Caring for the Transgender Patient Lorraine W. Bock, MSN, CRNP Bock CRNP Services, PC

Objectives At the completion of the program attendees will: Have an understanding of the history of the transgender movement Articulate the criteria for diagnosis of Gender Identity Disorder Be able to define common terms associated with the transgender movement Know the common procedures associated with gender change Know the hormones used in Gender Identity Disorder

The Beginning Dr. Harry Benjamin (1885-1986) – German born physician trained in Germany with a special interest in research. In 1941 was asked to see a child who “assured to be a girl” whose parent wished to support the child’s beliefs. Introduced the term transsexualism in 1954. In 1966 wrote the book The Transsexual Phenomenon, the first book on the subject.

Dr. Harry Benjamin In 1979 the Harry Benjamin International Gender Dysphoria Association was formed and named in honor of Dr. Benjamin The protocols in place currently for hormone replacement are based on his research.

Definitions Transsexualism/Transgendered - Person who aspires to or actually lives in the anatomically contrary gender role. The transexual identity has been present for at least 2 years. This is not a symptom of another mental disorder or chromosomal abnormality. Dual Role Transvestite/Cross Dresser – An individual that wears the clothes of the opposite sex in order to experience temporary membership in that sex. There is no sexual motivation for the dressing. There is no desire to permanently change to the opposite sex.

Definitions (con’t) Different Criteria for Boys/Girls Gender Identity Disorder (GID) of Childhood Different Criteria for Boys/Girls Girls A. Persistent & Intense distress about being a girl and has expressed desire to be a boy or insists that she is a boy

Definitions (con’t) 1. an assertion that she has or will grow a penis B. Persistent repudiation of female anatomical structures as evidenced by one of the following 1. an assertion that she has or will grow a penis 2. rejection of urination in a sitting position 3. assertion that she does not want to grow breasts or menstruate C. Has not yet reached puberty D. Symptoms present for at least 6 months

Definitions (con’t) Different Criteria for Boys/Girls Gender Identity Disorder (GID) of Childhood Different Criteria for Boys/Girls Boys A. Persistent & Intense distress about being a boy and has expressed desire to be a girl or insists that he is a girl

Definitions (con’t) B. Either of the following must be present 1.) Pre-occupation with stereotypic female activities as evidenced by cross-dressing or simulating female attire, or by intense desire to participate in games and past-times of girls and rejection of stereotypical male toys, games, & activities

Definitions (con’t) 2.) Persistent repudiation of male anatomical structures as evidenced by one of the following 1. an assertion that he will grow up to be a female 2. that his penis or testis are disgusting or will disappear 3. that it would be better not to have a penis or testes C. Has not yet reached puberty D. Symptoms present for at least 6 months

Definitions (con’t) Gender Identity Disorder NOS – One with a strong persistent identification with the cross-gender identity. A persistent discomfort with his or her sex. Sense of inappropriateness in the gender role he/she is currently in. Symptoms present for at least 2 years.

Definitions (con’t) GG – Genetic Girl TG – Transgendered Girl MTF – Male to Female FTM – Female to Male GRS – Gender Reassignment Surgery HRT – Hormone Replacement Surgery Spiro – Spironolactone

Tim/Trina

The Real Life Experience Undertake some Combination of: Maintain FT or PT Employment Function as a Student Function as a Community Based Volunteer Acquire a new legal first or last name Provide documentation that persons other than the therapist know that pt functions in the new gender role.

Hair Removal or Growth Electrolysis or Laser Hair Removal Can take up to 2 years of treatments Painful & Expensive Rogaine on the Face/Chest Can have adverse systemic effects Must be maintained to be effective

Breast Surgery Augmentation for Men Reduction for Females Most wait until after starting hormones to see what growth HRT stimulates Reduction for Females Most wear binders for several years before surgery Difficult to find Plastic Surgeons who will “go small enough”

Hormone Replacement Surgery Eligibility Criteria – 18 years of age Demonstrate knowledge of what hormones can & cannot do medically and what the risks are involved with HRT – medical & social Either 3 months of documented life experience OR Minimum of 3 months of psychotherapy after the initial evaluation has been completed

HRT (con’t) Readiness Criteria Pt has had further consolidation of gender identity during the real life experience Pt has made some progress in mastering other problems leading to or improving stable mental health Hormones are likely to be taken in a responsible manner

Biologic Effects of HRT Men Breast Growth Redistribution of body fat Decreased upper body strength Softening of skin Decrease in body hair/Stop loss of scalp hair Decreased fertility and testicular size Less frequent & less firm erections

Biologic Effects of HRT (con’t) Females Permanent deepening of the voice Permanent clitoral enlargement Mild breast atrophy/decreased hip fat Increased upper body strength Increased facial & body hair growth Male-pattern baldness Increased sexual arousability/interest

Medical Side Effects of HRT Men Increased risk of DVT/PE Development of benign pituitary prolactinemias Infertility Weight Gain Liver Disease Emotional Lability

Medical Side Effects of HRT Women Infertility Acne Shift in Lipid Profile Hepatic Dysfunction/Liver Tumor Development Emotional Lability Increase in Sexual Desire

Relative Contraindications Known Cardiovascular Disease Strong Risk Factors for CVD Cigarette Smoking Obesity Clotting Disorders Some Endocrine Abnormalities

Pre-Treatment Evaluation Must have the GID letter from psych Physical Examination w/ BP check Up to date on age appropriate screening tests Estrogen Therapy CMP, CBC, Free Testosterone Level Androgen Therapy Liver Profile, CBC,

On-going Evaluations Repeat Baseline Labs & Physical Exam w/ BP check at 6 & 12 months for both sexes then yearly thereafter Continue gender specific screening tests for pre-treatment gender For those receiving estrogen a prolactin level is needed at 1, 2,& 3 years

New Screening Tests Needed Males on Estrogen – Need instructed in self breast exam & need mammograms Females on Testosterone – Need annual liver palpation

Considerations after Gonadectomy Estrogen can be reduced by 1/3 to 1/2 after removal of the testes and still maintain feminization Testosterone can be reduced by 1/2 after oopherectomy due to risk of osteoporosis

HRT Dosing MTF Oral Estradiol (Estrace®)– 6-8mg PO or SL Oral Conjugated Estrogens (Premarin®) – 5mg PO Transdermal Estrogen (Vivelle®) – 2 0.1mg patches changed 2x/week. AND Spironolactone 200-400mg/d

HRT Dosing FTM Testosterone Injectable – 150-200mg q2weeks Transdermal Testosterone (Androderm) – 5 – 7.5mg changed QD Testosterone Gel (Androgel) – 5-10mg applied daily

Gender Reassignment Surgery Mastectomy or Breast Augmentation Reduction Thyroid Condroplasty Rhinoplasty Liposuction of Waist Face Lift/Facial Bone Reduction Blepharoplasty Hysterosalpingo-oopherectomy

Gender Reassignment Surgery Vaginoplasty by one of 3 methods Penile Skin Inversion Pedicles Rectosigmoid Transplant Free Skin Graft to Neovagina Phalloplasty including Vaginectomy Scrotoplasty Urethroplasty

Conclusion Patients who have GID and undergo treatment whether it is mental health therapy, HRT or surgical interventions go through rigorous events in order to “change.” They have a right to unbiased, holistic, primary care and PCP’s must be familiar with the subtleties of this condition.