Evidence Based Care of the Transgender Person
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Evidence Based Care of Transgender Patients discusses guidelines for the evidence-based care of transgender patients. It introduces key terminology used in transgender care and outlines recommendations for preventative care, hormonal therapy, and surgical options based on levels of evidence. Hormone therapy is recommended for treatment of gender dysphoria, with protocols outlining initiation and monitoring of hormone therapy for both MTF and FTM patients. Screening and preventative care recommendations are also provided based on a patient's anatomy and hormone use.
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Evidence Based Care of the Transgender Person
- 1. Evidence Based Care of Transgender Patients
- 3. Evidence Based Medicine Meta Analysis Systematic Review Randomized Controlled Trial Cohort Study Case Study Expert Opinion
- 4. Strength of Recommendation Taxonomy (SORT) • Disease vs. Patient-Oriented Outcomes – Surrogate results (BP, Glucose, etc) – Vs. quality measures that help patients live longer or better lives (Sx improvement, improved QOL) • Level of Evidence – Validity of a study base on assessment of design • Strength of Recommendation – Recommendation for clinical practice based on body of evidence (usually more than one study) Mark Ebell, et al. Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approach to grading evidence in the Medical Literature. Am Fam Physician (Feb 1 2004): 69; 3, 548-556.
- 5. Strength of Recommendation • A – Recommendation base don consistent and good- quality patient-oriented evidence • B – Recommendation based on inconsistent or limited quality patient-oriented evidence • C – Recommendation based on consensus, usual practice, opinion, disease-oriented evidence, or case series Mark Ebell, et al. Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approach to grading evidence in the Medical Literature. Am Fam Physician (Feb 1 2004): 69; 3, 548-556.
- 6. Goals • Introduction – Terminology, Pronouns – Gender vs. Sexual Orientation • Transgender Care & Scope of Family Medicine – Evidence Based Preventative Care – Evidence Based Hormonal Therapy • Evidence Based LGBTQ+ Mental Health – Culturally Competent approach to substance abuse – Suicide and Self Harm Risk
- 7. Goals: Healthy People • Harm reduction – Preventative care – Mental health – Substance abuse reduction • QOL maximization – Safe space – Hormone therapy – Patient-centered care Healthypeople.gov/2020/topicsobjectives2020/overview
- 8. Gender vs. Sexual Orientation Both are spectrums • Gender Identity: one’s sense of self as male, female or third sex • Gender Presentation: the expression of gender • Genderqueer: one who defies typical binary gender roles and lives outside expected gender norms • Transgender: literally “across gender” or “beyond gender” • Transition: period of time when a transgender person is learning how to cross-live socially as a member of the gender category opposite their birth sex/natal gender • Sexual Orientation: sexual attraction to males/females/transgender individuals, both, or none Itspronouncedmetrosexual.org; also at www.transhealth.ucsf.edu
- 11. Pronouns Matter • Intro to Gender Neutral/Gender Variant Pronouns – Ze-She-He – Per-Him-Her – Mx-Mr-Ms-Mrs – Hersband-Husband • More can be found at itspronouncedmetrosexual.com itspronouncedmetrosexual.com
- 12. We don’t live in a binary gender society anymore
- 13. Adolescents: Estimating GLBTQ+ Population • 2011 Youth Risk Behavior Survey (YRBS) • San Francisco School District middle schools • 35,000 respondents aged 12-17 – 12.1% reported being “unsure” – 3.8% middle school students identified themselves as LGBT – 1.3% identified as transgender • Growing body of data shows disproportionately high rates of harassment, bullying & violence aimed at LGBT Youth John Shields, et al. Estimating Population Size and Demographic Characteristics of LGBT Youth in Middle School. Journal of Adolescent Health 52 (2013) 248-250.
