11/18/2016

Faculty Beyond Gender: The Basics of Care Jennifer Hastings, MD

and UCSF Dept of Family and Community Medicine Parenting and Pregnancy Planning Medical Advisory Board, for LGBTQ Patients UCSF Center of Excellence for Transgender Care Satellite Conference and Live Webcast Director, Transgender Healthcare, Planned Parenthood Mar Monte Friday, November 18, 2016 1:00 – 3:00 p.m. Central Time Director of Medical Programming, Gender Spectrum Produced by the Alabama Department of Public Health Distance Learning and Telehealth Division

Disclosures Objectives • Define current and gender affirmative terminology

Jennifer Hastings, MD • Distinguish the difference between Commercial Interest Role Status sex and gender Nothing to disclose • Discuss how to create safe space for LGBTQ clients in your healthcare • All medications for transgender setting using best practices care are off-label using national and international guidelines

Objectives Objectives • Describe the basics of gender • Differentiate pathways to parenting affirmative medical care, including and pregnancy within the LGBTQ hormone treatment, basics of community surgery and preventive care • Describe the basics of care for • Know four online resources for transgender youth, including puberty providing gender affirmative care blockers • Identify strategies of pregnancy prevention for LGBTQ clients

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Sex and Gender Minorities Sex and Gender Basics

− Federally protected status • Sex − ACA expanded coverage − Gender Non Discrimination – Assigned male or female based on physical anatomy, chromosomes • – Internal, deeply felt sense of self as male to female or in between • Gender Expression – The external presentation as masculine or feminine or somewhere in between - how we wear our gender

Sexual Orientation Gender Identity Includes: . Attraction . Behavior . Sexual Identity

Sexual Identity: Lesbian, Gay, Same Gender Loving, Bisexual, • Erotic attraction “who I go to bed with” Heterosexual, Asexual, Pansexual, Queer ≠ who I actually have sex with (choice of partner/s) • Where as gender identity is Sexual Behavior: choice of sexual partners & Polyamory, Monagamy, Bipoly “who I go to bed as”

Gender Terminology Trans* Terminology CISGENDER: • / Trans masculine Identity congruent with assigned gender – FTM Female-to-Male (might be on ) – Assigned Female at Birth (AFAB) • Trans Woman / Trans feminine

STEALTH: – MTF Male-to-Female (might be on ) trans status not shared with others – Assigned Male at Birth (AMAB)

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Trans* Terminology The Gender Spectrum Gender Queer Gender Queer • OUT OF THE BINARY – Range of identities which lie – Gender Smoothie outside binary of male and female – Gender Bender / Gender Blender – can also refer to sexuality – Demi Gender – Pan Gender – Two Spirit – Tri Gender

The Gender Spectrum Challenges and Discrimination Gender Queer • A Report of the National Transgender – Neutrosis Discrimination Survey in US (Grant, – Demigirl Mottet & Tanis, 2011) – LadiBoi – Discrimination pervasive in education, employment housing, health care , – Androgyne public accommodations – Agender • Patients may request Gender Neutral Pronouns! – They, hir, zir

Challenges and Discrimination Access to Healthcare – 4 times more likely to have a – 19% refused care outright household income < $10K – 50% had to TEACH their own provider about basic trans* health – 4 times the national rate of HIV – 28% deferred care when sick or injured – 41% attempted suicide compared to – 48% deferred care due to inability to 1.6% of general population pay for care

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Intersectionality Health Care Reform Interconnected bio, social and cultural categories and axes of identity • ACA Medicaid Expansion • Many more LGBTQ, gender non-binary and gender creative people able to get care • Section 1557 of ACA prohibits discrimination based on gender identity or expression health in care setting that receives funding from HHS Intersections of oppression discrimination Kimberlé Crenshaw

Creating a Safe Health Center Creating a Safe Health Center • Inclusive forms / EHR Many patients have experienced – Names and pronouns trauma in health care settings (legal and current) • Create safe and welcoming space – “What pronoun do you use (today)?” – Involve your community groups – Spectrum of gender and sexuality options – Inclusive language and visuals – Documenting histories, exams, (posters, magazines) inclusive templates – Gender neutral bathrooms

