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Title Slide for 2019 Sexual and Gender Minority Health Conference

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Title Slide for 2019 Sexual and Gender Minority Health Conference 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 transgender health care . Describe the epidemiology of STIs among transgender people . Review diverse guidelines on how to apply gender- 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 trans man 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: - Metoidioplasty 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 genders 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 Vulva External pelvic area Penis, testicles Outer parts Labia or “lips” Outer folds Vagina Genital opening, frontal opening, internal canal Uterus, ovaries Internal organs Prostate Internal parts Breasts** Chest Pap smear, prostate exam Cancer screening, 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 Cervix Bilateral orchiectomy Ovaries Forehead reconstruction Laryngeal feminization surgery Penis Reduction thyrochondroplasty Prostate Scalp advancement Testes Vaginoplasty, penile inversion Uterus Vaginoplasty, colon graft Vagina Bilateral total reduction mammoplasty Metoidioplasty Phalloplasty Scrotoplasty Urethroplasty Soft tissue filler injections Voice surgery Other unlisted surgical procedure Gender Affirming Surgeries Feminizing . Breast augmentation . Vaginoplasty and labiaplasty . 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 vaginoplasties - 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, orgasm) Neovaginal Exam . Examine neovagina with anal or small vaginal speculum . Look for granulation tissue, warts, 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 trans woman. New sexual partner, cis-male • Increase in vaginal discharge 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 Chlamydia, Trichomoniasis, 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
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