Caring for Transgender Adolescent Patients Part 1 Initial

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Caring for Transgender Adolescent Patients Part 1: Initial Evaluation and Primary Care Perspective Part

Caring for Transgender Adolescent Patients Part 1: Initial Evaluation and Primary Care Perspective Part 2: Ongoing Management, Hormones, Primary Care

 Differentiate assigned sex at birth, gender identity and expression, and sexual orientation Objectives

Differentiate assigned sex at birth, gender identity and expression, and sexual orientation Objectives Discuss primary and specialized care that may be needed by transgender adolescents Explain how bias and stigma create disparities and lead to risks Provide initial management strategies for appropriate and competent care to gendernonconforming patients 2

 Gender & social justice Gender development Childhood Peri-Pubertal Content Overview Initial screening, intervention

Gender & social justice Gender development Childhood Peri-Pubertal Content Overview Initial screening, intervention Risk resiliency Puberty blockers Gender affirming hormones Testosterone Estradiol Gender affirming surgery Resources 3

 Professional responsibility AMA, AAMC, AAFP, AAP, SAHM, APA Recommend training on LGBT health

Professional responsibility AMA, AAMC, AAFP, AAP, SAHM, APA Recommend training on LGBT health Why Talk About Gender? Exclusion of coverage for gender care services illegal in some states Gender care is Patient-centered primary care Gender is developmental, universal Anticipatory guidance Prevention Future planning Models and promotes diversity Reproductive Justice under the Social Justice Umbrella 4

 Reproductive & sexuality health experts ARSHEP Commitment to Reproductive Justice Comfort talking about

Reproductive & sexuality health experts ARSHEP Commitment to Reproductive Justice Comfort talking about “sensitive” health topics Effective health education, health promotion Advocacy in public & legislative health settings Empower other providers to engage & gain knowledge, improve attitudes, develop skills Reproductive Justice • Autonomy over self, body, family, destiny • Focus on underserved populations • “Make sense” working together 5

Early Childhood and Prepubescent Gender Development 6

Early Childhood and Prepubescent Gender Development 6

Case 1 Patient “R” Prepubertal Gender Nonconformity R is an 8 y/o natal male

Case 1 Patient “R” Prepubertal Gender Nonconformity R is an 8 y/o natal male During the visit, R’s parent expresses concern that: “Most of his friends are female. ” “He hates sports. ” “I caught him wearing his older sister’s clothes and make-up last week. ” “He loves to paint his nails. ” 7

Case 1 Patient “R” What is your initial reaction? Are you concerned? Should his

Case 1 Patient “R” What is your initial reaction? Are you concerned? Should his parent be concerned? 8

Assigned gender/sex at birth: Sex assigned at birth; body parts, hormones, biology. Gender Identity:

Assigned gender/sex at birth: Sex assigned at birth; body parts, hormones, biology. Gender Identity: The understanding of one’s self (Female, transgender, gender non-conforming, genderqueer, non-binary, gender fluid, cisgender) Defining Gender Expression: Gender Ways in which a person Expression acts, presents self, and communicates gender within a given culture Citation: Olson, Forcier 9

Gender diverse/non-conforming Non-binary/Gender-queer/gender-fluid • A person who views their gender on a spectrum rather

Gender diverse/non-conforming Non-binary/Gender-queer/gender-fluid • A person who views their gender on a spectrum rather than fitting into society’s binary categories of male/female Gender Terminology Cisgender • A person whose gender identity aligns with the cultural notions of gender and the sex they were assigned at birth Terminology & paradigms - Unique to individual - Change, evolve with time & culture Transgender • A person whose gender identity differs from their assigned gender/sex at birth and conventional notions of gender 10

Identities include but are not limited to Identities and Transition Asserted female Gender Queer

Identities include but are not limited to Identities and Transition Asserted female Gender Queer MTF = male to female, transgender woman Asserted male Non-binary Trans feminine, Trans masculine, Agender FTM = female to male, transgender man Phenotypic Gender Transition Process and time when person goes from living as one gender to living as another gender 11

Sexual Orientation/Identity: Sexual concept of one’s self based on feelings, attractions, and desires; Defining

Sexual Orientation/Identity: Sexual concept of one’s self based on feelings, attractions, and desires; Defining Sexuality LGBTQ: Lesbian, Gay, Bisexual, Transgender, Questioning/Queer; Pansexual/Asexual Sexual Behaviors: Young Men who have Sex with Men (YMSM)Young Women who have sex with Women (YWSW) Citation: Olson, Forcier 12

Pansexual • Sexual attraction to people of any sex or gender Sexual Orientation Identities

Pansexual • Sexual attraction to people of any sex or gender Sexual Orientation Identities Asexual • A person who does not experience sexual attraction Queer • An umbrella term that may include the entire LGBT community and also people who fit outside social norms of sexual identity and gender expression; emphasizes fluid and experience-based identities and attractions 13

Case 1 Patient “R” Questions to explore How does your child feel about their

Case 1 Patient “R” Questions to explore How does your child feel about their gender? Does your child feel, act, more masculine or feminine? What is your child’s preferred name? How can parents a child explore gender? How does your child feel about you concerns? 14

Between ages 1 and 2 Conscious of physical differences between sexes Awareness of Gender

Between ages 1 and 2 Conscious of physical differences between sexes Awareness of Gender Identity At 3 years old Can label themselves as a girl or boy By age 4 Gender identity stable Recognize gender constant 15

Sexual Orientation and Gender Identity of Middle School Students Shields JP, et al. “Estimating

Sexual Orientation and Gender Identity of Middle School Students Shields JP, et al. “Estimating population size and demographic characteristic of LGBT youth in middle schools. ” J Adol Hlth. 2013: 248 -50. 16

How Many Adults Identify as LGBT in the U. S. ? Conron KJ, et

How Many Adults Identify as LGBT in the U. S. ? Conron KJ, et al. “Transgender health in MA: Results from a household probability sample of adults. AJPH. 2012: 102(1): 118 -122. 17

Coming Out—Transgender Patients Mean, (Age Range) Assigned Female at Birth Assigned Male at Birth

Coming Out—Transgender Patients Mean, (Age Range) Assigned Female at Birth Assigned Male at Birth Age of Presentation 14. 8 (4 -20) 15. 2 (6 -20) 14. 3 (4 -20) Tanner Stage 3. 9 (1 -5) 4. 1 (1 -5) 3. 6 (1 -5) Total n, (%) 97 (100) 54 (55. 7) 43 (44. 3) Spack N, Ge. MS Clinic, Boston Children’s Hospital. Pediatrics, 2012 18

 All prepubertal children play with gender expression & roles Gender Play Passing interest

All prepubertal children play with gender expression & roles Gender Play Passing interest or trying out gender-typical behaviors Interests related to other/opposite sex Few days, weeks, months, years 19

