#72: Transgender Care in Primary Care

December 11, 2017 | By Matthew Watto, MD

Trans patients need excellent primary care and you can provide it with expert tips from endocrinologists, Dr Vin Tangpricha, Professor of Medicine at Emory University School of Medicine, and Dr Jeffrey Colburn, Assistant Professor of Medicine at Uniformed Services University. Learn practical tips in caring for transgender patients including: defining terms like gender dysphoria, gender nonconformity, transgender; use of pronouns; patient counseling; fertility concerns; initiating and monitoring hormonal therapy; surgical options; and how to help trans patients navigate the complexities of gender affirming therapy.

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Background
Sex is assigned at birth based on a person’s external genitalia, usually as a binary term of male or female. Gender identity is a person’s sense of self as either male, female, or an alternative gender (e.g., boygirl, girlboy, transgender, genderqueer, eunuch) ⁹. The term transgender (commonly shortened to “trans”) describes a “diverse group of individuals who cross or transcend culturally-defined categories of gender. The gender identity of transgender people differs to varying degrees from the sex they were assigned at birth.” ⁹. Gender nonconformity describes “individuals whose gender identity, role, or expression differs from the norm for their assigned sex in a given culture and historical period” ⁹. These gender nonconforming individuals do not necessarily feel distress from their nonconformity. On the contrary, the DSM-V uses the term gender dysphoria to describe individuals who experience significant distress due to a discordance between their unique gender identity and their sex assigned at birth. The old terminology of gender identity disorder from DSM-IV is no longer used or preferred. A trans woman denotes a natal male transitioning to female (MtF). A trans man denotes a natal female transitioning to male (FtM).

Clinical Pearls:

1. The goals of care are to help your patient achieve a gender identity/expression, in which they feel comfortable. This may entail social, medical, and/or surgical transition⁹.
2. Gender diversity – Many trans patients have a non-binary understanding and expression of gender that does not conform to distinct identity as a male or female.
3. Transsexual – Older term used by medical professionals to refer to those individuals seeking transition to either male or female gender identity and sex characteristics. “Trans” is a newer, preferred term as it includes a broader range of non-binary gender roles/identities.
4. Set up a welcoming practice environment⁷ – Call patient by last name, not Mr. or Ms. Ask patient which name they’d like to be called and what pronouns they prefer (e.g. he, she, him, her, etc.). Use intake forms that allow patients to list their “legal name” and “preferred name”. Forms should have more than just male or female options (e.g. trans, genderqueer, trans man, trans woman). Post a non-discrimination policy in waiting rooms. If you make a mistake in pronouns or name, then just apologize!
5. Confidentiality – Be careful not to “out” patients. Do not discuss cases with other personnel unless they are necessary for care. Holding a separate trans health clinic can out patients. Dr Tangpricha integrates trans care in his general endocrinology practice for this reason.
6. Gender diversity therapist – Psychologist, psychiatrist, or social worker experienced in assisting patients and families with social transition. Dr Tangpricha recommends their assistance for most patients.
7. Before starting hormonal therapy – Assess for mental health disorders, homelessness, substance abuse, and strength of social supports. A gender diversity therapist can assist with evaluation and management if high risk conditions exist prior to and during a transition. Ask about history of venous thromboembolism, cancer, chronic infections (hepatitis, HIV).
8. Benefits of gender affirming therapy – Anecdotal improvements in substance abuse. Evidence exists for improvement in gender dysphoria, quality of life and sexual function. Data for surgery is less robust, but suggests few regret having a procedure^4,5,6.
9. Time to body change – Emotional changes, and increased sense of well being occur first. Body changes occurs in 2-3 months and peak at 2-3 years. Higher doses of hormones increase risk of side effects, but do not speed up changes or improve results.
10. Medical therapy MtF (trans woman)¹² – Spironolactone 50 mg twice daily. Estrogen pills (easier, cheaper) or injections. Check estradiol (E2) levels, testosterone levels (goal <50 ng/ml) and basic metabolic panel (for potassium) every 3 months in year one, then annually thereafter. Consider checking prolactin levels and refer to endocrinology if levels >50.
11. Surgical therapy MtF – Top surgery = breast augmentation. Bottom surgery = can include orchiectomy, and vaginoplasty. Vagina formed from existing anatomy.
12. Medical therapy FtM (trans man)¹² – Testosterone therapy given as gel or injection in same doses used for hypogonadal males. Consider addition of birth control pills if menses not fully suppressed on testosterone. Check blood count (risk polycythemia), and testosterone levels every 3 months during first year, then annually.
13. Surgical therapy FtM – Top surgery = breast reduction. Bottom surgery = can include hysterectomy, oophorectomy, metoidioplasty, or phalloplasty.
14. Cost – Medical therapy is covered by most insurance plans. Cost is approximately $50-200 per month w/insurance. Hormone therapy likely out of reach for uninsured or underinsured patients. Surgery is available through many insurers…if the employer checks the box! High cost and lack of experienced and vetted surgeons limits availability for many patients.
15. Fertility – Many trans men and women desire future fertility. Dr Tangpricha recommends “banking gametes” (i.e. sperm, or eggs) to preserve future options for fertility. Hormone therapy eventually causes infertility, but time course is uncertain.