Creating a Safe Health Center Meaningful Use 3: Sexual Orientation and Gender Identity (SOGI) • Train your entire staff on sex and gender spectrum Two Step Model for Intake: – 10 Tips for Serving Transgender 1. What is your current gender identity? Patients M, F, trans man, trans woman, gender queer,_____ , decline to state – Na tiona l LGBT Hea lth Educa tion 2. What sex were you assigned at birth? Center (training resources) M, F, Intersex, _____ , decline to state CDC has adopted and recommends this model. More information: www.transhealth.ucsf.edu

Electronic Medical Record issues challenging

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Gender Affirmative Model Cultural Humility • Explore your own gender • Strive to see the person in front of you … leads us to “Cultural ENGAGEMENT” in their gender of identity, not based on and RESPECT physical attributes or presentation key components of “Cultural • You are now a trans Competency” ally - key to providing good care Who is the person in front of you?

Diversity in Transition Transition • Not all people under the transgender • Psychological Transition umbrella need or want to transition – Adjusting to changes in thinking, • Need not be stereotype (Ken to Barbie) emotions, behavior, and relationships • Transition varies; no one way resulting from to transition mental shift of accepting one’s gender • More and more out of the binary identity • Increasing congruity between self- perception and external presentation • Takes time: identity may evolve

Transition Transition • Social Transition • Legal Transition – Coming out to people in your life as – Changing the name and gender on identity documents transgender, letting people know that you identify as male / female / other, – Birth Certificate, Driver’s License, PtSilSittPassport, Social Security, etc. letting people know that you have a new name, etc. • Medical and Surgical Transition – Accessing transition related health treatments: hormone therapy, surgery

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Overview of Hormones Overview of Hormones Trans* female spectrum: Trans* male spectrum: Rx to feminize, overcome testosterone Rx to masculinize ESTROGEN: IM, patch, , or oral TESTOSTERONE: 17 B NOT ethinyl estradiol IM, subcutaneous gel, patch , pellet ANTI-ANDROGEN: , never oral (although used in Europe) finasteride PROGESTERONE: not always used • AIM FOR PHYSIOLOGIC LEVELS or AIM FOR PHYSIOLOGIC LEVELS or desired physical response desired physical response

Most Common Safety / Long Term Questions Asked… Health Outcomes • But are hormones safe? • Summary: (risk / benefits of treating) – Safe in trans men: no • Are we causinggypg harm by prescribing? increase in CV events, • Evidence points to more harm in hormone related cancer, NOT treating or AsschemanAsscheman,, et al 2011 A long term follow up study of mortality in transsexuals receiving treatment with cross sex hormones Continuation of the Gooren study: (1975(1975--2006)2006) Eur J Endocrinology WierckxWierckx,, K et al 2012 J Sex Med

Safety / Long Term How does Hormone Therapy Health Outcomes Improve Health Outcomes? Trans women on oral ethinyl estradiol • Increased sense of wellbeing increased CV death and other • Decreased depression & suicide increased causes of preventable death – Suicidality decreased from (suicide, HIV, drug use) 30% to ~3% post tx – Importance of lifestyle issues: • Decreased victimization & homicide exercise, smoking, drugs • Decreased drug & alcohol misuse

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How does Hormone Therapy Guidelines for Trans* Care Improve Health Outcomes? • WPATH International Standards of Care (SOC) for the Health of Transsexual, Transgender and Gender Nonconforming People (Version 7 2011) • Decreased HIV risk behaviors • Tom Waddell/Lyon Martin/Howard Brown/Callen • Decreased homelessness Lorde/UCSF CoE for Transgender Health • Guidelines continually revised with collective • Increased access to preventive and experience and research; international dialogue primary care services about guidelines

Online Resources: Online Resources: Great support to do this care! Great support to do this care! • UCSF Center of Excellence for • WPATH Standards of Care, Transgender Health Primary Care 7th Version - wpath.org Protocol • Lyon-Martin Health Center – transhealth.ucsf.edu Consult Line • National LGBT Health Education – project-health.org/transline Center: Fenway Boston • Howard Brown Health Center, Chicago – lgbthealtheducation.org – howardbrown.org

Trans* feminine Feminizing Effects Take TIME - Months to Years Skin softens HORMONAL THERAPY Decreased hair growth Estrogen and anti -androgen, progesterone Muscle mass diminishes, fat redistributes to Feminization, a slow process…  development: What are the patient’s goals? – Unpredictable / genetics are not predictors (Genetics play a role) – Permanent develop