Gender Nonconforming Persistent, consistent, insistent Fluid, nonconforming Cross gender expression, role playing Agender Wanting

Gender Nonconforming Persistent, consistent, insistent Fluid, nonconforming Cross gender expression, role playing Agender Wanting other gender body/parts Refuses to ascribe to Not liking one’s gender & body (gender dysphoria) Non binary typical masculine or feminine assignments 20

Common Parental Reports Before Puberty Peri Puberty “She told me in first grade that

Common Parental Reports Before Puberty Peri Puberty “She told me in first grade that she was a boy. ” “We did notice anything different before puberty” “He wanted to grow his hair long and wear jewelry. ” “She adamantly refused to wear a dress to her aunt’s wedding. ” “He wanted to be in the school play in the role of Cinderella. ” “She had a miserable time with puberty. ” “Before puberty we thought maybe he was gay, but then he told us he was trans. ” 21

 All children Developmental stages Who to Screen? Nonconforming expression Concerns/problems with Mood Behavior

All children Developmental stages Who to Screen? Nonconforming expression Concerns/problems with Mood Behavior Social 22

How to Screen Ask! Parent(s) Ask! Patient • Child play, hair, dress preferences •

How to Screen Ask! Parent(s) Ask! Patient • Child play, hair, dress preferences • Do you feel more like a girl, boy, neither, both? • Concerns with these • How would you like to play, cut your hair, dress? • Concerns with behavior, friends, getting along at school, school failure, bullying, anger, sadness, isolation, other? • What name or pronoun (he for boy, she for girl) fits you? 23

Gender Screening 24

Gender Screening 24

 R reports: Case 1 Patient “R” Sometimes wishes he was a girl but

R reports: Case 1 Patient “R” Sometimes wishes he was a girl but prefers the pronoun “he” Sadness that his mother is upset Unsure what gender he would be if he could choose He would like to play with girl things without feeling bad What do you do next? 25

 Explain to R and his mom that: Case 1 Patient “R” Exploring gender

Explain to R and his mom that: Case 1 Patient “R” Exploring gender roles and gender expression during childhood is common R may or may not have gender identity concerns as he matures Support from family is essential Offer yourself as a resource Know national, local resources 26

CDC Behavioral Risk Factor Surveillance System (BRFSS) 2016 National estimate transgender persons 0. 6%

CDC Behavioral Risk Factor Surveillance System (BRFSS) 2016 National estimate transgender persons 0. 6% =1. 4 million Range 0. 3% ND to 0. 8% HI Highest 18 -24 versus older adults 27

DIAGNOSIS of GENDER DYSPHORIA F 64 DSM 10 Coding Pathology Based Marked difference between

DIAGNOSIS of GENDER DYSPHORIA F 64 DSM 10 Coding Pathology Based Marked difference between expressed/experienced gender and gender others would assign Must continue for at least six months Causes clinically significant distress or impairment in social, occupational, or other important areas of function In children, the desire to be of the other gender must be present and verbalized 28

GENDER DIVERSITY E 34. 9 ICD 10 Gender is universal, normal Developmental Perspective Variance

GENDER DIVERSITY E 34. 9 ICD 10 Gender is universal, normal Developmental Perspective Variance is expected aspect of biology & human development Diversity not = deviance Improve care Impact minority stress Patient-centered developmental care— Allows flexibility and clinical judgment Advocate for another form reproductive justice Advocate, empower vulnerable populations 29

Seminal Puberty Blocker Work Early Intervention: Gender Early blocking of puberty followed by cross

Seminal Puberty Blocker Work Early Intervention: Gender Early blocking of puberty followed by cross gender hormone replacement At follow-up, all 54 patients were satisfied with their pubertal development ▫ No patients decided to stop Gn. RH agonist therapy ▫ All patients eligible decided to take cross gender hormones ▫ There were no adverse events from Gn. RH agonists No suicides No street hormones Delemarre-van de Waal, Cohen Kettenis (2006) Reconfirmed over time…. Olson. KR 2016, de. Vries AL 2014, Steensma TD 2013, de. Vries AL 2012, Spack NP 2012, de. Vries AL 2011, Steensma TD 2013, Malpas J 2011, Teurk CM 2012, Bussey K 2011, De. Vries 2010, Wallien MS 2008, Drummon 2008, Zucker 2005, Green 1987, Davenport 1986 30

Large-scale (>150 children) longitudinal study of transgender children in 25 states (2016) 73 children,

Large-scale (>150 children) longitudinal study of transgender children in 25 states (2016) 73 children, age 3 -12 Trans. Youth Project (2017) 116 trans, 122 controls, 72 sibs age 6 -14 NIH Patient Reported Outcome Measurement Information System Symptoms of depression or anxiety during past week Symptoms of depression and self worth same Rates depression (50. 1) and anxiety (54. 2) no higher than 2 control groups -- their own siblings & cis age - and gender-matched children Slightly higher anxiety Significantly lower than those of gender-nonconforming children in previous studies Olson KR, Durwood L, De. Meules M, et al. Mental Health of Transgender Children Who Are Supported in Their Identities. Pediatrics. 2016; 137(3): e 20153223 Dunwood L, Mc. Laughlin KA, Oslon KR. Mental Health and Self-Worth in Socially Transitioned Transgender Youth. J Am Acad Child Adolesc Psych. 2017 Feb; 56(2): 116 -123. 31

“ Socially transitioned transgender children who are supported in their gender identity have developmentally

“ Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group. Especially striking is the comparison with reports of children with GID; socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex. 32

Trans youth often underrepresented in LGBT studies 2012 -14 SHINE study Trans Female Youth

Trans youth often underrepresented in LGBT studies 2012 -14 SHINE study Trans Female Youth (TFY) 301 TFY ages 16 -24, San Francisco Bay Area Risk assessment 26. 7% history of sex work Sexual debut most frequently 13 -15 (28. 6%), 16 -17 (28. 2%) In past 6 months 37. 2% any condomless anal intercourse in past 6 months Average of 3. 23 sexual partners per youth Parent and Non-parent Support assessment Compared youth with and without primary parental social support No associations between HIV risk and types of primary social support Education is needed for parents to accept and support trans children Le. V, Arayasirikul. S, Chen. YH, Jin. H, Wilson EC. JIntl. AIDSSoc 2016 Item 1: “talked about gender identity with you” 177 (58. 8) Item 2: “expressed affection when you first talked about your gender identity” 120 (39. 9) Item 3: “supported your gender identity despite feeling uncomfortable” 187 (62. 1) Item 4: “advocated for you when mistreated because of your gender identity” 125 (41. 5) Item 5: “required that other family respect you” 161 (53. 5) Item 6: “ever brought you to LGBTI organization or event” 56 (18. 6) Item 7: “connected you to LGBTI adult role model” 45 (15. 0) Item 8: “welcomed LGBTI friends and/or partners to your home” 190 (63. 1) Item 9: “supported your gender expression” 196 (65. 1) Item 10: “believe you could have a happy future as trans adult” 171 (56. 8) 33

