Primary Care of Transgender and
Gender Nonbinary Patients
Julie Prussack, MD
December 16, 2016
Disclosures
None
Disclaimer: No medications are currently FDA-approved for
gender alteration or affirmation. Discussion of treatment is based
on expert opinion.
Objectives
1. Understand common vocabulary, barriers to care, and
available guidelines as they relate to transgender and
gender non-conforming patients.
2. Review specific guidelines for primary care.
3. Briefly introduce hormone therapy for transgender
patients.
4. Become familiar with University of Michigan and
community gender resources.
Terminology
• Transgender (trans): A term for people whose gender
identity, expression or behavior is different from those
typically associated with their assigned sex at birth.
• Cisgender (cis): A term for people whose gender identity,
expression or behavior is the same as those typically
associated with their assigned sex at birth.
Transgender Terminology. National Center for Transgender Equality. Washington, DC, January 2014. URL:
http://www.transequality.org/sites/default/files/docs/resources/TransTerminology_2014.pdf
Terminology
• Transgender man (transman, FtM): A term for a
transgender individual who currently identifies as a man.
• Transgender woman (transwoman, MtF): A term for a
transgender individual who currently identifies as a woman.
• Gender non-conforming: A term for individuals whose
gender expression is different from societal expectations
related to gender.
Transgender Terminology. National Center for Transgender Equality. Washington, DC, January 2014. URL:
http://www.transequality.org/sites/default/files/docs/resources/TransTerminology_2014.pdf
Terminology
• Queer: A term used to refer to lesbian, gay, bisexual and,
often also transgender, people. Depending on the user, the
term has either a derogatory or an affirming connotation.
• Genderqueer: A term used by some individuals who identify
as neither entirely male nor entirely female.
• Transsexual: An older term for people whose gender identity
is different from their assigned sex who seeks to transition.
• Cross-dresser: A term for people who dress in clothing
traditionally or stereotypically worn by the other sex, but who
generally have no intent to live full-time as the other gender.
Transgender Terminology. National Center for Transgender Equality. Washington, DC, January 2014. URL:
http://www.transequality.org/sites/default/files/docs/resources/TransTerminology_2014.pdf
Terminology
• Bi-gendered: One who has a significant gender identity that
encompasses both genders, male and female.
• Intersex: A term used for people who are born with a
reproductive or sexual anatomy and/or chromosome pattern
that does not fit typical definitions of male or female.
• Transition: The time when a person begins living as the
gender with which they identify rather than the gender they
were assigned at birth, which often includes changing one’s
first name and dressing and grooming differently.
Transgender Terminology. Washington: National Center for Transgender Equality, January 2014. URL:
http://www.transequality.org/sites/default/files/docs/resources/TransTerminology_2014.pdf
Trans Student Educational Resources. Illustrations by Anna Moore. Design by Landyn Pan. URL:
http://www.transstudent.org/gender
A Visit to the Doctor
•
•
•
•
•
•
•
•
•
Calling to make an appointment
Arriving in the waiting room
Checking in with the clerk
Being called by the MA
Intake with the MA
Meeting the physician
Physical exam
Check out
Obtaining medications or studies
Health Disparities
• 2011 National Transgender Discrimination Survey: 6,450
transgender and gender non-conforming study participants
• 19% reported being refused medical care due to their
transgender or gender non-conforming status
• 28% were subjected to harassment in medical settings
• 2% were victims of violence in the doctor’s office
• 50% reported having to teach their medical providers about
transgender care
• Despite barriers, 62% had accessed hormone therapy
Grant et al. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for
Transgender Equality and National Gay and Lesbian Task Force, 2011.
Health Disparities
• Greater than 4 times the national average of HIV infection
(2.6% vs. 0.6%)
• 26% use or have used alcohol and drugs to cope with
discrimination
• 41% reported attempting suicide compared to 1.6% of the
general population
• 57% faced some rejection by their family
• Family rejection significantly increased rates of
homelessness, incarceration, sex work, HIV, suicide attempts,
smoking, and use of drugs and alcohol.
