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GUIDELINES for GENDER-AFFIRMING PRIMARY CARE with TRANS and NON-BINARY PATIENTS 1 Table of Contents

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GUIDELINES for GENDER-AFFIRMING PRIMARY CARE with TRANS and NON-BINARY PATIENTS 1 Table of Contents guidelines GENDERAFFIRMING PRIMARY CARE TRANS NONBINARY PATIENTS Guidelines for PRIMARY AUTHOR gender-affirming Dr. Amy Bourns, MD, CCFP primary care with trans and non Staff Family Physician, Sherbourne Health - Program Director, LGBTQ Enhanced Skills binary patients Residency Program Lecturer, Department of Family and Community Medicine, University of Toronto Trans and non-binary is an umbrella term REVIEWERS used to encompass all people whose gender identities and expressions do not align with norms Adrian Edgar, MD, CCFP (AM) / MCFP (AM), associated with their sex assigned at birth. Clinical Assistant Professor of Family Medicine, Dalhousie and Memorial Universities Gender-affirming primary care encompasses the delivery of culturally competent care to trans Allison Lou, MD, CCFP, FCFP, Lecturer, patients in the context of primary care and the Department of Family and Community collaborative provision of gender-affirming medical Medicine, University of Toronto interventions. Different medical treatment plans and psychosocial supports are offered depending Ed Kucharski, MD, CCFP, FCFP, Lecturer, on the needs and goals of the individual patient. Department of Family and Community Medicine, University of Toronto Marria Townsend, MD, CCFP, Clinical Assistant Professor, Faculty of Medicine, Department of Family Practice, University of British Columbia This publication was developed with financial Raymond Fung, MD, FRCPC, Lecturer, support from the Province of Ontario. The Department of Medicine, University of Toronto publication and any views expressed herein are those of Rainbow Health Ontario and do Sue Hranilovic, MN, NP-PHC, ACRN, Adjunct not necessarily reflect those of the Province. Lecturer, Faculty of Nursing, University of Toronto Thea Weisdorf, MD, CCFP, FCFP, Assistant Professor, Department of Family and Community Medicine, University of Toronto GUIDELINES FOR GENDER-AFFIRMING PRIMARY CARE WITH TRANS AND NON-BINARY PATIENTS 1 Table of Contents Part I: An introduction to gender-affirming Discontinuation of hormone therapy ..................28 ............ 3 care and hormone planning visits Referrals and advocacy in support of About Sherbourne Health and a history of this trans patients .............................................................28 document ....................................................................5 Disclaimer and limitations ......................................6 Supporting patients with transition- Changes in this edition ...........................................8 related surgeries (TRS) .................................... 30 Qualified providers: self-determined, based An introduction to trans and non-binary on experience and knowledge .............................32 communities and their health care .............. 9 OHIP TRS funding application and An overview of trans communities: size, referral process .........................................................33 diversity and language ...........................................9 References ..................................................................34 Colonialism, gender and Indigenous cultures ..10 Part II: Feminizing hormone therapy ....... 37 Introduction to gender-affirming Anti-androgens .........................................................38 primary care ........................................................ 11 Estrogen ......................................................................42 The role of the primary care provider (PCP) .....11 Effects and expected time course .......................43 Endocrinologist involvement .................................12 Progestins ...................................................................46 Taking the next step: providing gender- Special considerations for older affirming care to trans and non-binary transfeminine patients ............................................47 patients ........................................................................13 Monitoring and dose adjustments ......................48 A framework for providing gender-affirming Precautions and risk mitigation with primary care to trans and non-binary estrogen therapy ......................................................52 patients ........................................................................13 Specific conditions: Risk mitigation and An individualized approach ...................................15 long-term preventive care ......................................55 Long-term follow-up ................................................62 Hormone initiation ............................................ 16 References ..................................................................62 The hormone planning period ..............................17 Exploration of gender identity Part III: Masculinizing hormone therapy 65 and expression ..........................................................18 Testosterone ..............................................................65 Diagnosis ....................................................................19 Special considerations for older Patient expectations ................................................21 transmasculine patients ..........................................68 Psychosocial preparation and support ..............21 Monitoring and dose adjustments .......................69 Mental health and lifestyle considerations .......22 Precautions and risk mitigation with Capacity to consent .................................................23 testosterone therapy ...............................................71 Physical exam and baseline investigations .......24 Specific conditions: risk mitigation and Hormone coverage through the Ontario long-term preventive care ......................................76 Drug Benefit (ODB) and Exceptional Access Long-term follow-up ...............................................82 Program (EAP) forms ................................................25 References ................................................................83 Fertility and birth control ........................................25 Trans patients with ova ...........................................26 Conclusion ........................................................... 86 Trans patients with sperm ......................................27 Feedback .............................................................. 86 Sexuality ......................................................................27 Acknowledgements ......................................... 87 GUIDELINES FOR GENDER-AFFIRMING PRIMARY CARE WITH TRANS AND NON-BINARY PATIENTS 2 Tables Table 1. Effects, side effects and contraindications of anti-androgens .......................................................39 Table 2. Options and recommended doses of anti-androgens in feminizing therapy ................... 40 Table 3. Recommended parameters for monitoring anti-androgen therapy............................................... 42 Table 4. Effects and expected time course of feminizing hormones ................................................. 43 Table 5. Formulations and recommended doses of estrogen for feminizing hormone therapy ........... 46 Table 6. Recommended bloodwork for monitoring feminizing hormone therapy .................................... 49 Table 7. Precautions with estrogen therapy and considerations in minimizing associated risks ........................................................... 53 Table 8. Effects and expected time course of masculinizing hormones ........................................... 67 Table 9. Formulations and recommended doses of testosterone for masculinizing hormone therapy ........................................................................... 70 Table 10. Recommended bloodwork for monitoring masculinizing hormone therapy ............................. 73 Table 11. Precautions with testosterone therapy and considerations in minimizing associated risks ........................................................... 74 GUIDELINES FOR GENDER-AFFIRMING PRIMARY CARE WITH TRANS AND NON-BINARY PATIENTS 3 Appendices .......................................................... 87 Appendix L: Checklist for Patient Review – Initiation of Appendix A: Progestin Therapy ............................................ 125 Hormone Planning Period Checklist ........... 87 Appendix M: Appendix B: Checklist for Patient Review – Initiation of Hormone monitoring summary for Masculinizing transfeminine patients (collaborative Hormone Therapy ............................................. 126 PCP and nursing team).................................... 90 Appendix N: Appendix C Sample Request for an Unlisted Drug Hormone monitoring summary for Product, Testosterone Enanthate transmasculine patients (collaborative (Delatestryl) ........................................................ 128 PCP and nursing team) ..............................................92 Appendix O: Appendix D: Sample Request for an Unlisted Drug Preventive care checklist for transfeminine Product, Testosterone Cypionate patients ...............................................................................94 (Depo-Testosterone) ............................................... 129 Appendix E: Appendix P: Accompaniment to the preventive care Template Letter in Support of an Application checklist for transfeminine patients ............ 98 For Change of Sex Designation on an Ontario Birth Registration .............................................. 131 Appendix F: Preventive care checklist for Appendix Q:
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