Transcript Case: Shawn - Physicians for Reproductive Health

Caring for Transgender
Adolescent Patients
Part 1: Initial Evaluation and Primary Care Perspective
Part 2: Ongoing Management, Hormones, Primary
Care

Objectives
 Differentiate natal sex, gender identity and
expression, and sexual orientation
 Discuss primary and specialized care that may be
needed by transgender adolescents
 Explain how bias and stigma create disparities and
lead to risks
 Provide initial management strategies for appropriate
and competent care to gender-nonconforming
patients

Early Childhood and Prepubescent
Gender Development

Case 1 Patient “R”
Prepubertal Gender Nonconformity
 R is an 8 y/o natal male
 During the visit, R’s parent
expresses concern that:
 “Most of his friends are female.”
 “He hates sports.”
 “I caught him wearing his older
sister’s clothes and make-up last
week.”
 “He loves to paint his nails.”

Case 1 Patient “R”
 What is your initial reaction?
 Are you concerned?
 Should his parent be concerned?

Gender and Sexuality Spectrum and Fluidity
XY
Biological Gender
Male
XX
Intersex
Female
Gender
Identity & Expression
Masculine
Androgynous
Feminine
Sexuality
Attraction, Orientation, Behaviors

Gynephilic
Androphilic
Gender…
Gender
Expression
Who we are
Natal or biologic gender—Brain, hormones, body parts assigning male and
female
gender, usually at birth
Gender identity—Person’s basic sense of being male or female, especially as
experienced in self-awareness and behavior
Gender expression—Ways in which a person acts, presents self, and
communicates
Sexuality…
Who we love
LGBTQQI—Lesbian, Gay, Bisexual, Transgender, Queer,
Questioning, Intersex
YMSM—Young Men who have Sex with Men
YWSW—Young Women who have sex with Women
Other terms—Pansexual, asexual
Why Talk About Gender?
 Professional responsibility
 AMA, AAMC, AAFP, AAP, SAHM, APA
 Recommend training on LGBT health
 Gender care is
 Patient-centered primary care
 Gender is developmental, universal
 Anticipatory guidance
 Prevention
 Future planning

Case 1 Patient “R”
 You ask R’s mother if you can
speak to R in private to ask:
 How he views his gender.
 Does he feel more like a boy or
girl?
 Does he have a preferred name?
 How could his parents help?
 How does he feel about his
parents’ concerns.

Awareness of Gender Identity
Between ages 1 and 2
Conscious of physical differences
between sexes
At 3 years old
Can label themselves as a girl or boy

By age 4
Gender identity stable
Recognize gender constant
Sexual Orientation and Gender Identity of
Middle School Students

Shields JP, et al. “Estimating population size and demographic characteristic of LGBT
youth in middle schools.” J Adol Hlth. 2013:248-50.
How Many Adults Identify as LGBT in the U.S.?

Conron KJ, et al. “Transgender health in MA: Results from a household probability
sample of adults. AJPH. 2012:102(1): 118-122.
Coming Out—Transgender
Patients
Mean,
(Age Range)
Biological
Female
Biological
Male
Age of
Presentation
14.8 (4-20)
15.2 (6-20)
14.3 (4-20)
Tanner Stage
3.9 (1-5)
4.1 (1-5)
3.6 (1-5)
Total n, (%)
97 (100)
54 (55.7)
43 (44.3)

Spack N, GeMS Clinic, Boston Children’s Hospital. Pediatrics, 2012
Gender Play
 All prepubertal children play with gender expression &
roles
 Passing interest or trying out gender-typical behaviors
 Interests related to other/opposite sex
 Few days, weeks, months, years

Gender Nonconforming Youth
Persistent, consistent, insistent
 Cross-gender expression, role playing
 Wanting other gender body/parts
 Not liking one’s gender & body (gender dysphoria)

Illustrations of Gender-Nonconforming Youth
 “She told me in first grade that she was a boy.”
 “He wanted to grow his hair long and wear jewelry.”
 “She adamantly refused to wear a dress to her aunt’s wedding.”
 “He wanted to be in the school play in the role of Cinderella.”

