Care of the Transgender Patient in a University Setting



Care of the Transgender Patient in a University Health Clinic SettingKathryn M. Hicks, Autumn R. Schafersman, Tai A. Schmotzer, Jennifer K. Tyler-Simonson,and Karen SpencerWashburn University IntroductionUniversity health centers address a variety of general medical care needs that include urgent care for illness and injuries, primary care for stable chronic conditions, preventive exams, sexual health concerns, and mental health issues (“Student Health”, 2013). Across the nation, transgender persons are collectively increasing their visibility in society (Alegria, 2011). “Anecdotal evidence suggests that students are coming out as transgender on campuses across the country” (Beemyn, Curtis, Davis, & Tubbs, 2005, p. 49). This evolving patient population is presenting new challenges to nurses and nurse practitioners, most of whom have received little or no education on transgender health issues, and who lack experience with addressing the health care needs of transgender patients. In order to improve the wellbeing of transgender individuals, health care providers need to gain a better understanding of transgenderism, the social issues that influence the transgender community, and the specific health care needs of the transgender person. One definition of transgenderism is a discrepancy between one’s own experience of gender identity and the physical body (Gooren & Tangpricha, 2013). Some transgender students will chose to live as their natal sex (birth sex). While others will seek hormonal treatment to develop secondary sex characteristics of their desired gender. The most permanent transformation transgender students may chose is consenting to gender reassignment with breast augmentation and/or genital surgery (Gooren & Tangpricha, 2013)Hormonal treatment is costly and has specific health monitoring implications for transgender students. The development of guidelines to aid health care providers caring for this population is needed to prevent undesirable health risks. The goal is to develop comprehensive primary care guidelines for health care providers caring for transgender students at university health care centers. PurposeThe purpose of this project is to review the literature surrounding the health care needs of transgender students, with the intent to identify gaps within current student health care systems, and recommend guidelines and current resources available. Additional purposes are to provide education to health care providers and to promote sensitive care for transgender students. Current guidelines and best practices in hormonal therapies are identified for use in caring for a transgender students in developing the characteristics of the preferred gender.Significance for NursingIn the United States, it is difficult to obtain an accurate number of transgender individuals due to few direct studies or surveys being conducted. According to DeCuypere et al. (2007), the prevalence of transgenderism ranges from 1:11,900 to 1:45,000 for male-to-female transitions and 1:30,400 to 1:200,000 for female-to-male transitions (Coleman et al., 2011). The Williams Institute has estimated that transgenderism occurs in 0.3% of the adult population in the United States (Gates, 2011).Healthy People 2020 for Transgender Health utilizes epidemiological data obtained through behavior risk studies and a needs assessment in the United States from 1993 to 2010 with sampling pool of 50 to 517. The study reveals difficulty with discrimination when attempting to access appropriate care services. The medical provider’s role in discrimination of the transgender person was perceived as hostile and insensitive (“Healthy People”, 2010). The National Transgender Discrimination Survey report shows a lack of health care provider knowledge on transgender care. In fact, 50% of individuals reported teaching their medical providers about transgender care. Another 19% of transgender patients were refused treatment by a health care provider. As a result, 28% of transgender individuals postponed necessary medical care, and 33% delayed or did not obtain preventative care due to discrimination by health care providers (Grant, Mottet, & Tanis, 2010).Many transgender people do not have insurance. There are high rates of joblessness and poverty among these individuals. Health insurance coverage for the transgender-specific health services tend to be excluded by most commercial insurers (“Health Care”, 2011). Denial of coverage can extend to even basic health care services not related to transgender reassignment therapy. As a result, individuals with the strong desire for gender transition will find other means to achieve the same outcome. More than 50% of transgender individuals report using injectable hormones obtained illegally or utilized outside the conventional medical care setting (“Health Care”, 2011). This frequently resorts in the dangerous practice of self-administration of injectable silicone to facilitate the masculine or feminine physiological appearance. Therefore, the American College of Obstetricians and Gynecologists has urged public and private health insurance plans to cover the treatment of transgender therapy as a safer and more cost effective option (“Health Care”, 2011).There are a few primary care clinics that have specialized in transgender care, and have become knowledgable and well-known providers in the transgender population. These clinics are constantly being challenged with heavy patient loads. One clinic is the Fenway Community Health Center which was founded by activists as a grassroots clinic in 1971 in downtown Boston, Massachusetts. The purpose of the clinic was to become a local