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Home , Gender transitioning, Robert Eads

10/20/2017

Disclosures

Gyn Care for the Patient

I have consulted for Sage Therapeutics about post- Juno Obedin-Maliver, MD, MPH, MAS partum depression treatment and care pathways. University of California, San Francisco Assistant Professor (UCSF and SFVAMC) Co-Director, The PRIDE Study Founder, Stanford University LGBT Medical Education Research Group

What the Evidence Tells Us San Francisco, CA 20 October 2017

Today’s Objectives Today’s Plan

• Terminology • Why is this important? • Understand the difference between , , sexual • What do I need to know? orientation, , and . • Resources & Homework • Understand some of the reproductive health needs for transgender men & women Resources • Build a framework for providing sensitive and competent http://tinyurl.com/lwn6au5 gynecological care for transgender patients.

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Gender vs. Sex

Are we talking, gender? Or A day in theSex? life of 5M prenatal… Terminology

Right?

Gender vs. Sex Gender vs. Sex

Are we talking, gender? Are we talking, gender? Or Or A day in theSex? life of 5M A day in theSex? life of 5M prenatal… prenatal…

Sex: But what if the The biological and physiological characteristics that define males and . family gets Gender: The socially constructed roles, behaviors, activities, and attributes that a given Laverne instead society considers appropriate for men and women. of Jessie? “Male” and “” are sex categories, while “man” and “woman” are gender categories.

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Gender vs. Sex Gender vs. Sex

“Sex is what’s in your genes/jeans. “Gender identity is who you go to bed as. Gender identity is what’s between your ears.” is who you go to bed with.”

GenderThe Alphabet Identity Soupvs. Sex Transgender: an Umbrella

Gay Transgender (Trans*) is an umbrella term…

Bisexual For persons whose gender identity, gender expression, or behavior does not Transgender conform…to that typically associated with the sex to which they were assigned at birth. http://transhealth.ucsf.ed u/trans?page=guidelines- … and others terminology Use people’s affirmed gender

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Transgender: an Umbrella Terminology • Transition: The process of “gender transition” or Transgender (Trans*) is an umbrella term… “gender affirmation” may include social, medical, Use people’s affirmed gender and/or surgical processes.

• Transgender man/ (FTM^): • Putting it together! (Sexual orientation and GI) a man who was assigned female sex at birth. • Lesbian (Transgender/) Woman • Straight (Transgender/Cisgender) Man • Transgender woman/ (MTF^): • Bisexual (Cisgender/Transgender) Woman a woman who was sex at birth.

• Genderqueer/ Gender non-binary: someone who identifies outside of the of man and woman may have either sex assigned at birth.

Terminology: Principles for Use Quiz Time The following are • No single definition features that correspond • Vary geographically, with a person’s sex individually, & over time! assigned at birth:

• Avoid seeking or attaching A. Clothing, hair, make-up labels to people. 100% B. Reproductive organs • Follow patient lead in C. Vocal intonation language with name, D. Desire to carry a child pronouns, body organs E. “Opposite” gender attraction ASK patients & use THEIR language ! F. Pronouns 0% 0% 0% 0% 0% s s n on n a ti u rg a o o n n o ro e t P iv in ct l u ca d o ro V p Primary Care Protocol for Transgender Patient Care, Center of Excellence for Transgender Health, e R Desire to carry a child University of California, San Francisco, Department of Family & Community Medicine, April 2011 Clothing, hair, make-up

“Opposite” gender attraction

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LGBT ADULT Population Estimates

Massachusetts BRFSS I’m busy, what does this 0.5% transgender have to do with me?

Gates GJ. How many people are lesbian, But…we don’t really know! , bisexual, transgender? UCLA School of Law, 2011.

Patients Want LGBT-Specific Care Providers Don’t Ask About SOGI

When Health Care Isn’t Caring: Lambda Legal’s Survey of Sobecki et al. J Sex Med. 2012;9:1285–1294. Against LGBT People and People with HIV (New York: Lambda Legal, 2010). Available at www.lambdalegal.org/health-care-report

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Don’t be that doctor. Some MEN need OBGYN health care!

Southern Comfort: A documentary about the life of a trans man who died of .