Who to Screen?
 All children
 Developmental stages
 Nonconforming expression
 Concerns/problems with:
 Mood
 Behavior
 Social

How to Screen
Ask! Parent(s):
Ask! Patient:
Child play, hair, dress
preferences
Do you feel more like a girl, boy,
neither, both?
Concerns with these
How would you like to play, cut
your hair, dress?
Concerns with behavior, friends,
getting along at school, school
failure, bullying, anger, sadness,
isolation, other?

What name or pronoun (he for
boy, she for girl) fits you?
Kid-Friendly Gender Screening

Case 1 Patient “R”
 R reports:
 Sometimes wishes he was a girl but prefers the
pronoun “he”
 Sadness that his mother is upset
 Unsure what gender he would be if he could choose
 He would like to play with girl things without feeling bad
 What do you do next?

Case 1 Patient “R”
 Explain to R and his mom that:
 Exploring gender roles and gender expression during
childhood is common
 R may or may not have gender identity concerns as he
matures
 Support from family is essential
 Offer yourself as a resource
 Know national, local resources

Development Issues
Prepubertal Gender Nonconformity
 Epidemiology depends on definition, populations, survey,
instrument, or culture
 Gender variant 1:500
 Transitioned 1:20,000
 Prepubertal developmental considerations
 Many children 5-12 years with gender dysphoria do not
continue
to suffer as adolescents
 Some identify as homosexual or bisexual
• Natal males—63% to 100%
• Natal females—32% to 50%

Wallien, J Am Acad Child Adoles Psychiatry 2008; 47(12):1413–23
Pathologic vs. Developmental Perspective
 DIAGNOSIS of GENDER DYSPHORIA
 Marked difference between expressed/experienced gender and
gender others would assign
 Must continue for at least six months
 Causes clinically significant distress or impairment in social,
occupational, or other important areas of function
 In children, the desire to be of the other gender must be present
and verbalized
Patient-centered developmental care—
Allows flexibility and clinical judgment

Why Identify & Support Early?
Support Matters!




Family Acceptance Project Data
224 LGB white & Latino adults, ages 21 to 25 years
Open sexual orientation to at least one parent during adolescence
“Between ages 13-19, how often did your parents/caregivers…”
OR
Negative Health Outcomes
3.4
Unprotected sex
5.9
Depression
5.6
Suicidality
8.4
Suicide attempt
I love you.
I accept you, even if
I don’t understand.
Protective…Resilience

RyanC Peds2009, RyanC JChildAdolPsychNursing2010
Addressing Parents’ Questions
Behaviors and expression may be nonconforming,
but children can still feel that they are in the right-gendered
body
Family acceptance, love, support is critical.
All children are at risk for crisis when their true sense of identity is
discouraged and/or punished.


Adolescents and Gender
Case 2 Patient “K”
 K is a 12 y/o natal female brought
in by her mother for mood and
behavior concerns
 As you explore these concerns,
you learn
 K identifies as male and gender
expression is very masculine
 K is distressed by onset of
puberty and not sure what to do
next

Terminology: What’s in a Name?
Transgender—umbrella term for individuals & communities.
A person whose identity does not conform unambiguously to
conventional notions of male or female gender roles, but
blends or moves between them.
Gender nonconforming—individuals who do not follow
other people’s ideas or stereotypes about how they should look
or act based on the female or male sex they were assigned at
birth.
Cisgender—a person whose gender identity conforms
unambiguously to conventional notions of gender, and matches
their natal/biologic gender.

Transgender Umbrella
 Bi-gendered
 Cross-dresser
 Gender bender
 Pre/post-operative
 Two-spirit
 Intersex
 Stud
 Femme queen
 Genderqueer
 Femme boi or Femme
boy

Identities and Transition
Identities include but are not limited to:
MTF = male to female,
transgender woman
FTM = female to male,
transgender man
Transition 
Process and time when person goes from living as one
gender to living as another one

Case 2 Patient “K”
 13 y/o natal female with male
gender identify & expression,
distressed by onset of puberty
 K is interested in not having
periods, looking as male as
possible & has done some
preliminary investigation of
transgender
 What do you do next?

