Culturally Competent Medical Care of Transgender Patients
Gal Mayer, MD January 31, 2013 Introduction Presenter Information
Gal Mayer, MD (former) Medical Director Callen-Lorde Community Health Center
Primary care Cross-Gender Hormone care HIV care Oral health care Gynecology/Women’s health Mental health/social services 356 West 18th Street Sexual health clinic New York, NY 10011 Adolescent health 212-271-7200 Mobile health www.callen-lorde.org Introduction Course Objectives 1. Describe the modifiable barriers to accessing healthcare for transgender people and how to create a welcoming, inclusive environment. 2. Provide cross-gender hormone therapy to transgender patients by understanding their effects, benefits, risks, and administration. 3. Provide HIV and primary care to transgender patients by understanding the ways in which their clinical needs may differ from non-transgender patients. Introduction CME Disclosures Virtually all mentioned uses of the hormonal medications contained in this presentation are not FDA-approved and considered off-label.
The presenter has the following disclosures: Gilead Sciences – speaker bureau What does transgender mean? Exploring meanings What does transgender mean? Exploring meanings What does gender mean? Questions to ponder What is gender?
How do we know a person’s gender is?
How many genders are there? What does gender mean? Gender vs. sex Traditional . Gender is binary (M/F) . Synonymous with sex (chromosomes, genitalia)
New . Gender is a spectrum . Defined by several criteria . Separate from sex What does gender mean? Components of Gender Identity - The psychological awareness or sense of where one fits in on the man-woman spectrum Role – That part of behavior that is influenced by society’s expectation of what is gender- appropriate Expression – The way in which one communicates his or her identity through appearance and behavior (mannerisms, dress, speech, etc.) What does gender mean? A Combination of Traits Sex Genetic XY XXY (Klinefelter), XYY, XO (Turner) XX Anatomic Male CAH, Androgen Insensitivity Female Gender Identity Man Transgender, Genderqueer Woman Role Masculine Neutral Feminine Expression Masculine Androgynous Feminine Sexuality Attraction Homosexual Bisexual Heterosexual Label Gay, Lesbian, Straight, Queer, Butch, Fag, Bi, Femme, Dyke Behavior Same Sex Both Other Sex What does gender mean? Gender in a Population What does transgender mean? Exploring meanings What does transgender mean? Transgender Terminology
Definitions vary across cultures and communities and are only offered here for the sake of consistency. Transgender, Gender Variant, Gender Non-Conforming, Gender Different . Umbrella terms used to group the many gender different communities . People who transcend typical gender paradigms . (Non-transgender people are sometimes called cisgender) What does transgender mean? Transgender Terminology Transgender, Transsexual . Biological men and women whose gender identity most closely matches the other gender Genderqueer . Used to describe people whose gender identity does not fit neatly into either male or female categories Transsexual . Sometimes used to specifically describe persons who have undergone genital surgery What does transgender mean? Transgender Terminology Crossdresser . Individuals with a desire to wear the clothing of the other sex but not to change their gender; many are heterosexual men who crossdress for erotic arousal; previously called transvestite Drag Queen/King . Individuals, usually in the gay/lesbian community, who crossdress for entertainment purposes and/or to challenge social stereotypes
What does transgender mean? Sexual Orientation . Sexual orientation not the same as gender identity . Transgender people can be of any sexual orientation . Trans-women attracted to men and trans-men attracted to women may identify as heterosexual . Trans-women attracted to women may identify as lesbian . Trans-men attracted to men may identify as gay . Trans-people may also identify as straight, homosexual, bisexual, pansexual, omnisexual, asexual, queer, celibate, etc.