Trans MEN’s repro health care needs Trans women need repro health care too! Obstetrics: they get pregnant Obstetrics: transplants are on the horizon Family Planning: undesired Family Planning: semen analysis, cryopreservation Gynecology: they still have , uteri etc. Gynecology: they have neo-vaginas, and need support and mammos REI: PCOS, needing assisted reproduction REI: back to family planning

Urogynecology: genital reconstruction, Urogynecology: often involved in general urogyn reconstruction

RID: STIs, HIV RID: high rates of STIs, HIV

Oncology: sadly cancer too… Oncology: they get cancer too…

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National Committee Recognize This… Quiz Time What is the population prevalence of transgender people in the U.S.? 33%

A. 1in 100 20% B. 1 in 200 - 300 18%

13% C. 1 in 500 – 1,000 11%

D. 1 in 2,000 – 3,000 6%  Transgender identity is a spectrum E. 1 in 10,000 – 30,000

0 0 0 0 0 0 ve 1 3 ,0 o F. None of the above in - 3 b 0 a 1 0 – e  2 0 h Barriers to care are significant 0 t n i ,0 f 1 2 o e 1 in 500 – 1,000 in n 1 o  Appropriate referrals & safe environment are key 1 in 10,000 – 30,000N

“Transition” has 3 components

1 Social Okay, so what do I need to know? 2 Medical

3 Surgical

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Key Pearls for Caring for Trans* People Social Transition – Movement Advancement Project – LGBTQ Rights Maps

Regardless of stage of transition: • Not one “transition” or “complete” • Use correct pronouns • Learn about transition desires & offer support • If they have it, screen it • Whether they do or don’t want a family – help • Sxs may / may not be 2/2 transition

CA Legislature - is ahead of the curve

Medical Transition “Gender is no barrier to applying for Medi-Cal Services”

The bill would authorize the change of gender on a new birth certificate to be female, male, or nonbinary.

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Medical Transition – 2011 NTDS Gender Affirming Hormone Administration

Great references: http://transhealth.ucsf.edu/trans?page=guidelines-home Hembree et al. Endocrine Treatment of Gender-Dysphoric/ Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. 2017

Trans men: Testosterone: IM, transdermal patch or gel or cream, or subq implant. Most common regimen: Depo-methyltestosterone 50-100mg IM qwk • Pts learn to self-inject, patch & gel works more slowly • Initiation / Surveillance: lipids, A1c/fasting glucose, total testosterone, SHBG, albumin, HGB/HCT (see guidelines for more details) An active testosterone-sensitive cancer is a contraindication

Trans women: Estradiol +/- progestin +/- androgen blocker: oral, transdermal, IM Most common regimen: Most adults 2-4mg QD PO (lower start and slower titration can 62% have had hormone therapy, increases with age be done) +/- MDPA 5-10mg PO QD, +/- Spironolactone 200mg PO BID 23% hope to in the future • Initiation / Surveillance: lipids, A1c/fasting glucose, estradiol, total testosterone, SHBG, albumin, prolactin (see guidelines for more details) Transgender women (80%) > Transgender men (69%) An active estrogen/progestin-sensitive cancer is a contraindication

Testosterone Outcomes (for reference) Testosterone Outcomes (for reference)

• Deepened Voice • Increased HCT (hct>50%) • Amenorrhea • Acne • Hirsuitism (body/facial) • Weight increase >10% • Clitoral Growth (Avg 4- • Elevated LFTs (upto 15%) 5cm) • Laryngeal prominence • Sleep Apnea • Increased Libido • Aggression and hypersexuality • Breast Atrophy • Poor lipid profile^ • Redistribution of fat^ • Testosterone to male • Decreased insulin sensitivity^ levels^ • Increased IGF^ • Increased muscle • Decreased BMD after mass^ gonadectomy^

^ = statistical changes, not always clinically significant Blue = permanent changes Green = reversible changes Moore et al. J. clinical Endocrin. 2003 Red = high risk concerning changes Hembree et al. J Clinical Endo Metab, 2017 Hembree et al. J Clinical Endo Metab, 2017 Yellow = negative effects

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Monitoring Trans Men (for reference) Estrogen Outcomes (for reference)

• Gynecomastia • Venous thromboembolism • Enlarged areolae & • Cholelithiasis nipple • Hyperprolactinemia • Softened skin • Elevated liver enzymes • Reduced testicular volume • Depression • Decreased • Decrease in HgB spontaneous erections • Prolactinoma (case reports) • “Calming effect” • Redistribution of fat^ • ?Breast cancer (case reports) • Testosterone to female • Prostate carcinoma after levels^ orchiectomy (case report) • Decreased hair growth^ • Decreased insulin sensitivity^ • Decreased IGF^ ^ = statistical changes, not always clinically significant Green = reversible changes Moore et al. J. clinical Endocrin. 2003 Hembree et al. J Clinical Endo Metab, 2017 Red = high risk Hembree et al. J Clinical Endo Metab, 2017 Yellow = deleterious

