primary care for transgender people lori kohler, md associate clinical professor department of...
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PRIMARY CARE FOR PRIMARY CARE FOR TRANSGENDER PEOPLETRANSGENDER PEOPLE
Lori Kohler, MDAssociate Clinical ProfessorDepartment of Family and Community MedicineUniversity of California, San Francisco
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The Audience
Clinicians Nurses Social Workers Health Educators Pharmacists Psychotherapists ?
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PRIMARY CARE FOR TRANSGENDER PEOPLE
Clinical Background Who is Transgender Barriers to Care Transgender People and HIV Hormone Treatment and Management Surgical Options and Post-op care Evidence? Transgender care in prison
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Clinical Experience
Tom Waddell Health Center Transgender Team
Family Health Center
Phone and e-mail Consultation
California Medical Facility-Department of Corrections
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TRANSGENDER
refers to a person who is born with the genetic traits of one gender but the internalized identity of another gender
The term transgender may not be universally accepted. Multiple terms exist that vary based on culture, age, class
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Transgender Terminology
Male-to-female (MTF)
Born male, living as female
Transgender woman
Female-to-male (FTM)
Born female, living as male
Transgender man
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Transgender Terminology Pre-op or preoperative
A transgender person who has not had gender confirmation surgery
A transgender woman who appears female but still has male genitaliaA transgender man who appears male but still has female genitalia
Post-op or post operative A transgender person who has had gender confirmation surgery
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The goal of treatment
for transgender people is to improve their quality of life by
facilitating their transition to a physical state that more closely represents their sense of themselves
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Christine Jorgensen
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Old Prevalence Estimates
Netherlands:
1 in 11,900 males(MTF)
1 in 30,400 females(FTM)
United States:
30-40,000 postoperative MTF
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What is the Diagnosis?
DSM-IV: Gender Identity Disorder
ICD-9: Gender Disorder, NOS
Hypogonadism
Endocrine Disorder, NOS
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DSM-IV 302.85 Gender Identity Disorder
A strong and persistent cross-gender identification
Manifested by symptoms such as the desire to be and be treated as the other sex, frequent passing as the other sex, the conviction that he or she has the typical feelings and reactions of the other sex
Persistent discomfort with his or her sex or sense of inappropriateness in the gender role
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DSM-IV Gender Identity Disorder (cont)
The disturbance is not concurrent with a physical intersex condition
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
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Transgenderism
Is not a mental illness
Cannot be objectively proven or confirmed
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GENDER
SEXUAL ORIENTATION
GENDER IDENTITY
SEXUAL IDENTITY
AESTHETIC
SOCIAL CONDUCT
SEXUAL ACTIVITY
Assertive
Masculine
Dominant
Male
Passive
Submissive
Female
StraightLesbian/Gay
MaleFemale
Feminine
UnbridledMonogamous
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Barriers to Medical Care for Transgender People
Geographic Isolation
Social Isolation
Fear of Exposure/Avoidance
Denial of Insurance Coverage
Stigma of Gender Clinics
Lack of Clinical Research/Medical Literature
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Provider ignorancelimits access to care
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Regardless of their socioeconomic status all transgender people are medically underserved
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The Number of Transgender People in Urban Areas is Increasing Due to:
natural migration from smaller communities
earlier awareness and self-identity as transgender
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Urban Transgender Women
Studies in several large cities have demonstrated that transgender women are at especially high risk for:
Poverty HIV disease Addiction Incarceration
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Limited access to Medical Care for
TransgenderPeople
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Limited access to Medical Care for
TransgenderPeople
No Transgender Education in Medical
Training
No Clinical Research
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Limited access to Medical Care for
TransgenderPeople
No Transgender Education in Medical
Training
TRANSPHOBIANo Clinical Research
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Limited access to Medical Care for
TransgenderPeople
No Transgender Education in Medical
Training
TRANSPHOBIANo Clinical Research
No Health InsuranceCoverage
No Legal Protection
Employment Discrimination
Poverty
Lack of Education
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Limited access to Medical Care for
TransgenderPeople
No Prevention Efforts
No Transgender Education in Medical
Training
TRANSPHOBIANo Clinical Research
No Health InsuranceCoverage