neighborhood primary care clinic, but quickly began to specialize in caring for the lesbian, gay, bisexual, and transgender population. In 1975, the clinic recorded 5,000 patient care visits by transgender patients. In 2003, they recorded having 61,983 visits by 11,154 transgender individuals (Mayer, Mimiaga, VanDerwarker, Goldhammer, & Bradford, 2007). In 1990, the only other publicly-funded transgender care clinic was the Transgender Team at Tom Waddell Health Center. Today there are more clinics, but they are not distributed evenly through the country. In their 19 years of practice, Tom Waddell Transgender Team has seen nearly 1200 patients with over 400 patients currently active. Their practice consist of 80% male-to-female clients and 20% female-to-male clients (Davidson et al., 2013).Comprehensive transgender health care must seek to include primary care needs, which include health promotion, health prevention, chronic medication monitoring, adverse effects monitoring, and surveillance screening. Primary care can also be the connecting hub for mental health and social services. Primary care providers act as gate keepers and have someone consistently seeing and managing the individual as a whole (“Organizing”, 2012).Project ObjectivesThe objectives of this project are to review the literature focusing on the primary care needs of transgender students. Literature will be used to analyze gaps in transgender health care. In the future, clinical guidelines using the findings from the review of literature will be developed for a student health center at a midsized university in the Midwest. Lastly, health care providers will be educated and findings will be shared at a college health clinic.BackgroundAccess to health care has been a growing problem worldwide for some time, and transgender individuals and communities are no exception. Not only is it difficult for the average American to find and afford adequate health care, but public perceptions and education deficits bring another factor into providing care to the transgender individual. Transgender individuals should receive access to health care just as all other individuals. Some claim health care is a basic human right, and, if so, no health care establishment should refuse treatment to the transgender population (Grant et al., 2010). Primary care offices, urgent care centers, hospitals, mental health treatment facilities and student health facilities on college campuses should all treat the patient that comes before them, without thought of gender or transgender affiliation. As our heath care practices and policies change, student health care facilities should not be left out of the evolution of health services. While a growing number of college campuses across the country are starting to provide transgender health services, adequate, unbiased and consistent health care standards are yet to be established. Many are in great need of staff education, compassionate and unbiased care, gender-neutral treatment facilities, and changes to their policies and procedures to guide treatment of the transgender student (Beemyn et al, 2005). Private changing rooms, gender-neutral bathrooms, women’s health services outside women’s facilities, or even simple changes like using preferred names on medical records could help to change the perceptions of campus health services for transgender students (Beemyn, 2013). It will take student, facility, and administrative involvement to help guide college and university health services to where they need to be for the transgender community. Changes to student health care involves educating health care professionals and creating policies, guidelines, and procedures to aid in the health care and treatment of transgender students. This also means creating an environment that is transgender friendly. Lack of awareness of gender identity causes increased frustration and confusion for the transgender individual, as well as the health care provider (“Health Care”, 2011). Providing transgender as an option on student health intake forms will contribute valuable information for treatment and care of the transgender patient. The question not only provides the transgender individual’s perception of themselves, but also gives the provider more insight into the patient’s anatomy and physiology (“Transgender”, 2013). Providers must work past patients’ prior negative experiences, and work towards compassionate and informed care of the transgender population in the college setting (Grant et al., 2010). If a provider is perceived to be non-discriminative, then trust can be fostered and better care can be offered to the patient with open and honest dialogue (“Health Care”, 2011). Medical and psychiatric education are relevant parts of caring for the transgender person. Transgender individuals have higher incidences of HIV (2.64%), unemployment (4.67%), drug and alcohol abuse (25%), violence in medical care (28%), and suicide (41%) than those in the general population (Grant et al., 2010). An informed and educated relationship will foster and sustain positive outcomes for the transgender patient. Student health care of the transgender individual should be not only be specific to their natal sex, but their transitional sex as well (Coleman et al., 2011). Providers must be educated on the care and treatment for natal sex health, sexual reassignment and hormone therapies, genital reconstruction surgical plans, and the patient’s mental health throughout each transition (Coleman et al., 2011). The World Professional Association for Transgender Health (WPATH) is working to promote the need for medically necessary treatments and services for the transgender population. Unfortunately, most