10/20/2017 Disclosures Gyn Care for the Transgender 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 sex, gender, sexual • What do I need to know? orientation, gender identity, and gender expression. • 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. 1 10/20/2017 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 females. 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 “female” are sex categories, while “man” and “woman” are gender categories. 2 10/20/2017 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.” Sexual orientation is who you go to bed with.” GenderThe Alphabet Identity Soupvs. Sex Transgender: an Umbrella Lesbian 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. Queer http://transhealth.ucsf.ed u/trans?page=guidelines- … and others terminology Use people’s affirmed gender 3 10/20/2017 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/ trans man (FTM^): • Putting it together! (Sexual orientation and GI) a man who was assigned female sex at birth. • Lesbian (Transgender/Cisgender) Woman • Straight (Transgender/Cisgender) Man • Transgender woman/ trans woman (MTF^): • Bisexual (Cisgender/Transgender) Woman a woman who was assigned male sex at birth. • Genderqueer/ Gender non-binary: someone who identifies outside of the gender binary 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 4 10/20/2017 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! gay, 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 Discrimination 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 5 10/20/2017 Don’t be that doctor. Some MEN need OBGYN health care! Southern Comfort: A documentary about the life of Robert Eads a trans man who died of ovarian cancer. Trans MEN’s repro health care needs Trans women need repro health care too! Obstetrics: they get pregnant Obstetrics: uterus transplants are on the horizon Family Planning: undesired pregnancies Family Planning: semen analysis, cryopreservation Gynecology: they still have vaginas, 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… 6 National Committee Recognize This… Transgender identity is a spectrum Barriers to care are significant Appropriate referrals & safe environment are key Okay, so what do I need to What is the population prevalence of transgender people in the U.S.? A. 1in 100 B. 1 in 200 - 300 Quiz Time know? C. 1 in 500 – 1,000 D. 1 in 2,000 – 3,000 E. 1 in 10,000 – 30,000 F. None of the above 33% 10/20/2017 18% 20% “Transition” has 3 components 1in 100 1 11% 1 in 200 - 300 13% 1 in 500 – 1,000 1 in 2,000 – 3,000 6% 2 1 in 10,000 – 30,000 Social None of the above 3 Medical Surgical 7 10/20/2017 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 Pregnancy Services” The bill would authorize the change of gender on a new birth certificate to be female, male, or nonbinary. 8 10/20/2017 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 9 10/20/2017 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 10 10/20/2017 Are hormones safe? Goal: What are the effects of cross-sex hormones in transsexual men and women? n = 100, average 10 years on hormones So…what about health FTM (exogenous testosterone):