Providing Hormone Treatment

Providing Hormone Treatment
to Trans and Gender Non-Conforming Patients Sponsored by the Department of Family Medicine

Disclosures The speakers and members of the planning committee do not have conflicts of interest in this topic. There is no commercial support for this program. Our speakers will discuss uses of hormonal medications that are well studied, but off-label.

Transgender Demographics
Trans and gender non-conforming people comprise 0.6 % of the adult population. That’s 1.4 million American adults; Or 12 per practice size of 2000 patients! Source: The Williams Institute, 2016.

Hormone Therapy in Transgender and Non-Binary People
In a 2015 survey of almost 28,000 transgender and gender non-conforming people in the U.S., 78% wanted to receive hormone therapy at some point in their life, but only 49% had ever received it. A large majority of transgender men and women (95%) had wanted hormone therapy, compared to 49% of non-binary respondents. Transgender men and women were about five times more likely to have ever had hormone therapy (71%) than non-binary respondents (13%). Source: The Report of the 2015 U.S. Transgender Survey, The National Center for Transgender Equality, 2016.

A Transgender Professor
Case History: A Transgender Professor Theodore Hutchinson, PhD

Terminology, Obstacles to Health Care
and Disparities in Health Outcomes Gary Cordingley, MD, PhD

Confusing LGB with T L, G and B refer to sexual orientations.
T refers to gender identity. Sexual orientation and gender identity are quite different things, and are independent of each other.

Terminology Binary: the incorrect concept that phenomena in nature, e.g. gender identity and sexual orientation, must fall into either of two rigid categories. Transgender: People whose gender identity does not align with the sex that was assigned at birth. Their identities range anywhere from the binary “opposites” to somewhere in between (though there is a binary connotation). Cisgender: People whose gender identity is the same as their sex assigned at birth, i.e. non-transgender. Trans: often used as an umbrella term.

Wait … which is which now?
Terminology Wait … which is which now? Transgender boy or man: a person with male gender identity who was assigned female at birth. (Trans-masculine is a less binary term indicating an identity that is more masculine than feminine.) Transgender girl or woman: a person with female gender identity who was assigned male at birth. (Trans-feminine is a less binary term indicating an identity that is more feminine than masculine.)

Terminology Genderqueer: in theory, refers to non-binary (i.e. intermediate), internally felt gender identities. Gender Non-Conforming: in theory, refers to externally observable, non-binary gender expression such as in appearance, speech and behavior. Yet, some people now state that they “identify as gender non-conforming,” illustrating the rapid change of terminology in this field.

What does it mean to “transition?”
Terminology What does it mean to “transition?” Social Transitioning: to start living in a gender role congruent with one’s gender identity, with or without medical interventions. Also referred to as “going full time.” Medical Transitioning: using hormone therapy, surgeries, or both, to reduce gender dysphoria (distress due to non-alignment of mind and body). Please note: There is no one right way of doing trans; all are equally valid whether they involve medical interventions, surgical interventions, transitions -- or not. One person is not more trans than another. Each needs to find their own way and make their own journey.

Transgender People as a Group
Most of what we know quantitatively about trans people in the U.S. came from two large surveys. The first was conducted in 2008–2009 and involved 6,450 subjects. The second was conducted in 2015 and involved 27,715 subjects! Publications from these two surveys: Grant et al., National Transgender Discrimination Survey: Report on Health and Health Care, 2010; Grant et al., Injustice at Every Turn: A Report of the National Transgender Discrimination Survey, 2011; James et al., The Report of the 2015 U.S. Transgender Survey, 2016.

General Obstacles Transgender respondents were more likely…
to experience high levels of mistreatment, harassment and violence in every aspect of life, including from their own families and in their own homes. to be impoverished. to be unemployed. to be homeless. to be discriminated against in housing and in the workplace. Source: The Report of the 2015 U.S. Transgender Survey, The National Center for Transgender Equality, 2016.