N=245 LGBT Retrospective assess family accepting behaviors in Self esteem response to gender &

N=245 LGBT Retrospective assess family accepting behaviors in Self esteem response to gender & sexual minority status Depression Family Acceptance Project Social support Predicts improved General health status Substance use Protects against Suicidality Ryan CJ; 2010, 2009 34

Family acceptance, love, support is critical. All children are at risk for crisis when

Family acceptance, love, support is critical. All children are at risk for crisis when their true sense of identity is discouraged and/or punished. Addressing Parents’ Questions Behaviors and expression may be nonconforming, but children can still feel that they are in the right-gendered body 35

Adolescents and Gender 36

Adolescents and Gender 36

Case 2 Patient “K” Initial visit • 12 yro assigned female at birth brought

Case 2 Patient “K” Initial visit • 12 yro assigned female at birth brought in by their mother for mood and behavior concerns • As you explore these concerns, you learn K identifies as male and gender expression is very masculine K is distressed by onset of puberty and not sure what to do next 37

Case 2 Patient “K” Over time • Now 13 yro K is socially transitioned

Case 2 Patient “K” Over time • Now 13 yro K is socially transitioned for 4 months • K is interested in not having periods, looking as male as possible & has done some preliminary investigation of transgender • What do you do next? 38

 Establish privacy Setting Up the Initial Assessment Ask mom to step out of

Establish privacy Setting Up the Initial Assessment Ask mom to step out of room Explain what can (and can’t) be kept confidential Establish trust and rapport Ask name and pronoun Ask goals of visit Getting to know the person General adolescent health assessment HEADDSSS Leading into more detailed & sensitive history 39

 Interview only with parent in room All teens deserve private time Assume What

Interview only with parent in room All teens deserve private time Assume What Not to Do Name or pronoun Gender identity and expression correlate Disclose without patient’s consent Dismiss Parents as a source of support As a phase Refer for reparative therapy 40

Strength & Risk Assessment Assess personal strengths, resources, goals Assess social support and resources

Strength & Risk Assessment Assess personal strengths, resources, goals Assess social support and resources Address risk-taking or safety concerns Mental health—depression, anxiety, self harm, suicide Substance use/abuse Sexual activity—STI and pregnancy prevention 41

 Review history of gender experience Gender Experience Open-ended encouragement, “Tell me your story

Review history of gender experience Gender Experience Open-ended encouragement, “Tell me your story in your own words” Ask about specific feelings, thoughts, behaviors, preferences Parent may offer excellent insight into early childhood Document prior efforts to adopt desired gender Clothing, makeup, play Hormone use, if any Review patient goals 42

 Engage parent(s) to support their child Case 2 Patient “K” Explore parent’s concerns

Engage parent(s) to support their child Case 2 Patient “K” Explore parent’s concerns and priorities Assess parental support and knowledge Facilitate discussion and negotiations Establish expectations for all stakeholders Incorporate patient goals, with parental expectations, and management options 43

Remind Youth and Parents… What Is Healthy? • Gender and sexual development are natural

Remind Youth and Parents… What Is Healthy? • Gender and sexual development are natural parts of human development • Gender and sexual expression vary • Gender and sexual diversity are different than risk Open, honest communication is critical to healthy decision-making, behaviors, support, and access to care 44

 Mental health provider Assess/treat other mental health concerns Case 2 Patient “K” Continued

Mental health provider Assess/treat other mental health concerns Case 2 Patient “K” Continued Medical provider Assess and consent for hormonal management Consider appropriate referrals to providers with experience in transgender care Focus on individual needs of young person & family 45

Referrals and Seeking Specialized Care Many mental health and medical providers may not have

Referrals and Seeking Specialized Care Many mental health and medical providers may not have expertise in transgender health Transgender health “specialists” Variety of providers with experience and/or training in caring for transgender patients Wide variety of disciplines, degrees, specialties 46

Case 2 Patient “K” Continued Medical and mental providers assist with identifying Gender identity

Case 2 Patient “K” Continued Medical and mental providers assist with identifying Gender identity and gender needs Gender dysphoria, other psychosocial stressors Options, planning for safe social transition Benefit from delaying puberty Benefit of gender affirming hormones Benefit of surgical referrals Documentation and support for name, gender marker, and other options for transition K’s mother is supportive What options for care might you offer this family? 47

Improve quality of life by: Facilitating transition to physical state that more closely represents

Improve quality of life by: Facilitating transition to physical state that more closely represents the individual’s sense of self Treatment Goals Experiencing puberty congruent with gender Preventing unwanted secondary gender/sex characteristics Reduce need for future medical, surgical interventions Avoiding depression, risk-taking Establishing early, strong social support 48

Range of Treatment Approaches Gender identity stable Initiate puberty with hormones congruent with gender

Range of Treatment Approaches Gender identity stable Initiate puberty with hormones congruent with gender identity NO! No treatment until 18 (after full pubertal experience) GCS Living in Asserted Gender NO! Allow some experience puberty, to age 15 -16 or Tanner 4, then start Gn. RH analogues or hormones Gender identity stable Start Gn. RH analogues at Tanner 2 Initiate hormones several years later https: //ceitraining. org/ 49

Phases of Transitioning Reversible • clothes, hair, shoes, toys, Gn. RH analogues Partially reversible

Phases of Transitioning Reversible • clothes, hair, shoes, toys, Gn. RH analogues Partially reversible • masculizing and feminizing hormone therapy Irreversible • Surgical interventions 50

 Children with gender diversity or questions Benefits of Early Treatment See when concerns

Children with gender diversity or questions Benefits of Early Treatment See when concerns identified, ideally BEFORE puberty Gives providers time to engage with family and patient, build rapport and trust Offer relief to patient worried about upcoming puberty Consider “blocking” puberty Effects fully reversible “Buys time” and avoid reactive depression Psychotherapy facilitated when distress eased Prevent unwanted secondary sex characteristics Reduces needs for future medical interventions 51

 Assess needs of young person around phenotypic transition Beginning Hormonal Treatment Physical (Tanner

Assess needs of young person around phenotypic transition Beginning Hormonal Treatment Physical (Tanner stage) Psychological Social Review risks and benefits of hormone therapy Differentiate between reversible and irreversible physical changes Determine that youth has a realistic sense of what can and can’t be impacted by hormones 52

Timing Puberty Blocking Ideal before or early Tanner 2 Maintain prepubertal status Follow exam,

Timing Puberty Blocking Ideal before or early Tanner 2 Maintain prepubertal status Follow exam, LH, estradiol/testosterone Puberty Blocking Can use Tanner 3 -5 Halt continued puberty changes Prevent continued 2 nd gender characteristics Mental health & perimenopausal symptoms 53

 Prescribing provider will establish Planning for Hormonal Treatment Informed consent Reasonable goals, expectations

Prescribing provider will establish Planning for Hormonal Treatment Informed consent Reasonable goals, expectations Baseline screening labs Set up referrals and/or follow up Provider and patient should establish Disclosure when patient is ready Sources of social support Impact on school or work 54

Case 3 Patient “B” B is 16 yro MTF kicked out by her mother’s

Case 3 Patient “B” B is 16 yro MTF kicked out by her mother’s boyfriend for being “gay” B presents as female B is new to you and presents with chief complaint of “genital rash” What next? 55

 What name or pronouns should I use? What are gender(s) of your partner(s)?

