His Health



Transcript for Transgender Health Module Sara:[00:00:30] I can't believe it. They beat her so bad, and now she's dead. [00:01:00] Renee is dead. She's been gone all week, but I didn't know. I didn't know. That's just five sisters just erased, but who's counting, you know? She's been laid up in that morgue for just another week, just another John Doe, you know. When is this shit gonna stop? I'm tired of being afraid. It could have been me. [00:01:30] She was my sista, living here and there, hustling on these streets. We get by, but at least we did.I thought Dre slapping me last night was some big thing, but now I feel lucky. He ain't that bad, just a bit jealous. He knows he's my boo, though. He knows Byron and his homeboys, the rest of them are just business. He knows I'm careful, [00:02:00] and he kept accusing me of giving him syphilis. Yeah fucking right. He's just using that because he knows that he the only one that's fucking around with no protection. Syphilis is one thing, but if he gives me HIV I don't know what I would do.David:Yeah, so looking at that video, and what Sara's saying, it just strikes me that there's so much stuff goin' on in a transgender woman's life. And some of this stuff [00:02:30] is so real, from the threat of violence, the threat of death, losing her friends, also the risk of syphilis and other STIs. What are your thoughts? What goes through your head as you're kind of watching this?Ayana:My initial response was very visceral, in that the reality of the everyday life of transgender women is simply that where they're exposed to such things as domestic abuse or violence victimization.David:[00:03:00] Yeah, it can be pretty complicated, and I think that's part of the reason why we wanna bring the reality to this module, and kind of let people know, especially the providers who are watching, what's going on. And the goal of His Health is actually to increase the capacity, quality, and effectiveness of health care providers to screen, diagnose, link, and retain Black MSM and HIV clinical care.The thing is with this module, what we're gonna be talking about is His Health, and Her Health, to make sure we're inclusive of our trans male and female [00:03:30] brothers and sisters.Often in public health, transgender people are lumped in with men who have sex with men. There may be some watching this module who feel that we're doing just that.So why don't we address the elephant in the room, and talk about why it's important to include a module on transgender health. Providers who are unfamiliar with health needs of Black MSM are likely unfamiliar with the health needs of black transgender people as well. This is an opportunity to bridge that education gap.Black MSM patients may have partners who are [inaudible 00:03:59] or transgender, [00:04:00] and gender expression may not exist neatly on a binary.Ayana:I'm so glad that you said that David, because for so long, much of what we've known about transgender women and HIV has been included in data that has been collected with men who have sex with men.David:Yeah, and the unfortunate thing is a lot of times when they throw in LGBT, the focus is on the LGB part of it, the lesbian, gay, and bisexual, and transgender issues are often left out completely, or they just lump them in with MSM as you [00:04:30] said.But the purpose of this module is to make sure that we focus specifically on the transgender issues. So why don't you start us off and tell us what this module is gonna be about?Ayana:So as you know, from the data, that in the U.S. 28 percent of transgender women were found to be living with HIV, in four studies that were conducted where HIV testing was performed. In this population, there was a large portion that didn't even know their own status.[00:05:00] Today, we will be discussing a population of patients or clients who clinicians may encounter in their care, whose experienced gender does not conform to that of his or her assigned birth sex. This discussion will use the term transgender, an umbrella term that refers to a broad range of nonconforming gender identities, including, but not limited to, cross-dressers, androgynous, [00:05:30] and those who have undergone complete gender reassignment surgery.Some patients may be unsure of their gender identity, and may not have had an opportunity to discuss their concerns with a medical professional. Others may have a highly-developed sense of gender identity, and may request hormone therapy or may already be receiving hormones that are obtained by prescription or illicitly without a prescription.David:So with this [00:06:00] module, what kind of learner objectives will someone who's watching, one of these clinicians, whether it'd be a physician assistant, nurse practitioner, or a physician who really wants to take better care of their transgender patients, what should they be able to take home at the end of this module?Ayana:At the end of this module, you'll be able to recognize and address issues that present challenges to health care access and utilization for transgender and gender nonconforming patients, access health care needs of transgender and gender nonconforming patients, as [00:06:30] well as employ strategies to deliver culturally appropriate services and care.David:You know, obviously when we talk about LGBT issues in general, there's a lot of different things like sexual orientation, sexual identity, that we need to get into. When we start talking about transgender issues, and particularly gender identity, there's a whole slew of terms that I think a lot of providers don't know a lot about, and so we really need to break down those terms. Why don't you unpack some of those for the viewers who are watching right now?Ayana:Yes. Knowledge of transgender-related terminology [00:07:00] is important, one for awareness, but also for effective communication with the transgender patients. Let's review some of those commonly used terms.Transgender is an umbrella term for people whose gender identity extends beyond the conventional paradigm of birth-assigned