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Beyond Gender: the Basics of Transgender Care Jennifer Hastings, MD

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Beyond Gender: the Basics of Transgender Care Jennifer Hastings, MD 11/18/2016 Faculty Beyond Gender: The Basics of Transgender 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 1 11/18/2016 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 • Gender Identity – 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 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 Man / Trans masculine Identity congruent with assigned gender – FTM Female-to-Male (might be on testosterone) – Assigned Female at Birth (AFAB) • Trans Woman / Trans feminine STEALTH: – MTF Male-to-Female (might be on estrogen) trans status not shared with others – Assigned Male at Birth (AMAB) 2 11/18/2016 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 3 11/18/2016 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 4 11/18/2016 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 5 11/18/2016 Overview of Hormones Overview of Hormones Trans* female spectrum: Trans* male spectrum: Rx to feminize, overcome testosterone Rx to masculinize ESTROGEN: IM, patch, cream, or oral TESTOSTERONE: 17 B estradiol NOT ethinyl estradiol IM, subcutaneous gel, patch , pellet ANTI-ANDROGEN: spironolactone, 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 osteoporosis 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 6 11/18/2016 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 hips Feminization, a slow process… Breast development: What are the patient’s goals? – Unpredictable / genetics are not predictors (Genetics play a role) – Permanent develop 7 11/18/2016 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
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