- 14. Practice Recommendation: • ASK! – About gender identification – About sexual orientation – About bullying/violence (from peers OR family) – Teach that they are different – Allow as safe space for questioning (SOR C) Point toward resources (ex: Odyssey Youth Ctr, GSA in each high school in Spokane)
- 15. When does gender change? • It’s a spectrum: – Lifestyle/Social – Hormone – Legal – Surgical • Some patients want all of the above • Some want some of the above changes but not all- and it’s all ok. • Genderqueer patients may not desire any hormone therapy or may desire fluctuating hormone therapy
- 16. Things to Remember • A transgender patient’s body may have elements, traits, or characteristics that do not conform to the patient’s gender identity. • For trans people, their anatomy does not define them. • Do not define the person by their sex assigned at birth • Provide usual prevention and screening for the anatomy that is present, regardless of their gender identification (SOR C) Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 17. How will I change my practice? • Honor the patient’s gender identity and use the terminology the patient prefers • New patient forms • EMR capability of “other” for gender • Unisex bathrooms • Letters to patients with desired pronouns • All are recommendations from the Joint Commission (SOR C) The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community: A Field Guide.
- 20. Primary Care Protocols Project • Goal: Provide accurate, peer-reviewed medical guidance for care of transgender pt • Why? IOM Report 2011 “The Health of LGBT People” – High levels of joblessness and poverty – Lack of health insurance – Both private and public health care plans severely limit transgender access to surgery Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 21. Assessing Readiness for Hormones • Only absolute contraindication to hormone therapy is estrogen- or testosterone- sensitive cancer • Informed consent is key. – Patient-centered outcomes vs. disease-centered outcomes – Obesity, CV disease, dyslipidemia, hepatitis, HIV are all conditions that should not preclude treatment insetting of informed consent (SOR C) Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 22. Initiating Hormone Therapy • Baseline Labs: – MTF: • Estrogen: fasting lipids • Spironolactone: K+ and Cr • *remember that Cr clearance is based on muscle mass • The standard of testing LFTs is based on older studies with methodological flaws, using formulations which are no longer prescribed (ethinyl estradiol), and NOT controlling for alcohol and Hepatitis B/C – Follow up labs: • K if changing dose of spironolactone, then annual • Only check testosterone if not virilizing or stopping menses after 6 mo • No need to check estrogen levels • Prolactin screening once at 1-2 years after starting hormones – Other labs testing based on specific PMH, FHx, age and sexual or substance abuse risk factors Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 23. Initiating Hormone Therapy • Baseline Labs: – FTM: • Hemoglobin • LDL, HDL • Use Male reference values for testosterone (SOR A) –Follow up labs if on hormones: •Testosterone level after 6 months on stable regimen or if experiencing anxiety/aggression side effects –Hg/Hct Q6-12 mo (use male reference range) Other labs testing based on specific PMH, FHx, age and sexual or substance abuse risk factors Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 24. Hormone Administration • Goal: induce or maintain the physical and psychological characteristics of the sex that matches the patient’s gender identity • Cross-sex hormone administration is currently an off-label use of both estrogens and androgens • Is recommended for treatment of gender dysphoria • ICD-9: “Hormone imbalance in transgender individual” • Most medical problems that arise in transgender patients are NOT secondary to hormone use. • Discuss Fertility with ALL patients considering hormone therapy. (SOR C) Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 25. Hormone Administration • MTF – Estrogen • SL, TD, Injectable are preferable to Oral due to avoiding first pass liver metabolism (SOR B) • Dosing: – SL: 1-4mg estradiol a day – TD: 100-200 mcg estradiol a day – IM/SC: 10-20 mg estradiol valerate Q1-2 weeks » max 2 years (SOR C) – Over 35 yo/Smokers: risk of thromboembolic dz (SOR B) – After gonadectomy: cut pre-surgical dose in half then titrate to effect (SOR C) Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 26. Hormone Administration • MTF – Anti-Androgen • Spironolactone – Starting dose 100mg daily – May titrate up by 50mg a week to max of 400mg daily – Advise taking all at once in am over divided dosing to avoid diuretic effect interrupting sleep – Check K when starting and when titrating then Q6 mo (SOR C) • Finesteride – Adjunct for significant unwanted male pattern baldness – 1-5mg daily (SOR C) Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 27. Hormone Administration • MTF – Progesterone risks not well studied, benefits not well-characterized. • Nipple areola and libido benefits • 5-10 mg oral medroxyprogesterone daily • Depo-Provera 150mg IM Q3 mo for 2-3 years • Risk of weight gain and depression • Women’s Health Initiative: Oral Medroxyprogesterone increases CV disease, whereas IM may minimize additional risk (SOR B, C respectively) Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 28. Adjunct non-hormone