Estrogen Outcomes (for reference) Monitoring Trans Women (for reference)

Hembree et al. J Clinical Endo Metab, 2017 Usually GYN/Women’s health if/after surgery Hembree et al. J Clinical Endo Metab, 2017

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Are hormones safe? Goal: What are the effects of cross-sex hormones in men and women?

n = 100, average 10 years on hormones So…what about health FTM (exogenous testosterone): appears safe - no osteoporosis, CV events, hormone-related CA implications? MTF (exogenous estrogen): 25 % osteoporosis at lumbar spine, 6% thromboembolic event, 6% CV event after 11 years, no hormone-related tumors

“Long-Term Evaluation of Cross-Sex Hormone Treatment in Transsexual Persons” Wierckx, et al. J Sex Med 2011

Are hormonesAre hormones & SRS,and SRS EFFECTIVE? effective? What about GYN Cancer?

Goal: Assess prognosis of people with GID (now GD) Goal: Summarize published case reports (at that receiving hormones & SRS in terms of QoL? time).

Systematic Review & Meta-analysis: The group found 6 cases: 28 observational studies, n=1,833 (1,093 MTF) Ovarian Cancer: 2 • 80% improvement in QoL Cervical Cancer: 2 • 72% improvement in sexual function Endometrial Cancer: 1 • 78% improvement in psych sxs Vaginal Cancer: 1 Where there’s no smoke, there’s no fire.

Urban R, et al. Gynecologic malignancies in female-to-male …AJOG. 2011. “Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes” Au Murad, et al. Clin Endocrinology. 2010.

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Increased Rates of Abnormal Pap Smear Great resource on Gyn Care for Trans Men Goal: Investigate anecdotal high rates of inadequate paps among FTM.

Clinical chart review, case series. 233 FTM compared with 3625 cisgender female.

• FTM patients more likely to have inadequate paps 10.8% vs. 1.3% total tests. • Longer latency of follow-up • Years of testosterone use affected the model.

Peitzmeier et al. Female-to-male patients have high prevalence of unsatisfactory Paps compared to non- transgender females: implications for cervical cancer screening. JGIM, 2014

What about Breast Cancer? Case: Fibroids Goal: Examine the occurrence of breast cancer in Consult: 30 yo F with fibroids, wants to start Dutch MTF and FTM between 1975-2011. hormones for her (ugh!) transition. Can we start testosterone (T)? Patients 18-80, hormones 5-30 years. N= 2,307 MTF (52,000 p-y), 795 FTM (16,000 p-y) ID: 30 yo G0 transgender man w/ sxs fibroids. -Socially transitioned x 10 years, uses male pronouns • Among MTF, 1 confirmed, +1?: 4.1/100,000 p-y outside of VA/Air Force. • Among FTM, 1 case: 5.9/100,000 p-y -Now that out of active duty, wants to go on T -Uterus: 20x13x10cm, symptomatic Hormones not associated with increased CA -Endocrine: Waiting for GYN about on T with fibroids How to refer physiologically to cases? My response: No data, but go ahead, might help Gooren et al. Breast cancer development in transsexual subjects receiving cross-sex hormone treatment. J. Sex Medicine, 2013 fibroids, but what about his fertility?

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What about Fertility? Beyond surviving…thriving.

TIME

The Next Frontier in Fertility Treatment. My Brother’s Pregnancy and Sarah Elizabeth Richards. January 12, 2014. the Making of a New American Family. September12, 2016 “Over the past 15 years, activists have fought to compel insurers to cover transgender-related health care.... “Pregnancies like Evan’s – will stretch our cultural perceptions of What’s been left out of the spotlight: having babies.” gender norms even further….But what is you were born into a female body, know you are a man and still want to participate in the traditionally exclusive rite of womanhood? What kind of man are you then?

What about Family Planning? What about hormones and pregnancy? Goal: Provide info on reproductive wishes of Goal: Understand FTM who had been pregnant and transsexual men after SRS (FTM) delivered after transition.

