Sexual Health for Trans and Nonbinary People

Asa Radix, MD, MPH, FACP Callen-Lorde Community Health Center March 22-24, 2019 Disclosure ▪ I have no relevant financial, professional or personal relationships to disclose Learning Objectives

Upon completion of this presentation, learners should be better able to:

. Review terminology related to health care . Describe the epidemiology of STIs among transgender people . Review diverse guidelines on how to apply - and anatomy-based recommendations to patients of transgender experience

There are graphic surgical images in this presentation How many transgender clients do you currently provide care for (in any capacity)?

A. 0 B. 1-5 C. 6-10 D. >10

4 Are there National STI guidelines for transgender people?

1. Yes 2. No 3. I’m not sure CDC STD Guidelines 2015 Transgender Men and Women

Clinicians should assess STD- and HIV-related risks for their transgender patients based on current anatomy and sexual behaviors Case – Exposed to Gonorrhea

38 year old white presents to the STI clinic with 4 days burning on urination and lower abdominal cramping “I was exposed to gonorrhea" Condomless sex with cis-male partner 4 days prior PSH: - in Serbia PMH: - On hormones since age 22 Meds: transdermal testosterone What information does the provider need first to make an appropriate assessment?

A. Pelvic exam B. Urine HCG C. Pelvic ultrasound D. Surgical history & anatomic inventory E. Adherence to testosterone

8 Afebrile, BP 120/70

. Labs: Urine and anal GC/CT, RPR . HIV rapid negative . Received ceftriaxone/azithromycin for presumptive GC/CT . (Urine/anal NAAT positive for GC) Clinical Questions

. What is the impact of testosterone on susceptibility of STIs? Fertility?

. Does his surgery change the clinical evaluation? Transgender People and STIs

. STIs in TW - No national surveillance data (TW counted as MSM) - Increased VDRL seropositivity compared with MSM (India, Peru) and non-trans (India) - Increased prevalence GC/CT compared with MSM (USA) - Increased rates of HPV, Hepatitis B & C, HSV compared with MSM . Neovaginal risk (HIV/STI) not known . Limited data for TM

Grant NTDS 2010;Toibaro, Medicina 2009; Nuttbrock AJPH 2013; Gupta STD 2011, Shrivastava 2012; Silva-Santisteban AIDS Beh2012 Patients’ Fears . Being turned away, refused care or treated differently . Having to teach providers about trans people . Being asked unnecessary questions . Being ridiculed . Being assaulted by staff or other patients . Being misgendered

Adapted from the 2015 US Trans Survey HIV/STI Risk Assessment

. Pronouns: What are your pronouns? . Partners: What are the of your partners? How many partners in the last 3 months? . Parts: What words do you prefer to use for your body parts? What bottom surgeries have you had? . Practices: What kinds of sex are you having? Which behaviors might expose you to your partners’ fluids? . Protection: How do you protect yourself against HIV and STIs? . Past history of STIs

13 Examinations

. Defer unnecessary questions and exams - Build rapport before performing genital exams - Avoid satisfying your curiosity (ie, do you really need to know/see?) . Conduct sensitive genital exams only when necessary - Always explain the purpose of the exam - Use gender neutral terms - Ask patients what words they prefer . Acknowledge barriers and offer solutions - Stress of stigma and discrimination - Limitations of medical knowledge Gender inclusive language

Gendered Less Gendered External pelvic area , testicles Outer parts Labia or “lips” Outer folds Genital opening, frontal opening, internal canal , Internal organs Prostate Internal parts Breasts** Chest Pap smear, prostate exam Cancer , HPV screening Bra/panties/briefs Underwear Pads/Tampons Absorbent product Period/menstruation Bleeding

*Adapted from Potter et al. 2015 **Transgender women may prefer “breast” Anatomic Inventory & Surgeries

 Breasts  Bilateral breast augmentation   Bilateral orchiectomy  Ovaries  Forehead reconstruction  Laryngeal feminization surgery  Penis  Reduction thyrochondroplasty  Prostate  Scalp advancement  Testes  , penile inversion  Uterus  Vaginoplasty, colon graft  Vagina  Bilateral total reduction mammoplasty  Metoidioplasty   Urethroplasty  Soft tissue filler injections  Voice surgery  Other unlisted surgical procedure Gender Affirming Surgeries