therapy • MTF: – EMLA/lidocaine and oral analgesics prior to hair removal procedures – Viagra/Cialis for sexual dysfunction • Both: – Voice/Speech Therapy – Surgical referral if desired Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 29. Hormone Administration • FTM – Testosterone recommended, in any form • IM/TD patch/TD Gel/SC Depo Implant (SOR B) • Gel preferred for patient with polycythemia SE • Starting dose: – 50-200mg IM Q 2 weeks; alt: 100mg IM Q Week – Dosing can be changed Q7-10 days – Max dose 250mg Q2 weeks, as excess testosterone converts to estrogen (SOR C) – Avoiding excessive peaks and troughs ideal for avoiding emotional reaction, esp in pt with PTSD – Testosterone should not be withheld for hyperlipidemia (SOR C) Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 30. Hormone Administration IM injection testosterone allergy warnings: • Testosterone cypionate: suspended in cottonseed oil • Testosterone enanthate: suspended in sesame oil • Sustanon (Europe/Canada) suspended in peanut oil
- 31. Hormone Administration • FTM – Typically only 50mg testosterone needed to stop monthly periods, rarely can use a progestin (SOR C). • Anticipate it taking 2-3 months – For male pattern baldness: finasteride or mioxidil (but finasteride will decrease masculinization effects esp. clitoromegaly) – For undesired significantly increased libido: low dose SSRIs – For greater clitoromegaly: topical testosterone on clitoris (subtract that amount from total dose) Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 32. Hormone Administration • FTM – Testosterone is not a contraceptive. FTM patients having unprotected sex with fertile non-trans males are at risk for pregnancy if they have patent tubes and a uterus. – Some may desire pregnancy – Options: • Mirena IUD (progesterone effect is local not systemic) • Endometrial ablation • Hysterectomy – AVOID: Nexplanon, OCPs, TD Estrogen patch, etc. – In non-mensturating FTM, try NOT to use vaginal estrogen Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 33. Long-term side effects of cros-sex hormones • Single center cross-sectional study • N= 100 transgender patients – post-sex reassignment surgery – Average 10 yr hormone therapy • Outcomes: – FTM did not experience an increase in CV events, hormone-related cancers, or osteoporosis – 25% of MTF experienced a thromboembolic event – 6% of MTF experienced other CV SE after avg 11.3yr – Many MTF experienced osteoporosis – MTF: No reports of hormone-related cancer Wierckx K, et al. Long-term evaluation of cross-sex hormone treatment in transsexual persons. Journal of Sex Med. 2012 Oct;9 (10): 2641-51. Epub 2012 Aug 20.
- 34. Practice Recommendation • To decrease cardiovascular morbidity, more attention should be paid to decrease other cardiovascular risk factors during hormone therapy management in MTF patients (SOR C) Wierckx K, et al. Long-term evaluation of cross-sex hormone treatment in transsexual persons. Journal of Sex Med. 2012 Oct;9 (10): 2641-51. Epub 2012 Aug 20.
- 36. Surgical Options • MTF: – Orchiectomy – Vaginoplasty (using penile tissue or colon graft) • Usually includes clitoro-labioplasty to create an erogenously sensitive clitoris and labia minora/majora • Colon grafts do not require serial dilation and are self- lubricating – Penectomy – Breast Augmentation – Reduction Thyrochrondroplasty – Voice surgery – Facial Feminization Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 37. Surgical Options • FTM: – Bilateral Mastectomy/reudction – Hysterectomy/Oophorectomy – Metoidoplasty- construction of male appearing genitalia from testosterone-enlarged clitoris – Phalloplasty – Scrotoplasty – Urethroplasty – Vaginectomy Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 38. Preventative Medicine and Screening • Annual visit: MTF – Annual mammogram beginning at age 40-50 depending on risk factors, length of estrogen use, family history (SOR C) – Annual rectal exam +/- PSA age 50, depending on personal Hx and risk factors – USPSTF: PSA not useful if patient is on estrogen (SOR B) – Colonoscopy at age 50, depending on personal Hx and FHX, risk factors Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 39. Preventative Medicine and Screening • Annual visit: FTM – Annual lipids >30 yo or if preexisting hyperlipidemia prior to starting testosterone – Annual mammogram beginning at age 40-50, depending on risk factors, FHx, and presence of breast tissue. – Palpate chest if pt has had mastectomy – Bimanual pelvic exam Q1-2 years (SOR C) – Pap Q2-3 years based on current recommendations if has cervix – Pelvic U/S for new bleeding, if still has uterus/ovaries – TSH Q1-2 years or based on sx/preexisting thyroid dz – DEXA Scan at 5-10 years after beginning testotserone (SOR B) Marvin Belzer, et al. Center of Excellence for Transgender Health. Transgender Health Learning Center. Department of Family and Community Medicine at UCSF. Accessed at www.transhealth.ucsf.edu
- 40. Mental Health
- 41. Cultural Competency: Mental Health • Suicide is 3rd leading cause of death in adolecsents • Nonsuicidal self-harm occurs in 13-45% of teens • 17% of U.S. teens endorsed Suicidal Ideation over a 12 month period • LGBTQ+ are at independent increased risk, increased bullying victimization and stress Richard T. Liu, PhD, Brian Mustanski, PhD. Suicidal Ideation and Self-Harm in Lesbian, Gay, Bisexual, and Transgender Youth, Am J Prev Med 2012;42(3):221-228.