Setting Up the Initial Assessment
 Establish privacy
 Ask mom to step out of room
 Explain what can (and can’t) be kept confidential
 Establish trust and rapport
 Ask name and preferred pronoun
 Ask goals of visit
 Getting to know the person
 General adolescent health assessment HEADDSSS
 Leading into more detailed & sensitive history

What Not to Do
 Interview only with parent in room
 All teens deserve private time
 Assume
 Name or pronoun
 Gender identity and expression correlate
 Disclose without patient’s consent
 Dismiss
 Parents as a source of support
 As a phase
 Refer for reparative therapy

Strength and Risk Assessment
 Assess personal strengths, resources, goals
 Assess social support and resources
 Address risk-taking or safety concerns
 Mental health—depression, anxiety, self harm, suicide
 Substance use/abuse
 Sexual activity—STI and pregnancy prevention

Gender Experience
 Review history of gender experience
 Open-ended encouragement: “Tell me your story in
your own words”
 Ask about specific feelings, thoughts, behaviors,
preferences
 Parent may offer excellent insight into early childhood
 Document prior efforts to adopt desired gender
 Clothing, makeup, play
 Hormone use, if any
 Review patient goals

Case 2 Patient “K”
 Engage parent(s) to support their child
 Explore parent’s concerns and priorities
 Assess parental support and knowledge
 Facilitate discussion and negotiations
 Establish expectations for all stakeholders
 Incorporate patient goals, with parental expectations,
and management options

Remind Youth and Parents…What Is
Healthy?
Gender and sexual development are
natural parts of human development
Gender and sexual expression vary
Gender and sexual diversity are different than risk
Open, honest communication is critical to healthy
decision-making, behaviors, support, and access to care

Case 2 Patient “K”
 Mental health provider
• Assess/treat other mental health concerns
 Medical provider
• Assess and consent for hormonal management
 Consider appropriate referrals to providers
with experience in transgender care
 Assess gender nonconformity
 Assess readiness for transition

Referrals and Seeking Specialized Care
 Many mental health and medical providers will not
have expertise in transgender health
 Transgender health “specialists”
 Variety of providers with experience and/or training in
caring for transgender patients
 Wide variety of disciplines, degrees, specialties
YET!
We have
lots of work
to do 

Case 2 Patient “K”
 Medical and mental providers confirm:
 Gender identity and gender needs
 Gender dysphoria
 Benefit from delaying puberty or hormones
 K’s mother is supportive
 Are these recommendations in line with national
consensus and/or guidelines?

Treatment Goals
Improve quality of life by:
 Facilitating transition to physical state that more
closely represents the individual’s sense of self
 Experiencing puberty congruent with gender
 Preventing unwanted secondary sex characteristics
 Reduce need for future medical, surgical interventions
 Avoiding depression, risk-taking
 Establishing early, strong social support

Views on Treatment of Gender Dysphoria
in Adolescents
 No treatment until 18

Full pubertal experience
 Allow some experience of puberty
• Until age 15–16 or Tanner 4
• Then start GnRH analogues or hormones
 Gender identity stable, gender dysphoria DSM
criteria met
• Start GnRH analogues Tanner 2 (age 12–13)
• Initiate hormones several years later

Phases of Transitioning
Reversible
• clothes, hair, shoes, toys,
GnRH analogues
Partially
reversible
• masculizing and feminizing
hormone therapy
Irreversible

• gender reassignment surgery
(GRS)
Benefits of Early Treatment
 If transgender identified pre/early puberty consider
“blocking” puberty
 Effects fully reversible
 “Buys time” and avoid reactive depression
 Psychotherapy facilitated when distress eased
 Prevent unwanted secondary sex characteristics
• Reduces needs for future medical interventions

Beginning Hormonal Treatment
 Assess readiness for transition
 Physical (Tanner stage)
 Psychological
 Social
 Review risks and benefits of hormone therapy
 Differentiate between reversible and irreversible
physical changes
 Establish next steps for “real life” experience

Planning for Hormonal Treatment
 Prescribing provider will establish:
 Informed consent
 Reasonable goals, expectations
 Baseline screening labs
 Set up referrals and/or follow up
 Provider and patient should establish:
 Disclosure when patient is ready
 Sources of social support
 Impact on school or work

Case 3 Patient “B”
 B is 16 y/o MTF kicked out by her
mother’s boyfriend for being “gay”
 B presents as female
 B is new to you and presents with
chief complaint of “genital rash”
 What next?