Source: Grant et al. (2011). Injustice at Every Turn: http://www.thetaskforce.org/downloads/reports/reports/ntds_full.pdf What does transgender mean? Diverse Communities … androgyne, bi-gendered, butch queen, CD, crossdresser, drag king, drag queen, female-to-male, femme queen, FTM, gender bender, gender blender, gender challenged, gender fucked, gender gifted, gender-queer, male-to- female, MTF, new man, woman, non-op, non-operative transexual, passing man, passing woman, phallic woman, post-op, post- butch, TG, third sex, trannie/tranny, trannie-fag, trans, trans-butch, transexual/transsexual, transgender, transgenderist, transie, trans-man, trans- person, transexed, transexed-man, transexed-woman, transexual, transexual-man, transexual-woman, transvestic-fetishist, transvestite, trans-woman, tryke, TS, two-spirit… What does transgender mean? Transgender Prevalence No reliable data:
Surveys suggest that at least 0.3% of the US population is transgender
0.2% 1:500-2,000 TG identity1 1:2,000 TG hormones (Belgium) 1:2,900 MtF surgery/hormones (Singapore)2 1:11,900 MtF surgery (Netherlands)3 0.003% 1:30,000 MtF surgery (USA) What does transgender mean? Transgender Terminology Transition . The process from living and being perceived as the gender assigned at birth according to the anatomical sex (M or F) to living and being perceived as the individual sees and understands themselves . Does not necessarily include surgery or hormones . Transgender identity transition can be similar to the LGB “coming out” process What does transgender mean? Transgender Terminology Transition (continued) . Some transitions have milestones (living part- time, living full-time, etc.) and an endpoint, while others are continual processes . Transitions happen on many levels: hormonal, linguistic, psychological, intellectual, spiritual, surgical, social, emotional, legal, etc. . Common terms to describe transition: . MTF – male-to-female (transgender women) . FTM – female-to-male (transgender men) . Genderqueer What does transgender mean? Medical Diagnostic Terms Psychiatric Diagnoses . DSM IV – Gender Identity Disorder (302.85) . Often perceived as pathologizing . DSM V – Gender Dysphoria . Revised definition intended to depathologize will be released in 2013 Medical Diagnoses NB: Many clinicians avoid . Transsexualism these diagnostic codes and use more neutral . ICD-9: 302.5x ones (i.e. Unspecified . ICD-10: F64.0 Endocrine Disorder 259.9) What does transgender mean? Medical Terminology Cross-Gender Hormone Therapy . Not universally desired nor necessary (No-Ho) Sex Reassignment Surgery (SRS) or Gender Confirming Surgery (GCS) . Not universally desired (Pre-op, Non-op, Post-op) . Not easily obtainable: . Cost/insurance coverage . Need to meet criteria What does transgender mean? Diverse Utilization of Surgery Feminizing Procedures
Source: Grant et al., 2010: http://transequality.org/PDFs/NTDSReportonHealth_final.pdf What does transgender mean? Diverse Utilization of Surgery Masculinizing Procedures
Source: Grant et al., 2010: http://transequality.org/PDFs/NTDSReportonHealth_final.pdf What does transgender mean? Prejudice kills Transphobia . An irrational fear of gender-different people leading to systematic discrimination and violence
Tyra Hunter (1970-1995) Robert Eads (1945-1999) Brandon Teena (1972-1993) Died in Washington DC Care for ovarian cancer Raped and murdered by after paramedics withdrew delayed for one year John Lotter and Marvin treatment at scene of car because more than two Nissen after they discovered accident. dozen doctors refused to he was anatomically female. treat him. What does transgender mean? Health Disparities HIV Lifetime Suicide Attempt Risk Mental health 41.0% Suicidality and self-harm Substance use and abuse Tobacco use 2.5% Lack of culturally- 1.6% competent care Transgender General U.S. U.S. Military Population What does transgender mean? Stressful Psychosocial Realities
4x more likely19% to uninsured live on <$10,000 annuallyLack of Sexual 12% report Assault sexualHate violence compared to averageHealth Crimes 19%American refused care dueInsurance in school to transgender or 2x the rate of unemploymentWrongful gender non-Poverty conforming status 28compared% postponed to U.S. necessary rateIncarceration medical care when sick or 53% verbally 57% rejected injured due to harassedDiscrimination or Homelessness by family discrimination by health disrespected in publiccare providers accommodation 33% delayedFamily or did not Police (e.g.,Rejection hotel, Brutality try restaurantto get preventive, bus, etc.) healthcare due to discriminationHarassment by health Domestic care providers Violence What does transgender mean? Barriers to Healthcare
Real and perceived hostility in Negative prior experience healthcare settings
Real and perceived ID/Identity Lack of insurance/lack of lack of provider mismatch hormone coverage knowledge
Immigration Hours of Disproportionately affected by issues clinics psychosocial stressors
Institutional settings-lack of Culture of self-sufficiency transgender appropriate housing Creating a welcoming environment
What can we do? Creating a welcoming environment It’s not just a clinical issue Cultural competency and sensitivity training for ALL staff Transgender-sensitive and inclusive education brochures, prevention information available Become familiar with local support resources . Especially for assisting with name/gender designation change Creating a welcoming environment Facilities Matter Unisex or single-use bathrooms Creating a welcoming environment Inclusive Forms
No marital status question, but “partnered” would be an option if we had one.
