Reproductive Health Needs of Transgender People LGBT Domestic Violence Concerns and LGBT (, Gay, Bisexual, Transgender) Domestic Violence Concerns

August 15, 2014

Anita Radix, MD MPH Anita Radix, MD MPH has no relevant financial, professional or personal relationships to disclose:

There are no commercial supporters of this activity. This presentation will include discussion of the following non-FDA-approved or investigational uses of products/devices:

. Transgender hormone protocols (off label use of estrogen and testosterone)

3 . Describe terminology related to LGBT populations . Describe the individual and structural level barriers to care for LGBT patients . Identify the sexual and reproductive health priorities for LGBT patients . List ways in which you (your facility) can create a welcoming space for LGBT patients LGBTQQI – shorthand for the entire sexual minority community LGBTQ . MSM, WSW - Sexual Orientation . Identity, Attraction, Behavior . Gender Identity - Identity, Expression, Role . Transgender

. Identity: a label ◦ Often heterosexual, lesbian, gay, bisexual, questioning/ queer

. Behavior: who you have sex with ◦ MSM = men who have sex with men ◦ WSW = women who have sex with women

. Attraction: who you’re attracted to

Sexual Identity and behavior may be discordant ! Sexual Orientation

. Identity, attraction and behavior do not necessarily equal each other, and are fluid . NYC youth: of those who had same sex intercourse only, 64% define themselves as heterosexual

MMWR Early Release 2011;60[June 6]:1-133Weekly Report (2011) . 9.4% of the straight identified men reported having sexual intercourse with at least 1 man in the year before the survey . This group less likely to have used condoms . More likely to be foreign born, ethnic minority

Ann Intern Med. 2006;145:416-425 Who is TRANSGENDER?

. Umbrella term . A person whose gender identity or gender expression differs from that assigned at birth – Transgender persons can be of any sexual orientation

Kuper et al 2012, Lombardi, 2001, Operario et al, 2010 Terminology

Trans-women Born male, identifies as female Male-to-female, MTF Trans-man Born female, identifies as male Female-to-male, FTM Gender non-conforming Does not identify with only male or only female Cis-gender Born female identifies as female, born male identifies as male

National Center for Transgender Equality, 2009

Transition

The process from living as the gender assigned at birth to living as the individual sees and understands themselves

. Social transition . May include medical/surgical options

National Center for Transgender Equality, 2009 Transition

MTF - Feminizing FTM - Masculinizing

▶ Hormones (estrogen) ▶ Hormones (testosterone) ▶ Androgen blockers ▶ Chest masculinization ▶ , salpingo- ▶ Breast augmentation ▶ & ▶ Phalloplasty ▶ Orchiectomy ▶ Metoidioplasty ▶ Tracheal shave ▶ ▶ Facial bone reduction ▶ Scrotoplasty ▶ Urethroplasty ▶ Rhinoplasty ▶ Testicular prostheses

Double Incision Method with nipple grafting

Peri-areolar or “Keyhole” surgery FTM Masculinization - Testosterone

Hormone Starting Dose Average Dose Maximum Dose

Testosterone 100mg every 2 200 mg every 2 200 mg every 2 (cypionate or weeks weeks weeks enanthate) im Transdermal 2.5g daily 5-10g daily or usual 10g daily Testosterone replacement dose (gel, patch)

Measure im testosterone between injections Goal: 320-1000 ng/dL

Adapted from Endocrine Society Clinical Practice Guideline, 2010 Effects of androgenic therapy

. Deepening of the voice . Redistribution of fat from hips to waist . Irregular menses  cessation of menses . Clitoral enlargement . Male-pattern facial and body hair growth Side effects: Acne, headaches, fluid retention, androgenic hair loss, atrophic , polycythemia, hepatotoxicity, worsening of lipid profile, reduced fertility

WPATH Standards of Care Ver 7, 2011; Endocrine Society Clinical Practice Guideline, 2010 Feminizing (MTF) Regimens

. Estrogens + . Anti-androgens

Hembree, JCEM 2009, 94(9):3132–3154 MTF Feminization - Estrogens

Hormone Starting Dose Average Dose Maximum Dose

Conjugated 1.25-2.5mg/day 5mg/day 10mg/day Estrogen

17-ß Estradiol oral 2mg/day 4mg/day 8mg/day

17-ß Estradiol im 20mg IM q 2 20-40 IM q 2 40 mg IM q 2 week weeks weeks

17-ß Estradiol 25 mcg/day 50 mcg/day 100mcg/day patch

Goal: Serum estradiol 100-200 pg/dL

Adapted from Endocrine Society Clinical Practice Guideline, 2010 Agents for MTF – Anti-androgens

