Case: Shawn - Physicians for Reproductive Health
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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
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