sex, behavior, or appearance. The term may include, but is not limited to, people whose identity may be male-to-female, female-to-male, cross-gender, androgynous, [00:07:30] or bi-gender.The term male-to-female transgender, or transfemale, or even transwoman, is a person born with male anatomy whose gender identity is that of a woman.Female-to-male transgender, or transmale, or transman, is a person born with female anatomy whose gender identity is that of a man.A cross-dresser is a person who dresses as the opposite sex, and may [00:08:00] not seek any physical changes that you would see in someone who is transgender.In the Diagnostic Statistical Manual of Mental Health Disorders, the Fifth Edition, there's a term used for the provision of transgender-related care and replaces the older term, gender identity disorder. However, gender dysphoria is a controversial term within the transgender community, and clinicians should be sensitive to the [00:08:30] negative effects that can result from classifying gender identity as a disorder.When we talk about gender transition, this is the process of bringing the body and the mind into alignment. The transition could include physical transition with hormones or surgery, or social, psychological, linguistical, intellectual, and just spiritual aspects of self.Natal sex refers [00:09:00] to biological sex. Those identified at birth, i.e., male or female, or more explicitly persons born with penises are male and persons born with vaginas are female.Gender identity is self-view as man, woman, neither, both, or in between.Gender nonconforming individuals are those who may experience behaviors or interests [00:09:30] that fall outside of society's binary gender stereotypical expectations, and who may or may not identify as transgender.You want to be aware that there are some terms which are considered defamatory. Although providers should not use these terms, transgender persons sometimes use these as slang. Those terms would include transvestite, hermaphrodite, shemale, he-she, tranny, [00:10:00] or gender-bender.David:You mentioned a little bit earlier, and obviously there's a lot of terms to consider, so I think providers who are watching are gonna have a pretty steep learning curve to kind of get caught up with all these terms. You mentioned gender dysphoria. What causes gender dysphoria in your opinion?Ayana:There's no known cause David. We just don't know, but it's likely multifactorial.David:Okay.Ayana:In animal studies, intrauterine cross-hormone exposure has been shown to lead to cross-gender [00:10:30] stereotypical behaviors. Current research in humans though, focuses on the brain structure and subtle genetic factors.David:Okay. And so when we talk about all these terms, and we talk about tracking people, particularly transgender people living in this country, you know they do census data in a lot of cases for people. So Ayana, do we know exactly how many people in the United States identify as transgender?Ayana:There is little known about the exact number of transgender people living here in the U.S., [00:11:00] highlighting that there's a problem of true visibility. No generally reliable statistics exist because the U.S. Census Bureau does not allow people in their national surveys to identify themselves as being a gender different than the one indicated by their physical features at birth.There are other countries that do a slightly better job of census tracking of transgender people, like Singapore or Thailand.David:And do you know of anything ... Like in the United States in the future, are they trying to [00:11:30] improve that at all?Ayana:There was a particular study done by the National Center for Transgender Equality, which is still in the works.David:Okay. But obviously the point is, they tend to be more invisible in the census data in the United States?Ayana:Right. You can't respond to something you can't see.David:Right.Ayana:Transgender persons are not seen because they're not counted.David:Absolutely.[00:12:00] So from what you've just explained to us, transgender individuals in the United States are unseen, unrecognized, and underserved in this country. It seems like there's a lot of barriers to health care when it comes to someone who's transgender. But one of the main things that seems to stick out may be stigma. Can you talk a little bit about that, stigma as a barrier to care for transgender people?Ayana:That's right David. A national transgender discrimination survey was conducted by the National Black Justice Coalition, in collaboration with the National Center for [00:12:30] Transgender Equality, and the National Gay and Lesbian Task Force. This survey measured transgender people's experience of discrimination. The most significant finding was the combination of anti-transgender bias and persistent structural and individual racism, that was especially devastating for black transgender people.Black transgender people lived in extreme poverty, with 34 percent reporting household incomes of less than $10,000 a year. Black transgender [00:13:00] people were also disproportionately affected by HIV. Over 20 percent of the black respondents were HIV positive, with an additional 10 percent not knowing their status. Nearly half of the black respondents reporting have attempted suicide over their lifetime.What was interesting to note, that black respondents who were connected to their biological families, found acceptance at a higher rate [00:13:30] than the overall sample of transgender respondents.David:What do you make of that?Ayana:Well, I think that was interesting from an aspect of being a person of color. We, historically, have had a family-centered connection, and I think that even in spite of what has been reported with bias, and even being marginalized from families, there is [00:14:00] a connection between the individual, because we're talking about a human.David:Right, absolutely. And we talk a little bit about stigma overall in society, and I think that last group of slides told us about. But as far as like within health care settings, does that stigma translate into health care settings as well for transgender persons?Ayana:It definitely does. In a survey conducted by Lambda Legal, it highlighted the discrimination against LGBT people, and people living [00:14:30] with HIV. With about 4,916 respondents, eight percent of those respondents were identified as transgender, and four percent identified as gender nonconforming.In almost every category measured, there was disproportionately more transgender respondents reporting discrimination in barriers to care. Those categories included refusal of needed health care, [00:15:00] harsh or abusive language, being blamed for one's medical or health status, as well as being physically rough or abusive during physical exams. 