Issues in Transgender Primary Care

Issues in Transgender Primary Care
Carol F. Milazzo, MD, FAAP Vice Chair, Dept. of Pediatrics Sutter Roseville Medical Center World Professional Assn. For Transgender Health Samuel Merritt University 27 Feb 2011 The transgender community has been identified as having serious barriers to competent, sensitive and accessible health care. Primary care clinicians can successfully incorporate care of this population into their practices. Education, networking and practice accommodation are primary tasks to this goal. This presentation describes our experience in expanding a primary care practice to provide culturally competent and quality care to transgender youth.

Faculty Disclosure I have no personal financial relationship with any entity producing, marketing, re-selling or distributing health care goods or services consumed by, or used on, patients. The pharmaceutical treatments discussed are used in accordance with professional consensus represented by the WPATH Standards of Care, but may not have US FDA approval for these indications.

Biography – Staff Pediatrician, US Naval Hospital, Roosevelt Roads, PR – Assistant Professor in Pediatrics, Creighton University & Univ. of Nebraska 2000-present – Solo practice, Roseville, CA Fellow American Academy of Pediatrics, Member WPATH, IFGE, GLMA My biography. I served on contributing faculty at the medical schools of Creighton University and University of Nebraska prior to entering private practice in the Sacramento, CA area. I am a Fellow of the AAP, and member of the World Professional Association for Transgender Health and of the IFGE (International Foundation for Gender Education).

Practice Description 1500 sq. ft. (140 m2) ~5,000 active patients
~300 adolescent & young adult transgender patients (ages 5-40 yrs), FTM/MTF ≈ 1:1 Average 6-7 new referrals/mo. (↑ since 2007) Practitioners: 1 MD + 1 NP + support staff Here is a description of our practice. Our office is located on the second floor of this professional office building in a suburb of Sacramento, CA. We have about 5000 active records and attend about 40 adolescent and young adult transgender patients, mostly in the range of years. The ratio of male-to-female and female-to-male patients is approximately 1:1. This year, we have had an average of 3-4 new referrals per month for transgender health care. This has been increasing since 2006, we (and other clinicians) suspect due to heightened public awareness of gender identity issues through recent media coverage. Our clinicians consist of one MD and a nurse practitioner.

Query posted on online pediatric discussion group
“I have seen an increasing number of youths referred by mental health professionals for initiation and medical supervision of cross gender hormone treatment. I wonder if others have had similar experiences.” cfm To sample attitudes prevalent among our pediatrician colleagues, in June 2006 I posted this query on an online physicians’ discussion board (Medscape). “I have seen an increasing number of youths referred by mental health professionals for initiation and medical supervision of cross gender hormone treatment. I wonder if others have had similar experiences.” This post triggered a whirlwind of responses.

Responses to query “I find your post disturbing. Surely young adolescents are not given hormone treatments for this purpose. I hope you are not participating in this type of ‘treatment.’” This colleague shows discomfort and unfamiliarity with the issues. (The underlined emphasis is mine).

Responses to query “…this involves minors, and adolescents are often confused about their sexuality. Many [youths engage] in same-gender sex experimentation and this may contribute to confusion.” This colleague confuses sexual orientation with gender identity. These issues are independent. Many transgender youth do not engage in sexual experimentation because of discomfort with their anatomy.

Responses to query “The ‘mental health professionals’ sending you these patients need mental health evaluations themselves!” This colleague expresses a cynical attitude about this issue.

Responses to query “As child psychiatrist I think that my mission is not to … satisfy pathologic desires, even if patients say they would be better.” This colleague considers gender variance to be a pathologic desire.

Responses to query “I don’t understand why the medical profession has to assist people mutilating themselves into the physical appearance of the other sex. This is especially true of a minor.” This colleague shows bias and misunderstanding of the role of transgender medical supervision and surgery.

Responses to query “I profess my ignorance of the literature in this arena, but have an innate suspicion and caution re. study bias (a la Kinsey Report).” This colleague demonstrates the need for education.

Responses to query “I remain unconvinced of the appropriateness of this intervention. HBIGDA appears to be primarily a political advocacy organization. Treatments this drastic should be based on good science, not political beliefs.” Some organizations attempt to enforce conformity to their bias through demonizing and politicizing transgender health care needs. Child psychologist, Dr. James Dobson said of California law AB 196 that protects transgenders against discrimination in housing and employment that “The inmates are now fully in charge of the asylum.” (Dr. Dobson’s Newsletter September 2003). The Traditional Values Coalition’s Special Report “A Gender Identity Disorder Goes Mainstream” states “The promotion of ‘sex changes,’ and the normalizing of severe gender identity disorders by radical feminists, pro-same-sex attraction disorder activists, and sexual revolutionaries is part of their larger (transgender) agenda—namely the destabilization of the categories of sex and gender.”

