The Medical Care of G ender Patients

1. The Medical Care of Gender Patients Charles Moser, PhD, MD Sutter West Bay Medical Group 45 Castro, #125 San Francisco, CA 94114 415-600-4900 docx2@ix.netcom.com

2. Most of what I do is general medical care, hopefully with a bit more sensitivity Gender patients have the same medical problems as everyone else

3. You cannot discuss gender… …without insulting someone I apologize, in advance

4. Types of Gender Patients • Transsexual • Gender Dysphoria (DSM) • Transgender • Trans Man, Trans Woman • Non-Binary • Eunuch • Null, Neutrois • Gender Fluid • Agender, Genderless • Bigender, Trigender • Gender Queer • Two-Spirit • Pre-op • Post-op • Non-op • Wants Hormones • Does Not Want Hormones • Presents Full-time • Presents Part-time • Presents Differently • Presents Androgynously

5. The origin of Cis and Trans terms Not superimposable!

6. Gender Does Not Imply… • Who the person has sex with • Who the person wants to have sex with • Which sexual partner the person wants to attract • Who the person loves • Who the person lusts for • Who lusts for the person • Who the person dates • Relationship(s) the person has • Relationship(s) the person wants

7. The only things that are certain are… Death & Taxes Not your gender!

8. Bisexual vs. Pansexual More than just genitals

9. Electronic Health Records (EHRs) • All require a male/female designation • California just approved a gender neutral “X” • “Red Flag” Anti-Identity Theft Regulations • Legal Name vs. Patient Name • Health Insurance • Drivers License • Passport • Other government issued ID

10. It is easy to make errors Hello Dr. Moser, After my last appointment I went to the lab on campus to get my blood work drawn. At the laboratory I was provided paperwork that had my legal name and my dead name. I legally changed my name 10+ years ago, I have changed my name and sex with the state and federal government. On the paperwork it also listed my gender as male and female. On the labels printed for my blood were both names as well. This was a humiliating experience and feels like a HIPPA violation. The phlebotomist enquired why there were 2 names. I was forced to disclose that I was transgender. This feels inappropriate for a routine blood and urine collection. I have pictures of the documents to clarify, but I cannot send them here. Do you know how I can resolve this. The only explanation that I can find is when I was with Sutter briefly a decade or so ago and somehow they are linking my records via SSN, but this feels hugely inappropriate.

11. Gender Neutral Pronouns

12. Creating a Sex Positive Office • Do not assume, ask • Check your forms for gender pronouns and to allow for other genders, sexualities, and relationship structures • Train the staff, Sensitize the staff, Co-opt the Staff • Apologize!! • Respect the patient not being comfortable with his/her/er body • Patients with Diverse Sexualities have been abused by the medical system, you need to show that you are different

13. Creating a Gender Inclusive Office--------------------------------------------------------------------------------------------------------------

14. How Should You Refer to the Patient? • Trans? - But the patient may not be transitioning. • Transgender? – Same problem. • Transgendered – seen as offensive • Transsexual – old term (like homosexual is to gay) • Non-binary? – But many are binary and many non-gender pts are NB • Chosen Gender (male or female) • “Gender patient” • Not intersex (Disorders of Sexual Development) • It is evolving….

15. Basics of Obtaining a Sex History • Are you married (M/F), divorced, single or partnered? • Do you have sex with anyone besides your partner? • Are you and your partner fluid bonded (do not use barriers)? • Do you know about PrEP? • Do you have sex with men, women, or both? • Do you need birth control?

16. Basics of Obtaining a Sex History-2 • Probably do not need to ask about specific acts • Assume everyone does everything or will do everything • Any anal activity? • Identity is not behavior, but still important • Explain what you are doing or why you need know • If not sexually active, is that okay?

17. Review of Systems for all patients Do you have any medical questions about any of the sexual activities in which you engage or want to engage? Anything else about your gender or sexual interests that would help me take better care of you?

18. Review of Systems for Gender Patients • Any history of physical, emotional, or sexual abuse? • How old were you when you first had a sense of discomfort with your gender? • How old were you when you decided to pursue treatment? • Watch for “instant” gender patients • Any previous history of hormones? • Have you discussed your gender issues with a therapist? • Plans for children?

19. WPATH Letter of Diagnosis Other Psychiatric Diagnoses Understanding of the Risks and Benefits Commitment vs Curiosity

20. Sample Hormone Regimens MTF FTM Baseline CBC, CMP, lipid panel, ferritin, testo, +++ Testosterone cypionate 50 mg IM q7d. Can use testosterone gels low dose. Adjust according to level. • Baseline CBC, CMP, lipid panel, prolactin, testo, +++ • Estradiol 0.5 QD => 1 mg qd => 1 mg bid => 2 mg bid => 2mg tid • Spironolactone 100 mg bid, possible to increase to 200 mg bid