What name or pronouns should I use? What are gender(s) of your partner(s)? Have you ever had anal, genital, or oral sex? Sexual Health History Do you give, receive, or both? Other sexual activities? How many partners have you had in past six months? Do you use condoms…never, some, most, all of the time? Any symptoms of STIs? Any sex for shelter, food, drugs, other? Any forced sex or rape? 56

Case 3 Patient “B” Establish safety, trust, rapport Evaluate problem patient wants help with

Case 3 Patient “B” Establish safety, trust, rapport Evaluate problem patient wants help with If there’s time, begin HEEADDSSS assessment knowing health risks for transgender population HEADDSSS screen reveals Victimization at home and school Sex work with consistent unprotected receptive anal and oral sex Depression, considered suicide in past Substance use—meth and alcohol Street hormones and silicone injection Last HIV test—one year ago 57

Trans Student Health…Risks Health Risk Behavior Trans/Non. Conforming Youth Cis Youth Alcohol use 23%

Trans Student Health…Risks Health Risk Behavior Trans/Non. Conforming Youth Cis Youth Alcohol use 23% 17% Trans/genderfluid/non-conforming n=2, 168 (2. 7%) No condom at last sex 51% 38% No birth control at last sex 41% 25% Risk behaviors significantly higher among trans than cis Depressive symptoms 58% 21% Self-harm past year 54% 14% Emotional distress, bullying significantly more common among birth-assigned females than males Suicidal Ideation 61% 20% Physical bullying Relational bullying Prejudice-based reason: gender expression 25% 52% 35% 47% 12% 32% 5% 15% Student Survey 9 th and 11 th graders, n=81, 885 Protective factors • Family connectedness • Student-teacher relationships • Feel safe in community Eisenberg, Gower, Mc. Morris, Rider, Shea and Coleman. J Adolesc Health 2017. 58

 Given B’s sexual & drug history Case 3 Patient “B” HIV serology Syphilis

Given B’s sexual & drug history Case 3 Patient “B” HIV serology Syphilis serology NAAT urine GC/CT Rectal GC /CT Hepatitis C What immunizations? Hepatitis A & B HPV 59

Harm Reduction Counseling Sexual Psychosocial Safer sex options Support and survival Facilitate condom use

Harm Reduction Counseling Sexual Psychosocial Safer sex options Support and survival Facilitate condom use Housing/shelter/food referral Plan for future STI testing Family planning as appropriate Egg-sperm sex Pre. P or Pe. P education Close follow-up Vocational assistance Substance abuse screen/counseling Mental health screen/counseling 60

Gender or Sexual Minority Suicide, Substance Use, SES Disadvantage, Victimization Stigma Minority Stress Theory

Gender or Sexual Minority Suicide, Substance Use, SES Disadvantage, Victimization Stigma Minority Stress Theory Prejudice, Discrimination, Abuse, Lack of Acceptance, Isolation, Esteem, Resources Anxiety, Depression Minority Stress Adapted from O’Hanlan, et al (1997). A review of the medical consequences of homophobia with suggestions for resolution. JGLMA; 1: 25‐ 39. ) 61

Exposure to violence health disparities LGB students 12% v 5% more likely to not

Exposure to violence health disparities LGB students 12% v 5% more likely to not go to school at least one day during 30 days prior because of safety concerns Bias Negative Effects YRBS 2015 Absenteeism linked to low graduation rates, SES impact 29% LGB youth attempted suicide at least once prior year compared to 6% of heterosexual youth 2014, YMSM 80% HIV diagnoses among youth 62

Social stigma Familial rejection Social isolation Fear of physical attacks Countering Minority Stress Minority

Social stigma Familial rejection Social isolation Fear of physical attacks Countering Minority Stress Minority stress Early identification Resources, connection, support Change cultural appreciation for diversity Pro-diversity Resiliency Improved Health Outcomes Mental health Social Medical Financial Educational Identity congruent with anatomy/physiology Puberty in gender identified. living safely in identified gender 63

Internalizing effects of homophobia/ transphobia Impact of homophobia/ transphobia • Stigma • Shame •

Internalizing effects of homophobia/ transphobia Impact of homophobia/ transphobia • Stigma • Shame • Isolation • Stress • Depression * • Trauma/violence • Discrimination • Rejection • Lack of civil rights Decreased access to competent health services * * • Anxiety • Low self-esteem • (Resiliency) • (Better coping strategies) * Poor health outcomes • No screening • Low compliance • Present late in disease • Unsafe sex Poor psychological outcomes * Where culturally competent medical and mental health care can be a mitigating factor • Suicide • Unsafe sex 5. O’Hanlan, et al (1997) • Substance use • Eating disorders 64

Trans Survival. Barriers to Care Loss of parental and familial support Loss of housing,

Trans Survival. Barriers to Care Loss of parental and familial support Loss of housing, emotional, and financial care Loss of education, activities, opportunities Lack of health care Loss of insurance/ability to pay Access, availability of health providers Concerns regarding confidentiality, rights to care Social stigma Hostile or violent social environments Mental health sequelae 65

Trans Survival- • Transgender and gender diverse patients experience decreased access to care/worse health

Trans Survival- • Transgender and gender diverse patients experience decreased access to care/worse health outcomes compared to LGB counterparts • Racially diverse LGBTQ emerging adults’ health care access study • 206 participants, ages 18 -27; 86% racial/ethnic minority, 10% transgender • Findings: Barriers to Care • 68% reported relatively easy access to care • White and bisexual participants higher rates of insurance than racial/ethnic minority and gay or lesbian participants. • Trans patients more likely than cis to report delay in care and negative effects of disclosure to provider • Discrimination based on LGBTQ in healthcare, more limited access to/use of health services Macapagal K, Bhatia R, Greene GJ. Differences in Healthcare Access, Use, and Experiences Within a Community Sample of Racially Diverse LGBTQ Emerging Adults. LGBTHealth Vol 3, Number 6, 2016. DOI: 10. 1089/lgbt. 2015. 0124 66

