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

2. 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

3. The Beginning
Dr. Harry Benjamin ( ) – 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.

4. 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.

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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.

12. 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

13. Tim/Trina

14. 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.

15. 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

16. 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”

17. 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

18. 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

19. 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

20. 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

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

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

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

24. 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,

25. 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

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

27. 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

28. 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 mg/d

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

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

31. 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

32. 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.