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Feminizing Effects Informed Consent – Take TIME - Months to Years Estrogen and Spironolactone Maximum effect usually after 2-3 years Being aware of rare risks in context of benefits  Sexuality: (typical but not universal) • Blood Clots (rare) – Decrease in libido, ejaculate, • Liver / Gallbladder (rare) spontaneous erections • High Prolactin ()(rare)  Testicular Atrophy • Weight gain  Emotional changes noted by many • Increase BP – Easier access to tears, feelings, (more common – treat as with COC) multi-tasking • Risks of Spironolactone: high K, low BP

Limitations of Limitations of Feminizing Hormones Feminizing Hormones • Feminizing Hormones CANNOT: – Thin thickened vocal cords to increase • THUS the interest and importance of pitch of voice blockers for yypouth to prevent these – Change shape, size or structure secondary sex changes of bones – Reduce or eliminate Adam’s apple – Eliminate facial hair follicles

Trans* Masculine Effects of Masculinizing Hormones Effects Depend on Dose, Route, Genetics Testosterone Action Onset Max • Intramuscular, subcutaneous, topical Male pattern facial/body hair 6–12 mo 4–5+ yrs Acne 1–6 mo 1–2 yrs • What are patient’s goals? Voice deepening 1–3 mo 1–2 yrs Clitoromega ly 3–6 mo 1–2 yrs Vaginal atrophy 2–6 mo 1–2 yrs 2–6 mo Emotional changes/ ↑ libido Increased muscle mass 6–12 mo 2–5+ yrs Fat distribution 1–6 mo 2–5 yrs

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Informed Consent: Informed Consent: Reversibility Reversibility • Irreversible • Somewhat Reversible – Thickening of vocal chords – Clitoral enlargement – Facial and body hair • Reversible – Adam’s apple – Menses – Male-pattern balding – Libido – Fat / muscle distribution

Informed Consent: Informed Consent: Discuss Risks Discuss Risks • Weight gain • Male pattern baldness • Liver dysfunction (extremely rare) • RBC increase • Possible blood pressure increase • Acne vulgaris • Teratogen • Mood changes • Increase in LDL

Pregnancy and Testosterone Additional Considerations • Binding • Testosterone does NOT prevent – Prolonged binding can ovulation cause skin irritation / – Discuss contraception breakdown, breast ppgain, fungal infection • Testosterone MAY affect fertility • Pap smears – Discuss egg banking – Screening is based on anatomy • Testosterone IS excreted into breast milk – If you have one, screen it!

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Well Person Care Preventive Screening

• Primary care provider who is willing This is not too complicated! to learn and CARES If you have ‘an organ,’ it must be screened • Awareness of Trauma and accordinggg to current guidelines… Trauma Informed Care (of course, EHR and insurance may not • Discuss Sexuality, Fertility, agree that a ‘male’ needs a PAP…) Pregnancy and Parenting Planning

USPTF Cancer Risk USPTF Cancer Risk and Screening and Screening • Breast • Cervix and Anus- PAP intervals same if – Trans Man on hormones (no mammogram indicated if has had • Ovarian and chest surgery) – No data to support increase in cancer – Trans Woman (no data, but later exposure to estrogen changes risk risk with testosterone and onset of screening; at least 5-10 • Prostate – same guidelines if on yrs on HT) estrogen

Referrals Surgery: Every Person • Contact the office ahead of time to ensure Decides Which (If Any) respect for name, gender, trans status • Trans* female spectrum: • Discuss with radiology tech ahead of time so – Orchiectomy: removal of testicles that there is respect and understanding – Vaginoplasty: creation of vagina • Strategize with patient about how to handle – LbilLabioplasty: creatiflbiion of labia inappropriate care – Breast augmentation – Facial feminization – Tracheal shave (removal of Adam’s apple)

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Surgery: Every Person Silicone Decides Which (If Any) Significance of Silicone • Trans* male spectrum: • Trans men: pectoral, – Chest reconstruction surgery gluteal and calf areas – , oophorectomy • Trans women: lips , cheekbones, – (penis and testicles thighs, hips, with local tissue) • “Pumping Parties” – Phalloplasty becoming more common (penis and testicles with grafting)