70 percent of transgender or gender nonconforming respondents reported one or more of these experiences.David:That's a high number. Does that compare, is that a lot worse than just general lesbian, gay, and bisexual people? Do you think that's about the same or much higher?Ayana:I would estimate [00:15:30] or guesstimate that it is.David:Yeah, absolutely. And so, we're dealing with stigma already coming in for transgender patients to these clinical settings. What other factors are contributing to risky health behaviors, or just adverse outcomes in health?Ayana:Let's take a look at a chart of contextual [inaudible 00:15:46] factors that contribute to at-risk health disparity and HIV. These things would include misperception of risk, mental health issues, immigration status, social isolation, [00:16:00] economic marginalization, commercial sex work, physical abuse, unmet health care needs, and an incarceration history.Some additional barriers to care are low literacy, language and cultural barriers, and lack of access to health care, which we have seen improve for transgender people in some geographic locations through the Affordable Care Act. This is by way of the abolishment of the preexisting condition clause and Medicaid [00:16:30] expansion.David:Yeah, it seems that, when you're looking at a lot of those things in the slide that are talking about factors that adversely affect health, I've seen that with other kind of issues of racial disparity, sexual orientation disparities. But when we're talking about transgender patients that come in, there's an additional thing, because if they're coming in and dealing with all that stigma in addition to all these other factors.And the one thing that a lot of transgender persons are coming into clinical settings for is to get hormone therapy for [00:17:00] gender transition or gender confirmation. How does that impact, all that stigma, all those negative factors, how does that impact their access to hormones, and if they're getting hormones?Ayana:It really causes a barrier to access to hormones, and it leads to a transgender person having to access these hormones through non-traditional ways, such as the internet, or the black market, or even through friends. Less access to gender-confirming surgeries, relying [00:17:30] only on the use of nonsurgical options for transitioning.David:Right. Do you see a lot of patients that come in? Have you seen a lot of folks come in, they get their hormones on the black market, and have a lot of these side effects or have adverse outcomes because they're using hormones?Ayana:Of course. I've been working in the field for 14 years, and much of what we have now in terms of education and awareness on trans health, even guidelines to give providers [00:18:00] some insight on what to do to prescribe cross-hormone therapy, did not exist.David:Okay.Ayana:And so, when you found your patients who were engaged in care, they did access hormones through a number of those ways we just mentioned.David:Okay.Speaker 1:What a day. Could have just gone to the clinic. I've been wanting to get an appointment for a long time. Took the whole morning to get an appointment. All I got to say, it better not be like five years ago. Shit. Can it really be haven't seen a doctor since I was 17? That's a long time. Spending another six [00:00:30] hours in the emergency room, while they call me a freak, or no, treat me like a freak, poking their heads in to get in a good look. Asking about how hormones, and where did I get them. Ugh. Who prescribed them. What kind of surgeries I've had. When my last HIV test was. [00:01:00] Just about everything except for the hell I came for. My stomach hurts, and the whole time they really just trying to get the tee on what's under my skirt. All while calling me Jerome. Jonathan's space across town is good. At least maybe they'll see me for me, maybe, if I'm lucky, pay it. David:[00:01:30] When I hear Sarah's part of this story, I remember working at a teaching hospital, and it always seemed that that experience she's describing, coming in for a routine physical, or for a routine health complaint ... It could be sinus problems. It could be stomach pain. It could be something like that, and all of a sudden it turns into an expedition or a teaching moment where everyone wants to come in and focus on the fact that this patient is transgender. Do you see that a lot in your clinical practice, or do you hear [00:02:00] those experiences from your patients?Speaker 3:I have in fact heard of those experiences from many of my patients. It is quite an opportunity a clinician feels to have someone of transgender experience come to their environment, and to be able to have your students learn from that, but I caution a clinician in doing so. Because of the [00:02:30] historical trauma that transgender people have experienced with the healthcare environment, let's talk about how to create a welcoming or an inclusive environment for your transgender clients.David:Absolutely.Speaker 3:Agencies should prepare for caring for transgender clients by performing an environmental self-assessment. Creating a transgender-inclusive healthcare environment would entail such things as transgender 101 trainings for all staff. That's clinical [00:03:00] and nonclinical, and can include