Feminizing . Breast augmentation . Vaginoplasty and . Orchiectomy . Tracheal shave . Facial bone reduction . Rhinoplasty CASES Case 1 - “I think I have a UTI”

. 35 y/o transgender woman presents with complaints of abnormal urine stream for 6 weeks after SRS (orchiectomy, penectomy, vaginoplasty, labiaplasty). No sexual partners since surgery

. No other surgeries . PMH: Allergic rhinitis . estradiol 2mg daily . Dilations 4 times daily without pain, saline douche 2x daily . Occasional scant bloody discharge Exam: afebrile, normal exam Pelvic deferred

UA: dipstick urinalysis is negative for leukocytes and blood, nitrite neg Culture: S. lentus, E. coli, Grp B strep How would you manage this patient?

A. Treat for UTI with 3 days of ciprofloxacin or bactrim B. Treat for presumptive STI with ceftriaxone & azithromycin C. Refer back to surgeon D. Reassure patient that symptoms will resolve without treatment Vaginoplasty 101

. Electrolysis or laser - Start 3-6 months before - Not within 2 weeks of surgery . IV antibiotics (usually cefazolin) . VTE prophylaxis . Vaginal packing removed day 5-6 . Douching (saline or dilute povidone–iodine) . Initiate dilations Schecter, L. Transgender Health, 2016 6 weeks post-op

Image: http://marcibowers.com/mtf/mtf-services/grs/ Post-op Care

. Dilators 2-3 times daily for the first month . Generally life-time . Many (56%) use douches – iodine solution, low pH douch, tap water

Image: https://www.pelvicrelief.co.uk/product/soul-source- grs-vaginal-dilators-copy Post-Vaginoplasty Complications

. Urinary tract - Urethral stenosis/urinary retention - UTIs . Recto-vaginal Fistula - Occurs in up to 1/400 - Anorectal USG/CT/MRI for confirmation - Requires surgical repair with skin grafts . Vaginal stenosis - Often related to under-dilation - Can using xylocaine 2% jelly and gradually work up with the dilators. - Re-teach the correct method to use dilators, lubrication . Granulation tissue aggregation - bleeding and discharge, odor - silver nitrate cauterization . Vaginal prolapse . Wound dehiscence Follow up . Ask patient about their practices including douching and dilation . Difficulty/inability voiding/incontinence - Irregular stream common for 3-6 months . Discharge . Bleeding or pain . Is there any change during bowel movements? . Gas, fecal matter, rectal sphincter control . Sexual activity (pain, bleeding, sensation, ) Neovaginal Exam

. Examine neovagina with anal or small vaginal speculum . Look for granulation tissue, , lesions . Prostate is palpable at the anterior neovaginal wall

Illustration: Poteat & Radix, Transgender Individuals. In Sexually Transmitted Infections in HIV-Infected Adults and Special Populations. Laura Bachman (ed). 2017 Springer Neovaginal Microbiome

- Average pH of the neovagina is 5.88, range 5-7 - Lack of lactobacillus spp - (PI) Aerobic and anerobic microflora (Enterococcus faecalis & BV-associated bacteria, including Atopobium vaginae, Gardnerella vaginalis, Mobiluncus curtisii), bacteroides, fusobacteria, staph strep - (CV) E. coli, Proteus, providencia, Strep, bacteroides, staph epi - Vaginal bacteria common – don’t treat based on culture alone

Matsuki, S., Int J STD AIDS, 2015; Yang, C.,. Int J STD AIDS, 2009;Jain, Int J STD AIDS, 2007; van der Sluis, W.B., Int J STD AIDS, 2015;Bodsworth, Sex Transm Dis, 1994; Weyers, S., BMC Microbiol, 2009.Toolenaar J Clin Micro 1993; Weyers BMC Micro 2009 Case 2

36 year old . New sexual partner, cis-male • Increase in and odor • No condoms for sex PSH: 4 years before had vaginoplasty (penile inversion)

She’s worried she might have STI Examination of the neovagina shows no active bleeding • pH 9.0 • Vaginal swab PCR positive GC • Vaginal swab negative at 4 weeks after treatment