General Obstacles Transgender respondents were more likely…
to experience high levels of mistreatment and harassment by police. to report high rates of physical and sexual assault by staff or other inmates while incarcerated. to be harassed, attacked or sexually assaulted while accessing restrooms. to avoid public restrooms to minimize confrontations, to limit the amount they ate or drank in order to avoid restroom use, and to experience UTIs or other urinary symptoms because of such avoidance. Source: The Report of the 2015 U.S. Transgender Survey, The National Center for Transgender Equality, 2016.

Original source of cartoon untraceable.

Los Angeles Times report on JAMA Internal Medicine article.

Obstacles to Health Care
Concerning health insurance: One in four (25%) respondents experienced a problem in the prior year related to being transgender. More than half (55%) who sought coverage for transition-related surgery in the prior year were denied, and 25% of those who sought coverage for hormones were denied. 17% reported refusal by their insurance companies to change records in order to show their current name or gender. 13% reported they were denied coverage for gender-specific services involving routine sexual or reproductive health screenings (such as Pap smears, prostate exams and mammograms) due to their transgender status. Source: The Report of the 2015 U.S. Transgender Survey, The National Center for Transgender Equality, 2016.

Obstacles to Health Care
Concerning health care itself: One-third (33%) of those who saw a healthcare provider in the prior year reported having at least one negative experience related to being transgender, including being refused treatment, verbally harassed or sexually assaulted, or having to teach the provider about transgender people in order to get appropriate care. In the prior year, 23% of respondents did not see a doctor when they needed to because of fear of being mistreated as a transgender person, and 33% did not see a doctor when needed because they could not afford it. Fear of being disrespected or mistreated by a health care provider differed by gender identity, with transgender men (31%) being more likely to avoid care out of fear of discrimination than transgender women (22%) and non-binary respondents (20%). Source: The Report of the 2015 U.S. Transgender Survey, The National Center for Transgender Equality, 2016.

Disparities in Health Outcomes
Concerning psychological distress and attempted suicide: Thirty-nine percent (39%) of respondents experienced serious psychological distress in the month before completing the survey (based on the Kessler 6 Psychological Distress Scale), compared with only 5% of the U.S. population. Forty percent (40%) have attempted suicide in their lifetimes, nearly nine times the rate in the U.S. population (4.6%). Seven percent (7%) attempted suicide in the past year – nearly twelve times the rate in the U.S. population (0.6%). Source: The Report of the 2015 U.S. Transgender Survey, The National Center for Transgender Equality, 2016.

Concerning substance abuse: One-quarter (25%) of respondents used marijuana within the past month, compared to 8% of the U.S. population. Seven percent (7%) of respondents used prescription drugs that were not prescribed to them or used them not as prescribed in the past month, compared to 2% of the U.S. population. Four percent (4%) of respondents used illicit drugs (not including marijuana and non-medical use of prescription drugs) in the past month, and 29% have used them in their lifetimes. Overall, 29% of respondents reported illicit drug use, marijuana use, and/or non-medical prescription drug use in the past month, nearly three times the rate in the U.S. population (10%). Source: The Report of the 2015 U.S. Transgender Survey, The National Center for Transgender Equality, 2016.

Source: The Report of the 2015 U.S. Transgender Survey, The National Center for Transgender Equality, 2016.

Concerning HIV: Respondents were living with HIV (1.4%) at nearly five times the rate in the U.S. population (0.3%). HIV rates were higher among transgender women (3.4%), especially transgender women of color. Nearly one in five (19%) Black transgender women were living with HIV, and American Indian (4.6%) and Latina (4.4%) women also reported higher rates.

In Summary Trans and gender non-conforming people are subject to widespread discrimination and mistreatment, including increased rates of harassment, physical assault and sexual assault. They are more likely to be impoverished, unemployed and/or homeless. Within the health care system they often have negative experiences, and as a result are more likely to delay or forgo care. They experience high rates of psychological distress, attempted suicide, abuse of drugs and alcohol, and HIV infection.