everyone, including the janitor. It's so important that you have zero tolerance anti-discrimination policies in place, to be able to check any issues at the door that any of your transgender patients may have in your organization. Continuously assessing the structural barriers to accessing care is key. This, for example, would include [00:03:30] making sure that your hours of operation are workable for your patients, as well as considering their ability to pay. Conducting routine or regular patient satisfaction surveys would allow you to tell yourself if you're doing a great job. Adaptation from traditional approaches may be necessary, and you should consider this as not a detraction from your regular service provision, but an enhancement [00:04:00] of the quality of care you're able to provide your transgender patient population.Forms, medical record systems should allow gender-variant identification.David:With these systems, there's a lot of stuff we can do, and I definitely hear you about the electronic medical records. When I worked in a student health system, it made the world of difference when the correct pronouns were put in, and the rest of the staff, from the janitor to the front [00:04:30] desk person, everyone could kind of have that. After those systems and those forms are all taken care of, you have to whittle it down to, okay, you have the patient coming in. You have the provider, so what things can the providers do to kind of make the care more inclusive, make a safer space, and make our transgender patients feel more comfortable?Speaker 3:You want to make sure that your forms and your systems are helpful to elucidate your transgender clients being served. This would help [00:05:00] by using a two-step question on gender identity. For example, the two-step question would include question number one, which is what is your sex or gender now, and check all that apply. The second question would ask, what is your sex you were assigned at birth? You see how that works? If I were a [00:05:30] transgender man who considers this current gender as male, and you don't have the second question, you don't know anything about his experience as a transgender man.David:Yeah, and I think that's perfect, because you basically say what the person sees themselves as now, what their gender is right now, and what it was before, so it starts off acknowledging who is walking in that door at that moment.Speaker 3:Right. When you ask the right questions, you get all of the correct answers. David:Absolutely.Speaker 3:[00:06:00] Failure to adopt this two-step question method, though, does conflate gender, and keeps the population invisible. David:Okay, and regarding to how the patients and the providers kind of interact in that close relationship, what can the providers do from a personal level, on a very individual level, when they're working with transgender patients?Speaker 3:It's paramount to establish a reliable, trusting, nonjudgmental relationship. [00:06:30] You want to refer to the patient by his or her preferred name, even if the legal name is on all of their documents. Transgender people have challenges with getting their legal documents changed, and that varies from wherever you live, where it's often so much more difficult to get a driver's license with your current gender, or even to be able to put your preferred name on it. You want to also be able to [00:07:00] have the patient feel comfortable by you using their preferred pronouns. That's key in addressing or being able to even communicate with your patient, and you want to also address confidentiality, because all of the information that you will be collecting from your patient from now until your relationship develops, you want the patient to feel assured that what [00:07:30] you, what they tell you will be something that only you will utilize, and provide to other people on a need to know basis. Whenever you're taking care or working with your patient, you want to be able to allow the patient, as you do with all patient, to participate in as much of the planning of their care as possible. There's also a need to ensure that the education or the health promotion materials [00:08:00] that you use are really gender relevant, so for example, if I wanted to teach my trans female patient about self-breast exam, it'd be a little bit uncomfortable if the only thing that I had as a point of reference was a traditional brochure about self-breast exam in natal women. It, again, may be necessary for you to adapt from these traditional approach.David:[00:08:30] Right. How difficult do you think it is for providers and these clinics to kind of get out of old habits to do that? Do you see that a lot in your experience? Do you see patients that come in to see you that say, "The old clinic I went to just didn't know what the heck they were doing."Speaker 3:Old habits are hard to break. David:Right.Speaker 3:The provision of transgender-related care in one setting is optimal, and everybody wants to go to a place where you feel most comfortable, [00:09:00] someplace like Cheers, where everyone knows your name. However, the integration of this treatment is not possible in all places, and so when that happens, commissions should be able to make the necessary referrals to specialists who are comfortable and qualified to provide culturally relevant care.David:Absolutely.Speaker 3:Ongoing dialogue about the patient's concern as well as offering physical examination deferral when appropriate may convey a respect for [00:09:30] the patient. Patients who receive respect and encouragement from their care providers may be proactive about their health and remain in care.David:Yeah. What can providers specifically do? You mentioned a lot of these other things. It sounds like it's kind of more on a personal level, as far as using the correct pronouns, almost just treating folks like human beings, which should be a natural thing for most providers, but not all the time [00:10:00] is. What other things can they do as far as how they communicate that may be helpful with