exam 1 - lgbtx Flashcards
natal sex, gender, sexual orientation = identity
differences between sex assigned at birth, gender identity, and sexual orientation
Not binary scale
Its a spectrum
sexual orientation
-its possible for someone whose sexual orientation is heterosexual to be SA with same sex partner (female with a biological female that identifies as a man)
-How important is it to know the patient’s sexual orientation?
-It is more significant to know with whom pt is SA, and what sexual activities in which they participate with their partner(s)
-This permits a better opportunity to assess risk for STIs, pregnancy, and need for PrEP
other terms related to the gender minority community: trans, cis, non-binary
-Transgender- umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth
-Cisgender refers to people whose gender identity is congruent with the sex they were assigned at birth
-Non-binary or genderqueer: terms used by people who experience their gender identity and/or gender expression as falling outside the categories of man and woman.
-However, it is more inclusive to refer to this community as gender diverse or gender minority
what is LGBTQAI+
-Agender
-Asexual
-Bisexual
-Cisgender
-Gay
-Gender fluid
-Gender expansive
-Gender non-binary or genderqueer
-Gender non-conforming
-Intersex (differences of sexual development)
-Lesbian
-Pansexual
-Queer
-Questioning
-Transgender
sex assigned at birth definition
-The gender given to a neonate at delivery based on the appearance of the external genitalia
-Assigned male at birth (AMAB)
-Assigned female at birth (AFAB)
gender dysphoria / incongruence and DSM-V
-distress experienced by pts with gender discordance bc of incongruence between their gender identity and physical gender
-This term is included in the Diagnostic and Statistical Manual, 5th ed. (DSM-V) and should be used rather than gender identity disorder (an outdated term)
DSM-V dx of gender dysphoria:
-marked incongruence between one’s experienced or expressed gender and their assigned gender, -> at least 6 months, as manifested by 2+ of following:
-marked incongruence between one’s experienced or expressed gender and primary and/or secondary sex characteristics (in young adolescents, the anticipated secondary sex characteristics)
-A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced or expressed gender
-A strong desire for the primary and/or secondary sex characteristics of the other gender
-A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
-A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
-A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)
-The condition must also be associated with clinically significant distress or impairment in social, occupational or other important areas of function
what percent of population is intersex
-2%
-gender minority- 1%
complete gender insensitivity (AIS)
-common! - more common than people with green eyes
-XY
-loss of function gene -> blocks recognition of testosterone production
-you make test but body doesnt recognize it
-these people have no idea they are XY, they present as XX
-go through female puberty without mensuration -> no ovaries
-testicles are internal and stay warm -> increase risk of cancer -> gonadectomy
-normally testosterone produced at 11 weeks gestation
-partial- ambiguous genitals
-wait and see how that person identifies
-AIS
janice langbehn and lisa pond case
Lisa = SAH pt dies alone and partner not allowed to see her bc florida is “antigay”
But it is human right
Stats regarding health care discrimination of LGBATQAI+ pts
->50% of LGBTQAI+ pts experience some form of discrimination when seeking medical care
-20% of gender minority people have been denied care because they are transgender or gender non-conforming
->50% of gender minority patients find their practitioners are not sufficiently aware of their needs
-28% of gender minority patients have postponed medical care because of this discrimination
-LGBTQAI+ patients who are black or brown are 2x more likely to avoid medical care than white patients
-75% of lesbians report delaying or avoiding health care -> most likely to be financially challenged bc they are women
anti-LGBTQ bills
what diseases or conditions are lesbians/gay men pts at increased risk?