Sexual Health History
 What are gender(s) of your partner(s)?
 Have you ever had anal, genital, or oral sex?
 Do you give, receive, or both?
 How many partners have you had in past six months?
 Do you use condoms…never, some, most, all of the
time?
 Any symptoms of STIs?

Case 3 Patient “B”
 Establish safety, trust, rapport
 Evaluate problem patient wants help with
 If there’s time, begin HEEADDSSS assessment knowing
health risks for transgender population
 HEADDSSS screen reveals:
 Victimization at home and school
 Sex work with consistent unprotected receptive anal and oral
sex
 Depression, considered suicide in past
 Substance use—meth and alcohol
 Street hormones and silicone injection
 Last HIV test—one year ago

Risk Behaviors—MTF Youth
Anal sex (no condom)
UAI (receptive)
59%
49%
Sex for money/shelter
Sex & drugs
59%
53%
Coerced sex
52%
HIV
AA youth
Homeless
22%
RR ↑ 8×
18%
Incarceration history
37%

Garofalo R et al. Adolesc Health. 2006.
Risk Behaviors—MTF Youth
151 MTF youth LA & Chicago
Ever sex work?
70%
Ever HIV tested?
—of 19% (24) HIV+, few in care
85%
Ever homeless?
43%
Ever incarcerated?
52%
Street Drugs?
52%
Poverty (<$1000/month)?
70%

Wilson EC et al. AIDS Behavior. 2009
Case 3 Patient “B”
 Given B’s sexual & drug history
 HIV serology
 Syphilis serology
 NAAT urine GC/CT
 Rectal GC /CT
 Pharyngeal GC
 Hepatitis C
 What immunizations?
 Hepatitis A & B
 HPV

Minority Stress Theory
Stigma
Gender or
Sexual Minority
Prejudice, Discrimination, Abuse,
Lack of Acceptance
Isolation, Esteem, Resources
Suicide
Substance Use
SES Disadvantage
Victimization
Anxiety
Depression
Minority Stress

Adapted from O’Hanlan, et al (1997). A review of the medical consequences of
homophobia with suggestions for resolution. JGLMA;1:25‐39.)
Harm Reduction Counseling
 Safer sex options
 Facilitate condom use
 Plan for STI testing
 Support and survival
 Housing/shelter/food referral
 Vocational assistance
 Substance abuse screen/counseling
 Mental health screen/counseling
 Close follow-up

Trans Survival—Barriers to Care
 Loss of parental and familial support
 Loss of housing, emotional, and financial care
 Lack of health care
 Loss of insurance/ability to pay
 Access, availability of health providers
 Concerns regarding confidentiality, rights to care
 Social stigma
 Hostile or violent social environments
 Mental health sequelae

Consequences of Barriers
 1 of 4 withheld information about sexual practices
 (5 times more than heterosexual peers)

The Harris Poll, February 19–25, 2003
17. The Harris Poll (February 2003)
18. The Harris Poll (November 2002)
19. Gran, et. Al (2011)
20. Krehely(2009)
Create a Trans-Friendly Environment
 Visible nondiscrimination policy
 Staff training, openness
 Use preferred pronoun and name
 Transgender-inclusive materials
 Unisex/individual bathrooms
 Respect confidentiality, don’t “out”

Transgender Youth
Take Home Points
 Children and youth explore gender as well as sexual
identity
 Provider role
 Assessing individual goals, needs, risks
 Facilitating communication, support of family
 Referrals for support and resources
 Creating safe space for all youth


Caring for Transgender
Adolescents
Part 2: Understanding Medical Management &
Providing Ongoing Primary Care
Case 2 Patient “K”
 K is a 13 y/o natal female identifying
as male with some male gender
expression
 Currently uses given name in most
social situations
 Would like to use pronoun “he” and
male name
 K, his parents, other members of his
health care “team” agree:
 He is experiencing GID
 His gender identity as male is stable
 He would like to transition to male

Beginning Hormonal Treatment
 Establish commitment to next steps
 Gender incongruency
 Readiness for transition
 Expectations, goals
 Management plan
 Obtain informed consent
 Order baseline labs
 Establish follow-up