Response to responses “Not everyone may feel comfortable or competent with such issues, but we should recognize them, their seriousness, and learn to refer them to our colleagues who are experienced and willing to care for these patients.” -cfm Here was my response to the discussion. The agenda of WPATH (formerly HBIGDA) is recognition, respect and accessibility of appropriate, competent and compassionate health care for transgender patients.

Spectrum of Attitudes among health professionals
These responses to the query demonstrate a range of attitudes and misconceptions about the treatment of transgender youth. Professional ignorance and bias pose significant barriers to access to competent and sensitive health care for these patients. These responses demonstrate a range of attitudes and misconceptions among health care professionals that pose significant barriers to transgender adolescents who seek health care.

Objectives Recognize health care issues that transgenders face.
Understand diagnosis and clinical management of gender dysphoria. Identify resources for health professionals serving transgenders. Here are the stated objectives of the presentation.

Definitions Transgender = Gender variant – individuals whose gender expression or identification differs from culturally assigned expectations and stereotypes based on anatomic sex. Definition of the subject population. Transgender is an umbrella term that includes many gender variant people, including crossdressers, drag queens, drag kings, androgynous, feminine men, masculine women, transsexuals, genderqueer, etc. With regards to all members of the community, we aim to provide a trans friendly environment for health care.

Joan of Arc transgressed gender stereotypes by adopting male clothing
Joan of Arc transgressed gender stereotypes by adopting male clothing. She was burned at the stake for violating this cultural taboo. Joan of Arc

RuPaul transgresses gender stereotypes for entertainment purposes.

RuPaul transgresses gender stereotypes for entertainment purposes.
Boy George

Prince Charles Evzones
The Scottish kilt and Evzone uniform conform to gender norms in their respective cultures. Prince Charles Evzones

Utilikilts is a Seattle based company that markets kilts as an alternative gender non-conforming male attire. Utilikilts

Rosie the Riveter represented women entering a traditionally male profession.

Rosie the Riveter Bob the Builder
Humor slide – There has been a rumor that Rosie the Riveter and Bob the Builder wanted to collaborate on a construction project. But this did not work out when Bob was discovered to suffer erectile dysfunction! Rosie the Riveter Bob the Builder

Definitions Transsexual – A subset of transgender individuals that seeks conformity of the body with their gender identity through medical (hormone) and/or surgical means. Transsexuals are a subset of transgenders referred to medical professionals for hormones and/or surgery.

Definitions Note Gender identity and expression are independent of sexual orientation. Gender identity is independent of sexual orientation.

Diagnostic Criteria GID
Gender Identity Disorder (GID) in Adolescents or Adults – * A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). DSM-IV diagnostic criteria from DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) , APA, 2000.

Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. (Gender dysphoria). The disturbance is not concurrent with a physical intersex condition. DSM-IV diagnostic criteria from DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) , APA, 2000.

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. * Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, APA, 2000. DSM-IV diagnostic criteria from DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) , APA, 2000.

DSM-5 Gender Incongruence
A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration as manifested by 2 or more of the following indicators

A strong desire for the primary and/or secondary characteristics of the other gender A strong desire to be of the other gender A strong desire to be treated as the other gender

Incongruence between experienced expressed gender and primary or secondary sex characteristics A strong desire to be rid of one’s primary and/or secondary sex characteristics A strong conviction that one has the typical feelings and reactions of the other gender

GID in Children DSM-IV 302.6*
GID in prepubertal children has more variable outcome than in adolescents or adults. Some have gender dysphoria that resolves spontaneously. Therefore these children should not be offered physical treatment nor surgery… * Cohen-Kettenis & Pfafflin, 2003 Studies have shown approximately 80% of prepubertal children go on to identify with their biological gender. Half of these manifest heterosexual orientation, the other half manifest a homosexual or bisexual sexual attraction. Physical gender reassignment is not recommended for prepubertal children.

Etiology Nature vs. nurture? Anatomic evidence BSTc 2D:4D Ratios
Consensus favors considering an interplay of genetic and environmental influences on the manifestation of gender variance. The David Reimer case demonstrates that gender cannot be forcibly imposed on an individual through upbringing.

This published study demonstrated a morphologic gender difference in the bed nucleus of the stria terminalis of the hypothalamus where MTF’s resembled genetic females and not genetic males.