Single-center, cross-sectional, 50 FTM after T & SRS Online, cross-sectional, international • 64% in a relationship 41 FTM (social and medical transition) • 22% had children • 61% used testosterone prior to pregnancy • N = 8 female partner, donor sperm • 72% resumption menses within 6 mos • N = 3 birth before T & SRS • 84% used their own oocytes • 54% desired to have children • 24% unplanned pregnancy • 37.5% would have frozen eggs

Wierckx et al. Reproductive Wishes in Transsexual Men. Human Reproduction, 2012 Light et al. Transgender Men who Experienced Pregnancy After Female-To Male . AJOG, 2014.

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What about contraception/conception? What about contraception/conception? Conclusion: Transgender men have different gender Study goal: Understand contraceptive use among partners & family building options & needs transgender men “at risk” for pregnancy. 26 transgender men studied at San Francisco Clinic • 50% using testosterone (13/26) • Among those on T, 69% amenorrheic (9/13) ~~ • 50% “at risk” for pregnancy (13/26) – have uterus + sex with cisgender man or transgender woman • 85% wanted to avoid pregnancy • 42% no contraceptive method (11/26) 28%+

Bauer 2013 Cipres et al. Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco. Contraception. 2016

Quiz Time Who are transgender men partnering with sexually?

A. Cisgender men B. Cisgender women C. Transgender men 90% So…what about surgery? D. Transgender women E. Genderqueer people

F. All of the above 7% 0% 1% 0% 2%

en n n le e e p m m m o er r o e d de w p n n r er ge e de e is sg n u C n e rq ra g e All of the above Cisgender women T ns d ra en T G

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Gender Affirming Surgeries Surgical Transition – 2011 NTDS Previously called: sex re-assignment surgery (SRS) Trans Men and surgeries: / Creation of Penis Chest “Top” Surgery - More than 26 different procedures Creation of Testes aka. For Trans Men: For Trans Women: Hyst +/- BSO Chest Reconstruction Orchiectomy Metoidioplasty Penectomy Trans Women and surgeries: Phalloplasty Breast augmentation Breast Augmentation Orchiectomy Vaginoplasty Scrotoplasty Vaginoplasty Urethroplasty Tracheal shave Vaginectomy (+/- Facial reconstruction colpocleisis) Note: among all gender - 93% who have had surgeries also received hormones

On the left: Metoidioplasty Or “metas” (+scrotoplasty)

On the right: Phalloplasty Chest Or “phallos” Reconstruction

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SignalingGender IdentityApproachability vs. Sex

How can you signal to LGBTQ people that you are a safe person with whom they can disclosure and or discuss sexual orientation, gender identity? a

Consider in your practice: c What happens when patients come in the door? What happens behind closed doors? What happens between the doors? Vaginoplasty, (a) immediately What happens to open doors? b pre-op, (b) post-op & (c)10w

* Making Your Clinic LGBTQ Friendly * Get Involved Change the Landscape

1. Board and Senior Management are Actively Engaged •National, online, longitudinal 2. Policies Reflect the Needs of LGBTQ People cohort study 3. All Staff Receive Training on Culturally Affirming LGBT Care •Web Based Platform 4. Processes & Forms Reflect the Diversity of LGBT People & their Population •Designed for and by LGBTQ Relationships Research in people 5. Data is Collected on Sexual Orientation & Gender Identity State-of-the-art participant 6. All Patients Receive Routine Sexual Health Histories Identity and • management system 7. Clinical Care and Services Incorporate LGBT Health Care Needs Disparities for 8. The Physical Environment Welcomes and Includes LGBT People Equality •8600+ participants since May 2, 2017 9. LGBT Staff are Recruited and Retained 10.Outreach Efforts Engage LGBT People in Your Community See the webinar from The Fenway Institute: www.pridestudy.org National LGBT Health Education Center – Fenway Institute: Harvey Makadon - Webinar: 10 Things: Providing an Inclusive and Affirmative Health Care Environment for LGBT People

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Conclusions Thank You! • Transgender people and their reproductive health needs are diverse, but not Juno Obedin-Maliver, MD, MPH, MAS insurmountable [email protected] • Understanding the difference between sex, gender, and gender transition are critical to good care. Resources • There are reproductive health implications to http://tinyurl.com/lwn6au5 gender transition, but more data is needed. • You know the medicine, simple changes to care for transgender people help! Check us out at www.pridestudy.org !

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