college and university health services are lacking guidelines and procedures for implementing specific health treatments of the transgender student. Theoretical FrameworkHarm Reduction as a model of intervention and treatment is an appropriate theoretical framework when developing guidelines for student healthcare treatment of transgender patients. The Harm Reduction model was first developed in the late 1960s as a public health model to address concerns of health risk associated with tobacco, drugs, and alcohol use. It was adapted into a second phase during the 1990s to focus on AIDS prevention among injection drug users and gay men practicing unprotected sex. Harm Reduction is a model which recognizes the social, institutional, and economic circumstances which result in a lack of access to basic services (Enders, 2009). The model accepts the patient where they are, and gently guides them to embracing healthier choices, creating plans, reviewing scenarios, recognizing triggers, and considering safer alternatives of treatment (Enders, 2009). When the individual seeks healthier and safer alternatives, it lowers the health risks of the community at large. The goal of Harm Reduction model is to improve the quality of life in regard to mental health, employment, incarceration, homelessness, and disease transmission of the individual (Enders, 2009). Harm Reduction model makes assumptions, as other treatment theories do (Erickson, Riley, Cheung, & O’Hare, 1997). These assumptions are:Establishing successful interventions include individual and community life and well-being (Erickson et al., 1997).Recognizing the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities impact a person’s vulnerability and capacity to effectively deal with drug-related harm. (Erickson et al., 1997) One way that the Harm Reduction model of intervention applies to transgender patients is through substitution therapy, which has been used with drug abusers to encourage exchanging one street drug for safer alternatives. It has been reported that transgender patients may substitute pharmaceutically pure hormones for street hormones of unknown quality. Hormonal replacement is expensive and cost prohibitive for many transgender patients who may have challenges of employment, housing, and educational pursuits (Enders, 2009). They use unsafe and questionably pure hormone to seek the goal of gender transformation, but conceivably jeopardize their health due to the lack of quality control, primary care follow up, and necessary laboratory monitoring. Transgender patients have also been reported to use street quality cosmetic altering products such as silicone filler injections to the face, lips, and chest in order to decrease costs and health care provider barriers (Enders, 2009).Using the Harm Reduction model with transgender patients allows healthcare providers to lead the patient by providing resources that are relevant and respectful to the individual’s needs, choices, and limitations (Enders, 2009). Several Harm Reduction model approaches can be used by healthcare providers who encounter patients using street hormones. The first method is using informed consent, which recognizes the patient is best qualified to make decisions about their own body and life. The second method is to encourage health care providers to develop open dialogue with patients and to respect their choice of using street hormones while supporting a change to safer, quality controlled hormones. The third method is healthcare providers dispensing information regarding the risks and side effects of hormone replacement therapy. This aids patients in informed decision making regarding their health. The fourth method is providing clear explanations of how to safely acquire, use, and dispose of needles. The fifth method of health care providers is giving explanations of how to self-inject hormones safely (Enders, 2009).Review Of literatureIn order to thoroughly review the topic, a review of literature was performed assessing the definition of terms, the social aspects of transgender care, standards of care for transgender patients, and college health guidelines for initiation and management of transgender hormonal therapy. Databases used were CINAHL, Pubmed, UpToDate, and Medline. Mesh terms were transgender persons, gender identity, transsexual, transsexualism, homosexuality, primary care, student health services, hormone therapy, and surgical augmentation. Articles published within the last five years were reviewed first. However, language and terms have changed over the last fifteen years, and published material from 2001 to present was included. Articles chosen focused on student health centers, primary care, transgender care risks and experiences, hormonal guidelines, and surgical augmentation. A total of 26 articles were chosen as they were most relevant to the student health center environment and educational needs of care providers at these instituitions. Definition of TermsNew terms relating to identity and sexual orientation have flooded popular culture and the fields of science, nursing, and government creating a shift in the perception of gender. Not only are topics such as transgenderism and gender identity unfamiliar to health care providers, there is a lack of resources and information available. One of the definitions of gender identity is the sense someone has of being male or female, regardless of their original gender assignment (Gooren & Tangpricha, 2013). Transexualism is said to be the condition in which the person feels that they are actually of the opposite sex of their birth (Gooren &Tangpricha, 2013). Elements of transsexualism include the individuals realization of what their gender