Download The Role of the Primary Care Physician in Management of

Caring for the
Spectrum
Transgender Health for the Primary Care Provider
Christopher Kargel, DO, MPH
Family Medicine Resident (PGY3)
OPSO Winter Conference 2015
Disclosures
•
I have no financial incentives
to disclose.
•
I am inadequate to represent
the needs and desires of this
community.
•
Histories contained in this
presentation where obtained
for the explicit purpose of
educating physicians and
with the brave and generous
permission of those who
lived them.
“Let us not be governed today by what we did
yesterday, nor tomorrow by what we did today, for
day by day we must show progress.”
–Andrew Taylor Still, Journal of Osteopathy, Vol. V, No. 3, p.
127
•
Population estimates remain
notoriously unclear
•
Oregon Health Plan recently
changed coverage options
for transgender patients
making Gender Dysphoria
"above the line."
•
Individuals have already
started moving to Oregon for
the explicit purpose of
receiving healthcare.
•
We are woefully unprepared
to meet their needs.
Case #1
•
24 year old patient presents to clinic after moving with
partner from New York. Identifies as female and has been
living as female for several years.
•
First understanding that she was female came at 4 years
old.
•
Confusion became worse with puberty.
•
Initial attempts at counseling focused on religion.
•
Identified as queer for political reasons until she read the
transgender author.
Case #1
•
Multiple therapists throughout life. First several
approached issue solely from religion. After high
school, she found an accepting therapists, but
could not continue because of costs.
•
Felt forced to seek therapy through online social
communities.
•
Began taking hormone therapy on her own after
reading protocols on the internet and purchasing
medications online from Canada or India.
Gender Dysphoria
Terminology
•
Sex: biological indicator of male or female in
reproductive capacity
•
Gender: the public (and usually legal) lived role as
male or female
•
Gender assignment (Natal gender): initial, usually at
birth, assignment as male or female
•
Gender reassignment: an official change of gender
Gender Dysphoria
Terminology
•
Gender Identity: sense of one's self as male,
female, or other.
•
Gender Presentation: expression of gender
•
Gender Atypical (Genderqueer): one who does
not accept standard definitions of gender
Gender Dysphoria
Terminology
•
Transgender: one who lives "across" or "beyond" gender
•
The broad spectrum of individuals who transiently or persistently
identify with a gender different from their natal gender
•
Transsexual: person seeking hormonal/surgical treatment to modify
bodies
•
Transmale: transgender person who identifies as male (also referred
to as FTM (Female to Male) although some see this as insensitive)
•
Transfemale: transgender person who identifies as female
Gender Dysphoria
•
Previously referred to as Gender Identity Disorder.
•
DSM-V: A marked incongruence between one's experienced/expressed gender
and assigned gender, of at least 6 months' duration. Plus two of the following:
•
A marked incongruence between one's experienced /expressed gender and
primary and/or secondary sex characteristics
•
A strong desire to be rid of one's primary and/or secondary sex characteristics
•
A strong desire for the primary and/or secondary sex characteristics of the other
gender
•
A strong desire to be treated as the other gender
•
A strong conviction that one has the typical feelings and reactions of the other
gender
•
The condition is associated with clinically significant distress or impairment in
social occupational, or other important areas of functioning
Gender Dysphoria
Characteristics:
•
Anatomic Dysphoria
•
Adopt dress, behavior, and mannerisms of
experienced gender
•
Can be accompanied by alternative or fluid
expression of sexuality
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Increased risk of suicidal ideation and attempts
Gender Dysphoria
Differential Diagnosis
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Non-conformity to gender roles
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Transvestic Disorder
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Body Dysmorphic Disorder
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Schizophrenia (specifically the delusion of being
a different gender)
Gender Dysphoria
Patient Perspective
•
Disruption of identity
•
Appropriate language and culture context "virtually non-existent"
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Dysphoria versus challenges from external or internal oppression
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Challenges worse when combined with social biases against race,
mental illness, body habitus, piercings or tattoos, or
socioeconomic status
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Emphasis that condition "can be fatal"
Case #2
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22 year old patient who identifies as male presents as
partner of initial patient presents with acute on chronic
depression, anxiety, and difficulty sleeping.
