Joe Freund MD Franklin Family Practice 2016 Family Planning Update

Disclosures No financial disclosures There is discussion of NON-FDA approved therapies There is discussion of NON-FDA approved therapies

Objectives Recognize, communicate with and apply the basic concepts and vocabulary associated with transgender healthcare Identify the healthcare disparities and the needs of the transgender population Describe the steps involved in gender transition.

Words…. Sex (sexual identity) Disorder of Sexual Development (Intersex) Gender Gender roles Gender identity Sexual orientation Sexual preference Gender assignment Gender atypical, nonconforming (creative) Gender Identity Disorder Gender Dysphoria Transgender Transsexual Transition Cross-sex hormones Gender reassignment Sex reassignment surgery(gender affirmation)

Sex (Sexual Identity) The pattern of biological sexual characteristics: Chromosomes External /internal genitalia Gonads and hormones Secondary sexual characteristics All embryos female: males androgenized 6 th -12 th wks Brain also undergoes hormonal changes

Disorder/Difference of Sexual Development (Intersex) Anatomical or physiological aspects of the opposite sex, variations from the norm Multiple causes, syndromes Congenital virilizing adrenal hyperplasia Androgen insensitivity syndrome Turner’s syndrome (XO) Klinefelter’s syndrome (XXY) 5 alpha-reductase deficiency Pseudohermaphroditism

Gender Culturally dictated expectations, actions, behaviors which are based on the genitals Culture specific Changes over time

Gender Role Behaviors conveying : “I am a boy, girl, man, woman,…” The cumulative result of experiences, learning, specific instruction /indoctrination, and intuition, sensitivity to the surrounding expectations. More similarities exist than differences between boys and girls, but not always possible to figure out what is cause, effect, or what is at the root of it all.

Gender Identity Inner sense of place on the male-female spectrum Set early in life, by age 2-3 years old Formed by biology and external cues from family, those around the child, society. Most commonly, this is consistent with sexual identity, but not always.

Sexual Orientation Describes object of sexual impulses/attractions: Heterosexual…opposite sex Homosexual…same sex Bisexual…both sexes Asexual: positive identity or desire disorder ? and…polyamorous, demisexual, pansexual,…… but….. what is your point of reference?

Sexual Preference Sexual desires or chosen activities, actions and behaviors

Gender Assignment The initial assignment at birth as male or female “Natal gender”

Gender Atypical (nonconforming, gender creative) Features or behaviors that are not “typical” for the assigned gender in a given society in a given time.

Gender Identity Disorder Conflict between sexual identity and gender identity A strong persistent preference for living as a person of the opposite sex Causes clinical distress

Gender Dysphoria ”An individual’s affective/cognitive discontent with the assigned gender” *** “the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender.” DSM 5

Transgender DSM- “broad spectrum of individuals who identify with a gender different from their natal gender”

Transsexual “An individual who seeks, or has undergone, a social transition from male to female or female to male, which in many, but not all cases, also involves a somatic transition by cross-sex hormone treatment and genital surgery.”

Transition The period during which an individual is moving from the assigned sex at birth to their gender identity: male to female (MTF) female to male (FTM) masculine toward feminine feminine toward masculine

Cross-sex Hormones The use of masculinizing hormones in those assigned female at birth or The use of feminizing hormones in those assigned male at birth **********NOT FDA APPROVED************

Sex Reassignment Surgery Gender Affirmation Surgery Gender Confirmation Surgery Surgical procedures to change the body from the natal, to be consistent with the gender identity

Gender Reassignment Denotes an official, usually legal change of gender

Not Just the Binary… Gender Queer Bigender Androgyne Agender Gender fluid

Healthcare Disparities Substance use: marijuana crack, alcohol Violence: hate, domestic, school Smoking: 45-74%, many on estrogen! Depression, anxiety, PTSD Suicide ideation and risk (lifetime risk 32% of suicide attempts) HIV: transwomen of color at highest risk, up to 63%

Barriers Invisibility (paperwork, orientation, identity) Heterosexism/Cis-genderism Phobias Fear of rejection Experience of poor treatment Fear for job, family, safety Insurance use/exclusions(grandfathered) } Discrimination Discrimination

There is NO Typical Transition Self-awareness is the only universal Counseling Gender expression Hormones Gender Affirming Surgery Legal name change Legal gender marker change

WPATH World Professional Association for Transgender Health Standards of Care, v. 7 available on line Excellent resource for patients and providers Describes transition, steps, guidelines and recommendations Recommendations, NOT requirements, for counseling, hormonal care, surgeries

Challenges in Medical Settings Identifying trans correctly ALL staff must be trained and confident EHR Preferred names and pronouns Testing and care linked to gender markers Safe referral and testing locations Nongendered bathroom facilities

Identification ASK sex/gender marker Birth Legal Insurance Current gender Identity Two stage: What was sex assigned at birth What is your current gender identity?