identity is, their own physical body, and how they feel they should look (Gooren & Tangprich, 2013).Social Aspects of Transgender CareSocial aspects of transgender care include educational needs of health care provider, fear of negative experiences, and variability of transgender patients. Personal social concerns such as suicide and finances are noted among this population, and violence is a specific social concern for the transgender population. There are three focuses of educational needs of nurse practitioners regarding the care of transgender patients. These include acknowledging the definition and the range of transgenderism, the social influences on a transgender person, and the health care for the transgender person (Alegria, 2011). Transgender individuals may experience isolation and a lack of psychosocial support. Many times their only relationships with other transgender individuals are centered around drugs, alcohol, and sex negotiations being performed. Problematic substance use is prevalent amongst transgender persons (Davidson et. al., 2013).Numerous transgender individuals experience anxiety, post-traumatic stress disorder, and depression (Davidson et al., 2013). Suicide, suicide attempts, and suicidal ideation occur at a high rate in the transgender population. Transgender suicide is correlated to the discrimination and harassment that has been experienced increasing their depressive symptoms. To reduce the risk of suicide, those that provide care must keep this in mind and screen for suicidal ideation (Davidson et al., 2013). In a study containing 176 respondents, 30% stated that they had attempted suicide (Kenagy, 2005). Sixty-seven percent of those that attempted suicide did so as a result of being transgender (Kenagy, 2005). Sixty-four percent of transgender individuals have thought about suicide as a result of their gender status (Kenagy, 2005). Economic discrimination is also prevalent within the transgender population. Thirty-seven percent have reported economic discrimination (Lombardi, 2001). The negative biases against the transgender population have led to greater rates of unemployment (Alegria, 2011). Discrimination is not the only obstacle regarding employment. Claiming a work history under a different name and gender identity can be insurmountable (Davidson et al., 2013). Among working transgender individuals with a bachelors degree, it is reported that they earn 40% less than non-transgender individuals in the state of California (Davidson et al., 2013). Studies are now beginning to indicate violence as a major public health concern within the transgender community (Kenagy, 2005). A majority of transgender individuals experience violence within family, social, and interpersonal situations. Fifty-six percent experienced violence in their homes, and 51% have been physically abused. More than 50% have been forced to have sex or reported being raped or sexually assaulted at some point in their lives. Fifty percent reported being sexually abused as children, and two-thirds reported being afraid for their safety at some point (Kenagy, 2005). Health CareHealth care professionals caring for the transgender population need to focus on screening individuals for current violence as well as offering referrals for counseling and other community services to assist in managing the consequences of previous violence. Fear of potential negative consequences, as well as past experiences of violence, discrimination, and isolation, may lead a transgender individual to be reluctant to reveal their gender identity. This reluctance in disclosing information to health care providers may be related to embarassment, fear of discrimination, and fear of being outed to family members. These barriers make it difficult to evaluate the psychosocial needs of a transgender patient. “Purposeful effort needs to be made toward creating a receptive environment” (Alegria, 2011, p. 178). Individuals who chose to identify their transgenderism face anxiety and depression. However, the benefits of living authentically push many transgender persons to begin the transition. Once a decision to transition has been made, guidelines may assist the health care provider. The implementation of standards can be accomplished through the work of an interdisciplinary team that includes primary care (Alegria, 2011). While many providers may not know the patient does not identify with their natal sex, they will care for a transgender patient at some point in their practice (Algeria, 2011). This lack of knowledge often leads to suboptimal care, as well as creating barriers (Alegria, 2011). Insensitive treatment from practitioners was reported by 71% of respondents in a 2010 IRB approved needs assessment (Kosenko, Rintamaki, Raney, & Maness, 2013). This insensitive treatment was in the form of gender insensitivity, displays of discomfort by practitioners, verbal abuse as well as being forced to undergo procedures (Kosenko et al., 2013). However, these problematic behaviors even if well intended from the provider create barriers to adequate health care (Kosenko et al., 2013). The need for recognition of transgender individuals as well as the need to enhance their access to health care and educational and preventative services is identified in the literature. Lombardi (2001) acknowledges the need to increase the understanding of transgender health issues. In 1999, the American Public Health Association passed a resolution on transgender health issues. “Acknowledging health care discrepancies is only the start, however. To provide much needed services to this population, researchers, educators, and health care professionals of all types need concrete, comprehensive information