2D:4D Ratio 2D < 4D Male ♂ 2D ≥ 4D Female ♀
A relationship between gender variance and 2D:4D ratio has been shown and supports the hypothesis of a role for fetal hormone exposure in gender variance. 2D < 4D Male ♂ 2D ≥ 4D Female ♀

Short communication Typical female 2nd–4th finger length (2D:4D) ratios in male-to-female transsexuals—possible implications for prenatal androgen exposure Harald J. Schneider , , Johanna Pickel and Günter K. Stalla Clinical Neuroendocrinology Group, Max Planck Institute of Psychiatry, Kraepelinstrasse 10, Munich, Germany Received 26 April 2005; revised 25 July 2005; accepted 26 July 2005. Available online 2 September 2005. Typical female 2nd–4th finger length (2D:4D) ratios in male-to-female transsexuals—possible implications for prenatal androgen exposure Harald J. Schneider, Johanna Pickel and Günter K. Stalla Clinical Neuroendocrinology Group, Max Planck Institute of Psychiatry, Kraepelinstrasse 10, Munich, Germany Abstract Prenatal exposure to androgens has been implicated in transsexualism but the etiology of the condition remains unclear. The ratio of the 2nd to the 4th (2D:4D) digit lengths has been suggested to be negatively correlated to prenatal androgen exposure. We wanted to assess differences in 2D:4D ratio between transsexuals and controls. Sixty-three male-to-female transsexuals (MFT), 43 female-to-male transsexuals (FMT), and 65 female and 58 male controls were included in the study. Photocopies of the palms and digits of the hands were taken of all subjects and 2D:4D ratios were measured, according to standard published procedures. Comparison between right-handed individuals revealed that the right-hand 2D:4D in MFT is higher than in control males but similar to that observed in control females. In FMT we found no differences in 2D:4D relative to control females. Our findings support a biological etiology of male-to-female transsexualism, implicating decreased prenatal androgen exposure in MFT. We have found no indication of a role of prenatal hormone exposure in female-to-male transsexualism. Psychoneuroendocrinology Volume 31, Issue 2, February 2006, Pages

Prevalence Old estimate 1:30,000 New estimate 1:1000 – 1:2000
Old prevalence data counted only transsexuals in Europe who had completed sex reassignment surgery. This is inaccurate as it does not count individuals who were unable to complete surgery due to various impediments or who have not been diagnosed.

This article recently submitted for publication estimates the prevalence from 1:1000 to 1:2000.

Prevalence in Adolescents
There is no epidemiological data for this age group The observed sex ratio in adolescents approaches 1:1 Prevalence data from the Transgender Care Project report

Health Care Issues* Societal marginalization Internalization of stigma
Gender dysphoria Risk taking behaviors * An Overview of U.S. Trans Health Priorities: A Report by the Disparities Working Group of the National Coalition for LGBT Health, August, 2004 Issues that trans youth face.

Societal Marginalization
Trans youth experiences in school* Gender-based verbal harassment 96% Gender-based physical harassment 83% Did not feel safe in school 75% Dropped out of school 75% * A qualitative study of trans youth in Philadelphia, n=24, age range 16-21, Lydia Sausa, Ph.D., 2003 Alienation/marginalization

Barriers to health access Unemployment Depression Educational deficiencies, Discrimination by employers, ID incompatibility with presenting gender. Barriers to health care access.

Homelessness Rejection by family Lack of income Discrimination in housing Lack of accommodation by homeless shelters Homelessness

Internalization of Stigma
Thoughts of suicide 83% Attempted suicide 54% Self mutilation 21% * A qualitative study of trans youth in Philadelphia, n=24, age range 16-21, Lydia Sausa, Ph.D., 2003 High risk of suicide is a life threatening condition that requires intervention.

Gender dysphoria Engaged in body modification 88%
Engaged in hormone therapy 25% Received silicone injections 8% Intend to acquire hormones and/or undergo surgery in the future 33% * A qualitative study of trans youth in Philadelphia, n=24, age range 16-21, Lydia Sausa, Ph.D., 2003 Adulterated street hormone preparations: risk of adverse effects and toxicity of overdosing, sharing of infected needles leads to risk of hepatitis and other blood borne pathogens. Silicone injections have been associated with autoimmune disease, deformities and fatalities.

Risk taking behaviors Engaged in sex work 46% Alcohol use 75%
Illegal drug use 79% Sold illegal drugs 21% Sex under influence of alcohol 96% * A qualitative study of trans youth in Philadelphia, n=24, age range 16-21, Lydia Sausa, Ph.D., 2003 Many engage in sex work for survival. Many self medicate with substances to cope with stresses or are immersed in that lifestyle.

