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SF DPH SO/GI Initiative

SF DPH SO/GI Initiative. Nicole Rosendale, MD Assistant clinical professor of neurology, UCSF/ZSFG Sf dph so/ gi steering committee member 10/24/2018. Objectives. Define sexual orientation (SO) and gender identity (GI) terminology

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SF DPH SO/GI Initiative

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  1. SF DPH SO/GI Initiative Nicole Rosendale, MD Assistant clinical professor of neurology, UCSF/ZSFG Sf dph so/gi steering committee member 10/24/2018

  2. Objectives • Define sexual orientation (SO) and gender identity (GI) terminology • Recognize the impact of SO/GI on health and health disparities • Explain the value of SO/GI data collection efforts

  3. Gender Identity The way a person describes their own internal sense of gender GENDER SPECTRUM Woman Cisgender woman Transgender woman Transfeminine Man Cisgender man Transgender man Transmasculine Genderqueer Gender non-binary Gender fluid Androgynous Agender

  4. Sexual Orientation The way a person describes their own emotional/romantic/sexual attraction to others SEXUAL ORIENTATION SPECTRUM Gay Lesbian Homosexual Same-gender loving Straight Heterosexual Bisexual Questioning Pansexual Queer Asexual

  5. Dimensions of sexuality

  6. Why does SO/GI matter? • Provider-patient rapport improves compliance • Allows for proper screening, formulation of differentials, and creation of culturally appropriate treatment plans • Allows providers to understand the psychosocial stressorscontributing to or exacerbating a patient’s medical condition

  7. Understanding the whole person Presents to clinic intoxicated Drinks heavily Standard medical history & default provider interpretation Discriminated against by employers -> unemployed Relies on sex work to survive -> was raped Faces discrimination at clinics, unable to access gender affirming care Identity papers do not reflect gender identity Reuses syringes to inject hormones Harassed and beaten at school Rejected by family Genderqueer child in conservative family Moves to San Francisco

  8. Why does SO/GI matter? • Allows us to identify ongoing or emerging health disparities • Allows for advocacy around systems–based improvements SO/GI Data

  9. LGBTQ+ Disparities LGBTQ+ people of color experience disproportionate health impacts due to layering vulnerability of discrimination on multiple levels

  10. LGBT Identity in SF and SFHN

  11. Systems Changes

  12. Patient Form

  13. Questions?

  14. Gender Affirming Care Layla Welborn, FNP | Dimensions Clinic for Queer & Trans Youth SFDPH Quarterly Provider Meeting 10.24.18 An intro to working with transgender patients

  15. Core Elements in Gender Affirming Care • Welcoming space & attitude • Access to medically necessary treatment for those who need it • Hormone therapy • Surgery & procedure referral • Appropriate & respectful preventive screening & health care maintenance

  16. Julia • 23yo transgender woman, self describes as “AMAB transfem” & is attracted to gay men • legal name Jose • presents male w/ beard • prefers female pronouns • Last medical visit 5yrs ago in LA • CC: wants to start hormones

  17. Trans is... Everywhere!

  18. Language matters. A lot. They/Them He/him She/Her

  19. Relax into evolving language & identities—it’s awesome! ~ Transgender ~ Trans ~ Non-binary ~ Gender non-conforming (GNC) ~ Genderqueer ~ Gender creative~ Transwoman ~ transfeminine ~ Male to female (MTF) ~ Transman ~ transmasculine ~ Female to male (FTM) ~ Boi ~ El/La ~Two-spirit ~ AFAB / AMAB (Assigned Female or Male at Birth) ~ Cisgendered~ Agender ~ Asexual “Ace”

  20. Your gender doesn’t live in your genitals! • Sex assigned at birth • Gender identity • Gender expression • Sexuality/sexual orientation Independent categories; one does not determine another