“We require the following information for the purposes of helping our staff use the most respectful language when addressing you, understanding our population better, and fulfilling our grant reporting requirements. The options for some of these questions were provided by our funders. Please help us serve you better by selecting the best answers to these questions. Thank You.” Creating a welcoming environment Use the preferred pronoun Why is using the correct pronoun important? It is often stressful, frightening, and difficult for a patient to have to show, say, or write a name or gender that does not match their gender identity and chosen name, or disrobe, talk about body parts, and come out about transgender status. Creating a welcoming environment Use the preferred pronoun Which pronoun is correct to use? . Consider not using any pronouns (staff training) . No better way to find out then to ask politely . If you have to guess, ask your self what is this person’s gender expression? . Listen for new pronouns (hir, zie, s/he) and echo back the language you hear . Once you know the correct pronoun, make an effort to use it consistently . Everyone slips up; when you do, apologize and try harder Creating a welcoming environment Examples of TG Sensitivity Creating a welcoming environment Examples of Inclusive Materials
Creating a welcoming environment TG sensitivity – rules of thumb DON’T Refer to the transperson by what you assume their birth sex to be Use “Sir” or “Ma’am” Tolerate harassment of transgender clients Ask a transgender person irrelevant questions about their anatomy, sexual practices or orientation Discuss a client’s transgender status in public. Expect or mandate clients to conform to traditional gender stereotypes. Call someone “transgendered” or “a transgender” Refer to people as “Pre-ops,” “Post-ops,” or “Non-op” Refer to people as “she-male,” “he-she,” “it,” or “tranny” Refer to non-trans people as a “real woman (or man)” Creating a welcoming environment TG sensitivity – rules of thumb DO Apologize if you make a mistake Be aware that hormones and surgery are typically not impulsive decisions for trans people Use transgender inclusive language Refer to trans identified clients based on their gender expression/gender identity Be aware that it may take extra time and sensitivity to build rapport and trust Be aware that you are the front line staff for trans patients Respect and acknowledge their life experience, self knowledge, and process Listen. Many trans experiences are not heard or validated Continue to educate yourself Review of Gender Biology
Setting the Stage for Hormones Review of gender biology Embryology Review of gender biology Embryology Review of gender biology Sex Hormones
Acetate
Cholesterol Plasma LDL Cholesterol
5-Pregnenolone
17-Hydroxypregnenolone Progesterone Aldosterone
Dehydroepiandrosterone 17-Hydroxyprogesterone
4-Androstendione 11-Deoxycortisol
Estradiol Testosterone Cortisol Review of gender biology Hypothalamic-Pituitary-Gonadal Axis Review of gender biology Puberty Hormonal transition recapitulates puberty . Development of secondary sex characteristics . Variable timeline . Systemic process . Unpredictable results Review of gender biology Puberty
Tanner Breast Changes Puberty Hormones I nipple elevation <11yo Pre-hormonal
II palpable breast buds; 11y o Starting areolae enlarge (9-13) treatment
III elevation of breast 12y o 6-12 months contour; areolae (10-14) enlarge IV areolae form 13y o 1-2 years secondary mounds (10.5-15.5)
V mature breast contour; 16yo 2-5 years areolae recess to general breast contour Prescribing CGHT