Risk taking behaviors Sex under influence of illegal drugs 75%
Reported being HIV positive 13% Reported an STD 17% Engaged in risk behaviors for HIV transmission 96% * A qualitative study of trans youth in Philadelphia, n=24, age range 16-21, Lydia Sausa, Ph.D., 2003 Concomitant use of substances is associated with increased unprotected sex and STDs. Sex workers are often given a financial incentive not to use barrier protection.

Barriers to Access - Provider
COMPETENCE Lack of recognition of condition, its morbidity Lack of treatment knowledge and skills BIAS Reluctance/refusal to serve transgenders Insensitivity of provider/staff Institutional bias EXCLUSION OF CONDITION BY INSURANCE Some barriers from the provider’s perspective include: Competence – Ignorance of the condition and its morbidity and lack of knowledge and skills; Bias – Reluctance or refusal to serve transgenders due to bias or lack of professional competence; insensitivity or lack of cultural competence of the provider and staff; and bias of the institution in which the provider works that may constrain the treatment of transgenders (due to religious or cultural taboos); Exclusion of the condition by many health insurances – Non-reimbursement for services rendered to patients for these diagnoses.

Barriers to Access - Patient
Lack of support or hostility of parents/peers Poor self esteem/depression Mistrust of providers Low socioeconomic status Lack of transportation Lack of health insurance, finances Exclusion of condition by insurance From the patient’s perspective, barriers include: Lack of support/hostility from parents (of dependent minors) and significant peers Depression (secondary to above) causing a lack of motivation to seek needed care Mistrust of providers due to experienced or feared ridicule and discrimination Low SES that is associated with lack of transportation to the health provider, lack of health insurance, and inability to afford treatments Exclusion of the condition by many health insurances – many medical and/or surgical expenses are out-of-pocket.

Tasks Professional education Networking Practice accommodation
In view of these barriers, these three main task areas were identified to be implemented to adapt our practice to better serve transgender youth. The following slides describe these tasks in further detail.

Professional Education
STRENGTH: Medical school and residency training curricula include the principles of endocrinology. WEAKNESS: These curricula do not include transgender health care. The strength of current professional education is that medical school and residency curricula include the basics of endocrinology. Transgender medicine employs familiar medications that are used in the treatment of ordinary conditions such as menopause and hypogonadism. With training, primary care physicians CAN provide this care. The weakness is the widespread lack of knowledge and training in the use of these skills in the evaluation and treatment of patients with gender dysphoria.

Professional Education: Opportunities
The WPATH (formerly HBIGDA) Standards of Care, Sixth Version A major resource is the WPATH (formerly HBIGDA) Standards of Care, Sixth Version

WPATH Standards of Care (SOC)
publications_standards.cfm Online in English, Spanish and Croatian translations De facto authoritative consensus, in constant revision The SOC is the de facto authoritative consensus on transgender health care. It is available in print and online in English, Spanish and Croatian translations. It provides guidelines for a model collaborative team of mental health, medical and surgical clinicians to assure quality and appropriateness of services provided to each patient.

Here is the first page of the SOC as it appears on the WPATH website.

The WPATH Standards of Care, Sixth Version (formerly HBIGDA) The International Journal of Transgenderism Another education resource is The International Journal of Transgenderism.

The IJT, published quarterly, is the official journal of WPATH and the only peer reviewed journal on transgender medicine.

The WPATH Standards of Care, Sixth Version (formerly HBIGDA) The International Journal of Transgenderism Published Clinical Protocols Another resource is published clinical protocols.

Published Clinical Protocols
Online Anne Lawrence, M.D. Callen-Lorde Community Health Center (NY) Vancouver Coastal Health Transgender Health Program Tom Waddell Health Center (SF) Here are a few of the several centers that publish their clinical protocols online. Online protocols were the first such readily available resources for clinicians.

de Vries, A., Cohen-Kettenis, P., Delemarre-van der Waal, H. “Clinical Management of Gender Dysphoria in Adolescents.” IJT 9.3/4 (2006): Clinical protocols are now available in print. One such publication is this IJT article published in 2006 with clinical guidelines specific to transgender adolescents.

Ettner R, Monstrey S, Eyler A, eds. Principles of Transgender Medicine and Surgery, Haworth, Another is this first comprehensive textbook on transgender medicine and surgery, published in 2007.

The WPATH Standards of Care, Sixth Version (formerly HBIGDA) The International Journal of Transgenderism Published Clinical Protocols Professional meetings Professional meetings are a resource for continuing education.