the patient provider relationship with their transgender patients?Speaker 3:When conducting conversations of a sensitive nature, there's a couple of things you can do, like using some very sensitive leading questions. For example, I will discuss some sensitive topics. Very easy and simple, or you could say, "I'll be asking you some questions about [00:10:30] your sexual behavior," and I will ask you about what body parts you use for sexual activity. Most of all, I want you to feel comfortable. I don't want to assume anything. If you prefer me to use other words to describe body parts, let me know. These things are unequivocally basic in just leading the conversation, and allowing the patient to get adjusted for what's [00:11:00] about to happen next.David:Right. It sounds like providers just letting all their biases kind of go, and letting the patients kind of drive the experience in some respects, and just being open to different manifestations, different gender identities, different terms, different pronouns that maybe they're not traditionally used to. I think when you're talking about all this, what it brings up to me is kind of bringing us back to wholistic care, and a wholistic care assessment. I think one [00:11:30] of the important parts it sounds like is not only how the physician or nurse practitioner or physician assistant goes into it, but then the kind of history they take on a wholistic level. Why don't you walk us through some of the history taking in those whole health assessment that will really facilitate taking good care of our transgender patients?Speaker 3:Right. A whole health assessment really identifies not only the patient's medical history, but also the basic psychosocial information, but also circumstances that may inform the [00:12:00] need for other social support or case management. Most aspects of the routine medical screening for transgender patients are similar to those in the general population, and should really be based on the organ systems that are present with your patient. There are some caveats to taking a history of a transgender patient, so let's talk about them now.David:Let's do it.Speaker 3:The real life experience, or how long a patient has been living in their new gender role, is important to [00:12:30] document, as well as many of the traditional things that we want to know about our patients, education, occupation, marital or partnership status, tobacco use, alcohol use or recreational drug use, and this is particularly important because of some of the interactions or counter indications that happen when a patient who may be taking cross sex hormone therapy. Domestic abuse as well as violence victimization, which we talked about earlier.David:[00:13:00] Which Sarah. Yeah, definitely.Speaker 3:In the case of Sarah, we learned that she was a dropout in high school in the eleventh grade due to increased discrimination and bullying. She was employed. She worked as a commercial sex worker, and traveled around the country. She had no permanent resident, and often stayed in hotels during her work, as well as lived with friends. She didn't smoke tobacco, which was good, [00:13:30] because she was on hormones, but she does smoke marijuana daily, and she does drink on the weekends at clubs. David:Let's talk a little bit about the medical and surgical history, what kind of similar things and extra questions should providers be asking or inquiring about. Speaker 3:Essentially we want to take all of the regular things, again, that we would for non-transgender patients, but [00:14:00] for this particular population, we want to identify whether the patient has been taking cross sex hormones, for how long they've been on them, who prescribes them, without being judgmental, because again you will learn some of those things about how the patient has accessed their hormones up to this point. Does the patient have any adverse reactions or concerns about the hormones that they've been taking, and if they aren't taking [00:14:30] hormones right now, does the patient plan on taking hormones at some point, and how you can help in that process. Subcutaneous silicone injections is common. This is the medical or even industrial grade silicones being injected below the subcutaneous skin layer for the purpose of enhancing the body contour, like the face, the hips, or the breasts. Most of this procedure is common in [00:15:00] transgender women.David:Are there any complications with that that people may have, or anything that the physicians should be asking about when someone says, "You know, I've been injecting with silicone?"Speaker 3:Right. There are problems or complications that can come from this procedure. Noting that it is illegal in the United States to perform, and is often times performed by someone who is unlicensed and unformally trained. Some of the consequences [00:15:30] that happen from subcutaneous silicone injection are autoimmune reactions, granulomas of the skin, other dermatologic issues like hyperpigmentation, as well as the undesired disfigurement. The untoward effects of this silicone injection procedure can happen in the distant future, like five or 10 years post-procedure, even. In the medical history of Sarah, [00:16:00] we noted that she last completed her physical exam at age 17. She had initiated hormone therapy at age 17, which she obtained from a friend, and she's had multiple sessions of free floating silicone injections to the hip and face. She's currently taking cross sex hormone therapy that include primine, 1.25 milligrams, two tablets by mouth, twice a day, progesterone, [00:16:30] 10 milligrams by mouth once a day, and del estrogen, 20 to 40 milligrams intermuscular when she's able to get it. She has no history of hospitalizations or acute care visits, and no health issues that she's aware of. She was last tested for HIV in 2015, at a house ball event. Her results, as she report them, were negative. David:[00:17:00] Take us through the surgical history a little bit.Speaker 3:In taking a surgical history, of course we want to always note