Ani-androdgen Starting Dose Average Dose Maximum Dose

Spironolatone 25mgday 150mg/day 400mg/day

Finasteride 1mg/day 1-5mg/day 5mg/day

Dutasteride 0.5mg/day 0.5mg/day 0.5mg/day

Cyproterone Acetate 50 mg/day 150 mg/day 150mg/day

Flutamide 250mg/day 500mg/day 750mg/day

Leuprolide acetate 3.75mg/month 3.75mg/month 3.75mg/month

Goal: serum testosterone <55 ng/dL

Adapted from Endocrine Society Clinical Practice Guideline, 2010 . Breast development . Slowing of androgenic hair loss . Fat redistribution (smaller waist, wider hips) . Testicular atrophy . Decrease in erections . Reduction in prostate size . No effect on beard hair - electrolysis required

Sexual and Reproductive Health for Johanna

. 23 year old female comes to clinic with 3 days of burning on urination – Self-identifies as lesbian – She has never had a pap smear or gyn exam

. What questions should you ask her about her sexual and reproductive health?

. Are there any questions that you don’t need to ask? Johanna

On further questioning . Occasionally has sex with men . Doesn’t believe she is at risk for pregnancy or STIs . She declines & STI . “I don’t need that” Sexual Minority Women

 Earlier sexual debut

 More sexual partners, male or female

 Risky sexual activity

 Mental Health – Substance use, Depression, anxiety, suicide

 Less likely to use hormonal contraception

 Increased pregnancy risk

 Less likely to have routine screenings for STIs and

Charlton et al, 2013; Charlton et al 2011;Saewyc et al, 2004; Saewyc et al, 2008; Blake et al, 2001 Teen Hormonal Contraception - Growing Up Today Study % Contraceptive use before age 20

Lesbian 50

Heterosexual/bisexual 79.4

Heterosexual with same-sex contact 88.6

Heterosexual 67.8

0 10 20 30 40 50 60 70 80 90 100

Adapted from Charlton, et al, 2013 Sexual Minority Women in Growing Up Today (GUTS)

Sexual Orientation RR (95% CI) Completely heterosexual 1 Heterosexual with same-sex partners 5.82 (2.89-11.73) Mostly heterosexual + bisexual 2.28 (1.53-3.39) Lesbian 1.61 (0.40-6.55)

Elevated risk of pregnancy among sexual minority women (adjusted for race, age, region)

Charlton et al, 2013, AJOG Provider Misconceptions

That WSW . Are monogamous and have few lifetime partners . Exclusively partner with women . Lesbian sexual behaviors don’t transmit STD’s (not “real” sex0 . Do not screen WSW for STIs because of the belief they are not at risk

The Truth . 13% - 17.2 % self-identified lesbians reported a history of STI

. >70% have had a male sex partner . Oral-genital, vaginal-digital, anal-digital, oral-anal sex and sex toys all present a risk for transmission of pathogens - , genital , , syphilis, BV, HIV

MMWR Weekly Report, 63(10): 209-12, 2014; Bauer et al 2001; Diamant et al, 1999 Bacterial Vaginosis in WSW

. Prevalence 25% to 52% . lesbians are nearly twice as likely to have BV as matched heterosexual controls . Risk of BV appears to be associated with greater numbers of female sexual partners and more frequent use of vaginal lubricants . 73% concordance shown with BV in female sexual partners . BV has been transmitted between women by transfer of vaginal secretions

McCaffrey Intl J STD AIDS 1999; Fethers STI 2001; Marrazzo Intl J STD AIDS 2001 Berger Clin Infect Dis 1995; Criswell Obstet Gynecol 1969) Human Papillomavirus (HPV)

. Cervical neoplasia may occur in WSW without male contact . >10% of WSW report abnormal pap smears . Lesbians less likely to have had a pap test in 3 years compared with heterosexual women . Reasons for no Pap included – lack of insurance, previous adverse experiences, belief that Pap tests were unnecessary & unwillingness to disclose sexual identity – 10% of women told they were not at risk by provider

