1. Providing Primary Care to Trans & Gender Diverse People
Marcus Greatheart, MD, MSW, PGY2
March 10, 2016

2. Overview Trans Care BC Evolving approach to trans care
Trans care in the primary care setting
Trans sensitive history and physical exam
Gender affirming medical & surgical care
Screening & prevention
Accessing support

3. Evolving Practice Historical Context
Field of trans care led and held up by specialists from psychiatry, psychology, sexual medicine, endocrinology
Hx of pathologization of trans identities
Conversion or reparative therapy
Excessive gate-keeping
Expectation of binary transition

4. Consequences of Historical Approaches
Mistrust of health care providers
Avoidance of care
Self-medicating
False narratives
Non-disclosure of important information
Increased stigma
Clients who do present for care may be reluctant to disclose issues related to gender (may come with other presenting problems)
Clients who present for trans care may not disclose important information about their mental health
Clients may provide information they think we want to hear rather than the truth

5. Transforming Practice
Challenge the“Negative Transition Story”
Transform the old medical treatment pathways into a patient-centred approach across the gender continuum

6. Copyright © 2013 World Professional Association for Transgender Health
World Professional Association for Transgender Health SOC Version 7
Acknowledge there is very little in our formal training to prepare us for working with transgender patients but that most of us find our way to some extent when faced with a human being who needs our help.
Copyright © 2013 World Professional Association for Transgender Health

7. Shifting Approaches Shift away from pathologization
moving from a disease-based to an identity-based model
Explicit endorsement of the provision of gender affirming care to those with non-binary identities
Shift towards a range of care providers (including GPs, NPs, and nurses) doing assessments and delivering gender affirming care
The most significant change is the shift from pathologization to understanding transgender identities as part of human diversity
Critically important to the way that we approach care
Explain the concept of non-binary identites in case anyone isn’t familiar

8. Informed consent
An approach to working with trans patients seeking medical and surgical intervention
Acknowledges a person’s right to self-determination
Consistent with a non-pathologizing view of gender identity
Involves providing accurate information and support to allow a person to make informed decisions about gender affirming interventions

9. Informed consent
Patients must be able to understand information provided and how the decision could potentially affect them now and in the future
Understanding of potential medical risks and benefits of treatment
Understanding of possible social risks and benefits of treatment
Ways to mitigate risk

10. The role of counselling
Counselling is not a requirement but may be beneficial for some
Exploring gender identity
Exploring options for expressing gender differently or transitioning
Support with coming out to others
Counselling for partners, other family members
Building resilience and supports
Impact of medical and surgical treatments on mood, body image, relationships, sexuality
Support with mental health concerns unrelated to gender
Talk about why some people might prefer to avoid counselling

11. Challenges in the current system
Poor access (need to travel, long waits)
“Pockets of expertise”
Perception that trans care is out of scope for primary care providers, counsellors
Persistent misconception that all trans people are in need of mental health assessment
Lack of training opportunities for those who want to build their skills 

12. Proposed Levels of Care-Child and Family, Youth and Adults
Level 4- Specialty Services
Level 3-Skills to complete care planning process, referrals for Trans related surgery, initiate hormones)
Level 2- Culturally competent primary trans specific care (breast &, cervical screening, maintaining hormone tx, common meds, doses and side effects)
Level 1- Gender affirming (space, cultural safety, language, key concepts, signage, forms etc.) Prevention and Harm Reduction.
Clinicians with Advanced Trans Care Planning skills. Client remains attached to PC provider
June 16, 2016

13. What are the health care needs of trans people?
General needs: Same needs that anyone might have but keeping in mind the need for a trans-inclusive approach and the ways that trans people may be increasingly vulnerable to health and social disparity (Level 2)
Examples: general primary care, screening and preventative health care, sexual and reproductive health services, mental health and substance use services, assistance with housing, education and employment, etc…..
what is meant by a trans-inclusive approach is simple things like using language that is respectful of trans bodies and trans identities and basic knowledge about the medical or surgical interventions your patients have had and how that might affect their health
For example a trans guy in your practice who has had a full hysterectomy doesn’t need cervical screening but a trans guy who hasn’t had this surgery does. A pap is something every GP can do but doing a pap on a trans guy may present some unique challenges. A trans guy might find cervical screening emotionally difficult and or physically uncomfortable due to the effects of testosterone on the genital mucosa and you may need to build solid rapport and trust before he is ready for this. You will need to be respectful of the language he prefers for his genitals and be sure to use language that respects his gender identity while doing this exam.