Addressing the Trans Patient Honor choice of name & pronoun: use them {he/him/his} {she/her/hers} {ze/hir/zir} {they/them/theirs} Use pronouns consistent with presentation or as requested If you are confused or unsure, simply ask Mistakes happen; just apologize & move on

Caring for Transgender Patients Appreciate the trust, the risk taken when someone reveals their transgender status Open, non-judgmental communication Respect ASSURE CONFIDENTIALITY

Transgender Body Status An individual’s appearance or self-identity has no correlation with their body status Not everyone wants to or is able to use hormones or have surgery Do not make assumptions, ask if need to know

Transgender Care Do not forget basic healthcare ! Trans patients may actively avoid contact with the medical system May have been rejected or treated poorly in the past May be self treating May be receiving body alterations from untrained personnel IMMUNIZE ! Hep A, Hep B, HPV

Transgender Care Goal: improve quality of life Assess expectations and plans Hormone therapy / informed consent Therapist involvement / World Professional Association for Transgender Health Standards of Care “If you’ve got it, it needs to be checked !” “If you’ve got it, it needs to be checked !” Transwoman:prostate/breast*Transman:pelvic/PAP/breast

Transgender Hormonal Care Transman: Testosterone Transwoman: Estrogens Anti-androgens (Progesterone) ** Perfect for primary care NOT FDA APPROVED

Benefits of Testosterone Masculinization Lower voice Increased body and facial hair Coarsening of the skin Cessation of menses Increased muscle mass Enlargement of clitoris Increased libido Increased physical energy Osteoporosis protection Possible infertility

Possible Surgeries for FTM Top surgery: -Mastectomy and male chest construction Bott om surgery: (in addition to hysterectomy/BSO) -Metaoidoplasty: clitoral ligaments released, urethra may be extended to tip, scrotum may be created with testicular implants and possible vaginectomy -Penile construction/phalloplasty: Flap procedure, radial forearm most common, scrotum created, testicular implants placed

MTF Hormone Therapy Estrogens Anti-androgens (Progesterone)

Benefits of Estrogen Breast development Body fat redistribution Skin softening Decreased testosterone production Improved acne Slowed balding

Anti-androgen Necessary while testes are present Spironolactone most commonly used Blocks both testosterone production and action at receptors Monitor for dehydration, hyperkalemia, and renal/electrolyte abnormalities

Progesterone Not routinely used May assist in body fat redistribution and breast development Used mostly when maximal estrogen doses have been reached, or unable to use estrogens. May have an androgen-like effect and adversely affect moods. May help in suppressing testosterone

Surgery or Immobility:Estrogen Stop estrogens two weeks prior to surgery Resume when recovered and fully mobile

Possible Surgeries for MTF Genital surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty Other: breast augmentation, facial feminization, scalp advancement, liposuction/filling, cosmetic procedures, voice raising surgery, reduction thyroidchrondroplasty

Gender Creative Children AKA: “Nonconforming” or “Atypical” Often cross-gender behaviors present before the age of boys for each girl Cross-gender behavior may be lessened by discouragement Outcome: homosexual orientation, (more boys than girls), transgender

Trans at Puberty Identify before puberty Start hormone blockers in early puberty to prevent the unwanted body changes Add cross hormones later for the puberty consistent with gender identity Controversies: age of starting hormones and surgeries cost and insurance

Local Resources Helpful to Your Transgender Patients Counselors fluent in transgender issues Local support groups Speech coaches Surgeons for sexual reassignment surgery Plastic surgeons Hair removal providers

Summary Train staff…share your knowledge Look for and identify trans patients Respect, confidentiality Use name and pronoun as requested / as presenting Inclusion in everything (NOT exclusion) Advocate for patient : insurance, testing, referrals

Resources National LGBT Health Education World Professional Organization for Transgender Health Standards of Care, version GLMA: Health Professionals Advancing LGBT

Resources UCSF Center of Excellence for Transgender Health “Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline” J Clin Endocrinol Metab 94: 3132–3154, 2009

Joe Freund MD Franklin Family Practice 2016 Women's Health Care Symposium