Lesbians:
-Alcoholism- from depression, minorities met at bars
-Obesity
-Tobacco related disorders
-Breast, ovarian and endometrial carcinomas- not ever having been pregnant
-Cardiac disease
-Depression and anxiety
-Suicide
-PTSD
-Physical violence
Gay men:
-Alcoholism and drug use
-STIs- HIV/AIDS, Syphilis, HPV -> other STIs go up as HIV becomes less of a worry
-Hepatitis B and C
-Cardiac disease- stress
-Anal carcinoma
-Depression and anxiety
-Suicide
-Eating disorders and body dysmorphic disorders
-bisexual women:
-cardiac ds
-breast carcinoma
-obesity
-binge drinking
-tobacco dependence
-bisexual men:
-HPV
-anal carcinoma
-bisexual men and women:
-increased intimate partner violence
-alcohol
what diseases or conditions are bisexual women and men pts at increased risk?
bisexual women:
- cardiac ds
- breast cancer
- obesity
- tobacco dependence
bisexual men:
- HPV
- anal CA
bisexual men and women:
- increased IPV risk
- alcohol
violence in the gender minority community in 2024
-The Human Rights Campaign reported that in 2024, at least 36 gender minority people were killed through violence
-Of these, nearly half were black or brown transgender women
-tend to be sex workers
For what diseases or conditions are gender minority patients at increased risk?
violence:
-16-60% of transgender pts are victim of physical assault or abuse
-13-66% of transgender individuals are victims of sexual assault
-all minorities are at higher risk for sexual assault- even disabled
suicide:
-38-65% of transgender individuals report suicidal ideation
-up to 28% of young gender non binary individuals have reported suicidal ideation
-16-32% of transgender pts attempt suicide
mental health: depression, anxiety, and other psychiatric conditions
substance abuse
tobacco dependence
HIV/AIDS
STIs
how to have your office staff welcome LGBTQAI+ pts
-Practice cultural humility -> Your own experiences may not be similar to those that others have had
-Your pts may have different experiences or identities
-Do not expect pts to teach you about how to care for a LGBTQAI+ pt (or any other kind of pt)
-Help educate your staff: MAs, receptionists, phlebotomists, etc. all need to welcome all pts in a positive, affirming, compassionate and non-judgmental manner
avoid assumptions
-key principle of effective communication is to avoid making assumptions:
-Don’t assume that:
-You know a person’s gender identity or sexual orientation based on how that person looks or sounds
-You know how a person wants to describe themselves or their partners
-All of your pts are heterosexual and cisgender (not gender minority)
registration form: what components
-Registration forms should have a space for patients to enter their preferred name and pronouns
-This information should also be included in medical records
-pt’s pronouns and preferred name should be used consistently by all staff
use of pronouns
-use pts preferred names and pronouns
-transgender often change their name to affirm their gender identity
-name is sometimes diff from what is on insurance or identity documents
-If unsure about pt’s preferred name or pronouns:
-“I would like be respectful—what name and pronouns would you like me to use?”
-If pt’s name doesn’t match insurance or medical records:
-“Could your chart/insurance be under a different name?” -> make sure you confirm the pt before anything else
-“What is the name on your insurance?”
-If you accidentally use the wrong term or pronoun:
-“I’m sorry. I didn’t mean to be disrespectful.”
terms to avoid
-AVOID:
-homosexual -> gay, lesbian, bisexual, or LGBT
-transvestite; transgendered -> transgender, gender minority, gender non-binary (GNB)
-sexual preference; lifestyle choice -> sexual orientation
accountability of envirionment
-Creating environment of accountability and respect requires everyone to work together
-Don’t be afraid to politely correct your colleagues if they make a mistake or make insensitive comments
-“Those kinds of comments are hurtful to others and do not create a respectful work environment.”
-“My understanding is that this patient prefers to be called ‘Jane’, not ‘John’.”