•
Also notes racing thoughts, difficulty leaving the house,
trouble breathing, vague complaints of chest pain, acne.
•
Alludes to history of abuse, professional maltreatment
from health care workers, and history of suicidality.
•
Strongly focused on pursuing surgical re-assignment as
potentially curative treatment for mental health disorders.
Medical Management
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Individualized hormone therapy is a medical
necessity
•
Best conducted with comprehensive care and
psychosocial needs
•
Hormone therapy can be managed by qualified
primary care practitioner
Medical Management
Pre-Screening
•
Requirements:
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Persistent, well-documented dysphoria
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Capacity to make fully informed decisions
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Age of majority (alternate Standard of Care for children
and adolescents)
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Reasonably well-controlled medical or mental health
concerns
Medical Management
Pre-Screening
•
Recommendations:
•
Smoking cessation
•
Physical exam
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PARQ (may patient to articulate risks and benefits)
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Negative drug toxicity screening
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Discuss effects to reproductive health
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Laboratory screening: CBC, CMP, lipid panel
Medical Management
Feminizing Therapy
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Risks: Venous thromboembolic disease,
hypertriglyceridemia, cardiovascular disease,
type II diabetes, breast cancer
•
Contraindications: previous clots, estrogensensitive neoplasm, end stage liver disease
Medical Management
Feminizing Therapy
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Estrogens (dose related adverse effect)
•
Protesting (controversial)
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Anti-androgens
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Spironolactone (monitor blood pressure and electrolytes)
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Cyproterone acetate (not approved in US)
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GnRH agonists (expensive, injectables)
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5 alpha reductase inhibitors (assist in hair loss/growth, skin
consistency, sebaceous glands)
Medical Management
Masculinizing Therapy
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Risks: weight gain, polycythemia, acne, PCOS,
hyperlipidemia, psychiatric destabilization,
cardiovascular disease, hyperlipidemia,
diabetes, loss of bone density, feminine cancers
(breast, cervical, ovarian, uterine)
•
Contraindications: pregnancy, untreated
coronary artery disease or polycythemia
Medical Management
Masculinizing Therapy
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Testosterone
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Available oral, bucal, transdermal
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Can have cyclic effects, prefer lower, more
frequent dosing
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Progestin (short course for menstrual cessation)
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GnRH
Medical Management
Children and Adolescents
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Dysphoria does not always persist to adulthood,
can disappear before or during puberty
•
Others do not report symptoms until puberty
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Strong requirement for working with mental health
(asses dysphoria, provide counseling, treat
coexisting conditions)
Medical Management
Children and Adolescents
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Puberty suppression requirements
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Long lasting, intense dysphoria
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Dysphoria emerged or worsened with puberty
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Co-existing medical, psychological, social problems
have been addressed
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Adolescent and guardian provide consent
Medical Management
Children and Adolescents
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Puberty suppression agents
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GnRH analogues (inhibits leutenizing hormone
or estrogens and progesterone)
•
Progestin (block/neutralize testosterone)
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Continuous oral contraception (suppress
menses)
Medical Management
Children and Adolescents
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Hormone therapy available for above 16 years
old. Regimen differs from adult therapy.
