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

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

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

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

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

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

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

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

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

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

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 

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

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.

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.

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

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

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

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 -

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

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

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?

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

Testosterone Blockers Spironolactone: Begin at 50 mg and titrate to typical range of 200-300 mg daily Cyproterone: Begin at 25 mg and titrate to typical range of 25 -100 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

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 200-300mcg twice weekly Injectable: Begin with 5 mg and titrate to a usual dose of 10-20 mg q 2 weeks Transdermal indicated if > 40 + risk factors eg. smoking, requires special authority Maintain estradiol level in range of 300-800 Estrogen dose may be reduced post-gonadectomy Mention new UCSF guidelines suggest up to 8 mg

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

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

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

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

Testosterone Injectable: Begin with 25 mg and titrate to usual maintenance dose of 50-100 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 5-7.5 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

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

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

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

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

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

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 1-866-999-1514 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

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

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

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

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: http://www.checkitoutguys.ca 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

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

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

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?

Clinical support Call the RACE Line & select “Transgender Care” option: 604-696-2131 or 1-877-696-2131 Trans Care BC Care Coordination Team 1-866-999-1514 Primary care mentorship call; 1st and 3rd Wed from 5-6pm: 1-877-291-3022, participant code 7019866#

Clinical resources “Endocrine Therapy for Transgender Adults In BC: recommended guidelines” http://transhealth.phsa.ca “Primary Care Protocol for Transgender Patient Care” http://transhealth.ucsf.edu “Guidelines and Protocols for Comprehensive Primary Health Care for Trans Clients” http://sherbourne.on.ca