14. What are the health care needs of trans people?
Trans specific needs: Needs that are unique to transgender, gender diverse or gender-questioning people (Level 3)
access to counselling and support related to gender identity
access to peer support groups and information & support for friends and family
access to gender-affirming medical and surgical treatments
assistance with changing identification documents
Trans specific needs may be something you feel even less prepared to deal with. Having even a basic understanding of gender affirming interventions and how to assist patients to access them, where to refer patients for peer support and counselling etc can be extremely beneficial. Knowing where you as a professional can go for up to date information and support when clinical concerns arise will hopefully allow you to feel more confident about caring for transgender patients.

15. What is inclusive language?
Inclusive language is using words that respect people’s bodies, identities and relationships
Using inclusive language is a signal to people that they are seen, welcome and respected
It is a way we can begin to break down barriers to care for marginalized people

16. Trans inclusive history taking
Consider your use of gendered language in all patient encounters, not just with those who disclose trans or gender diverse identities
Always ask about names and pronouns
Frame questions in ways that make no assumptions about gender identity, gender expression or gender related goals
Consider gendered language when discussing care needs, prevention, and especially during exams

17. Relational words Gendered Language Neutral Language husband partner
pregnant women
pregnant people
dad
parent
sister
sibling

18. Anatomical words Gendered Language Neutral Language penis
external genitals
vagina
internal genitals
breasts/chest
upper body
pap smear
internal exam
female condom
internal condom
period
monthly bleeding
Here I have included some specific examples of language that can be used to improve comfort for trans identified people. Another option is to ask patients what words they would like you to use or mirroring the language they use.
Looking at skin on the outside/the inside
Avoid “normal”, say “skin looks healthy”
Avoid “well woman”
Avoid BV -

19. Trans sensitive examination
Trans people will have varying degrees of comfort with physical examination
Exams can be gender affirming or particularly difficult due to gender dysphoria or past negative experiences
Explain why you recommend an exam or test
Take extra time, invite clients to bring support person
Be especially careful of gendered language when examining sensitive body parts
Use neutral language or ask what terms the person prefers
Examine only those parts that are relevant to the situation
Examples of gender affirming exams – post-op from a gender affirming surgery a person might feel relief and pride about their body and may experience a particular exam as gender affirming
Things to mention: indicate testosterone tx on the requisition
Imagine what it’s like for a person who expends significant energy presenting themselves so that others will see them as they see themselves – then in your office they are expected to remove clothing, remove binding – allow you to examine parts that do not align – this must be approached with the utmost sensitivity

20. Gender transition Social steps Medical intervention (Level 3)
Name & pronoun change, clothing, makeup, hairstyle, etc
Medical intervention (Level 3)
puberty blockade, hormone therapy
Surgical intervention (Level 3 & 4)
upper body surgeries: male chest contouring, breast augmentation
Gonadectomy : hysterectomy, orchiectomy
Genital reconstruction: vaginoplasty, metoidioplasty, phalloplasty
Other procedures: electrolysis, tracheal shave, facial feminization

21. Assessment for hormones
Does this person have persistent gender dysphoria?
What are their goals, expectations of hormone therapy?
Are they able to provide informed consent for the requested treatment?
Are any physical and mental health conditions stable enough to proceed with treatment?
Are they ready from a psychosocial point of view?
If not, how can we support them to ensure they get this medically necessary treatment?