Silicone Sexuality and Gender • Risks: • Sexual identities, attractions, and – Local and systemic infection behaviors may shift, change, or evolve with transition – Embolization – (PE can be fatal) • – GlGranuloma 40% of 605 trans men recruited online from 19 different countries – Systemic inflammatory syndrome that who had begun using testosterone can be fatal reported a shift in their sexual orientation (Meier 2013)

Safer Sex

• What does this look like? Conversations About Sexuality • How do we talk about sex? Find Comfortable • Sharinggp fluids? Sperm? Ovulation? and Inclusive Language • Open minds, open hearts, open discussions

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Prevention of HIV Prevention of HIV Trans* Community Trans* Community • Increased awareness has led to data • PREP AND PEP are lifesaving collection recommendations so that • Strategies that you can integrate into trans population will be counted yygour work with the transgender • We now have trans specific populations you serve interventions with increased • Trans youth have the highest rate of awareness of high risk and HIV acquisition specific needs

Conversations Conversations About Sexuality About Sexuality • Gender neutral language – “Do you have sex with someone – “What are the gender identities of with ovaries / testes?” yypour sexual partners?” • Direct questions on specific – “What parts of your body do you sexual activities: use when you are sexual?” – “Knowing about your sexuality can help me take better care of you”

Family Creation Options Family Creation Options • “…it was assumed that trans women • Historically, LGBTQ individuals’ would forgo the ability to ‘father’ a reproductive choices have not child, that trans men would forgo the been recognized… ability to ‘mother’ a child, and that ‘true transexuals’ would be uninterested in doing so”

– “Family Creation Options for Transgender and Nonconforming People,” l dickey, K Duchamps, R Ehrbar, Psychology of Sexual Orientation and Gender Diversity 2016

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LGBT Surveys about Trans Survey about Fertility and Families Fertility and Families Pew Research Center: A Survey of LGBT Survey of 50 trans* men Americans: Attitudes, Experiences and • 54% wanted children Values in Changing Times 2013 • 38% considered freezing eggs egg • 16% had partners with a uterus who 51% of LGBT adults of any age either egg had children via ART have children or want to • 6% were parousthemselves have children Transgender Parenting: A Review of Existing Survey of 121 trans* women Research • 40% had biological children • 77% felt that sperm freezing should be offered Review of 51 Studies • 45% would have declined to donate sperm 2525--50%50% of all transgender individuals are parents due to dysphoria Wierckx et al., Hum Repro, Feb 2012; De Sutter et al., 2002, Intl J Stotzer et al., The Williams Institute 2014 Transgenderism

Trans Men, Pregnancy and Family Planning Unintended Pregnancy Pregnancy and LGBTQ Anu Manchikanti Gomez • “Are you or any of your sensual or

The Right to Parent: A Qualitative Exploration of Family egg sexual partners planning to get Desires Among Transmasculine and Gender Queer Emerging Adults pregnant in the next 12 months?

“Testosterone in a wayyp is birth control” Contraceptive attitudes and experienceexperiencess among transmasculine and genderqueer young adults. Contraception 2016

Survey of 20 young trans* men More information needed by providers and patients about HRT and fertility and pregnancy

Many did not know that they could get pregnant or that • Does your patient feel safe to share and pregnancy was possible after hormonal transition answer openly?

Pregnancy Prevention Pregnancy Prevention and LGBTQ and LGBTQ Youth • “Are you or any of your sensual or – LGBTQ youth use contraception sexual partners planning to get less frequently pregnant in the next 12 months?

• NO: – Currently, LGBTQ youth at – Pregnancy prevention programs increased risk of unintended MUST SPECIFICALLY ADDRESS pregnancy or involvement with LGBTQ identities and issues to be pregnancy effective!

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Pregnancy Prevention Pregnancy Prevention and Trans* and Trans* • “Are you or any of your sensual or sexual partners planning to get • If pregnancy not desired: Discuss pregnant in the next 12 months? contraception • NO: • For trans men: – Testosterone ≠ Contraception: – IUD, Implant, DMPA, ovulation can occur – typically non estrogen based – Sperm can still be present with estrogen

Pregnancy and LGBTQ • “Are you or any of your sensual or SPERM EGG UTERUS sexual partners planning to get pregnant in the next 12 months? • YES: – Does the person you are talking to + + = have ovaries or testes? – Discussion of sex/fertility and POSSIBLE PREGNANCY partner(s) WITH OR WITHOUT ASSISTED – Many family building options and REPRODUCTIVE TECHNOLOGIES (ART) not much research yet