Grant et al. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for
Transgender Equality and National Gay and Lesbian Task Force, 2011.
Why Primary Care?
• Bridging gaps is what we do.
• Gender issues affect the whole family.
• Why not?
UCSF Primary Care Guidelines
• Last updated June 2016 by the Center of Excellence for
Transgender Health, peer-reviewed
• Available online: http://transhealth.ucsf.edu/protocols
• Key concepts:
• Honor the patient’s preferred gender identity,
pronouns, and terminology.
• Provide care for anatomy that is present while
respecting patient’s gender identity.
Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San
Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition.
Deutsch MB, ed. June 2016.
Evidence-Based Trans-Medicine
Populations in which data exits
T (At least some data in transgender population)
NT (Data from other populations)
X (No data – expert opinion)
Strongest available data
M (Meta-analysis), R (RCTs), O (Observational), C (Consensus)
Overall strength of recommendation
S (Strong), M (Medium), W (Weak)
Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San
Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition.
Deutsch MB, ed. June 2016.
Fenway Health Guidelines
• Last updated Fall 2015 by the Fenway Health
Transgender Health Program, Boston, MA
• Available online: http://www.lgbthealtheducation.org/wpcontent/uploads/COM-2245-The-Medical-Care-ofTransgender-Persons.pdf
• Key concepts:
• Acknowledging the gender identity spectrum
• Hormone therapy and pre/post surgical care as
primary care
The Medical Care of Transgender Persons. Fenway Health Transgender Health Program. Fall 2015.
Evidence-Based Trans-Medicine
Populations in which data exits
T (At least some data in transgender population)
NT (Data from other populations)
X (No data – expert opinion)
Strongest available data
M (Meta-analysis), R (RCTs), O (Observational), C (Consensus)
Overall strength of recommendation
S (Strong), M (Medium), W (Weak)
Primary Care Protocol for Transgender Patient Care , Center of Excellence for Transgender Health, University of California, San
Francisco, Department of Family and Community Medicine, April 2011
Patient Intake
• Ask: What name do you want to be called? What is your current
gender identity? What sex were you assigned at birth? What
pronouns do you prefer?
• What treatments and surgeries have you had or do you wish to
have?
• Relevant past history, medications, allergies, family history,
social history
• Who is your Care Team?
• If possible delay sensitive physical examination until rapport has
been established
• Consider process improvement for use of preferred name, etc.
Primary Care Protocol for Transgender Patient Care , Center of Excellence for Transgender Health, University of California, San
Francisco, Department of Family and Community Medicine, April 2011
Cancer screening for transwomen
• Screening mammography in women >50yo with risk factors
including estrogen/progesterone use for >5 years, family
history of breast cancer. Frequency every 2 years (T O W).
• No screening for prostate or testicular cancer. PSA lowered
by estrogen/anti-androgens. Prostate is anterior to neovagina.
• Neovaginas have keratinized epithelium and do not require
Pap smears
• May consider speculum exam vs. anoscope exam of
neovagina to look for skin lesions
Cancer screening for transmen
• Routine breast cancer screening unless bilateral mastectomy
• If cervix present, perform Pap smears and cotesting per ASCCP
guidelines, include testosterone as hormone therapy on
requisition (testosterone can cause atrophy, 10x more likely to
have unsatisfactory sample)
• Emerging research on self-collected vaginal swabs for HPV
• If cervix removed but history of cervical cancer/high-grade
dysplasia, follow ASCCP guidelines
• No evidence of increased risk of endometrial or ovarian cancer
• Work-up abnormal symptoms including unexplained vaginal
bleeding with previous testosterone-induced amenorrhea
Cardiovascular (CV) health
• Evidence shows no increased CV risk in transgender men on
testosterone vs. natal women; unclear if increased risk of
MI/stroke for transgender women on estrogen.