Creating a Trans-Friendly Office
Krista Duval, DO

Objectives Identify instances in which the procedures or physical features of a practice’s front-office and clinical spaces might distress trans or gender non- conforming (GNC) patients Formulate changes in greeting, registration, and manner of referring to trans and GNC patients to be respectful and inclusive; reorient naming of body- parts according to the patient’s wishes

Welcome transgender people by advertising your services and displaying positive cues the office
List your practice on these websites transcaresite.org GLMA.org transohio.org WPATH.org Create a safe and inclusive space gender neutral bathrooms posters, magazines, signs, relevant health information post non-discrimination statement

Use forms and documents that are inclusive
What is your gender? _________________ What is you preferred name? __________________ What are your preferred pronouns? _____________ Do you identify as transgender or gender nonconforming?_________________

Train your office staff
If the patient’s name or gender does not match their insurance or medical records, you can ask: “Could your chart be under a different name?” or “What is the name on your insurance?” Avoid asking a person what their “real” or “legal” name is. Instead of “How may I help you, sir?” you can simply ask, “How may I help you?” You can also use “they” instead of “she” or “he” (“They are here for their 3 o’clock appointment.”)

Be mindful of your body language
Remember that facial expressions and other body language comprise much of human communication. Yet we are often unaware of our own facial expressions and body language. How would you feel if your practitioner looked like this?

Use patient’s preferred name and pronouns
“What name would you like me/us to use?” or “How would you like to be addressed?” Write preferred name and pronoun on the chart so everyone in the team knows how to address the patient. Be willing to make mistakes and learn from them “Respecting people’s gender identity is important to me. I apologize for using the wrong pronoun.” Ask for clarification if you are not sure

Ask about preferred terms for body parts
Respect and use the patients’ names for their body parts. Realize that a transgender man might prefer use of “chest” instead of “breast,” and “canal” instead of “vagina.” A transgender woman might prefer “genitalia” to “penis and scrotum.” Before examining a sensitive area such as chest or genitalia, ask for permission and provide a brief reason, e.g. “May I examine your chest? I need to check for lumps or other problems.”

Prepare for the examination
Recognize that a provider’s response to the patient’s sexual anatomy can have a profound effect on the patient. Providers should prepare themselves before a genital exam in which a patient’s sexual anatomy may or may not be what they expect. Focus on care rather than curiosity

Be respectful of privacy
Ask permission before using a patient encounter as a training opportunity Do not disclose transgender status to anyone who does not explicitly need to know

Model the language and behavior you expect from support staff
Use preferred name/pronoun even when they are not present Do not gossip or joke about transgender people Address discriminatory or inappropriate behavior

Be prepared to help with more than meds
National Center for Transgender Equality- information for legal change of name and gender on state and federal ID and record Equitas Health- links to medical, dental, legal services from LGBTQ-affirming professionals

Resources to share with patients TransOhio Ohio University LGBT Center Family Acceptance Project familyproject.sfsu.edu/publications My Child is Transgender: 10 tips for parents of adult trans children by Matt Kailey- available on Amazon

Resources for your office Fenway Institute - online modules on LGBT health topics. Module 7 is on transgender care 10 Tips for Working with Transgender Patients American Medical Association- resources for LGBTQ-inclusive practices ama-assn.org/delivering-care/physician-resources-lgbtq-inclusive- practice ama-assn.org/delivering-care/creating-lgbtq-friendly-practice

Gender-affirming Hormones and Medications
Katy Kropf, DO

Objectives Role of informed consent
Feminizing and masculinizing medication regimens Anticipated changes in physical and emotional state Hormonal changes that DO revert and those that DON’T revert with medication cessation

WPATH SOC 2012 World Professional Association for Transgender Health, Standards of Care 2012
Flexible Standards To promote optimal health care To guide treatment of people experiencing gender dysphoria. Standards not Mandates Acknowledges the role of making informed choices and the value of harm-reduction approaches. WPATH SOC 2012

