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Beyond Hormones Reproductive Health Needs of Transgender People LGBT Domestic Violence Concerns and LGBT (Lesbian, 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 ▶ hysterectomy, salpingo- ▶ Breast augmentation oophorectomy ▶ Vaginoplasty & labiaplasty ▶ Phalloplasty ▶ Orchiectomy ▶ Metoidioplasty ▶ Tracheal shave ▶ Vaginectomy ▶ 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 vaginitis, 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 Lesbians 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 birth control & STI screening . “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 cervical cancer 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 - chlamydia, genital warts, trichomoniasis, 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 . 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