• Unclear effect on blood pressure, lipids
• Counsel on modifiable risk-factors (smoking, diet, exercise)
• For CV risk calculators, may choose natal sex, affirmed gender,
or average (account for length of time on/off hormones) (X C M)
• Consider transdermal estrogen for transwomen with CV disease
or risk factors (NT O M)
Type 2 diabetes
• Screen based on risk factors and guidelines
• Some evidence that testosterone may lower insulin
resistance and estrogen may increase insulin resistance
• Encourage good diabetes control, but do not withhold
hormone treatment
• Important to obtain good control perioperatively
Osteoporosis screening
• Confounded by limited/conflicting recommendations for
screening in general population
• UCSF recommendations:
‒ All transgender people should start DEXA at age 65
‒ If increased risk, consider starting at age 50
‒ Transgender people without gonads or hormone
replacement should follow screening and prevention
guidelines for postmenopausal women (X C W)
• Fenway: Transwomen on estrogen do not need screening
Other musculoskeletal health
• Transmen on testosterone: Emphasize stretching, reps,
gradual increases in weight to avoid tendon rupture.
Sexual health
• STI screening recommendations are not specific to
transgender patients
• Screen based on risk factors
• Urine screening for chlamydia, gonorrhea, and
trichomonas can be used for all patients
• Be cognizant of possible history of trauma
• Discuss impact of gender-affirming treatments on sexual
function
• Take a complete sexual history
Taking a sexual history
•
•
•
•
•
•
•
Are you having sex? How many sex partners have you had in the past
year?
Who are you having sex with? (including anatomy and gender of
partners) What types of sex are you having? What parts of your anatomy
do you use for sex?
How do you protect yourself from STIs? (How often do you use
condoms/barriers? Any use of PrEP?)
What STIs have you had in the past, if any? When were you last tested
for STIs?
Has your partner(s) ever been diagnosed with any STIs?
Do you use alcohol or any drugs when you have sex?
Do you exchange sex for money, drugs, or a place to stay?
Gelman et al. Principles for Taking an LGBTQ-Inclusive Health History and Conducting a Culturally Competent Physical
Exam. In: Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. 2nd ed. Philadelphia: American College of
Physicians; 2015.
Fertility
• Prior to therapy, all transgender people should be
counseled on effects on fertility and options for fertility
preservation (T O S)
• Offer sperm banking (International Cryogenics) or oocyte
preservation (REI) – not possible if no natal puberty
• Hormone therapy is not contraception
• Evidence is limited re: return of fertility if hormone therapy
is discontinued
Mental health
• Screen for depression, substance abuse, suicidal
ideation/attempts, eating disorders, safety, stressors
• Work in partnership with mental health provider when
indicated
• Screen for non-prescribed treatments
• If obtaining non-prescribed hormones, help to obtain
prescribed hormones to reduce potential harm
• PCPs may feel comfortable initiating hormone therapy
with informed consent model (T O S)
WPATH
• Incorporated in 1979 as the Harry Benjamin International
Gender Dysphoria Association, changed name to World
Professional Association for Transgender Health in 2007
• 7th version of Standards of Care (SOC) published in 2012
• Mission to promote evidence based care, education,
research, advocacy, public policy, and respect in
transgender health.
World Professional Association for Transgender Health, 2016. URL: www.wpath.org
WPATH Criteria for Hormone Therapy
1. Persistent, well-documented gender dysphoria;
2. Capacity to make a fully informed decision and to
consent for treatment;
3. Age of majority in a given country (if younger, follow SOC
for Puberty-Suppressing Hormones)
4. If significant medical or mental health concerns are
present, they must be reasonably well-controlled.