How to start: Criteria for Hormones
Persistent, well documented Gender Dysphoria Capacity to make informed decision and consent Age of Majority (some different standards for <18) Significant medical issues reasonably controlled* * In selected circumstances it can be acceptable to prescribe hormones to patients who have not fulfilled these criteria. ex. Harm Reduction DSM-5 states that the initial condition for the identification of gender dysphoria in both adults and teenagers is a noticeable incongruence between the gender the patient believes they are, and what society perceives them to be. This disparity should be ongoing for at least 6 months and should consist of 2 or more of the subsequent criteria (American Psychiatric Association, 2013): Noticeable incongruence between the gender that the patient sees themselves are, and what their classified gender assignment An intense need to do away with his or her primary or secondary sex features (or, in the case of young teenagers, to avert the maturity of the likely secondary features) An intense desire to have the primary or secondary sex features of the other gender A deep desire to transform into another gender A profound need for society to treat them as another gender A powerful assurance of having the characteristic feelings and responses of the other gender The second necessity is that the condition should be connected with clinically important distress, or affects the individual significantly socially, at work, and in other import areas of life. WPATH SOC 2012

How to Start: Two Paths Therapist Letter Informed consent
Both assume that the provider in his/her best medical judgment believes that hormone therapy is indicated and medically appropriate. Regardless of approach: appropriately trained therapists can have a significant role in alleviating gender dysphoria and facilitating changes in gender role and psychological adjustment. WPATH SOC 2012

How to Start: Discuss Fertility
Hormones alone are not a reliable form of contraception Discuss fertility-preserving options prior to starting hormones Many people are able to conceive / maintain a pregnancy with a pause in hormones, but this has not been well studied. Patients should consider assisted reproduction options (i.e. sperm banking, oocyte cryopreservation) $$ UCSF Transhealth

Medication Regimens Feminizing (MtF) Estradiol Oral – 4$ list Topical
Compounded = approx. 30$/month IM – q 2 weeks Spironolactone Oral – 25 mg 4$ list Masculinizing (FtM) Testosterone IM (most common) - Weekly to every 2 weeks *See Lyon-Martin Protocol sheet

Contraindications Estrogen Spiro Relative Feminizing Regimens
Absolute Estrogen-sensitive cancer End stage chronic liver disease Relative Thrombosis hx/risk use transdermal Estrogen Spiro Relative hyperkalemia Masculinizing Regimens Pregnancy Unstable CAD Untreated polycythemia (hct >55%) WPATH SOC 2012

Follow-up: Labs Feminizing Regimens CBC, CMP (fasting glucose), lipids, prolactin Consider Total Testosterone if inadequate feminization Monitor BP Masculinizing Regimens CBC, CMP (fasting glucose), lipids Trough Total Testosterone Monitor BP *See Lyon-Martin Protocol sheet

Follow-up: Medication adjustment
Best assessment of hormone efficacy? Clinical response Is the patient developing characteristics consistent with their gender goals? Start low and taper up Some organizations advocate for hormone level monitoring. Some do not.

Medication Risks Source: WPATH’s Standards of Care, v. 7, 2012.

Expected changes Time course: Immediate to 2-5 years
Emotional Well-being “I feel like myself for the first time in my life.” “I feel like I can breathe for the first time in my life” “This is the best thing I’ve ever done in my life.” Testosterone: decreased access to emotions, harder to cry Estrogen: increased access to emotions, easier to cry

Feminizing Masculinizing MOST changes REVERT with med cessation
Breast growth Decreased libido and decreased spontaneous erections Increased body fat Softened skin Estrogens will NOT heighten voice pitch decrease facial hair change facial bone structure reverse male-pattern baldness Masculinizing Do REVERT with med cessation Muscle mass Fat redistribution Amenorrhea Vaginal Atrophy Do NOT Revert with med cessation Deepened voice Scalp hair loss Facial/body hair growth Thickened facial structure clitoromegaly T will NOT Substantially reduce breast tissue

Changes with Feminizing
Hormones Source: WPATH’s Standards of Care, v. 7, 2012.

Changes with Masculinizing Hormones
Source: WPATH’s Standards of Care, v. 7, 2012.