collection of gender identity data -all pts should be asked for following:
-chosen name
-given name
-current gender identity
-preferred pronouns
-practices can include a descriptive statement so to reduce or eliminate confusion for cisgender pts
-some EMRs do not have the flexibility to use these data
statistics: gender minority pts in US
-approx 150,000 youth and 1.4 million adults who identify as transgender, and approximately 1.2 million gender non-binary (GNB) adults
-These numbers may well underestimate the actual number of gender minority individuals
medical hx of the gender minority pt: what additional components
Past medical hx
Surgical hx: Includes but is not limited to gender-affirming surgical procedures
Organ inventory: AFAB vs AMAB
Medications:
-Prescribed medications- Hormone therapy
-Over-the-counter medications
-Alternative therapies
Family history:
-Diabetes mellitus
-Hypertension
-Thrombophilias
-Bleeding tendencies
-History of hormone-sensitive malignancies- Prostate carcinoma, Endometrial carcinoma, Ovarian carcinoma, Breast carcinoma (especially for AMAB)
Psychosocial history:
-Support- Family, friends and community
-Employment
-Housing
-Financial issues
Sexual history:
-Sexual orientation
-Sexual practices
-Need for contraception
organ inventory AFAB, AMAB
AFAB (assigned female at birth):
-Breasts
-Ovaries and Fallopian tubes
-Uterus
-Cervix
-Vagina
-Vulvar structures
AMAB (assigned male at birth):
-Prostate
-Penis
-Testicles
screening tests for the gender minority pt
cervical carcinoma: AFAB gender minority pts with a cervix
prostate carcinoma: AMAB gender minority pts with a prostate
-very hard to find a prostate on a transgender female on GAHT (prostate gets smaller)
breast carcinoma:
-Transgender women on gender affirming hormone therapy (GAHT) at age 50+ with risk factors
-Estrogen and/or progestin use for >5 years, family hx, obesity -> breast exam and mammo
-AFAB gender minority pts who have not had bilateral mastectomy
physical exam of the gender minority pt
-examine genitalia only if indicated regarding the complaint
-refer to genitalia either by the usual terminology or by asking pts if they have a particular term they prefer to use
-a transgender man may prefer the word canal to vagina
special considerations with gender minority pts
-General survey and skin exams may vary widely based on hormone therapy in gender minority patients
-There may be skin manifestations due to breast binding (AFAB gender minority patients) or due to testicular tucking (AMAB gender minority patients)
-In a transgender male pt having cervical cytology, communicate with the lab to indicate presence of a cervix to avoid confusion with a gay male pt having an anal Pap
-Offer someone to provide support during exam or other distraction
-Some transgender male pts may require sedation
-For transgender male pts, vaginal estrogens administered 2x weekly for several weeks prior to exam may also make exam more comfortable
-Allow pt to have as much control over exam as possible
-AMAB gender minority pts status post vaginoplasty may benefit from use of an anoscope in place of a vaginal speculum -> vagina tends to narrow and shorten so can be painful
Transgender men may experience anxiety during a pelvic exam
-Consider administration of anxiolytic 30-60 mins in advance
-Consider delaying exam until pt is comfortable with practitioner
chest binding: what is it and sequelae
-Devices used by people AFAB to conceal breasts by compressing chest
-May include commercially produced chest binders, Ace bandages, duct tape, etc.
-Should not be used by pts with cardiopulmonary ds
-May cause restrictive lung disease to worsen
-Should not be used for more than 8 hrs per day or at gym
sequelae:
-Restricted lung capacity
-Skin irritation or skin breakdown
-Syncope
-Rib fracture
-Pleural effusion
tucking: what is it and sequelae
-Displacement of testes into inguinal canal and repositioning flaccid penis and scrotum between legs and posteriorly towards anus
-Tape, tight underwear or other devices maintain genitals in this
position
-Many pts AMAB find tucking to be gender affirming
-May also keep them safe as they are more often read as female
sequelae:
-Urinary reflux
-Testicular torsion
-Hernia
-Prostatitis
-Epididymitis
-Orchiitis
-Cystitis
-Local trauma to skin from tape
untrue statements concerning gender-affirming hormone therapy (GAHT) for gender minority pts
-Pts must want to transition entirely from gender assigned at birth to the gender with which they identify