Letter from
mental health
professional?
Phases of Transitioning
Reversible
• clothes, hair, shoes, toys,
GnRH analogues
Partially
Reversible
• masculizing and feminizing
hormone therapy
Irreversible
• gender reassignment surgery
(GRS)

Benefits of “Blockers”
 Gonadotropin-Releasing Hormone (GnRH)
analogues block puberty
 Leuprolide
 Histrelin
 Delay irreversible secondary sex characteristics
 Allow time for teen to mature and make decision
 Allow time for parent and social support to develop
 Allow provider reluctance for irreversible effects in
minor

Risks of “Blockers”
 Bone mineral density reduced
 Reversible once hormones initiated
Shots hurt
 Height reduction (MTF) if started early
Going to the doctor
 Not necessarily bad thing for MTF
takes time and effort
 Negligible impact on height for FTMs
Relief >>> Risk or
 Lack of secondary sex characteristics compared to
Harms
peers
 Expense

GnRH Analogues
 Continuous GnRH secretion
 Suppress FSH, LH
 Initial ↑ LH, FSH followed by desensitized pituitary
 LH, FSH secretion suppressed
 Leuprorelin, Triptorelin, and Goserelin
 Monthly and three-monthly depot preparations
 Histrelin implant
 12 month
 Typically not covered by insurance

Dosing GnRH Analogues
 Select dosing schedule
 Monthly depot SQ or IM
• Range 3.75, 7.5, 11.5 mg
 3-monthly long-acting 11.25 mg IM
 Counseling and consent
 Few side effects aside from injection pain, withdrawal
bleed if menarcheal
 Expect to see some “effects” in 2-4 week range

Phases of Transitioning
Reversible
• clothes, hair, shoes, toys,
GnRH analogues
Partially
reversible
• masculizing and feminizing
hormone therapy
Irreversible

• gender confirmation/affirmation
surgery (GCS/GAS)
Case 3 Patient “B”
 Homeless 16 y/o MTF returns
 Presents as female
 Trades sex for drugs and shelter
 Diagnosed genital HPV last visit
 Follow visit plan
 To learn more about how you can
medically support her transition

Early Access to
Cross-Gender Hormones
Increased opportunities for preventive health care
Improved family functions, school performance
Child development in identified gender
Prevents risk taking, suffering
Leads to social change
Goals…improve quality of life

Feminizing Hormones
 Estrogens—induce development of female secondary
sexual characteristics
 Anti-androgen treatment reduces effect of
endogenous male sex hormones
 Spironolactone
 Use if no contraindications (renal disease, ↑ K)
 Progestins for breast tissue development?

Estrogen
 Estradiol
 Sublingual 2-8 mg/day total dose
• Decreased risk TE preferred over oral daily
• $4 at Walmart
 Patch 0.1-0.4 mg twice weekly
 Estradiol cypionate or valerate injection
 5–20 mg IM q 2 wks

Other Feminizing Options
 Anti-androgens
 Spironolactone 50-100 mg PO BID
 Finasteride 2-5 mg PO QD
 Progesterone
 Medroxyprogesterone (Provera) 5-10 mg PO QD
 Linked to weight gain, tubular breasts
 Unclear if benefit
 Cosmetics
 Hydroquinone, Vaniqua®, laser, electrolysis

Effects of Feminizing Hormones
 Varies from patient to patient
 Noticeable changes within 4 weeks
 Irreversible effects prior to 6 months
 Effects continue at decreasing rate for ≤ 2 years
 Post orchiectomy “spurt” of breast growth and
feminization
 Decrease estrogen dose needed

Predicting Effects of Feminizing Hormones
Action
Onset
Max
↓ libido, ↓ erections
↓testicular volume
May ↓ sperm production
1-3 mo
25% 1 yr
?
3-6 mo
50% 2-3 yr
?
Breast growth
3-6 mo
2-3 yr
Body fat redistribution
↓ muscle mass
3-6 mo
1 yr
2-3 yr
1-2 yr
Softens skin
↓ terminal hair
3-6 mo
6-12 mo
?
> 3 yr
No change in voice

Risks of Feminizing Hormones
 Complete risks are unknown
 Most studies performed in biological women
 Limited research regarding risks
 Mortality not necessarily increased
 FDA all administration off-label
 More research in the pipeline