Van der sluis , IJ STD AIDS 2015 STI Risk after Gender-affirming Surgery Author Study STI Buscema, 1987 Case report Condyloma acuminata Haney, 1990 Case series (2) Condyloma accuminata Bodsworth, 1994 Case report Gonorrhea (PI) Von Engeland, 2000 Case report Condyloma accuminata Harder, 2002 Case report SCC (PI) Harder, 2002 Case report SSC (PI) Liguori, 2004 Case report Condyloma accuminata Wasef, 2005 Case report Condyloma accuminata Jain, 2007 Case report Bacterial vaginosis Yang, 2009 Case report Condyloma gigantean (CV) Weyers, 2009 Case series (50) Bacterial vaginosis 64% Kokcu, 2011 Case report SSC (PI) Matsuki, 2014 Case report Condyloma acuminate (PI) Fernandes, 2014 Case report SS (PI) Van der Sluis, 2015 Case report Gonorrhea (CV) Eflering, 2016 Case report HSV

16 published papers: 7 condyloma, 2 gonorrhea, 2 BV, 4 Cancer, HSV Neovaginal STIs

. Condyloma acuminatum . Neisseria gonorrhoeae (often asymptomatic) . Bacterial vaginosis . HSV . No case reports of , , other STIs

Matsuki, S., Int J STD AIDS, 2015; Yang, C.,. Int J STD AIDS, 2009;Jain, Int J STD AIDS, 2007; van der Sluis, W.B., Int J STD AIDS, 2015;Bodsworth, Sex Transm Dis, 1994; Weyers, S., BMC Microbiol, 2009. Image: Matsuki, Int J STD AIDS. 2015 Jun;26(7):509-11 Image: Matsuki, Int J STD AIDS. 2015 Jun;26(7):509-11 Image: Callen-Lorde CHC 2017 Image: Neovagina squamous cancer, penile inversion. Depart. Microb. www.aaf-online.org Vienna. Austria. 2011 STI Screening for TW after Bottom Surgery ▪ Vaginoplasty - Recommendation: Screen for STIs if at risk using vaginal swab > urine Case 3

65 year old trans woman, sudden onset of vaginal bleeding with dilations

PSH: 14 years before had vaginoplasty Not sexually active Dilates 4-5 times per week Differential diagnosis of bleeding after vaginoplasty Colo-vaginoplasty Penile-inversion Diversion colitis STIs Mucosal atrophy Trauma STIs Trauma Post-operative bleeding Polyps Inflammatory bowel disease Post-operative bleeding

Van der sluis , IJ STD AIDS 2015 Case 4

36 year old trans man comes in for “STI check up” On testosterone cypionate, 200mg every 2 wks Pansexual, has cis-male partner 5 years ago had “bottom surgery” (metoidioplasty) without urethral lengthening No other surgeries He has not seen a provider since What STI testing will you do today?

41 Metoidioplasty (meta)

▪ Release of the /phallus from the labia minora ▪ May include urethral lengthening

Images from: http://marcibowers.com/ftm/ftm-services/ring-metoidioplasty/ Other procedures ▪ / colpoclesis ▪ Scrotoplasty with testicle implants ▪ united into an approximation of a scrotum. ▪ Mons reduction

Images http://www.drtimnathan-urology.com.au/insertion-of-testicular-prosthesis Phalloplasty

. Creation of phallus . Radial forearm . MLD (musculocutaneous latissimus dorsi flap from the back) . ALT (anterior lateral thigh flap)

http://ftmphalloplasty.tumblr.com/post/67597935657/innervated- island-pedicled-alt-phalloplasty http://transitionftmuk.co.uk/phalloplasty/ Rashid M, Tamimy MS. Phalloplasty: The dream and the reality. In J PS 2013;46:283-93 Images: http://plasticsurgerysushma.blogspot.com/2014/09/penile- http://brownsteincrane.com/rf-donor-site-photos/ enhancement-and-phalloplasty.html Phalloplasty with Glansplasty

Image: http://brownsteincrane.com/dr-chen-phalloplasty/img_2706_2_2/ Penile Implants

▪ Non Inflatable or semi rigid ▪ Always firm ▪ One or two bendable rods. ▪ Bend into position, erect, flaccid ▪ Inexpensive, fewer moving parts

http://www.phallo.net/penile-implants/coloplast- http://www.phallo.net/penile-implants/zsi-100-ftm- genesis.htm malleable-penile-implant.htm Penile Implants