-Pts must stay on a particular hormonal regimen for life
-There are no options for GAHT for GNB pts
-There are no options for GAHT for pts with underlying medical conditions
WPATH criteria for initiation of GAHT for gender minority pts
-Persistent, well-documented dysphoria (6 months+)
-Capacity to make a fully informed decision and to consent for tx
-Age of majority
-If significant medical and mental health concerns are present, they must be reasonably well controlled
gender affirming hormone therapy (GAHT) for the gender minority pt
-entirely possible for transgender individual to not use any medical or surgical means to accomplish transition
-Not all pts wish to have a medical and/or surgical transition
-Pts who identify as GNB may wish to use GAHT to reduce gender dysphoria while not fully transitioning
-It is not possible to choose which particular effects of GAHT one wishes to achieve
-Genetics and other factors often dictate what effects occur
risks of GAHT for pts desirous of feminization
Risks due to ESTRADIOL:
-DVT, PE, stroke, MI (based on data from Women’s Health Initiative) -> degree of risk is unknown
-HTN -> May use spironolactone to supplement (acts as antiandrogen) to mitigate risk
-DM -> Consider annual hemoglobin A1c or fasting glucose
-Hyperlipidemia -> Consider use of transdermal estrogen
-transdermal is always better -> bypass first pass effect & decrease risk of DVT (significantly from 5-> 0.5%)
-Decreased risk of hyperlipidemia AND of thromboembolic events
-Osteoporosis
data and exams to obtain before and during GAHT for pts desirous of feminization + monitoring parameters
prior to initiation:
-prolactin
-triglycerides
-bone mineral density
Monitoring:
-For desired and adverse effects every 3 months x 1 year; then every 6-12 months
-Serum testosterone and estradiol to determine results are in normal female range
-Testosterone: 30-100 ng/dL
-Estradiol: <200 pg/mL
-MAKE SURE LAB GENDER IS LABELED AS UNKNOWN -> ref ranges are diff
-Screen for breast and prostate carcinoma as indicated
GAHT for the pt desirous of feminization: estradiol and progesterone (dont need to know doses)
-Oral estradiol: 1-8 mg by mouth daily
-Transdermal estradiol: 50-400 mcg/day
-Estradiol valerate: <20-40 mg IM every two weeks
-Estradiol cypionate: 2-5 mg IM every two weeks
Progesterones:
-Medroxyprogesterone acetate 2.5-10 mg by mouth daily at bedtime
-Micronized progesterone 100-200 mg by mouth daily at bedtime
-make pts feel more female- gives menses
androgen blockers for the pt desirous of feminization
Anti-Androgens (Testosterone Blockers)
-Spironolactone (PO)
-Finasteride (PO)
-Dutasteride (PO)
risks of GAHT for pts desirous of virilization
-Polycythemia
-HTN
-DM in pts with hx of polycystic ovarian syndrome (PCOS)
->Otherwise, risk does not appear to be increased
-Hyperlipidemia
-Increased risk of elevated LDL and lowered HDL -> Use of transdermal testosterone seems to not affect lipid levels (estradiol can decrease)
-Unclear effect on risk of cardiovascular disease
-Variable effect on risk of osteoporosis -> Depends on when patient began testosterone and whether progestins were used
-progesterone can stop menses - depo, iud
data and exam to obtain before and during GAHT for pts desirous of virilization
Prior to initiation:
- CBC- polycythemia
-Lipid panel
-Bone mineral density if pt is at risk of osteoporosis
Monitoring:
-For desired and adverse effects every 3 months x 1 year; then every 6-12 months
-Serum testosterone to determine results are in normal male range (300-1000 ng/dL)
-Peak level should be drawn within 24-48 hours if patient is using parenteral testosterone
-Trough levels should be drawn right before injection
-Screen for breast and cervical carcinoma as indicated
GAHT for the pt desirous of virilization
-Testosterone cypionate 20-100 mg intramuscularly or subcutaneously weekly
-Testosterone enanthate 20-100 mg intramuscularly or subcutaneously weekly
-Testosterone topical gel 1% 12.5-100 mg topically every morning -> put it on bony part and dont let anyone touch
-Testosterone topical gel 1.62% 20.25-103.25 mg every morning
-Testosterone patch 1-8 mg every evening
-Compounded dihydrotestosterone cream 6-20 mg applied topically to clitorophallus in divided doses every 8 hours
-can do biweekly but you feel it wane; q1 wk preferred
GAHT for the gender minority pt
-Titrate dose based on patient goals and safety monitoring
-Be cautious regarding reference values!