any surgical procedure that's not related to the patient's transgender status, and then we do note that the patient could have some gender confirming surgeries, some of those listed here, as you can see. David:Okay. What about family [00:17:30] history? What's important about that?Speaker 3:Family history is really important to include this information, particularly because the biological family, knowing the history to help elucidate any hereditary medical factors, but you also want to be sure to collect information about the patient's surrogate family. Surrogate families really are something that is common in transgender people, as they may have been ostracized [00:18:00] by their biological families after they come out. We note that Sarah left home at age 15.David:Right, and so with the family history, it seems like really getting a sense of whether it's biological or a surrogate family, how much support they have in their lives.Speaker 3:Right, a social support system may be friends. It may be mentors, but these are the folks that you understand will be the patient's support [00:18:30] system if anything happens. They'll be there to have their back.David:Okay. Let's talk a little bit about mental health history, which is overlooked a lot of times with medical providers in general, so how about with our transgender population?Speaker 3:In addition to all the baseline history and psychosocial assessments that we gather, clinicians also have to perform a mental health and substance use screening in transgender patients initially, and then again annually at least and [00:19:00] any time more frequently as needed. Comorbid mental health conditions and substance use disorders have been shown to be more prevalent among transgender population. Even in Sarah, we saw that she reported anxiety and depression, which was related predominantly to her gender identity and gender discrimination, or transphobia.David:Okay. As far as sexual history, we know that [00:19:30] medical folk don't really like taking a thorough history all the time, so with our transgender patients, what's important? What are some of the things you would recommend as far as approaching a sexual history with a transgender patient that comes into their office?Speaker 3:Like all people, transgender individuals present with a variety of sexual orientations and behaviors. The terms gay, straight, lesbian, homosexual, heterosexual [00:20:00] may be defined differently by transgender individuals, depending on whether they're using their natal anatomy or their gender identity as a reference point. As with all people, these terms may be more about identity than behavior. Therefore the assessment of a patient's gender identity is distinct from the assessment of his or her sexual behavior. When taking a sexual and reproductive health history, you should ask and not assume. [00:20:30] Some of the things you want to know is, who are your partners, and how many partners have you had, say, for example, within the last 12 months? What safe sex practices do you perform? Are you having any sexual function issues? This could be a question that stems to elicit information about whether the patient is experiencing a common side effect that can occur with the use [00:21:00] of cross sex hormones, either masculinizing treatments, which cause vaginal dryness, or even feminizing agents, which can cause erectile dysfunction. It's very important to know whether your patient has any offspring. That's both transgender men and transgender women. Often times clinicians just assume that the patient is in their [00:21:30] current gender, and they haven't had any other experiences, and that's a no-no. You want to document if the patient also desires to have any biological children. This would prompt the need for further evaluation and counseling.David:Do you see a lot of your patients that come into your office, do they come in speaking about the hormones directly, not thinking years ahead about whether they want to have kids or not, and how do you broach that [00:22:00] conversation with them? Some of the transgender patients in my practice previously were just focused on the hormones, and when I brought up the topic of kids, they were like, oh, I really hadn't thought about that, or I was so focused on the hormones. What has your experience been with that?Speaker 3:It is. It becomes a ton of visual concern for the patient to get on their hormones, and to be on their hormones. Then when you pause the question about their desire to have children, most do [00:22:30] report that they are interesting in having children at some point in their lives. Those conversations come up at two points, one when starting cross sex hormones, but also when patients are inquiring about gender confirming surgeries like orchidectomies, or having hysterectomies, which would impair their ability to do so.David:[inaudible 00:22:53] Can you explain a little bit how hormone therapy affects reproduction in transgendered patients?Speaker 3:As you can imagine, [00:23:00] David, the utilization of a masculinizing or a feminizing hormone can stop or satiate the reproductive gonads, so in the transgender man, the menses is satiated, reducing the patient's ability to become pregnant. Conversely, for the transgender woman taking feminizing hormones, it would reduce the production of semen. David:All right. What else about the sexual and reproductive health history [00:23:30] can you tell us we need to do?Speaker 3:You'd want to know for your transgender men if they're not taking masculinizing hormones, what was the date of their last menstrual period? When was their last pap smear, and you also want to know, again, if they've had any gestational history. If your patient has breasts, you want to know if your patient is performing a self-breast exam. Conversely, in transgender women, you want to [00:24:00] understand if your patient is performing testicular self-exam. Asking your patient or eliciting from your patient whether they're having vaginal or penile discharge or issues is something