 Visible nondiscrimination policy Create a Trans. Friendly Environment Staff training, openness Use pronoun

Visible nondiscrimination policy Create a Trans. Friendly Environment Staff training, openness Use pronoun and name that patient requests This improves care for both trans and cis persons as it indicates carefully listening & respect Transgender-inclusive materials Unisex/individual bathrooms Respect confidentiality, don’t “out” 67

 • Inclusive intake forms • Welcoming signage • Staff training and education Welcoming

• Inclusive intake forms • Welcoming signage • Staff training and education Welcoming Office 68

Welcoming Office 69

Welcoming Office 69

 • Create accountability for homophobic/transphobic remarks • Staff Welcoming Office • Caregivers •

• Create accountability for homophobic/transphobic remarks • Staff Welcoming Office • Caregivers • Model acceptance, support for diversity • Knowledge about local resources • Therapist, psychiatrists, voice therapists, hair removal specialists, surgeons • Insurance coverage issues 70

 If done correctly, can signal welcoming office Some patients may be more comfortable

If done correctly, can signal welcoming office Some patients may be more comfortable answering questions by self-report Forms Can use as screening questions to flag areas for f/u in face to face Consider using blanks for write-ins Instead of marital status – relationship status A sign to youth, that your office will know how to care for him/her/they/ze. 71

Important personal health history as well Data that does not allow gender/sex minorities to

Important personal health history as well Data that does not allow gender/sex minorities to remain “invisible” SO/GI collection 72

Transgender Youth Take Home Points Children and youth explore gender as well as sexual

Transgender Youth Take Home Points Children and youth explore gender as well as sexual identity Provider role Assessing individual goals, needs, risks Facilitating communication, support of family Referrals for support and resources Creating safe space for all youth 73

Caring for Transgender Adolescents Part 2: Understanding Medical Management & Providing Ongoing Primary Care

Caring for Transgender Adolescents Part 2: Understanding Medical Management & Providing Ongoing Primary Care 74

Case 2 Patient “K” Continued K 13 yro natal female identifying as male with

Case 2 Patient “K” Continued K 13 yro natal female identifying as male with some male gender expression K already socially transitioned and is in your office wanting to talk about hormone options for care K, his parents State they want their child to be happy and healthy K and parent feels like they need some time to figure things out before they consider anything “irreversible” 75

 Establish commitment to next steps Beginning Hormonal Treatment Gender questioning, incongruency, dysphoria Readiness

Establish commitment to next steps Beginning Hormonal Treatment Gender questioning, incongruency, dysphoria Readiness for medications, exploring gender, and/or planning transition Expectations, goals Management plan Obtain informed consent Order baseline labs Establish follow-up Letters from mental health professionals may help inform providers and allow for coordinated care. However, not all children or families have immediate mental health needs that “require” mental health evaluation. 76

Phases of Transitioning Reversible • Clothes, hair, shoes, toys • Gn. RH analogues Partially

Phases of Transitioning Reversible • Clothes, hair, shoes, toys • Gn. RH analogues Partially Reversible • Masculizing and feminizing hormone therapy Irreversible • Surgical interventions 77

Benefits of “Blockers” Gonadotropin-Releasing Hormone (Gn. RH) analogues block puberty Leuprolide Histrelin Delay irreversible

Benefits of “Blockers” Gonadotropin-Releasing Hormone (Gn. RH) analogues block puberty Leuprolide Histrelin Delay irreversible secondary sex characteristics Allow time for teen to mature and make decision Allow time for parent and social support to develop Allow provider reluctance for irreversible effects in minor 78

Continuous Gn. RH secretion Suppress FSH, LH Initial ↑ LH, FSH followed by desensitized

Continuous Gn. RH secretion Suppress FSH, LH Initial ↑ LH, FSH followed by desensitized pituitary LH, FSH secretion suppressed Leuprorelin Gn. RH Agonists Triptorelin Goserelin 15 Monthly $500 -1000 3 -monthly depot $1500 -2000 Histrelin implant 24 + months $3500 (Vantas) 15, 379. 16 -$12, 560. 00 (Supprelin) 79

 Select dosing schedule Dosing Gn. RH Analogues Monthly or every 3 month depot

Select dosing schedule Dosing Gn. RH Analogues Monthly or every 3 month depot SQ or IM Range 3. 75, 7. 5, 11. 5 mg, 22. 5 mg, 30 mg Starting dose long-acting 11. 25 – 22. 5 mg IM Q 3 months Counseling and consent Few side effects aside from injection pain, need for labs & follow up Withdrawal bleed if peri-menarchal Hot flashes, mood changes…. “menopausal symptoms” Expect to see some “effects” in 2 -4 week range Effect = no changes, halting new gender characteristics, no menses, erectile dysfunction 80

Tanner stage Testicles (volume cc) Penis (length cm) 1 <1. 5 <=3 2 1.

Tanner stage Testicles (volume cc) Penis (length cm) 1 <1. 5 <=3 2 1. 6 -6 Scrotal skin thins, reddens No change Downy sparse 3 6 -12 <6 More coarse, spread laterally 4 12 -20 Scrotum darkens <10 Adult quality 5 >20 Average 15 Spreads to thighs prepubertal Assigned Male Puberty adult Pubic Hair 81

Tanne Breast r stage Aerola 1 No glandular Prepub- tissue Pubic Hair None ertal

Tanne Breast r stage Aerola 1 No glandular Prepub- tissue Pubic Hair None ertal Assigned Females Puberty 2 Breast bud, small firm tender glandular tissue Areaola widens Sparse, but in contour of fine breast 3 Elevates extends beyond aerola Areaola widens Increasing but in contour of coarseness breast lateral spread 4 Increases Secondary mound, project from contour Adult quality Returns to contour of breast, projecting papilla Spreads to thighs 5 Adult 82

GNC Boys Blocker Considerations for… Breast development early in puberty Broaden hips Early epiphyseal

GNC Boys Blocker Considerations for… Breast development early in puberty Broaden hips Early epiphyseal closure, shorter height Early identification before menses Low dose T for promoting height GNC Girls Tanner 4 -5 testes but minimal external gender characteristics Bigger heavier skeleton Adam’s apple Male pattern face, body hair Estradiol earlier for earlier puberty & height reduction 83

CONS Blocking PROS Few long term, lifetime outcome data Possible temporary adverse effect on