  21. Social + Medical Barriers = Health Disparities • Access to quality medical care is a key issue raised by transgender community Institute of Medicine, 2011 • Lack of adequate care across the U.S. is well-documented Alegria, 2011; Bradford, Reisner, Honnold & Xavier, 2012; Sanchez et al., 2009 • 50% of trans people report having to teach their providers about their basic health care needs; 25% delayed care b’c of disrespect & discrimination from medical providers Transgender Discrimination Survey, Oct 2010 • Health disparities are significant in the trans community Nat’l Center for Transgender Equality & National Gay and Lesbian Task Force, 2011

  22. Improving Access • National: ACAHealth care providers who receive federal funding cannot deny services based on a person’s gender identity. (Nondiscrimination in Health Programs and Activities rule, ACA Section 1557) • State: CA law protects against “transgender exclusion” by public insurance (Cal. Health and Safety Code Section 1365.5(a) ) • Local: Gender Health SF & SFHP

  23. Healthcare makes a difference • Rates of suicide attempt decrease w/ HRT • 80% improved gender dysphoria (= to controls) • 70% improved psych sx (= gen pop) • 80% improved QOLthosetx’d at younger ages had even better outcomes Meta-analysis, 1966-2008 by Murad, et al, 2011

  24. Gender Affirming Medical Interventions • Aim: to alleviate Gender Dysphoria • Hormone therapy • Gender Affirming Surgeries

  25. Hormone therapy is: • Medically necessary. American Medical Association, 2008 • Reasonably safe. Asscheman et al., 2011; Colizzi, et al, 2013; Elamin, et al., 2009; Gómez-Gil et al., 2012; Gorin-Lazard et al., 2012; Murad et al., 2010; Ott et al., 2011; Wierckx et al., 2013 • Effective in alleviating gender dysphoria. Murad et al., 2010 • Associated with improved quality of life & nearly universally positive psychosocial outcomes from a patient perspective. Murad et al., 2010

  26. Hormone therapy can be Rx’d: • In Primary Care—this is optimal • Using Informed Consent –this model now widely accepted • Without a mental health evaluation WPATH, 2011

  27. Indispensible Guidelines & Resources: • SFDPH Gender Health SF (GHSF): https://www.sfdph.org/dph/comupg/oprograms/THS • UCSF Center of Excellence for Transgender Health: http://transhealth.ucsf.edu/

  28. Julia • What do we need to know before starting hormone therapy?

  29. S: Learn person’s story & goals • Routine PMH, FH • PSH: special emphasis on family, community supports, relationships with other trans people • Sexual hx: use gender neutral language, what kinds of body parts/genitals do the people you have sex with have? • Gender history: • Can you tell me about how you decided to start hormones? • What do you know about the effects of hormones? • What kinds of changes do you hope to see? • What is most important to you? anything you are worried about? • Fertility goals Keep it open ended; allow pt to describe self & experiences in own terms; experiences & goals vary widely

  30. Things to avoid • questions for your own curiosity • commenting on your impression of person’s gender expression or their body • taking a “prove it” tone • assuming a sexual preference based on gender identity • assuming family/community support or lack of support—particularly based on ethnicity/nationality

  31. S: Learning Julia’s story cont. • “As a kid, I remember seeing pictures of a transvestite and saying to my dad, ‘Papi, that’s me.’ You know he was this big, tattooed gang member…He just said ‘Ok, hijo, I support you.’” • Delayed transition d/t family stress 2/2 deportation of some family members to Mexico & recent family homelessness, dropped out of college to help support them. Now stable & feels ready for hormones. • Goals: “to pass as a girl” “avoid FFS” “have a lot of dysphoria about my hips & legs, so want more fat there, & also breasts” Neutral about erections.

  32. O: Physical Exam • Early visits: Avoid invasive PE, genital & chest exams are not needed to start hormones • Later: If the person has the organ, then screen at the usual intervals • In general: Build some rapport before going there

  33. A: Diagnostic codes • Male to Female Transgender Person, ICD 10 F64.1 • Gender Dysphoria, ICD 10 F64.9 • AVOID outdated “GID” dx • “Transgender woman, has not socially transitioned d/t difficulty ‘passing’ as female, ready to start hormones, desires max feminization, declines cryopreservation, may consider adoption in future, neutral re erections, realistic goals”

