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Psych Unit 1 > 4 Transgender Patients in Primary Care > Flashcards

4 Transgender Patients in Primary Care Flashcards

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1
Q

Approximate number of adults who identify as Gender and Sexuality Minorities in the US

A

9 million - about the same # of people who live in the state of New Jersey

Lesbian/Gay = 1:10 general population
Transgender = 1:10,000 general population
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2
Q

What was AZ BIll 2586

A

A bill to include LGBT individuals in AZ’s equal opportunity laws

Chairman of the House Judiciary Committee would not grant it a hearing because he disagreed with the proposal

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3
Q

What protections did the ACA afford to LGBT people?

A

Finalized new rules confirming that LGBT people are protected against health care discrimination

Hospitals must treat transgender patients fairly, equitably, and with respect

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4
Q

How did the WHO update their position on transgender in 2016?

A

“Transgender now recognized worldwide as genetically inclined and not a mental disorder”

Gender dysphoria IS a condition you can treat

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5
Q

Sex is a ___________ construct

A

Biologic, immutable

Sex (XX, XY, or Intersex) does not mean gender

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6
Q

What is gender?

A

How a person sense their feminine, masculine, or non-conforming identity

Gender does not mean the same thing as biologic sex, and in the case of gender identity, may not be congruent with a person’s biologic sex

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7
Q

How is sexuality defined?

A

Who you are attracted to physically, romantically, and/or emotionally

Sexuality is NOT defined by biologic sex nor by gender identity

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8
Q

_____, _______, and ______ are three separate and unique things for up to 10% of your patients

A

Sex, Gender, and Sexuality

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9
Q

Umbrella term for someone whose gender identity is different than their birth sex

A

Transgender

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10
Q

Someone whose gender identity is opposite of their birth sex and may or may not seek medical treatment to transition (this term is now out of favor)

A

Transsexual

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11
Q

The stress felt when ones physical body or the way others see the person does not align with their gender identity

A

Gender Dysphoria

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12
Q

Someone who is born with ambiguous genitalia or sex organs of both sexes, may have chromosomal or genitalia differences from general population

A

Intersex

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13
Q

Someone who may move along the gender spectrum at different times

A

Gender fluid

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14
Q

Someone who may identify as androgynous or closer to the middle of the gender spectrum

A

Genderqueer

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15
Q

Someone who feels they are both genders

A

Bigender

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16
Q

Someone who feels like they are the gender they were born with

A

Cisgender

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17
Q

Native American term for someone who possess two genders or the body of one gender but the spirit of another

A

Two-spirit

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18
Q

Someone who identifies as neither male nor female but out of the gender binary entirely

A

Agender

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19
Q

Someone who enjoys wearing the clothing of the opposite sex but does not identify as another gender

A

Cross Dresser

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20
Q

Someone who dresses as the opposite sex to perform in a show

A

Drag Queen/King

21
Q

What does FTM mean?

A

Female to male

Aka trans man, trans masculine

22
Q

What does MTF mean?

A

Male to Female

Aka trans woman

23
Q

Someone who is attracted to people of the same gender

A

Homosexual

24
Q

Someone who is attracted to people of the opposite gender

A

Heterosexual

25
Q

Someone who is attracted to people of both binary genders

A

Bisexual

26
Q

Someone who is attracted to people along the gender spectrum

A

Pansexual

27
Q

What is the DSM-5 definition of Gender Dysphoria?

A

A marked incongruence between one’s experienced/expressed gender and natal gender of at least 6 months in duration, as manifested by at least two of the following:

  1. Incongruence between one’s own gender and primary/secondary sex characteristics (or anticipated secondary sex characteristics in adolescents
  2. Strong desire to be rid of one’s primary/secondary sex characteristics (or to prevent their development)
  3. Strong desire for the primary/secondary sex characteristics of the other gender
  4. Strong desire to be of the gender other than one’s natal gender
  5. Strong desire to be treated as the other gender
  6. Strong conviction that one has feelings and reactions of the other gender

The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning

Specify if:

  1. The condition exists with a disorder of sex development
  2. The condition is posttransitional
28
Q

What are the two ways to provide informed consent?

A

Informed consent model - PCPs perform the initial assessment, including physical health and any mental health risks before proceeding with care. Referrals are made as needed to specialists

Behavioral Health Model (aka Standards Model) - a letter of referral is necessary from a psychologist to assist in the medical transition assessment

29
Q

What is WPATH

A

World Professional Association for Transgender Health

Has evolved to better support the patient’s autonomy in choosing whether or not to seek a psychologist’s care for medical transition (though psychologist letters are still required for gender confirming surgeries)

30
Q

What is the main point of informed consent?

A

They teach the key points of what the hormones do to one’s body and what the permanent and impermanent changes will be

31
Q

Changes that will be permanent with Testosterone therapy (FTM transition)

A

The pitch of voice becomes deeper

Increased growth, thickening and darkening of body hair

Growth of facial hair

Possible hair loss at the temples and crown (male pattern baldness) with possible complete baldness

Increase in the size of the clitoris/phallus

32
Q

Changes that will NOT be permanent with Testosterone therapy (FTM transition)

A

Menstrual periods will stop, usually within a few months

Possible weight gain (fat will tend to go to abdomen and mid-section rather than buttocks/hips/thighs)

Increased muscle mass and upper body strength

Possible feelings of more physical energy

Skin changes, including acne that may be severe

Increased sex drive

Changes in mood or thinking; decreased emotional reactions; possible increased feelings of anger or aggression; possible mood improvement