about transgender individuals” (Lombardi, 2001, p. 869). While it is important for health care workers to know the proper manner to identify a transgender patient, it is even more important for them to understand experiences of gender vary greatly. Regardless of this variation, transgender patients are still at risk for receiving inadequate health care. One of the most prevalent health care issues among this population is discrimination and violence. Other health care concerns are the high rate of HIV infections in transgender women (i.e., male-to-female). This risk can be associated with high-risk sexual behaviors as well as the sharing of needles during the injection of hormones. Reasons that transgender individuals have identified for not seeking HIV/AIDS education and services is the “insensitive behavior among health care providers” (Lombardi, 2001, p. 871). Also, health care services may be difficult to locate for transgender persons due to the health care community’s reluctance to work with them. A health care worker’s attitude directly impacts the willingness of a transgender person to access and continue treatment. Transgender persons may be reluctant to seek care when others have reported negative treatment from a provider. Lombardi (2001) lists access difficulties that relate to gender changes. For instance, an individual may seek treatment in an unsafe manner such as purchasing hormones off the street and sharing needles to inject hormones. It is also noted that financial, social, and supportive constraints were even more prominent among youths. Other areas of concern revealed are current health related research, policies, and materials do not mention or deal with the actual lives of transgender persons (Lombardi, 2001).College HealthResearch on college-based health services for transgender people is sparse. In the few available studies on health care and the transgender college student, failure of most colleges and universities to meet their basic health-care needs is a common theme. A small number of institutions are beginning to implement programs specific to the health needs of an increasingly visible transgender student population. However, most schools still offer little or no support to this subset of the campus population. McKinney (2005) found that transgender students felt a general lack of resources at their colleges and universities. Lack of resources included gender neutral restrooms, recreation facilities, transgender student groups, and knowledgeable faculty and staff, especially at counseling and health care centers. Graduate student participants, in particular, did not feel that campus health care systems met their needs and their limited health insurance coverage made it difficult for them to seek off-campus health care. In 2009, a study on health care utilization and barriers to care among male-to-female transgender persons showed that study participants with good access to health care providers were more likely to have a medical evaluation before starting hormone therapy and obtaining hormone therapies from traditional sources. Participants were also more likely to adhere to risk-reduction behaviors, such as smoking cessation and obtaining syringes from traditional sources (Sanchez, Sanchez, & Danoff, 2009). In order to reduce risk taking behavior in college-age transgender individuals, initiatives aimed at increasing access to knowledgeable and transgender-friendly providers are imperative. By becoming educated on transgender health issues, providers at student health centers have an opportunity to positively affect the retention, academic success, and physical and mental well-being of transgender college students.Standards of Care for Transgender PatientsThe Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender nonconforming People is a publication completed by the World Professional Association for Transgender Health (WPATH). The SOC continues to provide clinical guidance for health professionals, assisting individuals with safe and effective pathways to achieve their health care outcomes in a way that maximizes their physical, psychological, and personal well-being (Coleman et al., 2011).According to WPATH and Harry Benjamin International Gender Dysphoria Association (HBIGDA), the first phase for patients desiring to begin the transition process is to find a qualified mental health professional for a full screening (Coleman et al, 2011; Meyer et al., 2001). The goal of psychotherapy is to maximize the patient’s overall psychological well-being, quality of life, and self-fulfillment. Individual and/or group counseling can offer support and guidance toward dealing with personal, family, and general public acceptance. Patients must be diagnosed with gender dysphoria by a mental health professional in order to proceed to hormonal or surgical treatments. According to WPATH, gender dysphoria refers to “discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth” (Coleman et al., 2011, p. 168). The process of treating gender dysphoria may include change in gender expression or body modification. Medical treatment options include feminization or masculinization of body through hormone therapy and/or surgery. Once a patient has explored all psychotherapy options and decides transgender modifications are the best treatment for their gender dysphoria, a qualified mental health professional can refer them to an endocrinologist or knowledgable provider for hormone therapy treatments (Coleman et al., 2011). The second phase of transition is seeking hormone replacement therapy which can vary from patient to patient. Some will seek the maximum feminization/masculinization while others are satisfied with minimizing