No Legal ProtectionNo Targeted
ProgramsFor Transgender
PeopleMental health
Substance abuse
Employment Discrimination
Poverty
Lack of Education
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Limited access to Medical Care for
TransgenderPeople
No Prevention Efforts
No Transgender Education in Medical
Training
TRANSPHOBIANo Clinical Research
No Health InsuranceCoverage
No Legal Protection
SOCIAL MARGINALIZATION
Low Self Esteem
No Targeted Programs
For TransgenderPeople
Mental healthSubstance abuse
Employment Discrimination
Poverty
Lack of Education
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Limited access to Medical Care for
TransgenderPeople
No Prevention Efforts
No Transgender Education in Medical
Training
TRANSPHOBIANo Clinical Research
No Health InsuranceCoverage
No Legal Protection
SOCIAL MARGINALIZATION
Low Self Esteem
HIV Risk Behavior
No Targeted Programs
For TransgenderPeople
Mental healthSubstance abuse
Employment Discrimination
Poverty
Lack of Education
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HIV RISK BEHAVIOR
Sex workDrug use
Unprotected sexUnderground hormones
Sex for hormonesSilicone injections
Needle sharingAbuse by medical providers
LOW SELF ESTEEM
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Why Sex work?
Survival
Access to gainful employment
Reinforcement of femininity and attractiveness
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HIV RISK BEHAVIOR
SOCIAL MARGINALIZATION
LOW SELF ESTEEM
Sex workDrug use
Unprotected sexUnderground hormones
Sex for hormonesSilicone injections
Needle sharingAbuse by medical providers
LOW SELF ESTEEM
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HIV RISK BEHAVIOR
SOCIAL MARGINALIZATION
LOW SELF ESTEEM
INCARCERATION
Sex workDrug use
Unprotected sexUnderground hormones
Sex for hormonesSilicone injections
Needle sharingAbuse by medical providers
LOW SELF ESTEEM
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HIV RISK BEHAVIOR
SOCIAL MARGINALIZATION
LOW SELF ESTEEM
INCARCERATION
Sex workDrug use
Unprotected sexUnderground hormones
Sex for hormonesSilicone injections
Needle sharingAbuse by medical providers
LIMITED ACCESS TO
MEDICAL CARE
LOW SELF ESTEEM
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Limited access to Medical Care for
TransgenderPeople
No Prevention Efforts
No Transgender Education in Medical
Training
TRANSPHOBIANo Clinical Research
No Health InsuranceCoverage
No Legal Protection
SOCIAL MARGINALIZATION
Low Self Esteem
HIV Risk Behavior
No Targeted Programs
For TransgenderPeople
Mental healthSubstance abuse
Employment Discrimination
Poverty
Lack of Education
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Access to Medical Care for
TransgenderPeople
Prevention Efforts
Transgender Education in Medical
Training
TRANSGENDERAwareness
Clinical Research
Health InsuranceCoverage
Legal Protection
SOCIAL INCLUSION
Self Esteem
HIV Risk Behavior
Targeted Programs
For TransgenderPeople
Mental healthSubstance abuse
Employment
Self-sufficiency
Education
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HIV RISK BEHAVIOR
SOCIAL INCLUSION
SELF ESTEEM
INCARCERATION
Sex WorkDrug use
Unprotected sexUnderground hormones
Sex for hormonesSilicone injections
Needle sharingAbuse by medical providers
ACCESS
TO MEDICAL
CARE
SELF ESTEEM
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Access to Cross-Gender Hormones can:
Improve adherence to treatment of chronic illness
Increase opportunities for preventive health care
Lead to social change
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Transgender Women Need
Improved access to medical care, including hormones and surgery
Social support and inclusion
Job training and education
Culturally appropriate substance abuse treatment
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Transgender Women Need
Legal Protection
Research to assess ways to reduce recidivism
Self esteem building
Targeted prevention efforts that address the social context that leads to diminished health and well-being
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Harry Benjamin International Gender Dysphoria Association (HBIGDA)
Standards of Care for Gender Identity Disorders – 2001 Eligibility Criteria for Hormone Therapy
1. 18 years or older
2. Knowledge of social and medical risks and benefits of hormones
3. EitherA. Documented real life experience for
at least 3 monthsOROR
B. Psychotherapy for at least 3 months
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Readiness Criteria for Hormone Therapy-HBIGDA 2001
Real life experience or psychotherapy further consolidate gender identity
Progress has been made toward emotional well being and mental health
Hormones are likely to be taken in a responsible manner
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HBIGDA Real Life Experience
Employment, student, volunteer
New legal gender-appropriate first name
Documentation that persons other than the therapist know the patient in their new gender role
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Initial Visits
Review history of gender experience
Document prior hormone use
Obtain sexual history
Order screening laboratory studies
Review patient goals
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Initial Visits Address safety concerns Assess social support system Assess readiness for gender
transition Review risks and benefits of
hormone therapy Obtain informed consent Provide referrals Screening labs
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Physical Exam
Assess patient comfort with P.E.