Professional meetings
WPATH Symposia National and international professional societies WPATH’s biennial symposia offer opportunities for education and networking with other medical, surgical and mental health professionals. The American Academy of Child and Adolescent Psychiatry (AACAP) offers workshops on gender variant youth at their annual meetings. The AAP is an appropriate venue for inclusion of transgender adolescent health care in educational offerings on sexual minorities.

The WPATH Standards of Care, Sixth Version (formerly HBIGDA) The International Journal of Transgenderism Published Clinical Protocols Professional meetings Peer discussion Peer discussion is another resource.

Peer discussion Online discussion groups, e.g. Yahoo! Transmedicine, Trans youth clinical support, Transhealthalliance, etc. Consults among local gender team members Online list-serves and discussion groups offer opportunities for near real time education among peers. Local gender teams (for example, Bay Area Gender Associates) provide a forum for mutual consultation.

The WPATH Standards of Care, Sixth Version (formerly HBIGDA) The International Journal of Transgenderism Published Clinical Protocols Professional meetings Peer discussion Academic curricula Academic curricula at medical schools and residencies is another educational opportunity.

Academic curricula AMA: “In June 2007, the AMA House of Delegates voted to revise current AMA policies to ensure inclusion and protection for transgender physicians, medical students and patients.” This recent AMA policy calls to end disparities in all aspects of the medical community that affect transgender individuals, an incentive to include transgender health in medical curricula.

Academic curricula American Medical Student Association: LGBT Health Action Committee GLMA: Trans Health Care Committee These other professional organizations also advocate transgender inclusion in medical curricula and to remedy health care disparities for transgender patients.

The WPATH Standards of Care, Sixth Version (formerly HBIGDA) The International Journal of Transgenderism Published Clinical Protocols Professional meetings Peer discussion Academic curricula Local education opportunities There are opportunities for education at the local level.

Local education opportunities
Educate local clinicians* Present at local grand rounds Presentations at hospital grand rounds and at community pediatric societies enable local primary care providers to serve transgender youth. The following slide describes a proposal to integrate existing resources in Sacramento county to provide mental health services to LGBT youth.

Networking FACILITATES: Consultation with colleagues
Referral of patients to/from other gender team members Patient access A second task area is networking. Networking facilitates: Consultation with colleagues to pool expertise; Referrals to and from other gender team members (SOC model), and Access between patients and providers.

Networking Join WPATH, IFGE, national societies
Network and advocate for transgender care inclusion within specialty societies Contact/speak at community organizations, e.g., PFLAG, gender support groups Join or form a local team of gender professionals Paths to networking include: Membership is organizations such as WPATH, IFGE Advocating within existing specialty societies to include transgender care Contacting and speaking at local organizations, such as PFLAG and gender support groups Joining or forming a local team of gender professionals

The SOC Gender Team Model
THERAPIST MEDICAL DOCTOR PATIENT The Standards of Care outlines a professional team model for services to transgender patients. The usual order of access is: The patient consults a mental health professional (therapist); After a variable period of therapy (usually 3 months minimum) to establish the diagnosis, work out co-morbidities and social adjustment issues, and determine eligibility and readiness, the therapist provides a letter of referral to a medical doctor for hormone therapy and supervision; The patient locates a surgeon and after the minimum period of “real life experience” (usually 12 months) the therapist provides a letter of referral to the surgeon (a concurring letter from a PhD or MD mental health professional is required for genital surgery); The surgeon consults with the medical doctor for relevant information. The local team most often includes the patient, therapist and medical doctor, while the surgeon is often geographically removed due to their limited numbers. SURGEON

Forming a Local Gender Team
Ask patients about local providers Contact local LGBT community center/transgender support groups Contact professional organizations, e.g., WPATH, IFGE Web searches, WPATH and GLMA online provider databases Find other local providers with whom to collaborate by: Asking patients about other providers they knew; Inquiries at the local LGBT community center and transgender support group; Inquiries through professional organizations such as WPATH and IFGE; and, Internet search engines and online provider databases.

Networking Advertising – practice web site
One way to network with colleagues and patients is through a practice web site.

Practice website Provides descriptive and useful information on health management, introduction to staff, practice flavor and policies. The website is often an important first patient contact with our office. Patients often resort to internet searches for preliminary information gathering. The website should include key information on policies and services offered.

This website includes a rainbow flag, a cue that the office is open to diversity.
There is a statement of respect and sensitivity for patient’s values. It mentions an interest in gender dysphoria. The CV link lists professional qualifications and organization memberships.

The bottom of the page lists links to useful resources on gender identity and gender variance.

Networking Advertising – practice web site
Letterhead* and Business cards Letterheads and business cards also facilitate networking with colleagues and the community.