CONS Blocking PROS Few long term, lifetime outcome data Possible temporary adverse effect on bone density Reversible once hormones initiated BMD normal in teens with precocious puberty treatment e l p m Delays decision to undergo cross hormone therapy until child is older e v e R y l Height reduction (MTF) if started early Not necessarily a bad thing Negligible impact on height for FTMs Co Lack of 2 ndary sex characteristics compared to peers Expensive! Insurance sometimes covers ! e l b i s r Prevents undesired irreversible pubertal changes Decreases distress, with mental health/self esteem benefits Prevents need for costly and invasive surgery as adult Cosmetic congruency as adult leading to passing & greater social & financial opportunities Delemarre-van de Waal, Europ. JEndo 2006 84

 Required medical visits, injections, labs, exam Height consideration Expense Risks of “Blockers” Time

Required medical visits, injections, labs, exam Height consideration Expense Risks of “Blockers” Time & effort with prior authorizations Wait and anxiety for patients/parents Bone mineral density reduced Reversible once hormones initiated Lack of secondary sex characteristics compared to peers Relief >>> Risk or Harms 85

Phases of Transitioning Reversible • clothes, hair, shoes, toys • Gn. RH analogues Partially

Phases of Transitioning Reversible • clothes, hair, shoes, toys • Gn. RH analogues Partially Reversible • masculizing and feminizing hormone therapy Irreversible • Surgical interventions 86

Case 3 Patient “B” Homeless 16 y/o MTF returns Presents as female Trades sex

Case 3 Patient “B” Homeless 16 y/o MTF returns Presents as female Trades sex for drugs and shelter Diagnosed genital HPV last visit Follow visit plan To learn more about how you can medically support her transition 87

Increased opportunities for preventive health care Early Access to Gender Affirming Hormones Improved family

Increased opportunities for preventive health care Early Access to Gender Affirming Hormones Improved family functions, school performance Child development in asserted gender Prevents risk taking, suffering Leads to social change Goals…improve quality of life 88

 Estradiol Estrogen Sublingual 2 - ? ? mg/day total dose Decreased risk VTE

Estradiol Estrogen Sublingual 2 - ? ? mg/day total dose Decreased risk VTE preferred over oral daily Patch 0. 1 -0. 4 mg twice weekly Estradiol cypionate or valerate injection 5– 20 mg IM q 2 wks, 5 -10 mg IM weekly Tailor hormone support according to Desired effects- acknowledges each patient may want & identify in different ways Average female levels 100 -350 mimicking “known” healthy cis phyisiology, until we have more data Avoiding side effects, adverse effects- harm reduction explicit 89

Estradiol Feminization Sublingual Intramuscular Agent 17 b estradiol Estradiol Cypionate Valerate Pre-orchiectomy 2 -12

Estradiol Feminization Sublingual Intramuscular Agent 17 b estradiol Estradiol Cypionate Valerate Pre-orchiectomy 2 -12 mg daily Sublingual 30 minutes, swish spit Maintenance after 2 years 5 -20 mg IM q 1 -2 weeks ? New data Subcutaneous? Transdermal Patch Gel 0. 1 -0. 4 mg twice weekly 1 gm applied to skin 2 -3 times daily Reduce to level needed to keep serum free testosterone suppressed, estradiol within average female range https: //ceitraining. org/ 90

Predicting Effects of Feminizing Hormones Action Onset Max Breast growth 3 -6 months 2

Predicting Effects of Feminizing Hormones Action Onset Max Breast growth 3 -6 months 2 -3 yrs Body fat, muscle changes Softening skin Softer, less male pattern terminal hair 3– 6 months 3 -6 months 6 -12 months 1 -3 months 2 -3 yrs 1 -3 months 25% see change in 1 yr ? 3 -6 months 50% see change by 2– 3 yrs ? > 3 years Emotional changes Change in libido, erectile dysfunction Decrease testicular volume Decrease sperm production 91

 Anti-androgens Spironolactone 50 -100 mg PO BID Finasteride 1 -5 mg PO QD

Anti-androgens Spironolactone 50 -100 mg PO BID Finasteride 1 -5 mg PO QD Other Feminizing Options Progesterone Prometrium 100 -200 mg nightly Other options Medroxyprogesterone (Provera) 5 -10 mg PO QD DMPA 150 IM Q 3 months Unclear if benefit or harm Cosmetics Hydroquinone, Vaniqua®, laser, electrolysis 92

Studies over time indicate that hormones have minimal clinically significant physiologic affects & suggest

Studies over time indicate that hormones have minimal clinically significant physiologic affects & suggest we can do less labs in future Risks of Feminizing Hormones VTE Increased BP Increased Weight Glucose intolerance Decreased Libido Gall bladder disease Erectile dysfunction Pituitary adenoma Liver dysfunction Breast cancer (3 cases) TG ↑ (pancreatitis) Anti-androgens HDL ↑ LDL ↓ ↑K ↓ BP 93

No single protocol when administering hormone therapy to transgender patients Baseline Labs Feminizing Hormone

No single protocol when administering hormone therapy to transgender patients Baseline Labs Feminizing Hormone Therapy Labs common prior to starting estradiol hormone therapy AST Labs for spironolactone use Cr, Na, K Labs for patients already using hormones Estradiol vs Testosterone LC-MS/MS (liquid chromatography–tandem mass spectrometry) most accurate for comparing measures over time 94

 ? How often Used to be Q 3 months Yearly Test according to

? How often Used to be Q 3 months Yearly Test according to need Lab Follow-Up for Feminizing Hormone Therapy Testosterone < 70 ng/d. L Estradiol 100 -350 ng/dl If concerns re overuse Goal “average female levels” Reassure patient How useful vs expensive Goals Dosing & labs by • Generate desired effects • Avoid side effects • Average natal levels BP, Na, K (Cr) If spironolactone Prolactin only if symptoms 95

 Emotional well-being STI testing, prevention Health Care Maintenance for MTFs Fertility considerations Sperm/embryo

Emotional well-being STI testing, prevention Health Care Maintenance for MTFs Fertility considerations Sperm/embryo banking Contraception Breast cancer screening Self breast exam Mammography 10+ years estradiol, age 50 According to cis guidelines at present Additional screenings, limited evidence ? Prostate screening for older patients ? Pap if neo cervix created 96

No evidence of increased cancer in trans pop Breast Gooring 2013, Turo 2013, Van

No evidence of increased cancer in trans pop Breast Gooring 2013, Turo 2013, Van Hurst, Doff Cancer Risks for MTFs Uterine ? Urban 2011 – 1 case report Goynbert 2004, Perrone 1994 – endometrial atrophy Ovarian Barry 2014, Erickson BK 2013, Dizon 2006, Cervical Peltzmeier 2014 Prostate 6 cases, older women E > 50 97

 Sperm preservation 1 month Masturbate, freeze Fertility Oocyte preservation 1 -3 months Consult,