On-going Clinical Questions?
Transline Clinical information and case consultation Staffed by expert providers from LGBT clinics Organized by Lyon-Martin Health Services in San Francisco

Gender Non-conforming Care
Transgender and Gender Non-conforming Care = rewarding medicine to practice

Treating Trans Children & Adolescents
Jane Balbo, DO Source: UCSF Center of Excellent for Transgender Health, Primary Care Guidelines

Interdisciplinary Team
Parents and patient Medical provider(s) Mental health provider(s) Lawyer? Consent of both parents/guardians required

Two Cohorts of Trans Youth
Early pubertal – Tanner Stage 2-3 Goal: suppression of puberty Late pubertal – Tanner Stage 4-5 Goals gender-affirming hormones for masculinizing/feminizing goals Menstrual suppression Dysphoria often appears at onset 2ndary sex characteristics

Examination To assess puberty
Severe dysphoria about chest and genitalia is common

Tanner Stages The New Zealand Digital Library

Puberty suppression

Monozygotic twins: Nicole and Jonas Maines
The earliest physical differences between the twins were achieved by pubertal suppression only.

Suppression of Puberty with GnRH Agonists (e.g. leuprolide, histrelin)
This is how endogenous gonadotropin releasing hormone works. Its physiologic release is pulsatile. Source: Colameco & Coren, JAOA, January 2009.

Suppression of Puberty with GnRH Agonists
Pulsatile GnRHa activates the receptor cells in the pituitary, while continuous GnRHa inhibits them. Source: Professor Mohamad Alhmayyd

Monitoring on GnRHa Exam, height/weight every 3-4 months
If fm hx, bone density at baseline, and during; adequate calcium, vitamin D supplementation Ultrasensitive LH, FSH, total testosterone/estradiol to assess suppression Liver, renal, lipids, glucose See UCSF Primary Care Guidelines for labs/frequency of monitoring

Adding feminizing/ masculinizing hormones
If patient continues to be gender dysphoric Conversation ongoing Endocrine Society guidelines – 16yo; others recommend sooner based on when puberty suppression initiated Testosterone (IM, transdermal) Estradiol (IM, oral, transdermal) +/- spironolactone

Menstrual suppression
Continuous oral contraceptives/ring Progesterone-delivery systems – q 3 month injection, 3-yr implant, 5-yr IUD

Surgical Intervention
Sexual intimacy, self-exploration and dysphoria WPATH and Endocrine Society recommend age 18yo Some surgeons will do younger

Ohio Resources THRIVE Program at Nationwide Children’s (614) 722-5765
Cincinnati Children’s Hospital Transgender Health Clinic Cleveland area: PRIDE Clinic/Metro TransOhio Youth/Family Support Groups ( Erin Upchurch

Surgical & Procedural Options
Gary Cordingley, MD, PhD

Source: The Report of the 2015 U. S

Chest Binding: a sometimes painful alternative to mastectomy
Image source: “Binding" refers to the process of flattening one's breast tissue in order to create a male-appearing chest. Binders can be hot and uncomfortable, and can restrict breathing. Binding with Ace bandages or duct tape can be harmful.

Source: The Report of the 2015 U. S

Chest/Breast (“Top”) Procedures

Mastectomy in a Trans Man (Before)
From: Belgrade Center for Genital Reconstruction Surgery, Miroslav Djordjevic, MD, PhD

Mastectomy in a Trans Man (After)

Augmentation Mammoplasty in a Trans Woman
Before After From: Sound Plastic Surgery, Joshua Cooper, MD, FACS

Criteria for Breast/Chest Surgery (One MHP Referral)
Criteria for mastectomy and creation of a male chest in FtM patients: Persistent, well-documented gender dysphoria Capacity to make a fully informed decision and to consent for treatment; Age of majority (if younger, follow SOC for children & adolescents); If significant medical or mental health concerns are present, they must be reasonably well controlled. Hormone therapy is not a prerequisite. Criteria for breast augmentation (implants/lipofilling) in MtF patients: Same four criteria as for mastectomy and creation of a male chest. Although not an explicit criterion, it is recommended that MtF patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better aesthetic results. WPATH, Standards of Care, 7th version, 2012.