Coleman et al. Standards of Care for the Health of Transsexual, Transgender, and GenderNonconforming People, 7th version. The
World Professional Organization for Transgender Health, 2012. URL: www.wpath.org
Criteria for Puberty-Suppressing Hormones
1. The adolescent has demonstrated a long-lasting and intense
pattern of gender nonconformity or gender dysphoria (whether
suppressed or expressed);
2. Gender dysphoria emerged or worsened with the onset of
puberty;
3. Any coexisting psychological, medical, or social problems that
could interfere with treatment (e.g., that may compromise
treatment adherence) have been addressed, such that the
adolescent’s situation and functioning are stable enough to start
treatment;
Coleman et al. Standards of Care for the Health of Transsexual, Transgender, and GenderNonconforming People, 7th version. The
World Professional Organization for Transgender Health, 2012. URL: www.wpath.org
Criteria for Puberty-Suppressing Hormones
4. The adolescent has given informed consent and, particularly
when the adolescent has not reached the age of medical consent,
the parents or other caretakers or guardians have consented to
the treatment and are involved in supporting the adolescent
throughout the treatment process.
Coleman et al. Standards of Care for the Health of Transsexual, Transgender, and GenderNonconforming People, 7th version. The
World Professional Organization for Transgender Health, 2012. URL: www.wpath.org
Physical effects of hormone therapy
•
•
Expected effects from treatment of transmen: deepened
voice, clitoral enlargement, facial and body hair growth,
amenorrhea, breast tissue atrophy, and decreased
percentage of body fat compared to muscle mass.
Expected effects from treatment of transwomen: breast
growth, decreased erectile function, decreased testicular
size, and increased percentage of body fat compared to
muscle mass.
Coleman et al. Standards of Care for the Health of Transsexual, Transgender, and GenderNonconforming People, 7th version. The
World Professional Organization for Transgender Health, 2012. URL: www.wpath.org
Feminizing Hormone Therapy (T O M)
Hormone
Estrogen
Initial-lowb
Initial
Maximum
Comments
If >2mg recommend dividing
bid.
Max single patch dose available
Estradiol transdermal 50mcg
100mcg
100-400 mcg is 100mcg. Frequency of
change is product dependent.
Estradiol valerate IMa <20mg IM q2 wk 20mg IM q2wk 40mg IM q2wk May divide dose to weekly.
Estradiol cypionate
<2mg q 2wk
2mg IM q2wk 5mg IM q2wk May divide dose to weekly.
IM
Androgen blocker
Spironolactone
25mg qd
50mg bid
200mg bid
Finasteride
1mg qd
5mg qd
Dutasteride
0.5mg qd
Estradiol PO/SL
1mg/day
2-4mg/day
8mg/day
Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San
Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition.
Deutsch MB, ed. June 2016.
Feminizing Hormone Lab Monitoring
Test
BUN/Cr/K+
Lipids
A1c or glucose
Estradiol
Total Testosterone
Baseline
3 mo.
X
X
Per USPSTF
Per USPSTF
X
X
6 mo. 12 mo. Yearly PRN
X
X
X
X
X
X
X
X
X
X
X
Comments
Only w/spironolactone
Otherwise no evidence
Otherwise no evidence
Sex Hormone
Binding Globulin
X
X
X
X
Optional to calculate
bioavailable testosterone
Albumin
X
X
X
X
“
X
Only if symptoms of
prolactinoma
Prolactin
Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San
Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition.
Deutsch MB, ed. June 2016.
Masculinizing Hormone Therapy (T O M)
Androgen
Testosterone Cypionate
IM/SQ
Testosterone Enthanate
IM/SQ
Testosterone topical gel
1%
Testosterone topical gel
1.62%
Initial – low
Initial
Maximum
Comment
20 mg/week
50mg/week
100mg/week
May double for q2wk
20mg/week
50mg/week
100mg/week
"
12.5-25 mg Q
May come in pump or
50mg Q AM
100mg Q AM
AM
packet
40.5 - 60.75mg
20.25mg Q AM
103.25mg Q AM "
Q AM
Patches come in 2mg and
Testosterone patch
1-2mg Q PM 4mg Q PM
8mg Q PM
4mg size; may cut
Testosterone cream
10mg
50mg
100mg
Needs to be compounded
Testosterone axillary gel
Comes in pump only, one
30mg Q AM
60mg Q AM
90-120mg Q AM
2%
pump = 30mg
Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San
Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition.