important. While your patient may not feel comfortable with telling you this information, if you ask the question, you may find that your patient may be having a issue that needs to be addressed. In asking that, you may learn of a history of a sexual [00:24:30] transmitted infection, or the need to screen for one.Text:Clinical Care of Transgender Patients. Sarah:Yes, God. I finally get to see Dr. Anderson today. Things are really moving forward. I thought those counseling sessions she sent me were going to be bullshit, but you know like I wasn't sure that I was the woman since age five, but I went like a good girl. [00:00:30] And baby, it blew my mind. Pretty cool. I'm getting to know myself a little better. Dr. Anderson said our focus would be non-highly on the present and the future. It feels good to work with someone you know, who listens and really cares. I told her the hormone therapy she prescribed me makes me feel great, like not that they don't have some side effects, but [00:01:00] baby it was worth it. I'm sitting and I slay. Not to mention I'm taking less shit from Drey but best of all I'm feeling more like myself. Speaker 3:All right so when I see that video with Sarah it makes me happy hearing that end product where she says, "Basically I feel like I'm more like myself every day." Do you get that experience once a lot of the transgender patients in your clinic start hormones? [00:01:30] Start feeling better, have that kind of experience that Sarah described. Anna:A whole lot gratitude and what was interesting for me is that she was a seeing a provider and she felt like the provider were meeting all of her needs. Speaker 3:Absolutely. Which, brings us to talking about kind of the clinical care in the setting. We've talked a lot about stigma, we've talked about making a safe environment, making a safe space for a lot of our transgender patients [00:02:00] in clinics, but as far as the clinical encounter, can you walk us through some of the steps as far as providers doing the physical clinical encounter, labs, so on, so forth. Anna:Most of the aspects of medical screening in transgender patients like we talked about before are similar to those in the general population, and should be based on the organ systems present. However, transgender patients regardless of their surgical status may [00:02:30] find aspects of a physical exam distressing or dramatic particularly breast, genital, pelvic, or rectal exams. When the immediate examination is not clinical indicated examination deferral can be offered until the patient expresses his or her readiness. Deferral of examinations is in an effort to increase the patients comfort and should be documented in the medical record. Speaker 3:And this [00:03:00] is the process of gender transition that we're talking about or gender confirmation. Talk us through what providers should be thinking about or bringing their patients through as they talk about gender transition or gender confirmation. Anna:Well, this process for gender transition is multi-faceted. And it's important to discuss with your patient his or her goals and desires for their plan of care. Start mention passing. Passing means to be identified socially in their new gender role. Passing is [00:03:30] not equally important to all and this is something that the provider should know. Transgender persons passing is not the goal for everyone. Likewise, cross-sex hormones or gender confirming surgeries may not be a patient's goal. The idea process encompasses psychotherapy or counseling to discuss one's gender issues. Psychological counseling may or may not have happened based simply [00:04:00] on the patient's access or insurance. The real-life experience, which is often where the patient begins and then has counseling again permitting access. Cross-sex hormone therapy is a +/- for some patients, as well as gender confirming surgeries. Speaker 3:And as far as the initial assessment of the medical transition and the gender transition that the patient's are going to be going through, what would you recommend to our providers [00:04:30] who are watching out there? Anna:Well, it should really be based on the patient's desire plan. Remember we talked about earlier about the patient being a part of the planning of their care. It's important to do all the usual assessments and to identify any conditions, which may be exacerbated by hormone therapy. Most of the health screening consists of identifying the patient's current hormonal status, any organ systems present, [00:05:00] raised ethnicity, and anything that can be determined to be affected. If the patient is not on hormones screening would be equivalent to the non-transgender individual of the same age and natal sex. You want to be sure to ask again as we talked about earlier, the patient's hormone use, their dose, duration, how they obtain them. And also to inquire [00:05:30] about needle sharing, which can be a common in injectable hormones. The psychosocial issue would be a part of the mental health assessment where we're assessing for depression, PTSD, which can be exacerbated by hormones. And also to asses the patient's social support network. Their employment status, whether they're doing such work or even using substances. Speaker 3:[00:06:00] So, as far as this initial assessment what kind of history and lab test are providers going to bring their patients through? Anna:Some patients may present prior to initiating hormone therapy having been on street hormones and others transferring care from another provider who may deliver their cross-sex hormone therapy in a different way. A thorough assessment, which focuses on the conditions, which may be a mask or exacerbated by cross-sex [00:06:30] hormones should be performed. Some of those would include, history of cardiovascular disease or hypertension, breast cancer, hepatitis or liver disease, thromboembolic disease, depression, anxiety or psychosis, alcohol, tobacco or drug use, or a history of health conditions impacted by hormone therapy. The lab tests that would be [00:07:00] performed