Gonad/Genitalia (“Bottom”) Procedures

Criteria for Gonadal Surgery (Two MHP Referrals)
Criteria for hysterectomy and salpingo-oophorectomy in FtM patients and for orchiectomy in MtF patients: Persistent, well-documented gender dysphoria; Capacity to make a fully informed decision and to consent for treatment; Age of majority; If significant medical or mental health concerns are present, they must be reasonably well controlled; Twelve continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual). The aim of hormone therapy prior to gonadectomy is primarily to introduce a period of reversible estrogen or testosterone suppression before the patient undergoes irreversible surgical intervention. WPATH, Standards of Care, 7th version, 2012.

Evolution of Terms for Trans Genital Surgeries*
Sex Change Operation SRS = Sex Reassignment Surgery GRS = Gender Reassignment Surgery GCS = Gender Confirmation Surgery GAS = Gender Affirmation Surgery Bottom surgery Older Newer *Of course, it makes sense to use the same term your patient does.

Metoidioplasty In Greek, met(a)oidioplasty means “toward male genitalia.” Metoidioplasty uses only local tissue; there is no grafting. Erections are possible. It does not preclude a later phalloplasty with grafted tissue. The surgeon separates the testosterone-enlarged clitoris from the labia minora, and severs its suspensory ligament to lower and extend the neo-penis into a more usual position. The neo-penis is 4-5 cm long and has the girth of a thumb. Placing a urethra in the phallus is an option allowing for urination while standing. A scrotum can be created from labia majora; testicular implants can be placed in a later procedure. Enough lengthening for vaginal penetration may not be possible.

Metoidioplasty Before After

Phalloplasty These are usually performed after a preceding hysterectomy or vaginectomy. There are multiple techniques; all involve taking graft tissue from a donor site and extending the urethra. Often performed in staged procedures. The donor skin can be free-flap (e.g. from forearm) or pedicled flap (e.g. from thigh). It is rolled into a tube and grafted to the inguinal area. A urethral hookup can be formed from buccal or vaginal mucosa. Later, an erectile implant may be placed. Unlike in metoidioplasty, the neo-penis does not contain its own erectile tissue. Scrotoplasty (with or without testicular implants) may also be performed using skin flaps.

Phalloplasty in a transgender man, showing tissue grafting scar on the left hip.
Source: Wikipedia

Vaginoplasty Usually involves penile inversion to produce the lining of the neo-vagina, which is therefore not self-lubricating. The vaginal vault is created between the rectum and the urethra. Orchiectomy is performed. Labia majora are created from scrotal skin. A clitoris is created from part of the glans penis. The prostate gland (the anatomic equivalent of the G-spot) is left in place. Post-operatively, frequent dilation is required to maintain the vaginal vault.

Vaginoplasty in a Transgender Woman
Appearance at the end of surgery Outcome one year later: normal appearance of the vulva. Clitoris is hooded. Vagina has normal depth and width From: Belgrade Center for Genital Reconstruction Surgery, Miroslav Djordjevic, MD, PhD

Criteria for Genital Surgery (Two MHP Referrals)
Criteria for metoidioplasty or phalloplasty in FtM patients and for vaginoplasty in MtF patients: Persistent, well-documented gender dysphoria; Capacity to make a fully informed decision and to consent for treatment; Age of majority; If significant medical or mental health concerns are present, they must be reasonably well controlled; Twelve continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual); Twelve continuous months of living in a gender role that is congruent with their gender identity. The 6th criterion (a.k.a. “the real life test”) is based on expert consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role before undergoing irreversible surgery. WPATH, Standards of Care, 7th version, 2012.

Jane Balbo, DO (moderator)
Panel Q&A Jane Balbo, DO (moderator) Gary Cordingley, MD, PhD Krista Duval, DO Theo Hutchinson, PhD Katy Kropf, DO

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