Attention Deficit Disorders Autism Spectrum Disorders
Carol F. Milazzo, MD 406 Sunrise Ave, Ste 280 Roseville, CA 95661 Tel. (916) Special interest in: Attention Deficit Disorders Autism Spectrum Disorders Gender Dysphoria Children Adolescents Young Adults This letterhead lists gender dysphoria as a practice interest. This medium can be a source of referrals through correspondence with patients and other health professionals. Fellow, American Academy of Pediatrics Member, Sacramento Pediatric Society International Foundation for Gender Education World Professional Association for Transgender Health

Practice Accommodation
Staff sensitivity The other identified task area was practice accommodation. This involves making office policies and environment comfortable for our patients and providing sensitivity training to the office staff. (The photo on the left shows Jessica, one of our first transgender adolescents. This photo appeared in our local newspaper in The photo on the right is of me with our support staff.) Patient comfort

Staff sensitivity - complaints
“The doctor said I could never pass as a woman with all my tattoos.” - MTF “I overheard the doctor repeatedly refer to me as ‘he’ when addressing his staff.” – MTF Perception of the provider/staff as judgmental or adversarial may interfere with patient compliance and safety Youths report these experiences in some physicians’ offices. These patients did not return to the offices where they experienced this insensitivity. Appropriate sensitivity aids in developing rapport, trust and patient compliance.

Staff sensitivity education
Ask patient about preferred pronouns & use them when addressing the patient When in doubt, ask! Do not make assumptions based on observed gender cues Be non-judgmental Use the patient’s preferred pronouns. These may not be apparent from initial observed gender cues. Avoid judgmental statements in conversation with the patient.

Patient comfort Offer appointments at convenient times for patient (and family/significant others) Reserve exam rooms & times that avoid uncomfortable situations with other patients Offer flexibility in scheduling for patient convenience. To avoid patient discomfort, schedule these youths during the first appointments of the morning or the afternoon to avoid periods when waiting rooms may become loud and crowded.

Patient comfort Have a gender-neutral restroom
“This is a SAFE Place” posters – GLSEN, PFLAG A gender-neutral (single stall) restroom provides a comfortable place for patients who during gender transition may feel discomfort in public single gender restrooms. “Safe Place” posters in the exam rooms assure the patient that the clinician will be nonjudgmental with the patient’s issues.

This type of poster is available on the web sites of PFLAG and GLSEN.

Patient comfort Intake forms—provide for preferred pronoun, preferred name, gender other than M or F The intake and registration forms provide a place for the patient’s preferred name and gender if they differ from that on the legal documentation.

Address When started therapy
HISTORY WORKSHEET Carol F. Milazzo, M.D. To help us better serve you, please fill out this form before your exam. Patient preferred name: Patient legal name: Birthdate: Age: Preferred pronoun: Gender [ ] M [ ] F [ ] Other Primary care physician Phone Address Therapist Phone Address When started therapy MEDICAL HISTORY: Please list all current and past medications and herbal preparations and duration Please list all medication allergies Please list past surgery and hospitalizations etc…. Here is a sample medical history worksheet. This streamlines and helps focus the encounter on issues relevant to treatment. Allowing and respecting the patient’s self-definition of gender and name preferences encourages rapport and patient participation.

Physician Encounter Patient types: Referred by gender therapist
Self-referred Initial inquiry about treatment resources Self-medicating (harm reduction) Full, partial or no gender reassignment Most youths seen are referred by a gender therapist after the initial evaluation period. At times, the medical doctor is the initial contact point for a patient who seeks gender health care services. For these, discuss the patient’s concerns, possible treatment options, the SOC guidelines, and refer to a local therapist for evaluation. If the patient has been self-medicating (with hormones off the street or the internet), follow a harm reduction model and offer medical supervision. Patients come with a range of gender identities. Some will seek full, partial or no gender reassignment to achieve gender congruity.

Physician Encounter Patient centered
Collaborate with patient in treatment planning Discuss patient goals, eligibility criteria, treatment options, expectations, risks, benefits and alternatives Collaboration with the patient improves communication and compliance. During the initial encounter: discuss and compare the available hormone protocol and surgical options; discuss the absolute and relative contraindications to treatment and the treatment of co-existing health problems. E.g. hyperlipidemia, diabetes, stroke, liver impairment, psychiatric disturbances, tobacco, alcohol or substance use.