Problem oriented exam only
Avoid satisfying your curiosity
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Male to Female Treatment Options
No hormones
Estrogens
Antiandrogen
ProgesteroneNot usually recommended except for weight maintenance
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Estrogen Premarin
1.25-10mg po qd or divided as bid
Ethinyl Estradiol (Estinyl) 0.1-1.0 mg po qd
Estradiol Patch 0.1-0.3mg q3-7 days
Estradiol Valerate injection 20-60mg IM q2wks
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Transgender Hormone Therapy
Heredity limits the tissue response to hormones
More is not always better
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Estrogen Treatment May Lead To
Breast Development Redistribution of body fat Softening of skin Emotional changes Loss of erections Testicular atrophy Decreased upper body strength Slowing of scalp hair loss
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Risks of Estrogen Therapy Venous thrombosis/emboli (po)Venous thrombosis/emboli (po) Hypertriglyceridemia (po)Hypertriglyceridemia (po) Weight gain Decreased libido Elevated blood pressure Decreased glucose tolerance Gallbladder disease Benign pituitary prolactinoma
(rare) Breast cancer(?)
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Spironolactone
50-150 mg po bid
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Spironolactone May Lead To
Modest breast development
Softening of facial and body hair
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Risks of Spironolactone
Hyperkalemia
Hypotension
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HIV and HORMONES There are no significant drug
interactions with drugs used to treat HIV
Several HIV medications change the levels of estrogens
Cross gender hormone therapy is not contraindicated in HIV disease at any stage
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Drug InteractionsEstradiol, Ethinyl Estradiol, levels areDECREASED by:
LopinavirLopinavir CarbamazepineNevirapineNevirapine PhenytoinRitonavirRitonavir PhenobarbitalNelfinavirNelfinavir Phenylbutazone
SulfinpyrazoneBenzoflavoneSulfamidine
Rifampin Naphthoflavone Progesterone Dexamethasone
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Drug InteractionsEstradiol, Ethinyl Estradiol levels areINCREASEDby:
NefazodoneNefazodone IsoniazidFluvoxamine FluoxetineIndinavirIndinavir EfavirenzEfavirenzSertraline ParoxetineDiltiazem VerapamilCimetidine AstemizoleItraconazole KetoconazoleFluconazole MiconazoleClarythromycin ErythromycinGrapefruit TriacetyloleandomycinAmprenavirAmprenavir FosamprenavirFosamprenavirAtazanavirAtazanavir
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Drug Interactions
Estrogen levels are DECREASED by:
Smoking cigarettes Nelfinavir Nevirapine Ritonavir
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Drug Interactions
Estrogen levels are INCREASED by:
Vitamin C
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Screening Labs for MTF Patients
CBC Liver Enzymes Lipid Profile Renal Panel Fasting Glucose Testosterone level Prolactin level
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Follow-up labs for MTF Patients
Repeat labs at 3, 6 months and 12 months after initiation of hormones and annually
Lipids
Renal panel
Liver panel
Prolactin level annually for 3 years
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Women over 40 years old Add ASA to regimen
Transdermal or IM estradiol to reduce the risk of thromboemboli
Minimize maintenance dose of estrogen
Testosterone for libido as needed
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Treatment Considerations- MTFs
Testosterone therapy after castrationLibidoOsteoporosisGeneral sense of well-being
Hair lossRogaine, proscar
Hgb and Hct will decrease-not anemia
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Cosmetic Therapies
PigmentationHydroquinone 3-4% topical
Hair RemovalEflornithine cream ElectrolysisLaser
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Follow-Up Care for MTF Patients Assess feminization Review medication use Monitor mood cycles and adjust
medication as indicated Discuss social impact of transition Counsel regarding sexual activity Complete forms for name change Discuss silicone injections Follow up labs
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Health Care Maintenance for MTF Patients
Instruction in self breast exam and care
Mammography – after 10+ years
Prostate screening?