▪ Inflatable Penile Implants ▪ 2-piece, 3-piece (reservoir) ▪ inflatable cylinders in the shaft of the penis, and a hydraulic pump providing an ▪ pump and release valve in the scrotum ▪ Expensive, 10-yr life span

Images: https://www.centerforreconstructiveurology.org/erectile- dysfunction/penile-implants-types/#.V6zoOk0rLIU Clinical Issues

▪ Cervix can be retained ▪ Ask client exactly what surgeries were performed “anatomic inventory” ▪ screening according to standard guidelines ▪ STI screenings based on behavior/anatomy STI Screening for TM after Bottom Surgery

▪ Metoidioplasty or phalloplasty - Did patient have vaginectomy? - Was there urethral lengthening (UL), aka urethral follow through? ▪ If UL, no vaginectomy - Vaginal swabs for GC/CT, Trich, BV ▪ If no UL – can use urine testing Case 5

A 28-year-old transgender man comes to your clinic for sexual health screening. He is sexually active with cis-gender women and transgender men only. He has never had vaginal receptive sex Meds: testosterone cypionate 100mg IM every week for 10 years and finasteride 1mg daily

He is interested in pregnancy using donor sperm What do we know about fertility? Reproductive Health for Trans men/NB

• 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 Trans men/NB and Pregnancy

. Study of 41 TGM . Identity - 50% male, 24% transgender, 20% GNC . 5 conceived while on testosterone . 32% unplanned pregnancy Image: https://www.ebab.com/gay-travel- blog/category/gay-life

Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Obstet Gynecol. 2014 Dec;124(6):1120-7 Light et al, OB&GYN 2014 Case 6

A 28-year-old transgender man comes to your clinic for sexual health screening. He had a pap test at age 21, exam was extremely painful and specimen was “inadequate” on two attempts

Meds: testosterone cypionate 100mg IM every 2 weeks for 10 years He now plans to have /metoidioplasty & surgeon requires a pap test He requests alternative options to a pap due to 2 paps that revealed “inadequate specimens” Pap Smears in Transgender Men

Based on study at Fenway Health, Boston . Transgender men patients may avoid pelvic exams and be less likely to have cervical (64% vs. 74%) . were more likely to have an inadequate Pap, (10.8 % vs 1.3%) . 20 % inadequate pap if on testosterone >6 months - Be sure to inform lab that patient is using testosterone and that it is indeed a cervical specimen - If amenorrhea present, indicate on lab requisition

Peitzmeier, Am J Prev Med 2014;47(6):808–812; Peitzmeier, J Gen Intern Med. 2014 May;29(5):778-84 Special considerations in screening transgender men for cervical cancer . If patient refuses speculum exam: - Allow self-collection of swabs for HPV instead of cervical cytology specimen - Perform external or bimanual exam, which may help patient become more comfortable with speculum exam in the future Summary ▪ Create welcoming clinical sites that facilitate disclosure of / ▪ Ask name, gender and pronoun ▪ Think about language ▪ Understand diversity of sexual orientation and behaviors “no assumptions” ▪ Anatomic inventory “if you have it, check it” ▪ Outreach in transgender communities ▪ Appropriate prevention materials & resources Trans inclusive Prevention Materials

NYS and NYC DOH materials Sources: http://www.queertransmen.org/15gms004_primedguide-redo_vfa4_booklet_eng.pdf http://librarypdf.catie.ca/pdf/ATI-20000s/26424.pdf RESOURCES

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. J Clin Endocrinol Metab, November 2017, 102(11):1–35

World Professional Association for Transgender Health. Standards of care for the health of , transgender, and gender nonconforming people, seventh version. September 2011. http://www.wpath.org/publications_standards.cfm.

Schecter L. Gender Confirmation Surgery: An Update for the Primary Care Provider. Transgender Health. 2016 1(1):32-40 RESOURCES

Fenway Health www.fenwayhealth.org

Callen-Lorde Community Health Center http://callen-lorde.org/transhealth/

UCSF COE Transgender Health http://transhealth.ucsf.edu/

@asaradix @callen-lorde