- 42. Cultural Competency: Self Harm • Risk factors in LGBTQ+ Youth (n=246): – Birth gender equal – Used several inventories: • Hx of Suicidal Ideation: Brief Symptom Inventory (BSI-18) • Self Harm: ARBA computerized self-administered interview designed for adolescents • Baseline Impulsivity: Barratt Impulsiveness Scale (BIS-11) • Sensation Seeking: brief Sensation seeking Scale (BSSS) • Gender Nonconformity (Boyhood Gender Conformity scale) • History of Attempted Suicide Hopelessness Scale for Children (originally designed for use w/ ethnic-minority youth) 10 item measure (D’Augelli) – 2.5 fold increased risk for self harm • Social Support (MSPSS= Multidimensional Scale of Percieved Social Support) Richard T. Liu, PhD, Brian Mustanski, PhD. Suicidal Ideation and Self-Harm in Lesbian, Gay, Bisexual, and Transgender Youth, Am J Prev Med 2012;42(3):221-228.
- 43. Cultural Competency: Self Harm • Risk factors in LGBTQ+ Youth (n=246): • Risk factors for Suicidal Ideation and Attempts were INDEPENDENT from risk factors for self harm. • Suicidal Ideation and Self Harm behaviors were NOT connected. • Increased Risk of Suicidal Ideation/Attempt: • Hx of Suicidal Ideation & Baseline Impulsivity: Richard T. Liu, PhD, Brian Mustanski, PhD. Suicidal Ideation and Self-Harm in Lesbian, Gay, Bisexual, and Transgender Youth, Am J Prev Med 2012;42(3):221-228.
- 45. Cultural Competency: Substance Abuse • Not universal, but LGBTQ+ use is more prevalent than the general populaiton • New York Transgender Project: – Heavy alcohol use: 60.4% – Marijuana: 40% – Cocaine 21% – Stimulants 3.9% – Opiates 3.5% • Higher in younger MTF Transgender people Larry A. Nuttbrock PhD (2012): Culturally Competent Substance Abuse Treatmetn with Transgender Persons, Journal of Addictive Diseases, 31:3, 236-241.
- 46. Cultural Competency: Substance Abuse • 50% of transgender individuals delayed or failed to seek treatment because of anticipated maltreatment • Less than 5% of substance abuse counselors have received transgender education • Afraid of “outing” side effects from combining hormone therapy with abused drugs (esp. alcohol) • Gender abuse as trigger for relapse Larry A. Nuttbrock PhD (2012): Culturally Competent Substance Abuse Treatmetn with Transgender Persons, Journal of Addictive Diseases, 31:3, 236-241.