STD screening
Beauty tips
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Surgical Options for MTFs
Orchiectomy (castration)
Vaginoplasty
Breast augmentation
Tracheal shave
Face reconstruction
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Post-op Care
Encourage consistent dilation
Vaginal skin care and lubrication
Surveillance of vagina?
Protection from HIV infection and other STDs
Douche with vinegar and water
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Morbidity and Mortality in Transexual Subjects Treated with Cross-Sex HormonesVan Kestern, et.al., Clinical Endocrinology, 1997
Retrospective study of 816 MTF and 293 FTM transexuals treated between 1975 and 1994
Outcome measure: Standardized mortality and incidence ratios calculated from the Dutch population
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Morbidity and Mortality (cont)
Results In both MTF and FTM transexuals,
total mortality was not higher than in the general population
Venous thromboembolism was the major complication in MTF patients treated with oral estrogens
No serious morbidity was observed that could be related to androgen treatment in FTM patients
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Hormones
are not the cause of every medical problem reported by transgender people
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Hormone Therapy for Incarcerated Persons-HBIGDA 2001
People with GID should continue to receive hormone treatment and monitoring
Prisoners who withdraw rapidly from hormone therapy are at risk for psychiatric symptoms
Housing for transgender prisoners should take into account their transition status and their personal safety
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Torey South v. California Department of Corrections, 1999
Transgender inmate on hormones since adolescence
Hormones were discontinued during incarceration
Represented by law students at UC Davis
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T. South v. CDOC, 1999
US District Court:
Prison officials violated South’s constitutional right to be free of cruel and unusual punishment by deliberately withholding necessary medical care
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Gender Program, CMF
Gender Clinic
Transgender support group
Harm reduction education by inmate peer educators
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Gender Clinic, CMF 7/00-8/03
25 clinic sessions
23 patient encounters/session, avg.