Sperm preservation 1 month Masturbate, freeze Fertility Oocyte preservation 1 -3 months Consult, labs, TVUS Daily US x 2 weeks cycle 1 -3 cycles Ever changing technologies Post Gn. RA, no change in fertility or birth defects (Lazar 2014) Live births after cryopreservation prepubertal ovary (Demeestre 2015) Uterine transplant, successful live birth (Brannstrom 2015) Trans men experiencing pregnancy (Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-tomale gender transitioning. Obstet Gynecol. 2014; 124(6): 1120– 7. ) 98

Sperm Oocyte Success rates IUI 15% Intracervical 5% Fertility 5% chance live birth per

Sperm Oocyte Success rates IUI 15% Intracervical 5% Fertility 5% chance live birth per egg frozen Goal 20 eggs= 50% success Costs $500/vial sperm $ 200 -1000 + annual fee Costs $500 consult $500 US/blood $150, 000/cycle $500 annual fee $7, 000 oocyte thaw, frozen embryo transfer 99

 Since the last visit, B reports: Case 3 Patient “B” More consistent use

Since the last visit, B reports: Case 3 Patient “B” More consistent use of condoms with new partners after your last visit Taking estrogen, purchased over the Internet She would like a stronger dose from you as she wants more feminizing effects and breast changes 100

 Excessive amounts Issues with Self. Prescribed Hormonal Therapy Increased risks and medication side

Excessive amounts Issues with Self. Prescribed Hormonal Therapy Increased risks and medication side effects Estradiol VTE risks Testosterone conversion to estrogens Does not increase feminization nor override heredity Quality Purity not guaranteed Medication and dose not guaranteed Safety Self-injection poses HIV & hepatitis risks 101

Estimated 1 million transgender adults (2009 - 2014) 2, 351 transgender people diagnosed with

Estimated 1 million transgender adults (2009 - 2014) 2, 351 transgender people diagnosed with HIV in Gender Minority Populations • 84% (1, 974) transgender women • 15% (361) transgender men • <1% (16) another gender identity • Around half lived in the South Transgender women over represented in HIV diagnoses • 22% transgender women in US live with HIV • 3 x > national average Clark H, Babu AS, Wiewel EW, Opoku J, Crepaz N. Diagnosesd HIV infection in transgender adults and adolescents: Results from the National HIV Surveillance System, 2009 -2014. December 2016. 102

HIV Prevention Health Care Maintenance for MTFs 103

HIV Prevention Health Care Maintenance for MTFs 103

Case 4 Patient “C” C is a 21 yro asserted male new to your

Case 4 Patient “C” C is a 21 yro asserted male new to your practice Self-injects testosterone from the Internet for two years Has just relocated to start a new job Wants to establish his identity as male at work 104

Testosterone Masculinization Injection Agent Testosterone cypionate Brand name Depo-Testosterone® Transdermal gel Testosterone enanthate Testosterone

Testosterone Masculinization Injection Agent Testosterone cypionate Brand name Depo-Testosterone® Transdermal gel Testosterone enanthate Testosterone crystals dissolved in gel Delatestryl® Andro. Gel® 40 -100 mg SQ every week Pre-oophorec tomy previously 100 -200 mg IM every 2 weeks Maintenace after 2 years Transdermal patch Androderm® 5 -10 g daily Start 2. 5 grams if comorbid conditions could be worsened by testosterone Reduce to level needed to keep serum free testosterone within lower-middle end male reference interval; Monitor risk of osteoporosis https: //ceitraining. org/ 105

Other forms Transdermals Compounded formulations 50 -150 mg/ml Androderm 2. 5– 10 mg daily

Other forms Transdermals Compounded formulations 50 -150 mg/ml Androderm 2. 5– 10 mg daily Androgel 2. 5– 5 mg packets with dosing 50– 200 mg daily Masculinizing Hormones Testopel 75 mg/pellet with 6 -12 pellets subcutaneous buttock insertion every 3 -4 months 150 mg or 2 pellets for every 25 mg T SQ weekly) Topical testosterone to clitoris will not increase size Progestins may be used short term to stop menses 106

Predicting Effects of Masculinizing Hormones Action Onset Max Male pattern facial/body hair Acne Voice

Predicting Effects of Masculinizing Hormones Action Onset Max Male pattern facial/body hair Acne Voice deepening 6– 12 mo 1– 6 mo 1– 3 mo 4– 5 yrs 1– 2 yrs Clitoromegaly Vaginal atrophy Amenorrhea Emotional changes/ ↑ libido 3– 6 mo 2– 6 mo 1– 2 yrs Increased muscle mass Fat distribution Tendon weakening 6– 12 mo 1– 6 mo 2– 5 yrs 107

 Common, mild Initial mood changes, resolve by 3 -4 months Risks of Masculinizing

Common, mild Initial mood changes, resolve by 3 -4 months Risks of Masculinizing Hormones Studies over time indicate that hormones have minimal clinically significant physiologic affects & suggest we can do less labs Initial weight gain, restabilize after 3 -4 months Acne Increase in Hgb, Hct Over time Male pattern baldness Pelvic pain Not clinically significant TG ↑ HDL ↓ LDL ↑ Insulin resistance Increased homocysteine Polycythemia 108

 Finasteride to treat pattern baldness Estrogen vaginal cream for atrophy Management of Side

Finasteride to treat pattern baldness Estrogen vaginal cream for atrophy Management of Side Effects of Masculinizing Hormones “Always time for lube!” Premarin vs estradiol, cost & coverage issue Retinoids, benzoyl peroxide, doxycycline for acne Creating amenorrhea Usually occurs over time & appropriate dosing of testosterone If menses continue OR if needs additional contraception LNG IUD, Etonorgestrel implant DMPA Continous COCs 109

No single protocol when administering hormone therapy to transgender patients Initial Lab Testing for

No single protocol when administering hormone therapy to transgender patients Initial Lab Testing for Masculinizing Hormone Therapy Labs common prior to starting testosterone hormone therapy AST Hb/Hct Cholesterol panel Labs for patients already using hormones Testosterone LC-MS/MS (liquid chromatography–tandem mass spectrometry) most accurate for comparing measures over time 110

 ? How often Used to be Q 3 months Yearly Test according to

? How often Used to be Q 3 months Yearly Test according to need Lab Follow-Up for Masculinizing Hormone Therapy Testosterone 400 -1000 ng/d. L Goal “average male levels” Reassure patient Allows titration to goals, side effects How useful vs expensive ? Need for Estradiol < 100 ng/dl Goals Dosing & labs by • Generate desired effects • Avoid side effects • Average natal levels Hb/Hct Ast Cholesterol 111

Case 4 Patient “C” Reports currently sexually active Reports had chest reconstruction surgery two

Case 4 Patient “C” Reports currently sexually active Reports had chest reconstruction surgery two years ago He is considering a hysterectomy & oophorectomy in the next year or two How might you support your patient in obtaining these surgical procedures? 112