Risks of Feminizing Hormones
 VTE
 Increased Weight
 Decreased Libido
 Erectile dysfunction
 Liver dysfunction
 TG ↑ (pancreatitis)
 HDL ↑ LDL ↓
 Increased BP

 Glucose intolerance
 Gall bladder disease
 Pituitary adenoma
 Breast cancer (3 cases)
 Anti-androgens
 ↑K
↓ BP
Case 3 Patient “B”
 Since the last visit, B reports:
 More consistent use of condoms with new partners
after your last visit
 Taking estrogen, purchased over the Internet
 She would like a stronger dose from you as she wants
more feminizing effects and breast changes

Issues with Self-Prescribed
Hormonal Therapy
 Excessive amounts
 Increased risks and medication side effects
 Does not increase feminization nor override heredity
 Excess estrogen can be converted to testosterone
 Quality
 Purity not guaranteed
 Medication and dose not guaranteed
 Safety
 Self-injection poses HIV & hepatitis risks

Baseline Labs
Feminizing Hormone Therapy




CBC
LFTs
Lipids
Chem 10
 Estrogen
 Testosterone
 Prolactin

If before or using
estradiol
• AST
• Prolactin
• T or E?
If spironolactone
• Potassium
Lab Follow-Up
for Feminizing Hormone Therapy
 Q 3 months 1–2 years
 Test according to need
 Testosterone level at 1 yr
 Goal
< 55 ng/dL
 Estradiol
 If concerns re overuse
 Goal “average female levels”
 K (Cr)
 If spironolactone

Goals
Dosing & labs by
Generate desired
effects
Avoid side effects
Average natal levels
Long-Term Procedural Options for MTFs
 Breast implants
 Orchiectomy/penectomy
 Vaginoplasty
 Facial feminizing
 Vocal cord surgery
 Plastic surgery (waist, hip, buttocks)
 Rib removal (11–12)

Health Care Maintenance for MTFs
 Emotional well-being
 STI testing, prevention
 Fertility considerations
 Sperm/embryo banking
 Contraception
 Breast cancer screening
 Self breast exam
 Mammography 10+
years or age 50
 Additional screenings,
limited evidence
 Prostate screening for
older patients?
 Pap if neo cervix
created?

Case 4 Patient “C”
 C is a 21 y/o FTM reporting.
 Self-injects testosterone from the
Internet for two years
 Has just relocated to start a new
job
 Wants to establish his identity as
male at work

Testosterone
 Multiple dosing regimens
 Oil-based testosterone for injection
 Cypionate or enanthate
 3cc luer lock syringe, 18 gauge needle to withdraw
 SQ 50–100 mg SQ weekly 5/8th inch 25 gauge needle
• Decreased peaks/troughs, side effects
 IM 50-100 mg weekly or 100-200 mg 1-1.5 inc 22
gauge every other week

Masculinizing Hormones
 Other forms
 Transdermal androderm 2.5–10 mg daily
 Androgel 2.5–5 mg packets with dosing
50–100 mg daily
 Topical testosterone to clitoris will not increase size
 Progestins may be used short term to stop menses

Predicting Effects of Masculinizing
Hormones
Action
Male pattern facial/body hair
Acne
Voice deepening
Clitoromegaly
Vaginal atrophy
Amenorrhea
Emotional changes/ ↑ libido
Increased muscle mass
Fat distribution
Tendon weakening

Onset
6–12 mo
1–6 mo
1–3 mo
3–6 mo
2–6 mo
2–6 mo
Max
4–5 yrs
1–2 yrs
1–2 yrs
1–2 yrs
1–2 yrs
6–12 mo
1–6 mo
2–5 yrs
2–5 yrs
Risks of Masculinizing Hormones
 Weight increase
 Mood changes
 Liver dysfunction
 TG ↑ HDL ↓ LDL ↑
 Insulin resistance
 Increased homocysteine
 Polycythemia
 Male pattern baldness
 Possible pelvic pain

Management of Side Effects of
Masculinizing Hormones
 Rogaine® to treat pattern baldness
 Estrogen vaginal cream for atrophy
 Retinoids for acne
 Progestin for menses
 Spotting may occur for several months followed by
amenorrhea