•
Surgery generally avoided until age of majority,
except for possible exception with chest surgery
Medical Management
Children and
Adolescents
•
Boston Globe,
December 11, 2011
•
Nicole and Jonas
Maines, identical twins
•
Started hormone
suppression at age 11
since identifying as
female since age 4
Surgical Management
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To be understood as not an elective cosmetic
procedure
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May or may not be necessary, case-dependent
•
Should discuss limitations of results
Surgical Management
Criteria
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Persistent, well-documented Dysphoria
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Capacity to make fully informed decisions
•
Age of majority
•
Reasonably well-controlled medical or mental health
concerns
•
12 months of appropriate hormone therapy (required for I
genital surgery only)
Surgical Management
Masculinizing Procedures
•
•
•
Breast/chest:
•
Subcutaneous mastectomy
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Creation of male chest
Genital:
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Hysterectomy / salpingo-oopherectomy
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Vaginectomy
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Phalloplasty, scrotoplasty, prosthesis implantation
Other: lipoplasty, voice modification, facial reconstruction
Surgical Management
Feminizing Procedures
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Breast/chest
•
•
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Augmentation mammoplasty
Genital
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Penectomy, orchiectomy
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Clitoroplasty, vulvoplasty
Other
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Facial reconstruction, liposuction/lipofilling, voice surgery, thyroid
cartilage reduction, hair reconstruction
Preventative
Management
Supportive therapy
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Speech therapy
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Osteopathic Manipulative Medicine
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Mental Health
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Social Work
Preventative
Management
Health Screening - Transmen
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Breast: annual physical breast exam, mammogram at current guidelines
•
Cervix: standard guidelines for natal females before hysterectomy, after
hysterectomy annual Pap x 3, then every three years if normal
•
Uterus: evaluate spontaneous bleeding, consider hysterectomy
•
Heart: standard screening if not on testosterone, annual lipid panel and
decreased blood pressure goals if on testosterone (130/90)
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Musculoskeletal: gradual exercise to decrease tendon rupture
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If testosterone > 5-10 years, bone density screening above 50
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If testosterone < 5-10 years, bone density screening above 60
Preventative
Management
Health Screening - Transwomen
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Breast: screening mammogram > 50 if risk factors present
•
Cervix: Pap smear of neovagina not indicated, visual inspection is
indicated annually
•
Prostate: PSA can be falsely low, Digital Rectal Exam for
screening
•
Heart: lowered blood pressure goals (130/90), annual lipid panel,
and annual blood sugar if on hormone therapy
•
Musculoskeletal: recommend calcium and vitamin D, bone density
screening if post-orchiectomy and off estrogen for 5 years
Preventative
Management
Health Screening - General
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Mental health
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Exercise (be aware of challenges with body image and
performance)
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Sexual health
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Silicone injections
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Substance abuse
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Thyroid hormone
Changes in Oregon
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October 1st, 2014
•
•
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January 1st, 2015
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Medical hormone treatment covered
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Mastectomy covered
Sometime in the future, it seems, possibly
•
•
Gender Dysphoria became "above the line" for mental health coverage
by OHP
Genital surgeries covered
Requires licensed mental health provider to diagnose Gender Dysphoria
Recommendations
Addressing the Patient
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Openly and initially admit your ignorance.
•
Ask to be notified if you make a mistake.
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Apologizing is effective, but less so if it is not followed by
change.
•
Use pronouns with caution. Ask what terms are preferred
by your patient for self and body parts.
•
Provide safety in the form of acceptance.
Recommendations
Providing Initial Care
•
Provide language for self understanding without pressure. Avoid forcing
a decision.
•
Understand individualization of therapy.
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Be aware of potential for history of abuse.
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Support sequelae: rashes from binding, acne, back pain, limits to
exercise, social phobias, challenge of mindfulness therapy because of
focus on corporeal senses
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Encourage small tools of expression: hair, make up, clothing, skin care,
hobbies, music (caution with voice issues).
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Find one part of the body they appreciate.
Recommendations
Emphases from the Patients' Perspectives
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"Dysphoria can be fatal."
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Be aware of latent oppression in language: "biologically
male" versus "assigned male at birth."
•
Understand how the patient wants to be discussed public
ally versus privately.
•
Use caution with mandates. The patient has likely had
agency removed from them historically. Required lab tests,
physical exams, and inpatient stays can accentuate this.
Recommendations
References
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World Professional Association for Transgender Health, "Standards of Care for the
Health of Transsexual, Transgender, and Gender-Nonconforming People"
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Endocrine Society, "Endocrine Treatment of Transsexual Persons"
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UCSF Center for Excellence for Transgender Health, "Primary Care Protocol for
Transgender Patient Care"
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Q Center in Portland
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oregontranshealth.com
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basicrights.org
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OHSU transfer line
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DSM-V
Questions?