STI Screening All trans patients Assess STI- and HIV-related risks based on current anatomy

STI Screening All trans patients Assess STI- and HIV-related risks based on current anatomy and sexual behaviors Diversity of transgender persons regarding surgical affirming procedures, hormone use, and their patterns of sexual behavior Providers must remain aware of common STI sx and screen for STIs on basis of behavior and sexual practices 113

During your sexual history-taking, C reports Case 4 Patient “C” He is in relationship

During your sexual history-taking, C reports Case 4 Patient “C” He is in relationship with a cisgender male & identifies as a gay man having receptive sex in both genital openings (anal/vaginal) Last STI screening—three years ago when C had parents’ insurance C has never had cervical screening and expresses anxiety over having “a Pap” How can you help? Does he need a pelvic exam? What about cervical screening? STI testing? 114

 According to cis guidelines at present Asserted Males & Cervical Cancer Screening ASCCP

According to cis guidelines at present Asserted Males & Cervical Cancer Screening ASCCP > age 21 Exposure to HPV necessary for cervical cancer What if NEVER sexually active? New technologies Fenway self swab study Urine HPV DNA testing Other? Post hysterectomy No history of abnormal pap, no future paps 115

 Transmasculine patients may have some pregnancy risk Contraception Testosterone not fail-safe contraceptive May

Transmasculine patients may have some pregnancy risk Contraception Testosterone not fail-safe contraceptive May continue to ovulate while on testosterone Testosterone may adversely affect development of fetus Consider Nexplanon, progesterone IUD, DMPA, other Avoid assumption—do Family Planning Do you want to be pregnant or have genetic children? 116

3 things that sound at odds, but are all true! 1. With sperm egg

3 things that sound at odds, but are all true! 1. With sperm egg sex, need contraception! Reproductive Counseling 2. Testosterone may impair future fertility 1. Does not mean cannot parent, as many ways to be a dad 2. Offer fertility preservation 3. Some trans men get pregnant after testosterone 1. 50% unplanned pregnancy on testosterone 2. 50% planned pregnancy coming off testosterone < 1 year Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014; 124(6): 1120– 7. 117

 Male chest construction Gender Confirmation Surgeries for Transmasculine Individuals Different technique than mastectomy

Male chest construction Gender Confirmation Surgeries for Transmasculine Individuals Different technique than mastectomy or implants Hysteroopherectomy w salpingectomy Phalloplasty/metoidioplasty No function without pump Rarely covered by health insurance Performed by specialized surgeons 118

 Emotional well-being Health Care Maintenance for FTMs STI testing Consider, don’t assume ?

Emotional well-being Health Care Maintenance for FTMs STI testing Consider, don’t assume ? HIV Family planning Contraception, fertility Breast cancer screening Instructions in self breast exam Mammography if breasts accord to cis guidelines Pap cancer screening Note FTM on testosterone Atrophy looks like dysplasia ? Dexa scans Testosterone > 5 yrs Age > 50 119

What Health Care Providers Can Do… Infrastructure Make office, clinic, wait areas gender neutral

What Health Care Providers Can Do… Infrastructure Make office, clinic, wait areas gender neutral Training Work with clinic staff to create trans-friendly environment Zero tolerance policies Screen All patients, at various points of development and age All children with mood, behavior, and school problems Identify Become comfortable; take a more detailed gender history Offer primary care Promote open disclosure and acceptance Offer referrals & resources Offer gender care and/or referral to gender experts Advocacy Promote diversity in your professional and personal communities 120

Trans Supportive Culture 121

Trans Supportive Culture 121

 Screening for gender issues, like sexual health concerns, important throughout life span Transgender

Screening for gender issues, like sexual health concerns, important throughout life span Transgender Youth Take. Home Points Medical management of treatment, including hormones, safer than self-prescribing Mental health and support is important STI and other health care maintenance continue Recognize vocational, financial, and social discrimination 122

Resources on Transgender Health Care World Professional Association for Transgender Health www. wpath. org

Resources on Transgender Health Care World Professional Association for Transgender Health www. wpath. org Vancouver Coastal Health Guidelines for Transgender Care transhealth. vch. ca The Fenway Guide to LGBT Health, American College of Physicians www. amazon. com/Fenway. Lesbian-Bisexual-Transgender. Health/dp/193051395 X Center of Excellence for Transgender Health http: //transhealth. ucsf. edu/ Transgender Law Center Health Care Issues www. transgenderlawcenter. org/issues/health 123

 National Center for Transgender Equality www. transequality. org Provider Resources— Transgender Health cdc.

National Center for Transgender Equality www. transequality. org Provider Resources— Transgender Health cdc. gov/lgbthealth/transgender. htm transbodies. com Freeing Ourselves A Guide to Health & Self Love for Brown Bois: www. brownboiproject. org 124

 Physicians for Reproductive Health Adolescent Reproductive and Sexual Health Education Program: prh. org/teenreproductive-health/arshep-explained/

Physicians for Reproductive Health Adolescent Reproductive and Sexual Health Education Program: prh. org/teenreproductive-health/arshep-explained/ Trainings on Transgender Health Massachusetts Transgender Political Coalition: www. masstpc. org/projects/trainings. shtml The National LGBT Health Education Center: www. lgbthealtheducation. org Center of Excellence for Transgender Health: www. transhealth. ucsf. edu Callen-Lorde Community Health Center: www. callenlorde. org/transgender-health-training 125

 Massachusetts Transgender Political Coalition: www. masstpc. org/publications Resources: Changing Name and Gender The

Massachusetts Transgender Political Coalition: www. masstpc. org/publications Resources: Changing Name and Gender The Name Change Project from the Transgender Legal Defense and Education Fund: www. transgenderlegal. org/work_show. php? id=7 Transgender Law Center: www. transgenderlawcenter. org Health Care Rights and Transgender People: www. transequality. org/Resources/Health. Care. Right _Updated. Aug 2012_FINAL. pdf 126

Insurance and Billing Information Medicare Benefits and Transgender People: www. transequality. org/Resources/Medicare. Benefit s.

Insurance and Billing Information Medicare Benefits and Transgender People: www. transequality. org/Resources/Medicare. Benefit s. And. Trans. People_Aug 2011_FINAL. pdf Human Rights Campaign: Finding Insurance for Transgender-Related Healthcare (list of links to the carriers’ websites where major guidelines for transgender-related treatments are openly available): www. hrc. org/resources/entry/findinginsurance-for-transgender-related-healthcare Department of Veteran’s Affairs Directive: Providing Health Care for Transgender and Intersex Veterans: transequality. org/PDFs/VHA_Trans_Health. pdf 127

Questions? 128

Questions? 128

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Thank You! 130

Thank You! 130