would include a CBC, liver enzymes, a lipid profile, a basic metabolic panel, a fasting glucose, and testosterone, estradiol, and prolactin levels. As well as STI/HIV screenings.Speaker 3:Can any provider when we're talking about hormones and hormone therapy, cross-hormone therapy, can any provider [00:07:30] prescribe these medications?Anna:Yes, of course. It is an off-label indication, like other medications we may prescribe, however hormone therapy can be provided in primary care settings according to standard guidelines, such as the guidelines published by the Endocrine Society. Although, there are several retrospective cohort studies that suggest hormone therapy is generally safe, particularly the over the short and mid-term course, limited data exists on the [00:08:00] long term effects of cross-sex hormone therapy. Clinicians should inform patients that hormone therapy may increase the risk for cardiovascular disease, certain cancers, liver disease, and sexual function issues. Some of these recommendations are based solely on evidence from current clinical gender studies and social science research literature. Speaker 3:Okay. Talk a little bit about ... It sounds like especially with the potential for both short term and long term [00:08:30] side effects that you know the patient is assuming with this gender transition, gender confirmation that they're going to be possibly inuring some other risks. And so, walk us through kind of the informed consent process that's typical when you're starting a patient on hormones. Anna:Right. So, when a patient seeks hormone therapy in your practice you can consider the use of the following informed consent model. Looking at completing all of these [00:09:00] itemized things, till you get to a yes. If there is some area where you have not completed you should go back and re-asses or re-apply and move forward until you can get the patient through and initiated on their hormones. Speaker 3:Right. One of the things we used to do with some of the transgender students that I saw and started on hormones, is we'd give them the consent form, we'd draw labs, and then we'd basically have them go [00:09:30] home to read the consent form and make sure they understood line by line kind of what was going on, the potential risks and benefits. And then when they're labs came back their initial baseline labs you talked about, then we would actually have them sign, discuss it again, and then start the hormones. Was that a process that you guys used or was it something? Anna:Right. In the organization where I work I created a consent form, which highlights the very important things that the patient needs to know before making this very important [00:10:00] decision about starting cross-sex hormones. That would include knowing the risks as well as the perceived benefits of the treatment.Speaker 3:Right. And for our providers that are out there watching this module right now, a lot of medicine is a business and a lot of things are about billing. And so, some providers who want to get interested in prescribing hormones or providing competent transgender care, may be wondering, "How do I bill for this in the current climate of ICD 10 coding, these kind of other things [00:10:30] were you have to bill in order for insurance companies to pay for things, or to at least cover." So, what would you recommend to them? Anna:Right, sure. Diagnostic coding for medical visits for transgender patients for hormones or any other health diagnosis can't include ICD 10 codes like E34.9, which is hormone imbalance for transgender patient. Or simply using encounter for therapeutic drug level, which [00:11:00] is Z51.81. Speaker 3:And what about this gender dysphoria code? Anna:Well current or by history diagnoses of gender dysphoria should be documented, but it should not be used on a medical reimbursement form because it is a psychiatric diagnosis. Speaker 3:Okay. So, Anna we've talked a lot about transgender health today, for the providers that are watching this module, what take home lessons would you want them to bring back to their clinical practice? Anna:If I [00:11:30] had to sum it up, here are my recommendations. Put nondiscrimination policies in place in your clinics. Provide cultural competency training for all staff. Create clinical environments with visual cues that are warm and welcoming.And integrate gender care into your HIV or primary care services. Be an advocate for transgender patients. If you see discrimination say something, [00:12:00] stand up, be a voice for the voiceless. Speaker 3:Yeah, I think that last point is a really important one because a lot of times in these practices physicians lead by example. Nurse practitioners lead by example. Physician assistants lead by example. So, if they see you tolerating something and not speaking up when someone is being discriminated against that's going to set the tone for the entire staff. Anna:Right, be the voice for the voiceless.Speaker 3:Absolutely. Before we warp up I just want to give the audience some resources that can be used if they want some more information [00:12:30] on transgender health, use of hormones, and medical care for transgender patients. The American Medical Student Association is a good resource. As well as the World Professional Association of Transgender Health . The Endocrine Society as we talked about before that makes some of the guidelines that are typically used when talking about hormone treatment for transgender patients is also a good resource. As is the Vancouver Coastal Health organization. And then finally the UCSF Center for Excellence for Transgender [00:13:00] Health transhealth.ucsf.edu is an amazing, amazing resource because I've actually used that myself when we were integrating some stuff in Philadelphia. So, Anna Elie I want to thank you so much for taking the time, it's been a pleasure and you've given a lot of great information for the audience out there. Anna:Welcome. Text:His Health. Grow strong together. ................
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