Sex Steroids Sex hormones are steroids, a class of
molecules derived from cholesterol. Cholesterol

Testosterone Estradiol

Sex Hormone Mechanism of Action

Regulation of Sex Hormones
Hypothalamus GnRH Pituitary FSH LH Gonad Testosterone or Estradiol/Progesterone

Pubertal Stages (Tanner) Male
P1 Prepubertal, testicular length less than 2.5cm P2 early increase in testicular size, scrotum slightly pigmented, few long and dark pubic hair P3 testicular length cm, lengthening of the penis, increase in pubic hair P4 testicular length cm, increase in length and thickening of the penis, adult amount of pubic hair P5 testicular length greater than 4.5cm, full sperm production

Pubertal Stages (Tanner) Female
P1 Prepubertal P2 Early development of subareolar breast bud +/- small amounts of pubic hair and axillary hair P3 Increase in size of palpable breast tissue and areolae, increased amount of dark pubic hair and of axillary hair P4 Further increase in breast size and areolae that protrude above breast level adult pubic hair P5 Adult stage, pubic hair with extension to upper thigh

Treatment Options Fully reversible interventions: Pubertal delay, hormone blockers (extends diagnostic period) Progestogens Androgen blockers: spironolactone, finasteride Leuprolide, Histrelin (GnRH agonists) Treatment options for youth include: Fully reversible hormone blockers (under 16 years of age), historically progestogens, androgen blockers such as finasteride and spironolactone, more recently leuprolide (GnRH agonist used for precocious puberty)

Progestins Medroxyprogesterone/Provera® – 10 mg/d cost 10 mg tab = $0.18 (generic) Progesterone/Prometrium® mg/d cost 100 mg tab = $1.00 (no generic)

Progestins – desired effects
Used for “chemical castration”, contraception (mini-pill) Effects reversible Suppresses estrogen and testosterone production Stops periods Not feminizing by itself, but contributes to breast growth when used with estrogen

Progestins – adverse effects
Elevates cholesterol Decreases bone density Some report depression (Provera)

Androgen Blockers Spironolactone mg/d div. twice daily cost 100 mg tab = $1.17 Blocks testosterone receptors Diuretic, retains potassium (avoid salt substitutes), sodium and water loss (dehydrationcramps), mild decrease in blood pressure Decreased blood count since testosterone stimulates RBC production

Androgen Blockers - MTF
Finasteride (Proscar®/Propecia®) Blocks 5-alpha-reductase Stops conversion of testosterone to DHT 5mg tabs = $ $3.00 1mg tabs = $2.00

Estrogen Blockers Tamoxifen – binds and blocks estrogen receptors in breast, partial agonist on endometrium. Adverse effects: endometrial cancer, hypertriglyceridemia, thromboembolism. 20 mg tab = $0.72

Estrogen Blockers Clomiphene - binds and blocks estrogen receptors. Adverse effects: ovarian enlargement, cyst formation. 50 mg tab = $2.83

GnRH Agonists Block release of FSH/LH at pituitary, therefore no stimulation of gonads to produce sex hormones

GnRH Agonists Leuprolide (Lupron®) intramuscular $300/mo.
Depo-Lupron® intramuscular $1,500-$2,000/mo.

GnRH Agonists Histrelin subcutaneous hydrogel implant Vantas®, $1,400/year for prostate Ca/uterine fibroids Supprelin LA®, $16,700/year for CPP

GnRH Agonists – adverse effects
Decreases bone density with prolonged use Local irritation (implant)

Treatment Options Partially reversible interventions: Cross-gender hormone therapy Testosterone enanthate, cypionate (IM, transdermal) Estradiol (oral, IM, transdermal) Partially reversible, cross gender hormones (usually 16 years or older)

Treatment Options Irreversible interventions: Surgery Mastectomy Hysterectomy Phalloplasty Metoidioplasty Vaginoplasty Augmentation mammoplasty Irreversible surgery (usually 18 years or older), including mastectomy, vaginoplasty, phalloplasty

Physician Encounter Collaborate with patient in treatment planning
Discuss patient goals, eligibility criteria, treatment options, expectations, risks, benefits and alternatives Obtain informed consent, and consent of parent/guardian if patient is a dependent minor (may qualify as confidential reproductive care for minors in some states?) Risks include permanent sterility. Present options for sperm banking and egg harvesting. Obtain informed consent of the patient, and of the legal guardian if the patient is a minor. A minor may be able to access gender health services under state laws for confidential reproductive care. Legal counsel is advised if considering this.