How to do it safely and effectively Prescribing CGHT Published Standards Prescribing CGHT Different Approaches Traditional Model Informed Consent Model . Assignment of mental health . Pathologizing diagnoses not diagnosis (GID) necessary . Assignment of diagnosis of . No clearance from mental Transsexualism health needed . Evaluation and clearance for . No mandated psychotherapy transition by mental health . No RLE provider . Prescription after medical . Mandated psychotherapy evaluation and obtaining . Necessity of Real Life informed consent Experience (RLE) Prescribing CGHT Initial assessment Keep in mind: . Transgender patients are likely to have had previous negative healthcare experiences . Developing trust and rapport may take longer than you are used to . Avoid genital and rectal exams on first visit if possible . Be sensitive to dissociation from genitals . Discuss choice of language to describe anatomy . Don’t say “pre-op” or “post-op” Prescribing CGHT Initial assessment Thorough history and physical exam: . Personal or family history of cardiovascular disease, breast cancer, diabetes mellitus, hypertension . History of hepatitis, thromboembolic disease, gallstones . History of prescribed or street hormones use . History of depression, anxiety, or psychosis . Alcohol, tobacco, and other drug use including silicone injections and “pump parties” Prescribing CGHT Initial assessment Initial laboratory exams: . Basic chemistry, liver function tests, lipid profile, hemoglobin/hematocrit . Prolactin (MTF), thyroid function, free testosterone (MTF) . Hepatitis A, B, C, HIV, syphilis . FTM - Pap smear, gonorrhea/chlamydia screen (does not need to be done 1st appointment) Prescribing CGHT Initial assessment Counseling on minimizing modifiable risk factors: . Smoking cessation . Alcohol and drug use harm reduction . Safer sex . Proper nutrition and exercise Prescribing CGHT Initial assessment Thorough assessment of the patient’s psychosocial support system . Meeting with transgender care coordinator when appropriate, if possible Prescribing CGHT Initial assessment Counseling and Education Visit . Appointment with RN/health educator for most patients . Can also be done by mental health provider for patients with mental health issues . Can also be done by medical provider . Review of alternatives to and risks/benefits of cross-gender hormone therapy . Discussion of realistic expectations of physical changes Prescribing CGHT Initial assessment Once all components have been completed, patient signs a specific informed consent and initial dose of hormones is prescribed Stress on harm-reduction approach Prescribing CGHT Silicone Use
>25% of transwomen inject silicone to create a more “feminine” appearance May be industrial grade and mixed with paraffin or cooking oil Pump Parties – venues for sharing and injecting silicone Risks: pulmonary embolism, ARDS, disfigurement, local infection, HCV, HIV, MRSA, mycobacteria Prescribing CGHT Appropriate follow-up Ongoing assessment of patient’s physical, emotional, and psychological changes and reactions to hormone therapy Ongoing assessment of the patient’s psychosocial support system Ongoing counseling on minimizing modifiable risk factors Prescribing CGHT Appropriate follow-up
Routine screening on all organs as long as they are present: . Testicular and prostate exam . Pap smear and gonorrhea/ chlamydia screening . Breast exams and mammograms . Periodic syphilis, HIV, other STI screening Prescribing CGHT Appropriate follow-up Periodic laboratory testing: . MTF . q6-12 mos: fasting glucose, lipid profile, liver function, prolactin . as needed: testosterone, potassium, hemoglobin . FTM . q6-12 mos: fasting lipids, liver function, hemoglobin Prescribing CGHT Appropriate referrals Referrals to surgeons . FTM: reduction mammoplasty, liposuction, hysterectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty, scrotoplasty, urethroplasty, phalloplasty, testicular prostheses . MTF: breast augmentation, tracheal shaving, orchiectomy, penectomy, vaginoplasty, clitoroplasty, labiaplasty, facial bone reduction, rhinoplasty, blepharoplasty, reduction thyroid chondroplasty Prescribing CGHT