-If pt is AFAB and is registered as female, the lab will report female reference values
-if your test goes above normal -> turns into estrogen!!!!! and also polycythemia risk (Too Much Testosterone = Estrogen + Polycythemia)
effects of feminizing hormones chart
effects of virilizing hormones
contraception and fecundity definition
-fecundity= potential to become pregnant
-fertility= persons experience with fecundity
-Contrary to common belief, GAHT does not preclude fecundity; Hormone therapy does not prevent you from becoming pregnant
-patients on T still ovulate
-Be sure to ask your pt about sexual practices
-Counsel appropriately about contraception or about measures to improve possibility of conception
gender minority children and adolescents stats and overview
-Incidence rates vary from 0.5-3.7%, though likely to be underestimated
-However, it is increasing in incidence and is occurring at a younger age
-Children at age 18 months may express gender dysphoria
-The majority of individuals who socially transition (change name) by the age of 12 continue to identify as transgender 5 years later
-Only 1.3% of pediatric pts detransition
-Over 19% of pts regret having bariatric surgery
Symptoms usually include the desire to:
-Dress in clothes of the opposite gender
-Assume traditional roles of opposite gender in play
-Play with toys traditionally used by children of opposite gender
uterine transplant
-max 2 kids then remove due to immunocompromise
-cant deliver vaginally
the pediatric and adolescent transgender care team… Should include the following pediatric subspecialists:
-Endocrinology
-Psychiatry
-Gynecology
-Plastic surgery
-Urology
approach to the pediatric pt with gender dysphoria
-Refer to gender dysphoria clinic at presentation
-Develop trusting relationship
-Review potential for any existing risk
-Mental health
-Substance use
-Safety in the home
-Sexual behavior
-If any immediate risks are identified, manage as needed and refer to a transgender program
medical tx of peri-pubertal gender minority pts
-never treat a pre-pubertal pt!
-Hormone blockers
-Gonadotropin releasing hormone (GnRH) agonists (puberty blockers) with consent of parent(s) and patient
-Leuprolide 7.5 mg intramuscularly every week
-GnRH analogues give pt time to consider the gender dysphoria while avoiding continuation of puberty
-pauses puberty for 2 years
-It also reduces the extent of tx if pt chooses to undergo hormone therapy and/or gender-affirming surgery
-Puberty suppression should only be used in patients after they become pubertal
-“Stage, not age”: onset of puberty based on Tanner staging
effects of GnRH analogues in children and adolescents
-Cessation of development of secondary sex characteristics
-Atrophy of breast tissue
-Amenorrhea
-Possible decrease in testicular volume
-for 2 years
adverse effects of GnRH in children and adolescents
-Possible transient decrease in bone mineralization in gender minority AMAB and AFAB pts
-Possible decrease in fertility
-Pts should consider preservation of fertility prior to puberty suppression or GAHT
-preservation of oocytes, sperm banking
GAHT for feminizing effects in adolescents
-Estrogens
-Estradiol 0.5 mg by mouth daily x 6 months
-Then increase to 1 mg by mouth daily x 6 months
-Then increase to 2 mg by mouth daily
GAHT for virilizing effects in adolescents
-Testosterone enanthate 50 mg intramuscularly every two weeks x 6 months
-Then increase to 100 mg intramuscularly every two weeks x 6 months
-Then increase to 150 mg intramuscularly every two weeks x 6 months
monitoring in adolescents using GAHT
-Vital signs
-Tanner staging
-Bone age if still growing in height
-Bone mineral density
-Testosterone and estradiol
-Electrolytes, A1c, hepatic panel
-Lipids
-LH, FSH
gender affirming feminizing surgical procedures
-Breast augmentation- sometimes in addition to hormone growth
-Penectomy
-Orchiectomy
-Vaginoplasty
-Facial feminization
-Forehead contouring
-Tracheal shave
-Vocal feminization- not common (voice therapy instead)
-medically necessary- covered
breast augmentation
-#1 regret in breast reduction is that they didnt do it sooner
-some breast development from estradiol
pre- and postoperative male to female genital confirmation surgery (penectomy - remove penis, orchiectomy - remove testes, scrotoplasty = create scrotum, vaginoplasty -create vagina): what sources for vaginal epithelium?