Deutsch MB, ed. June 2016.
Masculinizing Hormone Lab Monitoring
Test
Baseline
3 mo. 6 mo. 12 mo. Yearly
Lipids
Per USPSTF
A1c or glucose
Per USPSTF
Estradiol
X
X
Total Testosterone
X
X
X
PRN
X
X
X
X
Sex Hormone
Binding Globulin
X
X
X
X
Optional to calculate
bioavailable testosterone
Albumin
X
X
X
X
“
Hemoglobin &
Hematocrit
X
X
X
X
Comments
Otherwise no evidence
Otherwise no evidence
X
Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San
Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition.
Deutsch MB, ed. June 2016.
Surgical Treatment
•
•
•
•
•
Top surgeries and bottom surgeries
Voice and facial surgeries
Primary care may be front lines for surgical follow-up
Examine for healing
High risk of UTIs and urinary problems
University of Michigan Resources
• Comprehensive Gender Services Program: 734-998-2150
or [email protected]
• Mental Health Resources
• Referrals to Primary Care, Hormone Prescribers,
Surgeons, Speech Therapy
• Support Groups: Over 30, Parents, Partners,
Transgender Teens, Trans-Masculine, TransFeminine
URL: http://www.uofmhealth.org/conditions-treatments/transgender-services
University of Michigan Resources
•
•
•
•
•
•
Reproductive Endocrinology: Dr. John Randolph
Plastic Surgery: Dr. William Kuzon
Urology: Dr. Dana Ohl
Family Medicine: Dr. Phillip Rodgers & others
Corner Health Center: Dr. Kathryn Fessler
Adolescent Health Initiative
• Voices of Transgender Adolescents in Health Care
https://www.youtube.com/watch?v=CHN3YhMi-5A
University of Michigan Resources
Pediatric Gender Management Program at Mott
Dr. Daniel Shumer, Endocrinology [email protected]
Sara Wiener, Social Work [email protected]
Dr. Ellen Selkie, Adolescent Medicine [email protected]
Dr. Joanna Quigley, Child Psychiatry [email protected]
http://www.mottchildren.org/conditions-treatments/gendermanagement
Community Resources
• Integrative Empowerment Group
Ann Arbor/Ypsilanti; 734-945-6210
Counseling, therapy, yoga with LGBTQ expertise
• Ozone House
Ann Arbor/Ypsilanti; Crisis Line 734-662-2222
Youth shelter, drop-in center, positive programming
• Ruth Ellis Center
Highland Park; 313-252-1950
Residential and drop-in, mental health services, education
• Spectrum Center
Ann Arbor; 734-763-4186
Support center for LGBTQ students at University of Michigan
Community Resources
• Planned Parenthood Michigan
Ferndale and other locations; 248-399-5900
Sexual healthcare for men and women
• Riot Youth/Neutral Zone
Ann Arbor; 734-214-9995
Programs for high school students in arts, music, education, leadership
• Unified
Detroit/Ypsilanti/Jackson; 734-572-9355
HIV testing, condoms, behavioral health, housing assistance, support groups
• Michigan Organization on Adolescent Sexual Health (MOASH)
Lansing; 517-318-1414
Health resources geared towards youth
Community Resources
• Stand with Trans
Farmington; https://facebook.com/standwithtrans
Community building, engaging trans youth and allies
• Affirmations
Ferndale; 248-398-7105
Community spaces and activities, support groups, wellness classes
• Youthville Detroit
Detroit; 313-869-2200
Groups, activities, leadership programs; health center for patients 10-21yo
• Trans Lifeline
877-565-8860
Hotline staffed by transgender people for transgender people