Marrazzo Am J PH 2001, Johnson JGLMA 1987

Sexual Health for Transmen Case Presentation

Michael is 22 y/o transman (FTM) . PMH: Socially transitioned age 16, started testosterone age 18 . Menarche age 13, menses ceased after 3 mo testosterone . No pregnancies, Never had a pap smear . Sexually active with men (gay), uses condoms . No surgeries (binds chest)

He has questions about long term adverse effects on hormones and wants to know whether testosterone prevents pregnancy (partner wishes to discontinue condoms)

The Gyn Office

Consider barriers for transgender patients . Patient discomfort - The only male in the waiting room . Registration forms (gender options, legal/preferred name) . Provider/staff discomfort, lack of knowledge

Grant, NTDS 2010, Obstet Gynecol 118 (6);1454-58, 2011 Low Uptake of Preventive Care

. Transgender persons avoid medical care - 28% delayed care when ill - 33% delayed preventive care . High rates of discrimination in healthcare - 70 percent experienced mistreatment - >19% denied care . Fear of disclosure of gender identity (32%) . Financial barriers - Lower rates of insurance, coverage

Grant, NTDS 2010; Lambda, 2011; Bauer, BMC Pub Health 2012; Xavier, 2000

Medical Assessment – Best Practices

Keep in mind:

. Transgender patients may have had previous negative healthcare experiences . Developing trust and rapport may take longer than you are used to . Pay attention to pronouns . Avoid assumptions about sexual orientation, or behavior . Be sensitive with your physical exam - ask before you touch . Think about how you talk about body parts

Grant, NTDS 2010; Lambda, 2011 Initial Assessment- Medical History

. Past Medical & Surgical History . Transition history – How long has patient been living in the gender with which they identify? – Hormone use, dose, duration, obtained “on the street” or prescription – Future plans for surgery/hormones . Psychosocial issues: depression, PTSD, intimate partner violence, support network, employment, sex work and substance use . Sexual history

Physical Exam

. Breast/chest exam . Genital exam – Speculum exam (cervical if indicated) – Bimanual exam . Patients on testosterone – Clitoromegaly – Atrophic vaginitis/ redness, decreased rugae, caliber – Increase in unsatisfactory paps? – Consider 2 weeks intravaginal estrogen before exam Binding HIV & STI Risk in Transgender Men

. Few data on HIV & STI risk among transmen – Prevalence of HIV 0-3% – Prevalence of STIs 6-37% . Risk Behavior – 26% transmen start having sex with men after initiation of hormones – High rates of unprotected anal/vaginal sex – Substance use during sex . Biology – Testosterone →atrophic vaginitis (increased HIV risk?)

(Herbst, 2008; Conare, 1997; Kenagy, 2002; Reisner, 2010 ; Rowniak, 2011) Testosterone related

. Irregular bleeding may occur after initiating transdermal or low dose im testosterone – Increase testosterone dose – Change to weekly im testosterone – DMPA

Persistent bleeding: . Pelvic sonogram . or if indicated . Intravaginal estrogen therapy

Endocrine Society Clinical Practice Guideline, 2010; CLCHC Hormone Protocols 2013 Reproductive Health Reproductive Health

. Masculinizing hormone therapy reduces fertility but may not prevent pregnancy . Discuss fertility/reproductive options before initiation of hormones - Oocyte or embryo crypreservation - Successful pregnancies reported after cessation of testosterone . Contraception: condoms, DMPA, hormonal (levonorgestrel) IUD

ES 2010; More, J Clin Endocrinol Metab 1998;7:319-28; Unger, AJOG 2013; FSRH CEU 2012 Sexual & Reproductive Health Issues for Transwomen HIV Prevalence in TGW

Baral, Lancet 2012 Meta-analysis of risk of HIV infection in transgender women versus all adults 15–49 by country

TGW 50 times more likely to be HIV+

Baral, Lancet 2012 Factors linked to HIV risk among TGW

. Behavioral – High rates of sex work (>40%) – Lower rates condom use (financial, primary partner) – Needle sharing for hormones/silicone? . Biological – Anal receptive sex – Neovaginal sex ? Penile inversion vs. sigmoid colon loop . Increased rates of STIs (Argentina, Guatemala) – VDRL: 42.3% transgender vs. 18.1% nontransgender – ↑ HPV, Hep B, Hep C, HSV, chlamydia (anal) vs. MSM

Schulden, Pub Health Rep, 2008; Bockting, Health Ed Res,1998; Nuttbrock AJPH 2011; Toibaro, Medicina 2009; Sol dos Ramos Farias, M, 2011;Hernández et al., 2010; Tabetet al., 2002