-penile skin and scrotal skin -> does not self lubricate
-perineal tissue -> self lubricates and no smell
-intestinal mucosa -> lubricates but it smells
-self dilation
vaginoplasty: -Potential sources of vaginal epithelium:
-Penile or scrotal epithelium (will not self-lubricate)
-Intestinal mucosa (will self-lubricate)
-Less common due to odor and large amount of mucus production
-Peritoneal tissue (will self-lubricate and no smell)
pre- and postoperative facial feminization
-forehead contouring
-tracheal shave
gender affirming masculinizing surgical procedures
-Mastectomy -MC
-Chest reconstruction
-Monsplasty- fatty tissue in pubic area
-Hysterectomy, bilateral salpingectomy and oophorectomy
-Vaginectomy - removal of vaginal tissue
-must have hysterectomy with vaginectomy
-no vagina and retains uterus -> abnormal bleeding -> there will be no signs of it without the vagina
-Metoidioplasty: Testosterone growth (“clitoral release”) to create a small phallus
-Phalloplasty: Construction of a full-sized penis using skin grafts from the forearm, thigh, or abdomen.
-Scrotoplasty- from labia majora
-Urethral lengthening
pre- operative and postoperative subcutaneous double mastectomy and chest reconstruction
masculinizing procedures: metoidioplasty
-Releases the clitorophallus from its suspensory ligament and labial tissues
-The clitorophallus has usually had significant growth due to testosterone (take it before surgery)
-usually results in penis of 4-6 cm in length - 2-3 inches
-Vaginal penetration may or may not be possible
-Tumescence and orgasm are almost always preserved
masculinizing procedure: phalloplasty
-Creates a penis from donor site
-Radial forearm
-Anterolateral thigh
-Musculocutaneous latissimus dorsi
-Erection is possible with penile implant
-Sensation and orgasm are often possible
-there is no lengthening during erection
-intense scarring
gender affirming procedures for gender non-binary (GNB) pts
For AMAB patients:
-Breast augmentation
-Penectomy
-Orchiectomy
-Scrotectomy
-Vulvoplasty
-Phallus-preserving vaginoplasty
For AFAB patients:
-Subcutaneous mastectomy
-Vagina-preserving phalloplasty
For AMAB or AFAB patients who identify as agender:
-Gender nullification surgery
- can still urinate
hair removal procedure
-Often requested by gender minority people desiring feminization to remove undesired facial hair
-Required prior to neovaginoplasty and phalloplasty- cant have hair growing in the vagina
-While laser hair removal is now an approved method, patients may still require electrolysis, especially for gray or white hairs
-Financial barriers are of real concern
-Pts also commonly seek hair removal from nonmedical individuals who may not be sufficiently knowledgeable in what is needed or what techniques are required
vocal changes
-GAHT is unlikely to yield a feminine-sounding voice in postpubertal patients
-Gender minority patients may choose to have voice therapy, phonotherapy, or both
-Voice therapy helps AMAB patients speak in a more typically feminine manner
-Patients more commonly choose only voice therapy
-In a meta-analysis of 17 studies, 80 to 85% of patients stated they were satisfied with their outcomes
fertility preservation (FP) in pts considering use of GAHT
-Approx 40-54% of gender minority adults wish to become parents
-It is currently unknown whether testosterone affects fertility adversely
-Estrogen results in smaller seminiferous tubules and abnormal appearing Sertoli and Leydig cells
-Numerous agencies recommend FP prior to beginning GAHT
-Thus, many pts may be adolescent at the time of FP
-Some theories of etiology of being transgender male suggest such pts have higher circulating androgens during fetal development
-There is evidence that this circumstance is associated with decreased fertility
-Some literature also suggests an increased incidence of PCOS in transgender men
consideration regarding FP
-oocyte cryopreservation procedure can cause significant dysphoria
-Includes potential for cessation of GnRH agonists -> Progression of puberty
-Delay or interruption of GAHT
-Cost and access to care are significant concerns for many patients