  34. ~ breast growth ~ redistribution of body fat • ~ skin softening ~ shrinkage of testes • ~ decreased muscle mass & libido (vs change) • ~ decreased spontaneous erections • ~ stops male pattern baldness (no regrowth) • ~ possible infertility ~ mood changes Feminizing Hormone Tx: Anti-androgen + Estrogen

  35. Estrogencounseling on risks: Clinically significant (WPATH, 2011): • Venous thromboembolicdz (^ w/ PO estradiol) (likely ^risk) • Hypertryglyceridemia (likely), CVD (likely w/ other risk factors), HTN (possible), DMII (possible w/ other risk factors)

  36. Take-aways: • Assess for, counsel on & manage other risk factors for thromboembolicdz, esp smoking • DO NOT use ethinylestradiol • Select route of hormone administration based on risk, eg avoid PO in higher risk pts • Use opportunity to discuss healthy lifestyle • Manage any emerging conditions as you would any other patient • Remember: informed consent, risk of not treating

  37. P: Starting Julia on feminizing hormone therapy • Counsel benefits, risks, unknowns hormone tx—use GHSF Pt Ed/consent forms fantastic guide! • Check baseline labs: electrolytes & o/w screening labs per guidelines for all pts • F/U: 1-2 wks for anticipated HRT start

  38. Selecting route, dosing • PO/SL, IM, patch: Avoid PO in smokers, best fit for pt lifestyle/preferences • Starting dose: • estradiol 1mg PO BID OR • estradiol 20mg IM q2wks • + spiro 25-50mg BID

  39. Monitoring feminizing hormone tx • 6 wks: monitoring; 3mo: labs, including hormone levels • Balance pt reported alleviation of gender dysphoria & body/mood changes w/ physiologic parameters • Suppressed spontaneous erections • Lab monitoring: use physiologic female ranges that correspond w/ gender identity (not sex assigned at birth): • Estradiol: upper limit 433 • Testosterone: 14-76

  40. Mack • 21yo self-described Black male • legal name Macy • returning to care after 3 years d/t insurance prob • prev on T x~6mo in 2013 • wants to restart T

  41. S: learning Mack’s story • Works in landscaping & doing in-home care for an uncle, lives w/ mom, saving money to go to performing arts school for dance • Prefers He/Him pronouns; “just always felt like a dude” family “doesn’t know about trans stuff, they see me as a lesbian.” No plans to discuss as comfortable w/ this. • Goals: deep voice, grow more muscles, stop periods “as fast as possible.” • Interested in egg cryopreservation for future partner pregnancy but unwilling to delay T & unable to afford.

  42. Masculinizing Hormone Tx: Testosterone • deepened voice • clitoral enlargement • growth in facial and body hair • cessation of menses • atrophy of breast tissue • decreased % of body fat compared to muscle mass • Also: change in fat distribution, increased energy, libido • CANNOT BE USED AS BCM

  43. Testosteronecounseling on risks: Clinically significant risks: • Polycythemia (likely ^risk) • HLD (possible) • Psych. Destabilization, CVD, HTN, DMII (possible w/ additional risk factors) NOT clinically significant risk: wt gain, acne, sleep apnea, balding, elevated liver enzymes

  44. O: NAD, VSS, Cor RRR, Lungs CTABA: Female to Male Transgender Person, F64.1; Gender Dysphoria, F64.9 • “Transgender man, previously on T age 18 w/ good relief dysphoria, ready to restart, priorities: stop periods, ^muscle mass, interested in cryopreservation eggs but unable to afford”

  45. P: Re-start Mack on masculinizing hormone tx • Counsel benefits, risks, unknowns of tx; provided copy GHSF masculinizing hormone tx pt edu handout • Check baseline labs: CBC hemogram • F/U: 1-2 wks for anticipated HRT start

  46. Selecting route, dosing • Injectable: IM vs. SubQ • Start: 50-100mg Q2wks vs. 25-50mg weekly • Typical: 200mg Q2wks vs. 100mg weekly • Topical: • Androderm patch: start 4mg daily • Gel: start 25mg daily, typical 50mg daily

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