secondary sex characteristics. Hormone therapy must be individualized based on the patient’s goals, risk/benefit of medications, medical conditions, social class, and economic status (Coleman et al., 2011). The amount and rate of physical effect from hormone therapy depends on the medication dose and route chosen. The primary goal of hormone therapy prior to surgical intervention is to introduce a period of reversible estrogen or testosterone suppression before an irreversible procedure is chosen (Coleman et al, 2011). The third phase of transition is surgical intervention for gender dysphoria which may not be desired by all patients. It is recommended that surgery be considered only after both the medical provider responsible for endocrine transition and the mental health professional find surgery advisable. After completing at least one year of consistent and compliant hormone treatment and one year living continuously in a gender role, surgery may become an option. Health care professionals should document the patient’s experiences including the start date of living full-time in the desired gender role.In the primary care setting, the patient’s medical history should be collected and reviewed. It should include all medications; prior health screenings; family history of clotting disorders; cardiovascular disease, diabetes, mental illnesses, any cancers (especially those driven by exogenous hormones); sexual health history; and the psychosocial history in regards to acceptance, support, and available resources from family, friends, and healthcare providers (Feldman & Goldberg, 2006). In addition to general medical care, practitioners caring for transgender patients must also consider specific transgender concerns. Many clinicians are not experts in this area, but will be called upon to coordinate and co-manage hormone therapy such as monitoring labs, side effects, drug interactions, smoking cessation, and minimizing co-morbidities.The WPATH (Coleman et al, 2011), Endocrine Society (Hembree et al., 2009), British Columbia Transcare Project (Feldman & Goldberg, 2006; Dahl, Feldman, Goldberg, & Jaberi, 2006) and Tom Waddel Health Center (Davidson et al., 2013) guidelines are the leading resources for hormone therapy of transgender individuals. These guidelines provide thorough treatment algorithms (see Appendices A, B, C, and D for comparison proofs). At the present time, recommendations for transgender hormonal therapy initiation and management are primarily based on expert opinion. The primary care provider needs to be aware that few studies have been performed on the efficacy and safety of hormone preparations or on the dose-response of transgender hormonal treatment. In addition, long-term studies are needed to provide data on the long-term risks of disease, especially for cardiovascular disease and cancer, as transgender patients age and the duration of hormone exposure increases (Gooren, 2011). These guidelines provide algorithms for the initiation and management of hormone therapy for transgender patients (see Appendix A, B, C, and D for comparison proofs). Implementation PlanIntroductionWith the growing community of transgender students, increased education on transgender health care issues is needed in college and university health care systems. A substantial component of the health care needs of the transgender student revolves around hormonal therapy. With this project, the team intends to educate college providers on the health care needs of transgender patients, and provide guidelines for the initiation and maintenance of hormonal therapy for use in the student health care setting. Purpose and Intent of PlanThe purpose of this project is to review literature discussing the primary health care needs of transgender students in college or university health care systems. The literature review will foster a better understanding of the appropriate and expanded care needs of the transgender community. The project will educate college health care providers on the health care requirements of transgender patients, analyze gaps within the current university health care systems, and review the current health resources for this growing population. The ultimate goal of the project is to positively impact the future of university health care for transgender students. Within this project, recommendations, current guidelines, and best practices will be discussed, focusing on hormonal therapies for the transgender student. In the future, interviews with transgender student(s) and a clinical expert(s) will be performed to discuss health care gaps and current guidelines for college or university transgender students. Review of literature, current guidelines, and interviews with two student health center nurse practitioners will be conducted and will be used to understand the health care needs of transgender students at a small Midwestern university. Information gained from the sources will aid in structuring a guideline for hormonal therapy in the college or university health care setting. After developing the guidelines, the project team will educate the clinic staff at a small Midwestern university on primary care and hormonal therapy guidelines for transgender patients. Finally, the project team will submit guidelines and findings to an appropriate journal, publish, and submit to WPATH for education of transgender health care in the college or university health care system. MethodsFirst, the need for adequate and appropriate health care for the transgender patient in the college or university health care system will be defined. The project team will analyze the literature, policies, and guidelines to identify gaps in the care of the transgender