22. Estrogen + testosterone blockers
Goals: to reduce testosterone-related secondary sex characteristics, induce estrogen-related secondary sex characteristics & reduce gender dysphoria.
Testosterone blocker + Estrogen
Start low and titrate q 4-6 weeks
Base dose changes on lab values, patient goals, response, side effects
Goals are to maintain hormones in "female” reference ranges, induce changes and minimize side effects and risks

23. Testosterone Blockers
Spironolactone: Begin at 50 mg and titrate to typical range of mg daily
Cyproterone: Begin at 25 mg and titrate to typical range of mg daily
Spironolactone is 1st choice, watch K+, if ineffective or contraindicated cyproterone is used
Cyproterone requires special authority, watch ALT
Maintain testosterone in female range
Blockers are discontinued post-gonadectomy

24. Estrogen
Oral (17 β estradiol): Begin with 1-2 mg and titrate to typical range of 4-6 mg daily
Patch: Begin with 50 mcg and titrate to typical range of mcg twice weekly
Injectable: Begin with 5 mg and titrate to a usual dose of mg q 2 weeks
Transdermal indicated if > 40 + risk factors eg. smoking, requires special authority
Maintain estradiol level in range of
Estrogen dose may be reduced post-gonadectomy
Mention new UCSF guidelines suggest up to 8 mg

25. Effects & expected time course (estrogen +blocker)
Expected Onset
Expected Maximum Effect
Body fat redistribution
3-6 mos
2-5 years
↓ muscle mass/strength
1-2 years
Softening of skin/decreased oiliness
unknown
↓libido
1-3 mos
↓ spontaneous erections
Breast growth
2-3 years
↓ testicular volume
Changes to body & facial hair
6-12 mos
> 3 years
Fertility
*Variable effects
Main point is around how long it takes to see changes and the fact that they’re variable
Talk about fertility here – hormone tx isn’t a reliable form of contraception and hormone tx has the potential to negatively affect fertility

26. Estrogen Risk Level Estrogen Likely  risk
Venous thromboembolic, triglycerides, gallstones, LEs,  weight
Likely  risk with additional risk factors
Cardiovascular disease
Possible  risk
BP, prolactin, prolactinoma
Possible  risk with additional risk factors
Type 2 diabetes
No  risk or inconclusive
Breast CA

27. Labs (estrogen + testosterone blocker)
Baseline (and q 6-12 months thereafter):
testosterone, prolactin, CBC, ALT, fasting glucose and lipids, electrolytes, GFR, TSH
Following dose changes:
T level, E level, ALT, electrolytes
* goal is typically to maintain hormone levels in the female range, induce physical changes at expected rate and minimize adverse effects

28. Testosterone
Goals: to reduce estrogen-related secondary sex characteristics, induce testosterone-related secondary sex characteristics & reduce gender dysphoria
Testosterone
Start low and titrate q 4-6 weeks
Base dose changes on lab values, patient goals, response, side effects
Goals are to maintain hormones in male ranges, induce changes and minimize side effects and risks

29. Testosterone
Injectable: Begin with 25 mg and titrate to usual maintenance dose of mg weekly
Patch: Begin with 2.5 mg and titrate to typical dose of 5-10 mg daily
Gel/Cream: Begin with 2.5 g and titrate to a typical dose of g daily
Special authority required for injectable (& topical under special circumstances)
SC or IM
Maintain testosterone in male range
Dose may be reduced post-gonadectomy

30. Effects & expected time course (testosterone)
Expected Onset
Expected Maximum Effect
Skin oiliness/ acne
1-6 mos
1-2 years
Facial/ Body Hair Growth
3-6 mos
3-5 years
Scalp hair loss
> 12 mos
variable
↓ muscle mass/strength
6-12 mos
2-5 years
Body fat redistribution
Cessation of menses
2-6 mos
n/a
Clitoral enlargement
Vaginal atrophy
Deepened voice
3-12 mos
Fertility
*Variable effects
Talk about fertility here – hormone tx isn’t a reliable form of contraception and hormone tx has the potential to negatively affect fertility

31. Risks: testosterone Risk Level Testosterone Likely  risk
Polycythemia,  weight, acne, balding, sleep apnea
Likely  risk with additional risk factors
Possible  risk
Hyperlipidemia,  LEs
Possible  risk with additional risk factors
Cardiovascular disease,  BP, destabilization of some Ψ disorders, type 2 DM
No  risk or inconclusive
Breast CA, cervical CA, ovarian CA, uterine CA, loss of bone density