Cross-Gender Hormone Therapy Prescribing CGHT General Guidelines These medications and dosages are for use in the adult population, not in adolescents still going through puberty Slow escalation over first 2-3 months to full doses with frequent monitoring Prescribing CGHT General Guidelines Doses of testosterone and estrogen should be decreased after orchiectomy or hysterectomy with oophorectomy Anti-androgen agents may be discontinued after orchiectomy After gonadectomy, sex hormones should be continued Prescribing CGHT Agents for FTM Androgens – injectable . Testosterone (cypionate or enanthate) 100-300mg (IM) every two weeks Androgens – other . Transdermal/Transmucosal Testosterone (Androgel, Androderm, Testim, Striant, etc.) 5-10g daily or usual replacement dose . Impantable (Testopel) 150-450mg every 3-6 months Prescribing CGHT Agents for MTF
Oral Estrogen . Estradiol (Estrace) 6-8mg daily NB: Most potent estrogen . Conjugated estrogens 5-10mg daily NB: Mixture of nine estrogens; available from animal (Premarin) or plant (Cenestin) sources
Prescribing CGHT Agents for MTF
Oral Estrogen (continued) . Esterified estrogens (Estratab, Menest) 5-10mg daily NB: Derived from modified soy . Ethinyl estradiol (oral contraceptives) NB: not recommended; significant drug interactions with HIV medications; very small dose of estrogen Prescribing CGHT Agents for MTF
Injectable Estrogen . Estradiol valerate (Delestrogen) 20-40mg (IM) every two weeks Transdermal Estrogen . Estrogen cream (Premarin) . Estradiol patches (Climara, Estraderm) 50-100g daily NB: expensive; difficult adherence Implantable Estrogen . Estradiol pellets NB: limited experience; not approved Prescribing CGHT Agents for MTF
Progesterone use is controversial in hormone transition. Many experts do not recommend it. Oral Progesterone . Medroxyprogesterone acetate (Provera) 10mg daily for 10 days every 28 . Micronized progesterone (Prometrium) 200mg daily for 10 days every 28 Injectable Progesterone . Medroxyprogesterone acetate (Depo-Provera) 150mg (IM) every six weeks Prescribing CGHT Agents for MTF
Anti-Androgens . Spironolactone (Aldactone) 100-400mg daily Risks: hyperkalemia, hypotension NB: K+-sparing diuretic; most popular anti- androgen; interferes with testosterone production and blocks androgen receptors . Flutamide (Eulexin) 250-750mg daily Risks: hepatic injury, bone marrow toxicity
Prescribing CGHT Agents for MTF
Anti-Androgens (continued) . Leuprolide acetate (Lupron) 3.75mg (IM or SC) monthly NB: GnRH analog . Cyproterone acetate (not available in US) . Ketoconazole (Nizoral) NB: anti-fungal agent; risk of hepatic injury precludes its use for this purpose Prescribing CGHT Agents for MTF
5--Reductase Inhibitors . Finasteride (Proscar, Propecia) 1-5mg daily . Dutasteride (Avodart) 0.5mg daily . NB: decrease synthesis of 5-- dihydrotestosterone; more effective for hair re-growth than other secondary sex characteristics Prescribing CGHT Agents for MTF
Others . Clomid . Vitamin B12 . Oral contraceptives . HCG analogs . Ketoconazole . NB: unproven or unclear efficacy; sometimes more readily available on the street Effects of CGHT
What to expect in hormonal transition Cross-gender hormone therapy Androgenic therapy Testosterone (FTM) . Deepening of the voice . Genital changes . Irregular menses cessation of menses . Clitoral enlargement . Atrophic vaginitis . Increased libido . Minimal breast atrophy . Redistribution of fat from hips to waist Cross-gender hormone therapy Androgenic therapy Testosterone (FTM) . Increased upper body strength (with exercise) . Integument . Male-pattern facial and body hair growth . Male-pattern hair loss . Psychological sense of well-being Cross-gender hormone therapy Androgenic therapy Testosterone (FTM) . Side effects: acne, headaches, weight gain, fluid retention . Risks: polycythemia, hepatotoxicity, worsening of lipid profile and increased homocysteine level, emotional lability, infertility, insulin resistance Cross-gender hormone therapy Estrogenic therapy Estrogens & Anti-androgens (MTF) . Breast development . Magnitude of enlargement is highly variable; size beyond B cup is uncommon . Maximum effect after two years . Integument . Body hair diminishment . Slowing, stopping, or reversal of androgenic hair loss . Softening of the skin Cross-gender hormone therapy Estrogenic therapy Estrogens & Anti-androgens (MTF) . Fat redistribution to a gynecoid habitus (smaller waist, wider hips) . Reduction in upper body muscle mass and strength . May result in loose skin for a short time . Psychological sense of well-being . No effect on beard hair . Longer growth cycle and higher follicle density . Electrolysis, laser or other hair removal usually required Cross-gender hormone therapy Estrogenic therapy Estrogens & Anti-androgens (MTF) . Genital changes (chemical castration) . Testicular atrophy . Reduction in penis size . Decrease in frequency and strength of erections . Decrease in volume and content of semen . Reduction in prostate size . No effect on prominence of larynx . No effect on pitch and resonance of voice Cross-gender hormone therapy Estrogenic therapy Estrogens & Anti-androgens (MTF) . Risks: thromboembolism, increased risk of breast cancer?, hyperprolactinemia/pituitary adenoma, hepatotoxicity, cardiovascular risk?, infertility, anxiety/depression, gallstones, hypertension . Smoking increases risk of thromboembolism on estrogen Cross-gender hormone therapy Estrogenic therapy
Venous Thromboembolism Risk: Patients at higher risk for thrombotic events may benefit from using transdermal estrogen
Cases Controls Adjusted* OR No use 145 384 1 Oral estrogen 45 39 4.2 (1.5-11.6) Transdermal estrogen 67 180 0.9 (0.4-2.1) *Adjusted for obesity, family history of VTE, history of varicose veins, education, age at menopause, hysterectomy, and smoking. Circulation. 2007; 115:840-5 Cross-gender hormone therapy Progestin therapy Progestins . Breast enlargement is the most common reason TG women seek progesterone . Role in CGHT is unclear . Many clinicians do not use progestins for hormonal transition . Some clinicians use progestins for only the first six months of transition . Some use progestins cyclically (10/28 days) to mimic the biological female cycle Cross-gender hormone therapy Progestin therapy Progestins . Side effects: weight gain, edema . Risks: phlebitis, depression, mood swings, androgenic effects . WHI data on use of conjugated estrogens with progesterone showed an increased risk of DVT, stroke, pulmonary emboli (PE) and myocardial infarction (MI) Cross-gender hormone therapy Safety of CGHT Use Very few published studies of long-term safety of FTM or MTF regimens 2007 Retrospective study from Netherlands12 . 30 years follow-up of 2236 MTF and 876 FTM . MTF: 20-fold increase (6-8%) in incidence of venous thrombosis on ethinyl estradiol; increase in PRL levels . FTM: polycythemia is rare; no change in mortality Transgender and HIV-positive
What you need to know about the HIV-infected transgender patient Care of the HIV-infected Case 27 y/o HIV-infected transgender woman transferring care from California . 3mos ago: CD4=250, VL=56,000 . ARV-naïve . PMH: HIV+ 2008, started CGHT 2005 . Meds: spironolactone 100mg bid Premarin 2.5mg bid . SocHx: 1/2ppd smoker, 3-4 EtOH/wk denies drug use Care of the HIV-infected Transgender HIV Prevalence No national surveillance data Transwomen traditionally designated as MSM Convenience sampling: . Meta-analysis showed HIV prevalence estimated at 11.8% (self-report) to 27.7% (confirmed) among MTF4 . Higher rates seen among sex workers – 68%5 (Atlanta) . African-American MTF 41-63%6,7 . FTM prevalence 2-3% (San Francisco, Washington, DC)7,8 Care of the HIV-infected Transgender HIV Incidence High incidence: 3.4-7.8 per 100 person-years 9,10 African-American transwomen: 18.2 per 100 person-years 10 Care of the HIV-infected Risk Factors Predictors of HIV infection among transwomen: . African-American race 5,7 . Syphilis 5 . High number of sex partners 7 . Less than high-school education 7 . History of sex work 8 . Unemployment 8 Care of the HIV-infected Adherence Lower adherence rates noted among HIV+ MTF11 . Negative provider interactions . Perceived negative effects of ARVs on hormones . Diversion of ARVs to purchase hormones Psychosocial factors 4,5,8,11 . Homelessness . Unemployment . Substance use . Incarceration . Social isolation Care of the HIV-infected Case (continued)