student. Stakeholders will be identified as transgender students and health care providers in the college or university student health care environment. The project team then will begin to translate the transgender health care needs into action-oriented “implementation strategies”. Next, the team will outline objectives to be incorporated in the process and the action needed to accomplish each objective. The resulting content of the Implementation Plan is an action-oriented, manageable plan. This will be given in an adequate timeframe to provide the student health care practitioners with the information and guidelines to manage hormonal therapy needs of the transgender student. Description of Implementation PlanThe Implementation Plan table, which is included in this document, is composed of five sections:Implementation Strategies/objectivesAssociated Projects/tasksProject TypeTime FrameScopeCreate Project proposalReview of LiteratureInterview transgender student and clinical expertWrite proposal from researchNew initiativeAugust 2013-November 2013To be completed Fall 2013Propose to Advisory Board and FacultyWritten ProposalGive Presentation of project findings New initiativeDecember 2013Proposal to be completed by late November 2013Presentation December 5, 2013Develop guidelines for carePrepare research for guidelinesWrite guidelines on Hormone Therapy for transgender studentsApproval of guidelines for usage in the Clinical settingExisting operations New initiativeJanuary 2014- April 2014 To be completed over one semesterSpring 2014Educate staff and clinical advisor on guidelines/carePrepare written set of guidelines/ handoutEducate a clinical advisor on guidelinePresentation to staffClinical Advisor to continue use and teachingsNew initiativeApril 2014- May 2014To be completed after guidelines are approved1-2 month initiation of guidelines and teaching sessions Publish & Share findings in a journalSubmit guidelines and findings to scholarly journalPublish findings in appropriate journal Submit presentation and/or guidelines to WPATH websiteNew initiativeMay 2014Once Teachings are completedMay 2014 for submission to journalOnce submitted, it may take longer for possible publishing and transfer to WPATH websiteDescription of Project Output & Dissemination PlanManuscript #1 is a review of literature focusing on the health care needs of transgender college students to be submitted to The Kansas Nurse. Manuscript #2 will provide guidelines for initiating hormone therapy, screening side effects, and monitoring health care practices within the college health clinic and primary care clinic for transgender individuals. This manuscript will be submitted to The Kansas Nurse spring 2014. Clinical guidelines will be presented to student health center providers in the spring 2014. A graduate project poster presentation will be performed May 2014. ReferencesAlegria, C. (2011). Transgender identity and healthcare: Implications for psychosocial and physical evaluation. Journal of the American Academy of Nurse Practitioners, 23, 175-182. , B. (2013). Ways that U.S. colleges and universities meet the day-to-day needs of transgender students. Transgender Law and Policy Institute. Retrieved from , B., Curtis, B, Davis, M.,Tubbbs, N.J. (Fall 2005). 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Health care utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City. American Journal of Public Health, 99(4), 713-719.Student Health. (2013, November 23). Washburn University, Topeka, KS. Retrieved from health resources. (2013). American Medical Student Association. Retrieved from A Male-to-Female Hormone Therapy RegimensEstrogenBritish Columbia Transcare Project (Dahl, et al., 2006)Tom Waddell Heatlh Center (Davidson, et al., 2013)Endocrine Society (Hembree et al., 2009) Oral: EstradiolPO an option if: <40 yrs. and low DVT risk1-2mg q day Gradually Increase up to Max 4mg q day (A-3)Starting: 2-3mg q dayTypical: 4mg q dayMax: 8mg q day (p. 14)2-6mg/day (p. 19)Parenteral: Valerate or cypionateValerate: Start: 20-40mg IM q 2 weeks Ave: 40mg IM q 2 weeks Max: 40-80mg IM q 2 weeksCypionate: Start: 20-40mg IM q 2 weeks Ave: 40mg IM q 2 weeks Max: 40-80mg IM q 2 weeks (p. 14)5-20mg IM q 2 wks. or 2-10mg IM q wk. (p. 19)TransdermalUse transdermal If: > 40 yrs. and at risk for DVTstart at 0.1mg/day applied twice weekly; gradually increase up to max 0.2mg/day, applied twice weekly (A-3)Starting: 0.1mg/dayAve: 0.2mg/dayMax: 0.4mg/day (p. 14)0.1-0.4mg twice weekly (p. 19)Antiandrogens: SpironolactoneSpironolactone: Start: 25-50mg BID Typical: 50mg BID Max: 200mg BID (p. 10)100-200mg/day (p. 19)GnRH agonistPer Endocrine Society Guidelines – Hembree et al. (p. 10)3.75mg SC q month (p. 19)5-alpha reductase inhibitor (finasteride & dutasteride)Finasteride: Low: 1mg q day High: 5-10mg/day (p. 10)VTE = Venous Thromboembolic diseaseAppendix B:Monitoring Male-to-Female on Hormone TherapyBritish Columbia Transcare Project (Dahl, et al., 2006)Tom Waddell Health Center (Davidson et al., 2013)Endocrine Society (Hembree, et al., 2009)Office visit Feminization takes place over years (A-7)q 2-3 months for 1st year Then 1-2 times per year (p. 22)Serum testosterone and estradiol monitoringq 3 months until stable in target range (typically < 7.2pg/ml) (A-7)Optimal 6 months after starting if Not showing expected Demasculinization (p. 18)q 3 months. Serum testosterone < 55ng/dlSerum estradiol ≤ 200 pg/mlEstrogen dose c serum estradiol level (p. 22)If takingSpironolactoneSerum potassium, urea, and creatinine 1 week after commencement or dosage change, then with other labs if level and dose are stable (A-7)Testosterone: Optimal 6 months after start if not showing expecting demasculinizationBUN/SCr: Baseline, 2 months after starting or dose adjustment, q 6 months when on stable doseLytes: Baseline, 2 months after starting or dose adjustment, q 6 months when on stable dose (p. 18)Serum electrolytes q 2-3 months for 1st year (p. 22)Routine cancer screeningBreast, prostate, lung, colorectal, anal (A-7)Routine (breast, colon, prostate) per ACS and ACOGs recommendations (p. 22)Bone mineral density (BMD)For those at risk (A-7)Baseline if risk factors presentOtherwise age 60 or noncompliant (p. 22)Other monitoringCardiovascular, thrombosis risk, BP, weight, lung, extremities, edema, pain (A-7)Fasting glucose: Baseline, 3 months after starting or dose adjustment, then 1 year after starting or dose adjustmentFasting lipids: Baseline, 3 months after starting or dose adjustment, then 1 year after starting or dose adjustmentLFTs: Optimal 1 year after starting if pt has risk for liver disease (e.g. excessive weight gain, risk behaviors for acquiring viral hepatitis, heavy alcohol use)Prolactin Baseline for pt. with previous unmonitored estrogen therapy, prolactin level, previous or current exposure to phenothiazines. Optimal after 1 year (pt. on high dose estrogen, suspected or taking doses above prescribed, pt. also on phenothiazine) (p. 18)Other lab testsLiver enzymes: 1 month after starting or dose change, 3 months thereafter, and q 6 months once estrogen dose is stableLipid profile: 1 month after starting or dose change, 3 months thereafter, and q 12 months once estrogen dose is stableFasting glucose: 1 month after starting or dose change, 3 months thereafter, and q 6 months once estrogen dose is stableHemoglobin A1c: If significant weight gain, increase in fasting glucose level or family history of DMProlactin: 3 months, 6 months, then q 1 yr. x3, then stop if stable (A-7)Appendix CFemale-to-Male Hormone Therapy RegimensTestosteroneBritish Columbia Transcare Project (Dahl, et al., 2006)Tom Waddell Health Cener (Davidson, et al., 2013)Endocrine Society (Hembree, et al.,2009) Oral160-240mg/day (p. 19)ParenteralEnanthate or cypionate25-40mg/week -or- (50-80mg q 2 weeks) Gradually increase q Month until blood Testosterone is Within normal male Range or visible Changes (typically 50-100mg q week -or- 100-200mg q 2 weeks (preparations come in 100mg/ml or 200mg/ml) (A-9)50-100mg q 2 weeks Or 25-50mg q weekTypical dose: 200mg q 2 weeks or 100mg q weekMax dose: 400mg q 2 weeks or 200mg q week (p. 20)100-200mg IM q 2 wks.Or 50-100mg IM q wk. (p. 19)TransdermalTransdermal Gel: 5-10g q day; start with 2.5g q day if there are comorbid conditions that may exacerbated by testosteroneTransdermal Patch: 5-10mg/day; apply daily; start with 2.5mg patch if there are any comorbid conditions that may be exacerbated by testosterone (A-9)Transdermal Gel Testin 1%: Start: 2.5mg q morning Typical: 5mg q morning Max: 10mg q morningTransdermal Gel Androgel 1%: Start: 2.5mg q morning Typical: 5mg q morning Max: 10mg q morningTransdermal Patch: Start: 2-2.5mg/day Typical: 5mg/day Max: 7.5mg/day (p. 20)1% gel: 2.5-10g/dayPatch: 2.5-7.5mg/day (p. 19)Maintenance(after 2 years)Reduce testosterone to level needed to keep serum free testosterone within the lower-middle end of the male reference interval, and monitor risk of osteoporosis (A-9)Appendix DMonitoring of Female-to-Male on Hormone TherapyBritish Columbia Transcare Project (Dahl et al., 2006)Tom Waddell Health Center (Davidson, et al., 2013)Endocrine Society (Hembree, et al., 2009)Office visitq month after initiating treatment or while adjusting med dosages, then q 3-4 months for 1st yr, then q 6 months (A-11)q 2-3 months for 1st year 1-2 times per year (p. 23)Serum testosterone2-4 weeks after starting testosterone or after a change in dose, then q 6-12 months (A-11)Optimal q 3-6 months after starting or dose adjustment (p. 23)q 2-3 months until levels are normal physiologic male range (p. 23)Serum EstradiolDuring 1st 6 months of testosteroneNo menstrual bleeding for 6 months (p. 23)CBC & LFTsCBC (Hgb): 3 months, 6 months after starting Testosterone or after dose adjustment, then q 1 yearLiver enzymes: 3 months, 6 months after starting testosterone or after dose increase, then q 1 year (A-12)CBC: Baseline, 3 months after starting or dose increase, then 1 year after starting or dose increaseLFTs: Baseline if PCOS suspected Optimal 1 year after starting if pt. has risks for liver disease (excessive weight gain, behaviors for acquiring viral hepatitis, heavy alcohol use) (p. 23)Baseline, q 3 months x 1 yr., then 1-2 times per year (p. 23)Other labFasting glucose: 3 months, 6 months after starting testosterone or adjusting dose, then q 1 yearHemoglobin A1c: If elevated lipids, significant weight gain, elevated fasting glucose, hx of glucose intolerance, or family hx of diabetesLipids: 3 months, 6 months after starting testosterone or adjusting dose, then q 1 year; increase if pre- existing high lipid levels or high lipid levels, significant weight gain, hx of glucose intolerance, or family hx of diabetes (A-12)Fasting glucose: Baseline if PCOS suspectedFasting lipids: Baseline, 3 months after starting or dose adjustment, then 1 year after starting or dose adjustmentUrine HCG Baseline if pregnancy is a possibility (p. 23)Other monitoringWeight, cardiovascular risk, diabetes risk, BP, destabilization of bipolar disorder, schizophrenia, and schizoaffective disorder (A-11)Weight, BP, fasting lipids, fasting glucose (if family hx), A1c (if DM) (p. 23)Bone mineral density (BMD)Baseline if risk factors presentOtherwise age 60 or noncompliant (p. 23)Cervical tissue presentPap smear as recommended by ACOGs (p. 23)No mastectomyMammograms as recommended by ACS (p. 23) ................
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