32. Labs (testosterone) Baseline (and q 6-12 months thereafter):
testosterone, CBC, ALT, fasting glucose & lipids, TSH
Following dose changes:
testosterone, CBC, ALT
* goal is typically to maintain hormone levels in the male range, induce physical changes at expected rate and minimize adverse effects

33. Hormone therapy follow up
Follow up q 4-6 weeks while titrating and then q 6–12 months
Review effects of hormones, dose, side effects, mood, supports, social challenges
Check BP, other physical exam as indicated
Review labs
Adjust dose if indicated

34. Surgical interventions
Upper surgeries:
mastectomy + chest contouring
Breast construction – only under special circumstances
Gonadectomies
Hysterectomy/BSO
Orchiectomy
Genital reconstruction
Vaginoplasty or simple vulvoplasty
Phalloplasty or metoidioplasty, clitoral release
Breast construction eligibility criteria: less than AA cup size or greater than 1.5 Cup size asymmetry after 18 months hormone therapy or hormone therapy medically contraindicated

35. Assisting Patients to Access Surgery
Some GPs/NPs are qualified to complete the necessary assessments
if you are interested in training to become a qualified please contact Trans Care BC
If you wish to set up surgical assessments for your patient, refer to a known assessor, or refer to Trans Care BC
Upper body surgeries – 1 person assessment
Lower body surgeries – 2 person assessment
In some cases, surgeons may request additional assessment e.g., Under age 18

36. Referring for Surgery
Forward assessment documentation plus a short referral note to the surgeon
Mastectomy + chest contouring – via Dr. Bowman’s office (centralized list)
Breast construction – any plastic surgeon in BC*
Orchiectomy – any urologist in BC
Hysterectomy/BSO – any gynecologist in BC

37. Referring for surgery Vaginoplasty, vulvoplasty – GRS Montreal
Phalloplasty, metoidioplasty, clitoral release – GRS Montreal or if patient wants surgery in the US refer to Trans Care BC for consideration of Out of Country surgery application

38. Cancer Screening Breast/chest cancer screening
Breast-screening mammography in those on feminizing meds over age 50 with additional risk factors (e.g., estrogen +/- progestin use > 5 years, positive family history, BMI > 35).
Post-chest surgery: annual chest wall/axillary exam; mammography as for cisgender females if no surgery
Prostate Cancer screening
PSA is falsely low in androgen-deficient setting, even in presence of cancer; only consider PSA screening in high risk patients.
If appropriate use a digital vaginal exam to evaluate the prostate in trans people who have had vaginoplasty

39. Cancer Screening Uterine cancer Cervical screening
Screen as per provincial guidelines when a cervix is present
Carefully document that this is a cervical screen and include testosterone use
Refer to Tips for Providing Paps to Trans Men available at:
Uterine cancer
Evaluate spontaneous vaginal bleeding in the absence of a mitigating factor (missed testosterone doses, excessive testosterone dosing leading to increased estrogen levels, weight changes, thyroid disorders, etc.) as for post-menopausal natal females

40. Osteoporosis
Effects of hormone therapy on osteoporosis risk not well understood
Testosterone believed to be protective
Maintain hormone therapy in patients who have undergone gonadectomy
If not possible to maintain hormone therapy consider BMD, use of bisphosphonates after 5 years off hormones & age over 50
Encourage vitamin D/Calcium supplementation

41. Trans-relevant Health Promotion
Primed: The back pocket guide for trans men and the men who dig them
Brazen: Trans women’s safer sex guide
I Heart My Chest
Transgender Health Information Program

42. Referrals Consider trans sensitivity when making referrals
Where to refer?
Is there a specialist who you know to be trans sensitive?
Consider inquiring about experience working with trans people
What to include in the referral letter? Do you need to identify the patient as trans?

43. Clinical support
Call the RACE Line & select “Transgender Care” option: or
Trans Care BC Care Coordination Team
Primary care mentorship call; 1st and 3rd Wed from 5-6pm: , participant code #

44. Clinical resources
“Endocrine Therapy for Transgender Adults In BC: recommended guidelines”
“Primary Care Protocol for Transgender Patient Care”
“Guidelines and Protocols for Comprehensive Primary Health Care for Trans Clients”