Pathways to Pregnancy  Pathways to Pregnancy  How the Sperm Gets to Egg How the Sperm Gets to Egg • Donor sperm • Intrauterine insemination • Donor egg • Traditional surrogacy • Preservation options: • Gestational surrogate with egg donor – Freezing of egg or sperm • Sexual intercourse, planned or • IVF / In Vitro Fertilization unplanned ISSUES: age, cost, legal rights, parenting contracts, • Intravaginal or intracervical health concerns, privacy, homophobia, internalized insemination homophobia, transphobia

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Family Building Options Fertility Options for LGBTQ • Pregnancy: self, partner / spouse / • Lesbian Identified where one partner surrogate / with or without Assisted Reproductive Technologies (ART) has uterus and ovaries: • Adoption- public, private – Find sperm (friend, relative, donation, • Extended families, step children • Foster children pp)urchase) • Single parenting – Egg from one, uterus from another • Blended families • Chosen families – Adoption, Fostering, Assisted Reproduction

Fertility Options for LGBTQ Pregnancy Fertility • Gay and one partner has sperm for Trans* – Inseminate (friend, relative, surrogacy for uterus, eggs) • Unknown future fertility BUT successes – Adoption, Fostering , Assisted • consider banking for eggs and sperm Reproduction (expensive) • Many ways to make a family

Pregnancy Fertility Pregnancy Fertility for Trans* for Trans* • Pregnancy in trans men – stop testosterone • Viable sperm count in trans women – Oocyte/embryo preservation – Stop estrogen if desiring fertility – Preserve one ovary at time of hysterectomy – Sperm cryopreservation – Keep ovaries and/or uterus with genital surgery

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Barriers for Fertility Preservation Trans* Men and Pregnancy for Transgender Patients • N = 41 • Lack of knowledge about pregnancy and fertility preservation by both • Used testosterone pre-pregnancy providers and patients 61% • Invasiveness of procedures • MdiMedian age was 28 • Expense • Unknown success of fertility procedures • Used own eggs 88% after long term use of hormones • Delivered in a hospital 78%

CA Jones, L Reiter, E Greenblatt (2016) FertFertilityility preservation in Transgender Men Who Experience Pregnancy After FemaleFemale--toto-- transgender patients, International Journal of Transgenderism Male Gender Transition. AD Light, J Obedin-Obedin-MaliverMaliver,, JM Sevelius,Sevelius, JL Kerns, Obstetrics & Gynecology 124 (6), 11201120--1127,1127, 2014

Trans* Fertility for Youth Trans* Fertility for Youth

• Counseling about future fertility Post-pubertal youth have option of fertility – Fertility options are limited for youth who start puberty blockers – If have uterus, ovaries can carry at onset ofbf puberty or contribute to pregnancy – Parent and child may present – If testicles, can contribute sperm different priorities

Trans* Fertility for Youth The Gender Journey on Puberty Blockers • Supporting gender expansive youth Pediatric reproductive oncologists • The child displays distress harvest pre-pubertal gonadal that is alleviated by expression of gender identity tissue: expression of gender identity ButBut,, you can never maturing eggs and sperm in-vitro know for sure and (experimental at this time) you need to listen to and follow the child.

Diane Ehrensaft, PhD, Developmental Psychologist

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What We Know: Family What We Know: Family Acceptance Saves Lives Acceptance Saves Lives • Higher rates of family rejection = • Family Acceptance Project shows poor outcomes in LGBT kids that LGBT kids do better with even – 8.4x increased attempted suicide small amounts of acceptance – 5.9x increased depression – 3.4x more likely to use illegal drugs

– 3.4x more likely to engage Ryan, C., Huebner, D. et al. “Family Rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and in unprotected sex bisexual young adults.” Pediatrics 123/1 (2009): 346346--352.352.

Key Concepts Gender Terminology • Transgender or Trans*: • Gender ≠ choice Umbrella term • People whose gender identity or gender • Gender is a spectrum expression is different from the sex • Acceptance is key to health assigned at birth • There are medical interventions that support gender identity • Pregnancy and Parenting planning are possible for LGBTQ individuals!

