 • 32 y/o MTF transgender person referred by mental health for initiation of cross-sex HRT

  24. Case #1 • Take a history • Med & SurgHx • Meds • Social history • Support system • Desires, goals, time frames • Baseline labwork • K+, Lipids, ? LFT, ? FSBG

  25. 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

  26. 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)

  27. Case #2 • 23 y/o FTM transgender person seeks initiation of cross-sex HRT

  28. Case #2 • Testosterone • Intramuscular / Subcutaneous 50-100mg/wk • Transdermal 5-10mg/day • Topical 2.5-10g/day • “Side effects” – acne, dyslipidemias • Mood, diet, lifestyle

  29. Case #2 • Clinical progress monitoring • Induction of amenorrhea • Voice, clitoral, body hair and oil changes • F/u schedule and other needs similar to MTF

  30. 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?

  31. 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

  32. Cancer Risk & Screening • Breast • FTM • MTF

  33. Cancer Risk & Screening • Breast • FTM • MTF • Cervix & Anus

  34. Cancer Risk & Screening • Breast • FTM • MTF • Cervix & Anus • Ovarian

  35. Cancer Risk & Screening • Breast • FTM • MTF • Cervix & Anus • Ovarian • Prostate

  36. Cancer Risk & Screening • Breast • FTM • MTF • Cervix & Anus • Ovarian • Prostate • Uterus

  37. Cancer Risk & Screening • Breast • FTM • MTF • Cervix & Anus • Ovarian • Prostate • Uterus • Pituitary

  38. Cancer Risk & Screening • Breast • FTM • MTF • Cervix & Anus • Ovarian • Prostate • Uterus • Pituitary • Everything else

  39. Long Term Outcomes ?

  40. “See… I told you those small planes are unsafe”

  41. 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

  42. Cardiovascular Risk – Retrospective Cohort

  43. BMI

  44. Post-HRT Characteristics - MTF

  45. Post-HRT Characteristics - FTM

  46. 24 MTF15 FTM Cross – sectional study

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