Goal: Listeners will learn the basics of caring for trans (transgender) patients and those with gender dysphoria, and how to create a welcoming practice environment for these patients in the primary care setting.

Learning objectives:
After listening to this episode listeners will…

1. Define gender, gender nonconformity, gender dysphoria, transgender, transsexual
2. Utilize the appropriate pronouns when interacting with trans individuals
3. Offer resources to patients/families for assistance with social transition
4. Counsel trans patients about decisions on fertility
5. Anticipate cost of hormonal therapy, surgical therapy and potential barriers to care
6. Screen trans individuals for common comorbid conditions
7. Prepare your healthcare team for interaction with trans individuals
8. Counsel patients on basics of hormonal therapy and when to expect body changes
9. Become familiar with surgical options available to trans patients

Disclosures: Dr Tangpricha reports no relevant financial disclosures.

Time Stamps

• 00:00 Intro and disclaimer
• 01:00 Guest bios
• 03:27 Getting to know our guest
• 08:00 Clinical case of a trans female
• 09:00 Defining terms and discussion of gender
• 14:15 What’s the difference between transgender and transexual?
• 16:05 How to handle mistakes in use of pronouns
• 17:12 How to set up a welcome practice environment
• 19:03 Maintaining confidentiality
• 20:37 Back to the case: What needs to be done before starting hormone therapy?
• 25:20 Evaluating for comorbidities, mental health issues and social risk factors
• 27:26 Is gender dysphoria driven by biology?
• 27:54 Evidence for hormone therapy and surgery as treatment for gender dysphoria
• 29:00 Cost and availability of medical and surgery therapy
• 34:00 Initial history and laboratory evaluation prior to hormone therapy
• 36:00 Choice of hormonal agent and route of administration
• 37:38 Fertility in trans women and men
• 40:30 When to expect body changes after starting therapy
• 43:00 Dr Tangpricha’s take home points
• 45:25 Monitoring of trans female on hormone therapy
• 46:57 Therapy and Monitoring of trans male on hormone therapy
• 49:56 Surgical therapy for MtF transition
• 52:33 Surgical therapy for FtM transition
• 55:50 Mental health clearance prior to surgery
• 57:54 Dr Colburn’s take home points
• 60:16 Outro

Links from the show:

1. AACE apps for diabetes and osteoporosis
2. The Tipping Point (book) by Malcolm Gladwell
3. Dr Michael Holick YouTube video on Vitamin D
4. Murad, MH. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol (Oxf). 2010 Feb;72(2):214-31. (FREE)
5. Wesp, LM. Hormonal and Surgical Treatment Options for Transgender Women and Transfeminine Spectrum Persons. Psychiatr Clin North Am. 2017 Mar;40(1):99-111. (Free abstract)
6. Gorton, RN. Hormonal and Surgical Treatment Options for Transgender Men (Female-to-Male). Psychiatr Clin North Am. 2017 Mar;40(1):79-97. (Free abstract)
7. Vanessa Goes to the Doctor (Youtube Video) How to provide a welcoming practice environment for the transgender patient.
8. WPATH Website
9. WPATH-Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People 7th Version
10. DSM-5 on Gender Dysphoria diagnosis, treatment, and complications
11. Best practices in LGBT care: A guide for primary care physicians Cleveland Clinic Journal of Medicine. 2016 July;83(7):531-541
12. Hembree, W et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. J Clin Endo & Metab, jc.2017-01658, https://doi.org/10.1210/jc.2017-01658
13. Callen-Lourde.org -Global leader in LGBTQ healthcare. Provides excellent comprehensive care, provided free of judgment and regardless of ability to pay
14. Fenway Guide to Lesbian, Gay, Bisexual, And Transgender Health, 2nd Edition 2nd Edition (book) by Harvey Makadon et al.
15. Wikipedia summary – https://en.wikipedia.org/wiki/Gender_dysphoria