Assigned Sex Gender Identity • “Biological sex,” chromosomes, • A person’s internal, deeply felt sense anatomy of being male, female, something other or in between • Usually based on external genitalia • Independent of assigned sex: can be fluid

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Gender Expression Gender • External expression of gender • The complex interrelationship between an individual’s identity, also fluid – Sex (gender biology) • “How I do gender in the world” – Internal sense of self as male, female, both or neither – Outward presentations and behaviors

Sexual Orientation Sexual Orientation and • Includes: Gender Identity • Erotic attraction – – Attraction “who I go to bed with” – Behavior • Where as gender identity is – Sexual Identity “who I go to sleep as” • SEPARATE from gender identity and gender expression

Basic Concepts of Building Cultural Fluency Immerse yourself… many more excellent Gender Care books, blogs, films • Genitals do not determine gender • BOOKS and BLOGS:

• Gender is on a spectrum rather than – Trans Bodies, Trans Selves, Ed. Erickson-Schroth being binary: male or female – The Gender Creative Child, Diane Ehrensaft

• Transgender identity is not – Gender Born, Gender Made Diane Ehrensaft pathology or mental illness – Transgender 101, Nicholas Teich

• Access to hormones improves health – She’s Not There, A Life in Two Genders, • Exploring our own gender journey is Jennifer Boylan central to patient centered care – Neutrois.me/Non Binary Transition Micah

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Building Cultural Fluency Building Cultural Fluency Immerse yourself… many more excellent Immerse yourself… many more excellent books, blogs, films books, blogs, films – Second Son, Ryan Sallans • FILMS - DOCUMENTARIES - TV SHOWS:

– The Transgender Child, Stephanie Brill, – Straightlaced- How Gender’s Got Us All Tied Up Rachel Pepper – Trans, The Movie – The Transgender Teen, Stephanie Brill, – From Three to Infinity Lisa Kenney – I’m Just Anneke – No Dumb Questions – I am Jazz – TransParent, HerStory

On Line Resources On Line Resources • UCSF Center of Excellence for • Lyon-Martin Health Center Transgender Health Primary Care Consult Line Protocol - transhealth.ucsf.edu – project-health.org/transline • National LGBT Health Education Center: Fenway Boston • Howard Brown Health Center, lgbthealtheducation.org Chicago • WPATH Standards of Care, – howardbrown.org 7th Version – wpath.org

Building Knowledge Resources – CONFERENCES: General and Youth • Philadelphia Trans-Health Conference • National Center for Transgender Equality: Injustice at Every Turn: National Transgender Discrimination Study; 2011 – Mazzoni Center – www.transequality.org • Gender Odyssey • Physicians for Reproductive Health (PRH), part of the – Seattle and this year LA Adolescent Reproductive and Sexual Health Education • Gender Spectrum- focus on youth Program (ARSHEP): http://prh.org/new-updated- educational-modules-available/ – Bay Area, annually Summer • California Family Health Council brochures on Trans Sexual • National Transgender Health Summit, UCSF Health and Fertility in English and Spanish

– April, every other year in Oakland – http://www.crc.org/programs-and-services/resource- • WPATH International 2 years library/clinicalguidelines-and-research

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References References • Cahill Sean R., Baker Kellan, Deutsch Madeline B., Keatley Joanne, • Lisa L. Lindley and Katrina M. Walsemann. Sexual Orientation and Risk of Pregnancy Among New York City High-School Students. American Journal of Public and Makadon Harvey J.. LGBT Health. December 2015, ahead of print. Health: July 2015, Vol. 105, No. 7, pp. 1379-1386.doi: 10.2105/AJPH.2015.302553 doi: 10.1089/.2015.0136. • Obedin-Maliver J, Makadon HJ. Transgender Men and Pregnancy. Obstetric • dickey l, Duchamps K, Ehrbar R, Family Creation Options for Medicine: The Medicine of Pregnancy. 2015. OnlineFirst, published on October 28, Transgender and Nonconforming People. (2016)Psychology of Sexual 2015 as doi:10.1177/1753495X15612658. Available at: obm.sagepub.com/content/ Orientation and Gender Diversity, Vol. 3, No. 2, 173–179 early/2015/10/21/1753495X15612658.full. pdf+html