21. SurgeriesSex Reassignment => Gender Reassignment => Gender Confirming => Gender Affirming =>Feminizing/Masculinizing Genitoplasty => Genital Reconstructive Surgeries MTF FTM Top Surgery – Chest Phalloplasty, metoidoplasty Facial Masculinization TAHBSO, vaginectomy Penile implants Testicular implants Scrotoplasty Urethroplasty • Breast Augmentation • Vaginoplasty, Labiaplasty • Facial Feminization • Hair Removal, hairline advancement • Nullification • Tracheal Shave • Orchiectomy

22. Trans Slang • Top surgery ===============> • Bottom Surgery ===========> • Orchi ====================> • FFS or FMS (less common) ===> • Nullification ==============> • Bilateral Mastectomy • Phalloplasty/metoidoplasty or genital reconstruction • Orchidectomy • Facial feminization or masculination • Removal of genitalia and secondary sex characteristics

23. Many clinicians forget the patient is Trans Everyone needs to know… which organs are present and which are absent Update the Surgical History!

24. Specific Goals of Treatment MTF FTM Create a second adolescence Sex Characteristics Grow beard, body hair Voice change Change in skin texture Clitoromegaly Adjust to male sex role Adjust to increase libido • Create a second adolescence • Sex Characteristics • Grow Breasts • Remove body hair • Grow scalp hair • Change in skin texture • Adjust to female sex role • Telling partners

25. Medical Diagnoses • Gender dysphoria F64.0 • Other specified gender dysphoria F64.8 • Other gender identity disorders F64.9 • Gender identity disorder, unspecified F64.9 • Polyglandular Dysfunction E31.9 • FTM/MTF on hormones Z79.895 • Endocrine Disorder in transsexual E34.9 • Gender identity non-binary Z78.9 • Code to identify sex reassignment status Z87.890

26. What is Long Term? • Years? • Age? • 40 years starting at 18 • 20 years starting at 58 • High Dose vs. Low Dose • Maintenance of changes • Indications to wean or stop

27. Long Term Hormonal Therapy • As we age, hormone levels decrease or are absent, naturally • Long term hormonal treatment can have negative effects • As we age, we take more medications => more drug-drug interactions • As we age, kidney and liver function decreases • What used to be a good dose is not • As we age everything wears out and our reserves are lower

28. Hormones can… • Induce enzymes to break down the exogenous hormone • Inhibit other hormones – Everything is connected • Induce other changes in metabolism • Weight gain • Unusual growth • Joint pains

29. Cis Individuals • If you live long enough you will not produce sex hormones • Slow reduction over years • HRT is out of favor at present • Most cis individuals are okay with that, • Many trans individuals are not

30. Concerns about Estrogen Use • DVT/PE • CVA • MI? • Breast CA? • Pancreatitis • Migraine • Fluid Retention • Hyperlipidemia • Weight gain • Elevated BP • Mood changes • Glucose intolerance • Prolactinoma • Endometrial hyperplasia if uterus is present

31. Benefits of Estrogen Use • Decreased Vaginal or Neovaginal Atrophy • Increased Libido • Treat Hot Flashes • Prevent Osteoporosis • Possible decrease in heart disease • Decreased Alzheimer’s and/or Cognitive Decline • Decreased Depression

32. Concerns about Testosterone Use • PE • MI • CVA • Polycythemia • Peliosishepatis • Dependency, abuse • Nausea • Edema • PCOS? • Headache • Seborrhea • Male Pattern Baldness • Libido changes • Hyperlipidemia • Gynecomastia • Liver Function Test increases • OSA • Bacterial Vaginosis

33. Benefits of Testosterone Use • Preserved libido • Less depression? • Increased strength, vitality • Increased muscle mass?

34. All Patients • Treat other medical problems • Health Care Maintenance – men/women • Watch for sexual dysfunction • Watch for psychiatric issues (depression, isolation, etc.) • Mammograms/Pap Smears/PCOS • When to stop hormones

35. Controversies - MTF • Use/Need for Progesterone • Mammograms, Prostate CA • Injectable vs. Oral vs. Transdermal • When to stop hormones • HCM for men/women – • Vaccinate HPV, Hep A, Hep B, Meningitis, MMR, Discuss PrEP

36. Controversies -FTM • Breast CA screening • Need for Hysterectomy or PAP • Detecting Ovarian CA • Need for Birth Control • HCM for men/women – • Vaccinate HPV, Hep A, Hep B, Meningitis, MMR, Discuss PrEP

37. Normals, HCM, PrEP by Gender • PrEP – Effective after one week in men, 3 weeks in women • Cardiac Risk • Testosterone Poisoning • Averaging the risk? Pick the best? Pick the worst?

38. My goal is for… all patients to grow old as a little old ladies/gents Safety first!

39. And for those of you who think you can always “read” a Trans Person…

42. The First Playboy Transgender Playmate Ines Rau

43. Things are not always what they seem to be

44. We can misconstrue the details

45. Hope This Helped Further Questions to: Charles Moser, PhD, MD Sutter West Bay Medical Group 45 Castro Street, #125 San Francisco, CA 94114 415-600-4900 moserc@sutterhealth.org