Factors linked to HIV risk among TGW

. Gender Identity Discrimination (linked to): – Unprotected anal receptive sex – Depression – Substance use . Non-inclusion in STI/HIV campaigns . HIV prevention is a low priority – Safety, survival, emotional – gender validation

Schulden, Pub Health Rep, 2008; CDC 2007;Nuttbrock AJPH 2011; Harawa 2005; Operario 2010 Higher Risk But Less HIV Screening

. Transgender persons avoid medical care – 28 % delayed care when ill – 33% delayed preventive care – Low rates of HIV screening (46% never tested) – 45-65% HIV+ TGW unaware of HIV status

Grant, NTDS 2010; Clements-Nolle Am J PH 2001; Lambda, 2011;; Bauer, BMC Pub Health 2012; Herbst AIDS Behavior, 2008 Genital Tucking Soft Tissue Fillers

>25% of transgender women inject “silicone” to enhance feminine appearance

Images: Fox, L. J Am Acad Dermatol, 2004 Bladder

Prostate

 Examine neovagina with anal or small vaginal speculum  Look for granulation tissue, warts, lesions  Prostate is palpable at the anterior neovaginal wall Issue Duration When to refer Swelling Slowly regresses 9-12 months Signs of infection

Sutures vicryl and monocryl resorbable sutures 21-60 days Bleeding 2 -4 weeks Clots, dripping Sloughing 6-8 weeks Pain, persistent (>2 mo) bleeding, discharge Urine stream 2-4 months Pain, urinary retention, irregular persistent issue UTI Common first 2 months- UA, culture and treat Granulation posterior entrance of the No response to silver tissue (fourchette) nitrate Pain with Reduce size, lubricate dilation intercourse Not before 2 months Sexual & Reproductive Health Issues for MSM Estimates of New HIV Infections in the United States for the Most-Affected Subpopulations, 2010

CDC. Estimated HIV incidence among adults and adolescents in the United States, 2007–2010 Proportion of MSM Attending STD Clinics with Primary and Secondary Syphilis, Gonorrhea or Chlamydia by HIV Status†, STD Surveillance Network, 2012 STI Site Tests HIV Blood Rapid test, EIA, confirm with Western blot

Oral fluid Rapid test, confirm w/ Western blot

Syphilis Blood RPR, VDRL, FTA-ABS, TPPA, MHA-TP

Gonorrhea Urethra, Pharynx, Rectal NAAT or culture

Chlamydia Rectal, Urethra/urine NAAT or culture

Hepatitis C Blood Anti-HCV, HCV RNA

Anal Health

. Fissure . Abscess . Proctitis . Foreign objects . Neoplasm . HPV (warts)

Exam should include digital anorectal exam (DARE) and anoscopy Anal pap HIV-infected

MMWR:

MMWR June 14, 2013/62 (23); 463-465 MMWR:

MMWR June 14, 2013/62 (23); 463-465 May 14, 2014 Creating a Welcoming Space Unique Issues in LGBT Health

Bias in Stigma and Stigma and Health Care Discrimination Discrimination

Social Determinants

Health Care Disparities Barriers to Health LGBT Health in Medical Curricula

. Of 150 US and Canadian medical schools surveyed, median time dedicated to teaching LGBT-related content – 5 hours (3-8 hours) Schools with no LGBT content in curriculum: • Pre-clinical: 9 • Clinical: 44 • Neither: 5

Oberdin-Maliver, JAMA 2011; 306: 971-977 Barriers to Health

Lambda Legal, 2010. When Healthcare isn’t Caring Disclosure

. >50% have withheld their sexual orientation from their health care provider . Many believe that disclosure would adversely affect their health care . 24% have withheld information about sexual practices, compared with 5% of heterosexuals

LGBT Health and Services Needs in NYS, 2009; Harris Poll, Nov 2002; Smith, AJPH 1985; Harris Poll, Dec 2003 Creating a Welcoming Space . LGBT-sensitive intake forms – allow clients write in their gender . Use language that is sensitive to transgender identities . Post nondiscrimination policy . Cultural competency training for staff

ACOG Committee Opinion. Health Care for Transgender Individuals, Dec 2011

Acknowledgements

Rona Vail, MD, Susan Weiss, FNP, Peter Meacher MD, & the Callen-Lorde Team Thank you!