• Jones CA,,, Reiter L, Greenblatt E (()2016): Fertilit ypy preservation in • Pew Research Center. A Survey of LGBT Americans: Attitudes, Experiences and transgender patients, International Journal of Transgenderism, Values in Changing Times. Washington, D.C.: Pew Research Center; 2013. pewsocialtrends.org/ les/2013/06/SDT_ LGBT-Americans_06-2013.pdf DOI:10.1080/15532739.2016.1153992 • Short, Elizabeth, Riggs, Damien W., Perlesz, Amaryll, Brown, Rhonda and Kane, • Keo-Meier, C., Herman, L., Reisner, S.L., Pardo, S., Sharp, C., & Graeme 2007, Lesbian, gay, bisexual and transgender (LGBT) parented families : a Babcock, J. (2014). Testosterone treatment and MMPI-2 improvement literature review prepared for the Australian Psychological Society, The Australian in transgender men: A prospective controlled study. Journal of Psychological Society., Melbourne, Vic. Consulting and Clinical Psychology, doi:10.1037/a0037599 • T’Sjoen G, Van Caenegem E, Wierckx K. Transgenderism and reproduction. • Khimm S. The New Nuclear Family. The New Republic. 2015 Curr Opin Endocrinol Diabetes Obes. 2013;20:575-9. Available at: ncbi.nlm.nih.gov/ newrepublic.com/ article/122349/new-nuclear-family pubmed/24468761

References - Youth Contact Information • Brill S, Pepper R, (2009) The Transgender Child.

• Byne W, Brandley SJ, Coleman E, et al. Report of the American Psychiatric Association Task Force on treatment of gender identity Jennifer Hastings, MD disorder. Arch Sex Behav, 2012;41(4):759-796

• Ehrensaft, D. (2011). Gender Born, Gender Made: Raising Healthy Gender-Nonconforming Children. [email protected]

• Hidalgo M , Ehrensaft D, Tishelman AClarkLA, Clark L, Garofalo R, Rosenthal S, Spack N, Olson J. The Gender Affirmative Model: What We Know and What We Aim to Learn. Human Development, 2013; 56: 285-290 [email protected]

• Olson J, Forbes C, Belzer M. (2011) Management of the transgender adolescent. Arch Ped Adol Med;165(2):171-6.

• Rosenthal S. Approach to the Patient: Transgender Youth: Endocrine Considerations. JClinEndocrinolMetab 2014, 99(12):4379-4389.

Addendum Medications for Feminization Estrogen Start Average Max • Slides to augment understanding and for Q&A: Estradiol 0.5 mg oral tab 2 mg sl bid 4 mg sl bid Generic estrace Sublingual sl bid – How puberty blockers work – Cases Estradiol valerate 5 mg IM q week 5 mg IM q week 40 mg IM q o IM week – Dosing details of feminizing and Estrogen Patch 50‐200 mcg/d 200 mcg/d 400 mcg/d masculinizing hormones (1‐2 50‐100 mcg (apply #2 100mcg (apply #4 100 patches, change patches, change mcg patches, twice weekly) twice weekly) change twice weekly)

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Medications for Feminization** Medications for Feminization Anti‐androgens Start Average Max Progestins Start Average Max

Spironolactone 25 mg po bid 100 mg po bid 150 mg po bid blocks Increase by 25 mg Rarely get Testosterone bid weekly increased benefit Micronized 100 mg po every 100 mg po every 200 mg po every receptors and over 100mg bid Progesterone day day day decreases production of T 5a‐reductase Medroxypro gester 2.5‐5 mg po 5‐10 mg po every 10 mg po every inhibitors one every day day day Finasteride ¼ of generic 5 mg ½‐1 tab of 5 mg po 5 mg po q day tab po Dutasteride 0.5 mg po every FOR MALE day PATTERN ** consider Baseline labs: Follow up Labs: BALDING estrogen initially CBC, CMP, Lipids, Kif on spiro Lipids, Minoxidil 5% Apply to scalp then titrate spiro consider TSH Consider hormone every day levels

Medications for Masculinization Testosterone Initial Typical Maximum Testosterone 20 mg IM/SQ 50 mg IM/SQ q wk 100 mg IM/SQ Cypionate q wk q wk 200mg/cc Higher doses may aromatize to estrogen Testosterone topical gel 1%, 12.5-25 mg 50 mg QAM 100 mg QAM 1.62% and QAM compounded Testosterone 1‐2 mg QPM 4 mg QPM 8 mg QPM Patch (brands very May be difficult to slightly in dosing) get insurance coverage Ask about goals for transition. Baseline labs: CBC. Follow A1c and lipids per USPSTF guidelines. Consider testosterone levels.

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