800 patient encounters
250+ unduplicated patients
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Gender Clinic, CMF
50-70 inmates receiving feminizing hormones
60-70% HIV+
Majority are people of color
Majority committed nonviolent crimes
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Identification of Transgender Inmates-Challenges
Strict grooming standards No access to usual feminizing
accessories No access to evidence of usual
appearance No friends or family to support
patient identity
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Identification of Transgender Inmates-Challenges
Hormones as income or barter
Secondary gain in a man’s world
Temporary loss of social stigma and separation from family influence
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Identification of Transgender Inmates-Challenges
The grapevine impedes clinician use of consistent subjective tests, lines of questioning
The grapevine creates competition and influences treatment choices
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Hormones in Prison
Estradiol injections only, no po
Non negotiable forms avoid use as barter
Provide hormones despite prior use
Increase opportunities for education
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Special Concerns
No access to bras Safety- showers, housing Vulnerability- sexual abuse Domestic Violence Visibility to corrections Empowerment as a woman in a
men’s facility
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Gender Program Development
Medical staff training and collaboration Consistent delivery of care Privacy during clinic visits Collaboration with mental health
providers Parole planning and referral Duplication of model in other
correctional facilities Realistic HIV prevention efforts
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Summary
All transgender people are medically underserved
Hormone treatment is not optional for transgender people and contributes to improved quality of life
There are many unanswered questions about long term effects of hormone therapy but the benefits outweigh the risks for most patients
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Summary Inclusion of transgender issues in medical
training and health promotion efforts is the only ethical and compassionate option
Transgender women are at increased risk for incarceration. Programs to address their needs in correctional facilities must be developed
People who work in HIV prevention and care have unique opportunities to improve the lives transgender people
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Alexander Goodrum
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Selected On-line Resources
• www.hbigda.org
The Harry Benjamin website• www.symposium.com/ijt/
International Journal of Transgenderism• www.lorencameron.com
Photos of FTMs • www.lynnconway.com
Photos of MTFs, FTMs and much more
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To Contact Me
• Email: [email protected]• Phone: (415)206-4941• Pager: (415)719-7329• Mailing Address:
Department of Family and Community Medicine
995 Potrero Ave.Ward 83San Francisco, CA 94110
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FTM and HIV Risk
SFDPH Transgender Community Health Project suggested a low prevalence of HIV among the 132 FTMs in the study
FTMs in SF do engage in survival sex, IDU, and sex with other men
No HIV prevention programs in SF target FTMs
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Female to Male Treatment Options No Hormones
DepotestosteroneTestosterone Enanthate or Cypionate 100-200 mg IM q 2 wks (22g x 1 ½” needles)
Transdermal TestosteroneAndroderm or Testoderm TTS 2.5-10mg qd
Testosterone GelAndrogel or Testim 50,75,100 mg to skin qd
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Testosterone TherapyPermanent Changes
Increased facial and body hair
Deeper voice
Male pattern baldness
Clitoral enlargement
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Treatment Considerations- FTMs
Testosterone cream in aquaphor for clitoral enlargement
Estrogen vaginal cream for atrophy/incontinence
Proscar, Rogaine for hair loss
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Testosterone Therapy Reversible Changes Cessation of menses Increased libido, changes in sexual behavior Increased muscle mass / upper body strength Redistribution of fat Increased sweating / change in body odor Weight gain / fluid retention Prominence of veins / coarser skin Acne Mild breast atrophy Emotional changes
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Risks of Testosterone Therapy
Lower HDL Elevated triglycerides Increased homocysteine levels Hepatotoxicity (oral only) Polycythemia Unknown effects on breast,
endometrial, ovarian tissues Potentiation of sleep apnea
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DRUG INTERACTIONS Testosterone Increases the anticoagulant effect of
warfarin
Increases clearance of propranolol
Decreases blood glucose-may decrease diabetic medication requirements
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Screening Labs for FTM Patients
CBC
Liver Enzymes
Lipid Profile
Renal Panel
Fasting Glucose
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LABORATORY MONITORING FOR FTMs
3 Months after starting testosterone and every 6-12 months:
CBC (Hgb and Hct will go up)
Lipid Profile
+/-Liver Enzymes
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FOLLOW-UP CARE FOR FTMs
Assess patient comfort with transition
Assess social impact of transition
Assess masculinization
Discuss family issues
Monitor mood cycles
Counsel regarding sexual activity
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FOLLOW-UP CARE FOR FTMs Review medication use
Discuss legal issues / name change
Review surgical options / plans
Continue Health Care MaintenanceIncluding PAP smears, mammograms, STD screening
Assess CAD risk
Minimize maintenance dose of testosterone
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SURGICAL OPTIONS FOR FTMs
Chest reconstruction
Continue SBE on residual tissue
Hysterectomy/oophorectomy
Genital reconstruction
–Phalloplasty
–Metoidioplasty
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FTM Quality of Life Survey 2004E. Newfield, L. Kohler, S. Hart
On line survey with standardized QOL form (SF-36v2)
377 completed surveys in 6 months
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FTM QOL Survey Results
Diminished QOL among FTMs relative to men and women in US, especially related to mental health
FTMs who received testosterone or surgery had higher QOL scores than those who did not
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