AUTHORIZATION FOR AND CONSENT TO MEDICAL TREATMENT (WPATH)
Carol F. Milazzo, M.D. AUTHORIZATION FOR AND CONSENT TO MEDICAL TREATMENT (WPATH) 1. I hereby agree and consent to allow Dr. Milazzo to provide and supervise my medical treatment in accordance with the WPATH Standards of Care. 2. I have read and understood the information provided to me on medical treatment protocols, their risks, benefits and alternatives. 3. I agree that I meet the eligibility criteria and readiness criteria for this medical treatment. 4. I have had a chance to ask questions. 5. The medical treatment protocols, their risks, benefits and alternatives have been adequately explained to me. 6. I agree to comply with medical examinations and laboratory testing which Dr. Milazzo deems necessary to supervise my treatment. Signature: Date: Signature: Relationship:_____________ (parent/conservator/guardian for minor under 18 years old) Witness: Informed consent documents the understanding and agreement between the physician and the patient that the treatment will comply with parameters of established and recognized standards. The patient is provided a copy of treatment protocols. This documentation is important as most health insurance carriers lack familiarity with practice guidelines for transgender medicine. An attorney’s input on the wording of this document may be advisable.

Physician Encounter Medical, family and social history and review of systems for issues that may impact treatment—smoking, endocrine, cancer, liver, coagulation problems, STD’s, prior or concurrent treatments, family support, ability to afford treatments The review of medical, family and social history will help focus the physical exam and elucidate treatment options.

Physician Encounter Problem focused (or expanded) physical examination
Investigate physiologic issues— pre-treatment hormone levels, intersex conditions Order baseline and other indicated laboratory tests Focus the examination on relevant organ systems. Investigate physiologic issues, ordering hormone levels, special studies (e.g., sex chromatin studies) as needed, examination of secondary sex characteristics. Order baseline laboratory tests and any others indicated by history and physical findings.

Follow up management Reassess goals
Monitor for clinical response, adverse effects and adjust treatment Follow up laboratory tests Provide referrals to competent and sensitive consultants, mammograms, pelvic exams, surgeons Follow up as per protocols and for coexisting conditions. Refer to competent consultants for other needed services.

Follow up management Assist with ID documentation change DMV Form DL 329 Transgenders require their physician’s assistance to obtain appropriate ID documentation.

Follow up management Provide referrals to local peer support groups (mentoring) Provide referrals to family support groups: Trans Youth Family Allies, PFLAG transgender network Gender Spectrum Family Direct patients to support resources in the community

These patient resources can be downloaded from the internet.

Billing issues ICD-9-DM Diagnostic codes Medical diagnoses
Endocrine disorder (259.9) Hypogonadism (257.2) Mental health diagnosis Gender identity disorder (302.85) Billing issues are important to practice viability. Health insurance carriers usually do not reimburse medical doctors for mental health diagnoses; therefore, we use ICD-9-DM codes appropriate for medical interventions. For example, endocrine disorder is a non-specific code, but hypogonadism more specifically describes a sex steroid deficiency. Upon initial presentation, FTMs are deficient in androgens and MTFs are deficient in estrogens. MTFs develop an iatrogenic androgen deficiency with hormone treatment.

AMA Resolution “June 2007, the AMA House of Delegates voted to revise current AMA policies to ensure inclusion and protection for transgender physicians, medical students and patients.” This 2007 AMA resolution calls to end disparities in all aspects of the medical community that affect transgender individuals, an incentive to include transgender health in medical curricula.

AMA Resolution 122 (2008) RESOLVED, That the AMA support public and private health insurance coverage for treatment of gender identity disorder; and be it further RESOLVED, That the AMA oppose categorical exclusions of coverage for treatment of gender identity disorder when prescribed by a physician. This recent AMA resolution calls to end exclusion of health care plans for transgender services.

References World Professional Association for Transgender Health’s Standards of Care for Gender Identity Disorders, Sixth Version, February 2001. References: WPATH Standards of Care

References An Overview of U.S. Trans Health Priorities: A Report by the Disparities Working Group of the National Coalition for LGBT Health, August,

References Sausa, L. The HIV Prevention and Educational Needs of Trans Youth: A Qualitative Study,

References de Vries, A., Cohen-Kettenis, P., Delemarre-van der Waal, H. “Clinical Management of Gender Dysphoria in Adolescents.” IJT 9.3/4 (2006): The Guidelines for Adolescent.

Resources PFLAG Transgender Network www.pflag.org
Trans Youth Family Allies

Resources Gender Spectrum Family www.genderspectrum.com
Children’s National Medical Center, Outreach Program for Children with Gender-Variant Behaviors and their Families

Resources Gender Health Center, Sacramento Sacramento provider resource list at

Resources World Professional Association for Transgender Health

Contact information Carol F. Milazzo, MD, FAAP THANK YOU! Here is contact information for presenter.

Issues in Transgender Primary Care

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