Initial Lab Testing for
Masculinizing Hormone Therapy





If using T
CBC
LFTs
Lipids
Cr, Glucose
Testosterone

• AST
• Hb
• Testosterone
total
• Lipids
Lab Follow-Up for
Masculinizing Hormone Therapy
 Q 3 months 1-2 years
 Test according to need
 Testosterone level at 1 yr
Goals
Dosing & labs by
 Goal 300-750 ng/dl
 CBC
 Liver function tests
 Lipids
Generate desired
effects
Avoid side effects
Average natal levels

Case 4 Patient “C”
 C had chest reconstruction
surgery two years ago
 He is considering completing his
transitioning with a hysterectomy
& oophorectomy in the next year
or two
 What might be some problems
inherent with obtaining GCS?

Gender Reassignment Surgeries for FTMs
 Male chest construction
 Different technique than mastectomy or implants
 Hysteroopherectomy
 Phalloplasty/metoidioplasty
 No function without pump
 Rarely covered by health insurance
 Performed by specialized surgeons

Case 4 Patient “C”
 During your sexual history-taking, C reports
 He is in relationship with another male & identifies as a
gay man having insertive sex in both genital openings
(anal/vaginal)
 Last STI screening—three years ago when C had
parents’ insurance
 C has never had a Pap test and expresses anxiety
over having
“a Pap”
How can you help? Does he need a pelvic exam?
What about a Pap? STI testing?

Assure
That he is not alone and many patients
are uncomfortable with pelvic exam
Provide
Information on why exam is necessary
Use
Preferred pronouns and terms for
anatomy
Discuss
Steps of the exam before and during
Support
Making positive decisions about
reproductive and sexual health
Maintain
Best practices for both anatomy &
hormones
Health Care Maintenance for FTMs
 Emotional well-being
 STI testing
 Including HIV
 PCOS
 Glucose testing
 Fertility
 Contraception
 Breast cancer screening
 Instructions in self breast
exam
 Mammography
 Pap cancer screening
 Atrophy looks like
dysplasia
 Dexa scans
 Testosterone > 5 yrs
 Age > 50

STI Screening
 CDC guidelines according to anatomy & behaviors
 Female anatomy < 25 y/o yearly NAAT screen for GC
and Chlamydia
 Vaginal and anal sex with MSM screen for syphilis and
HIV

Contraception
 FTM may have some pregnancy risk
 Testosterone not fail-safe contraceptive
 May continue to ovulate while on testosterone
 Testosterone may adversely affect development of
fetus
 Consider DMPA, Mirena®, and barrier methods
 Avoid assumption—do Family Planning
 Do you want to be pregnant or have genetic children?

Transgender Youth Take-Home Points
 Screening for gender issues, like sexual health concerns,
important throughout life span
 Medical management of treatment, including hormones,
safer than self-prescribing
 Mental health and support is important
 STI and other health care maintenance continue
 Recognize vocational, financial, and social discrimination

What
Health
Providers
CanDo?
Do…
What
Can Care
Family
Physicians
Infrastructure
Make office, clinic, wait areas gender neutral
Work with clinic staff to create trans-friendly
Training
 Screen patients of allenvironment
ages
Zero tolerance policies
 Practice and administrative changes
All patients, at various points of development
 Offer primary care and
andreferrals
age
Screen
All children
mood, behavior, and school
 Integrating transgender
healthwith
services
problems
 Teach students, residents and colleagues
Become comfortable; take a more detailed
Identify
gender history
Offer primary care
Promote open disclosure and acceptance
Offer referrals &
resources
Offer gender care and/or referral to gender
experts
Advocacy
Promote diversity in your professional and
personal communities
Resources on Transgender Health Care
 World Professional Association for Transgender
Health: www.wpath.org
 Vancouver Coastal Health: Guidelines for
Transgender Care: transhealth.vch.ca
 The Fenway Guide to LGBT Health, American
College of Physicians: www.amazon.com/FenwayLesbian-Bisexual-TransgenderHealth/dp/193051395X
 Transgender Law Center: Health Care Issues:
www.transgenderlawcenter.org/issues/health

Provider Resources—Transgender Health
 National Center for Transgender Equality:
www.transequality.org
 cdc.gov/lgbthealth/transgender.htm
 transbodies.com
 Freeing Ourselves: A Guide to Health & Self Love for
Brown Bois: www.brownboiproject.org