33
Q

Risks and possible side effects of testosterone therapy

A

Loss of fertility (may want to harvest eggs), but NOT reliable birth control

Changes in cholesterol, higher BP, and other changes —> inc CVD risk

Increased risk of DM, appetite/weight changes, sleep apnea

Abnormal LFTs

Increased H/H and sweating

Weakening of tendons —> increased risk of injury

Worsening/triggering of HA and migraines

Increase in frustration, irritability or anger, aggression and impulse control

Worsening of bipolar disorder, schizophrenia, and psychotic disorders

34
Q

Most important adverse outcomes from testosterone therapy

A

Very high risk of erythrocytosis (hematocrit >50%)

Moderate risk:
• Liver dysfunction
•CAD
• CVD
• HTN
• Breast or uterine CA (b/c of neglecting screenings!)
35
Q

During testosterone therapy, the masculine changes in your patient’s body may take ______ to become noticeable and usually take ______ to be complete

A

Several months —> 3-5 years

36
Q

During Feminizing Hormone Therapy, the feminine changes in the body may take _____ to become noticeable and usually take up to _______ to be complete

A

Several months —> 3-5 years

37
Q

Changes that will be PERMANENT with feminizing hormone therapy

A

Breast growth and development

Testicles will get smaller and softer

Testicles will produce less sperm, and you will become infertile (varies, person to person)

38
Q

Changes that are NOT permanent with feminizing hormone therapy

A

Loss of muscle mass and decreased strength, particularly in upper body

Weight gain - tends to go to the buttocks and thighs

Skin will become softer and acne may decrease

Facial and body hair will get softer and lighter and grow more slowly (most women will choose to have electrolysis or laser therapy)

Male pattern baldness may slow down or stop (but hair doesn’t grow back)

Reduced sex drive

Decreased erections

Changes in mood or thinking, increasing emotional reactions

Will not change the bone structure of the face or body, will not shrink adam’s apple

39
Q

The risks and possible SE of estrogen therapy

A

Loss of fertility (still use birth control)
Increased risk of DVT, PE, MI, stroke, death* (esp if smoker, >45, HTN, HLD, DM, or FH of CVD)
HTN
DM
N/V
Gallbladder disease
Elevated LFTs
May cause or worsen HAs/migraines
Prolactinomas
May worsen depression or cause mood swings
Increased risk of breast cancer (higher than in natal men but lower than in natal women)*

40
Q

Most important adverse outcomes from estrogen therapy

A

Very high risk of thromboembolic disease

Moderate risk:
Macroprolactinoma
Breast cancer
Coronary artery disease
Cerebrovascular disease
Cholelithiasis
Hypertriglyceridemia
41
Q

Risks and possible side effects of Androgen blockers (Spironolactone)

A

Increased urine production and frequency; changes in kidney function

Drop in BP and feeling lightheaded

Increased thirst

Increase in the potassium leading to muscle weakness, nerve problems, and heart arrhythmias

42
Q

What are the different preparations for testosterone replacement?

A

Testosterone Cypionate or Enthanate
• 1-3 ml syringe and 18g needle to draw
• 23-25g 1 1/4 in needle to inject IM or SQ
• Injected every other week

Testosterone Topical Gel 1% (packet or pump)

Testosterone Patch (may be cut PRN)

43
Q

What different preparations are available for estrogen therapy?

A
  1. Estradiol Oral/Sublingual (cheaper, easier)
  2. Estradiol transdermal
  3. Estradiol valerate IM
  4. Estradiol cypionate IM
44
Q

Besides estrogen replacement, what other preparations are available for MTF transition?

A

Androgen Blockers:
• Spironolactone
• Finasteride

Progestin Preparations (not necessarily necessary):
• Medroxyprogesterone acetate
• Micronized progesterone

45
Q

Important screening and prevention for transgender males

A
  1. Evaluation q3months for signs of virilization and any adverse effects**
  2. Blood lab for total T every 3 mo for first year (goal is 400-700ng/dL up to 900ng/dL
  3. Measure H/H at baseline and q3mo for first year, then 1-2x per year***
  4. Monitor body weight and BP at every appt
  5. Fasting lipids should be done at baseline and annually
  6. If cervical tissue remains, reg pap screening**
  7. Osteoporosis screening
  8. If no mastectomy, mammography screening per ACS
46
Q

Important screening and prevention for transgender females

A
  1. Eval q3mo first year for signs of feminization and any adverse effects
  2. Measure total T and estradiol every 3 mo during first year; Serum T should be <50ng/dL, Estradiol should be 100-200pg/mL
  3. For pts using spironolactone, electrolytes q3mo with attention to potassium
  4. Cancer screening for prostate
  5. Bone mineral density is recommended at baseline, with BMD at age 60 or if therapy stopped
47
Q

What procedures are used for gender confirming surgery for trans females

A

Vaginoplasty/clitoro-labioplasty (complications = urethral stenosis, fistulas, hair growth within the neovagina)

Mammoplasty (complications = capsule formation, implant rupture)

48
Q

What procedures are used for gender confirming surgery for trans males

A

Mastectomy (complications = nipple necrosis, skin flap complications, contour irregularities, scarring)

Metoidoplasty - frees the testosterone enlarged natal clitoris from the labia minors and suspensory ligament, and lengthening of urethra (complications = urethral fistula)

Phalloplasty - construction of phallus with neourethra and erectile prosthesis (complications = urethral stenosis and fistulas, flap loss, necrosis)

Scrotoplasty - adjunct to metoidioplasty/phalloplasty (complications = risk of infection during expansion period)

Psych Unit 1 (6 decks)

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