- 47. Cultural Competency: Tobacco • LGBTQ+ individuals smoke at higher rates than the general population. – Systematic review of 42 studies (Lee, Griffin & Melvin 2009). – Even higher in bisexual individuals who don’t identify with LGBT community/label – Am Lung Assoc 2010 Six state Health Surveys (CA): • Men: 19% heterosexual to 26.5% gay, 29.5% bisexual • Women: 11.5% heterosexual to 22.3% lesbian, 30.9% bisexual • Few Transgender studies, but est. 30% • LGBTQ+ Youth age 13-24: 63% (n=500) Michelle Eliason PhD, et al. The Last Drag: An Evaluation of an LGBT-Specific Smoking Intervention. Journal of Homosexuality, (2012) 59:6, 864-878.
- 48. Cultural Competency: Tobacco • Minority stress • Association between smoking and sensation- seeking and impulsivity • Targeted marketing by tobacco industry- 1990 – Free giveaways at gay bars – Funding LGBT organizations and events – Increased advertisements in LGBT publications • Community normalization Michelle Eliason PhD, et al. The Last Drag: An Evaluation of an LGBT-Specific Smoking Intervention. Journal of Homosexuality, (2012) 59:6, 864-878.
- 49. Cultural Competency: Tobacco • Less access to Primary Care Physician • 2-3x less likely to have health insurance • PCP less likely to ask their LGBT patients if they smoked than their heterosexual patients Irony: • 8 week intervention with nicotine patch, bupropion, and counseling: abstinence rates at end of intervention were identical between Gay and Heterosexual men • The Last Drag classes (lastdrag.org) Michelle Eliason PhD, et al. The Last Drag: An Evaluation of an LGBT-Specific Smoking Intervention. Journal of Homosexuality, (2012) 59:6, 864-878.
- 50. Cultural Competency: Tobacco • The Last Drag – Week 1: orientation and Pre-test • Pre-test: readiness to quit, stages of change model – Week 2: Plan to quit smoking: process and tools – Week 3: Quit night • 2 days later: Becoming a nonsmoker and peer support – Week 4: Staying smoke-free: Short-term – Week 5: Staying smoke-free: Long-term – Week 6: Post-test and celebration Michelle Eliason PhD, et al. The Last Drag: An Evaluation of an LGBT-Specific Smoking Intervention. Journal of Homosexuality, (2012) 59:6, 864-878.
- 51. Cultural Competency: Tobacco • The Last Drag – CLASH (Coalition of Lavender Americans in San Francisco) – August 2005 to January 2010 – 19 program offerings – 371 LGBT Smokers, age 21-78; 73% male – 29% only went to one class -> n=233 – Nonsmokers at end of class: 59% – Nonsmokers at 6 months: 36% – Rates lower for trans and ethnic minorities Michelle Eliason PhD, et al. The Last Drag: An Evaluation of an LGBT-Specific Smoking Intervention. Journal of Homosexuality, (2012) 59:6, 864-878.
- 53. How will it change my practice? • Ask about LGBTQ+ specific bullying and victimization • Ask about Hopelessness • Ask about Perceived Social Support • Ask about substance abuse • Tobacco cessation • Ask about fears
- 54. Future: Aging LGBTQ+ Population • Many go back into the closet when they are in need of assisted living, home nursing, hospice • It gets better campaign • Barriers: Health, Isolation, Income – Lack of culturally competent caregivers – Stigma: born in an era of strict gender roles – Lack of insurance – Successful careers while in the closet Randi Ettner and Kevan Wylie. Psychological and social adjustment in older transsexual people. Maturitas, November 2012 226-229.
- 55. Future: LGBTQ+ Aging • Why come out as an elderly individual? • Retirement and/or death of a spouse brings on the feeling that “life is short” • “Who am I?” comes back up • “Will I die never having lived life authentically?” • Age related changes can bring on humor, self distance, and honesty Mark Ebell, et al. Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approach to grading evidence in the Medical Literature. Am Fam Physician (Feb 1 2004): 69; 3, 548-556.
- 56. Future: LGBTQ+ Aging • It’s not uncommon or unusual for transgender patients to present for the first time to a physician as transgender in their 60-80’s • Hormone therapy and/or surgical therapy can still improve QOL and is still appropriate in the elderly (SOR C) • Cases of Elderly individuals desiring to start transitioning with hormones, surgery or both Mark Ebell, et al. Strength of Recommendation Taxonomy (SORT): A Patient-Centered Approach to grading evidence in the Medical Literature. Am Fam Physician (Feb 1 2004): 69; 3, 548-556.
- 57. Questions?