Specialized Health Services
 Fenway Institute (Boston): www.fenwayhealth.org
 Testing guideline for trans people: checkitoutguys.ca
 Hasbro Children’s Hospital (Providence):
www.hasbrochildrenshospital.org
 Children’s Hospital Los Angeles: www.chla.org
 BC Childrens Hospital (Vancouver): www.bcchildrens.ca
 Howard Brown Health Center (Chicago):
www.howardbrown.org
 Mazzoni Center (Philadelphia): mazzonicenter.org
 Whitman Walker Clinic (Washington, DC): www.wwc.org
 Callen-Lorde Community Health Center (New York):
www.callen-lorde.org

Trainings on Transgender Health
 Physicians for Reproductive Health Adolescent Reproductive
and Sexual Health Education Program: prh.org/teenreproductive-health/arshep-explained/
 Massachusetts Transgender Political Coalition:
www.masstpc.org/projects/trainings.shtml
 The National LGBT Health Education Center:
www.lgbthealtheducation.org
 Center of Excellence for Transgender Health:
www.transhealth.ucsf.edu
 Callen-Lorde Community Health Center: www.callenlorde.org/transgender-health-training

Resources: Changing Name and Gender
 Massachusetts Transgender Political Coalition:
www.masstpc.org/publications
 The Name Change Project from the Transgender
Legal Defense and Education Fund:
www.transgenderlegal.org/work_show.php?id=7
 Transgender Law Center:
www.transgenderlawcenter.org
 Health Care Rights and Transgender People:
www.transequality.org/Resources/HealthCareRight_U
pdatedAug2012_FINAL.pdf

Insurance and Billing Information
 Medicare Benefits and Transgender People:
www.transequality.org/Resources/MedicareBenefitsA
ndTransPeople_Aug2011_FINAL.pdf
 Human Rights Campaign: Finding Insurance for
Transgender-Related Healthcare (list of links to the
carriers’ websites where major guidelines for
transgender-related treatments are openly available):
www.hrc.org/resources/entry/finding-insurance-fortransgender-related-healthcare
 Department of Veteran’s Affairs Directive: Providing
Health Care for Transgender and Intersex Veterans:
transequality.org/PDFs/VHA_Trans_Health.pdf

Research on Transgender Health
 National Transgender Discrimination Survey:
www.thetaskforce.org/downloads/reports/reports/ntds
_full.pdf
 National Transgender Discrimination Survey Report
on Healthcare:
www.transequality.org/PDFs/NTDSReportonHealth_fi
nal.pdf
 Clements-Nolle, K., Marx, R., and Katz, M. (2006).
Attempted Suicide Among Transgender Persons: The
Influence of Gender-Based Discrimination and
Victimization. Journal of Homosexuality, 51(3), 53-69.

Provider Resources and Organizational
Partners
 www.advocatesforyouth.org—Advocates for Youth
 www.aap.org—American Academy of Pediatricians
 www.aclu.org/reproductive-freedom American Civil Liberties
Union Reproductive Freedom Project
 www.acog.org—American College of Obstetricians and
Gynecologists
 www.arhp.org—Association of Reproductive Health
Professionals
 www.cahl.org—Center for Adolescent Health and the Law
 www.glma.org Gay and Lesbian Medical Association

Provider Resources and Organizational
Partners
 www.guttmacher.org—Guttmacher Institute
 janefondacenter.emory.edu Jane Fonda Center at Emory
University
 www.msm.edu Morehouse School of Medicine
 www.prochoiceny.org/projects-campaigns/torch.shtml NARAL
Pro-Choice New York Teen Outreach Reproductive Challenge
(TORCH)
 www.naspag.org North American Society of Pediatric and
Adolescent Gynecology
 www.prh.org—Physicians for Reproductive Health

Provider Resources and Organizational
Partners
 www.siecus.org—Sexuality Information and Education Council
of the United States
 www.adolescenthealth.org—Society for Adolescent Health and
Medicine
 www.plannedparenthood.org Planned Parenthood Federation of
America
 www.reproductiveaccess.org Reproductive Health Access
Project
 www.spence-chapin.org Spence-Chapin Adoption Services

Please Complete Your Evaluations Now