Current labs: . CD4=182 . VL=82,000 She is interested in treatment and there are no major concerns with adherence Genotype is fully sensitive What considerations do you have? . Interactions with CGHT? . Is CGHT contraindicated? Care of the HIV-infected Coadminstration Cross-Gender Hormone Therapy is not contraindicated in HIV disease Care of the HIV-infected Hormone/ARV Interactions There are next to no published data on hormones other than oral contraceptives Estrogens and 5-reductase inhibitors are metabolized partially by CYP3A4 Spironolactone has no interactions
Care of the HIV-infected Hormone/ARV Interactions We need studies Care of the HIV-infected Hormone/ARV Interactions From the DHHS guide to HIV care (2012): “Several RTV-boosted PIs decrease oral contraceptive estradiol levels. A small study from Malawi showed that NVP use did not significantly affect estradiol or progestin levels in HIV-infected women. Overall, data are relatively limited and the clinical implications of these findings are unclear. The magnitudes of change in drug levels that may reduce contraceptive efficacy or increase adverse effects are unknown.” Care of the HIV-infected Hormone/ARV Interactions ethinyl estradiol levels ethinyl estradiol levels Fosamprenavir Atazanavir/rtv Atazanavir Darunavir/rtv Etravirine Fosamprenavir/rtv Rilpivirine Lopinavir/rtv Saquinavir/rtv Tipranavir/rtv Nevirapine
Source: Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents (http://aidsinfo.nih.gov/guidelines) Care of the HIV-infected Benefits of CGHT Improved adherence to ART and medical care Increased opportunities for targeted preventive care Improved relationship and rapport with provider Improved self-esteem Acknowledgements
Rosalyne Blumenstein, CSW Carrie Davis, MSW Richard di Furia Nathan Levitt Barbra Ann Perina Jason Schneider, MD Anita Radix, MD Scout, PhD Hundreds of generous sharing patients Thank you. Additional Resources
The Gender Identity Project at The Lesbian, Gay, Bisexual & Transgender Community Center; http://www.gaycenter.org/programs/mhss/gip.html TransGender Care; http://www.transgendercare.com/default.asp Transsexual Women’s Resources; http://www.annelawrence.com/ Oriel, KA. “Medical Care of Transsexual Patients,” Journal of the Gay and Lesbian Medical Association, Vol 4., No. 4, 2000; [email protected] The Harry Benjamin International Gender Dysphoria Association’s Standards Of Care for Gender Identity Disorders, Sixth Version. February 2001; http://www.hbigda.org/soc.html Guidelines for Transgender Care http://www.vch.ca/transhealth/resources/careguidelines.html For Ourselves Reworking Gender Expression FORGE http://www.forge-forward.org Transgender Health Program: Vancouver Coastal Health http://www.vch.ca/transhealth/ Transgender Care www.transgendercare.com True Selves: Understanding Transsexualism--For Families, Friends, Coworkers, and Helping Professionals by Mildred L. Brown Additional Resources
National Center for Transgender Equality http://www.nctequality.org Sylvia Rivera Law Project www.srlp.org Gender Identity Project at LGBT Center of NYC www.gaycenter.org Positive Health Project www.positivehealthproject.org National Coalition for LGBT Health www.lgbthealth.net Trans Health http://www.trans-health.com/ Transgender Health Initiative of New York http://www.transgenderlegal.org/our-work/health/thiny/ Trans 101: Transgender Law Center http://www.srlp.org/documents/TLC_new_trans_101.htm Trans Basics http://www.transfamily.org/trans.htm Transgender Law Center www.transgenderlawcenter.org Medical Therapy and Health Maintenance for Transgender Men: A Guide For Health Care Providers www.nickgorton.org Transgender Care Conference http://hivinsite.ucsf.edu/InSite?doc=2098.473a