Gender Flashcards
Define transgender
someone whose gender identity is not congruent with the sex they were assigned at birth
what regular contraception is recommended for those on testosterone therapy?
progesterone only. Oestrogen antagonises the effect of testosterone
IU systems and injections may suspend menstruation. The coil can exacerbate menstrual bleeding
does testosterone therapy provide protection against pregnancy?
no
it is also is teratogenic if pregnant
if on testosterone therapy and in need of emergency contraception, what can be used?
either oral formulation
the coil may be considered but an exacerbate menstrual bleeding
For patients assigned male at birth treated with oestradiol, GNRH analogs, finasteride or cyproterone,
can it be relied upon as a method of contraception?
no but there may be a reduction or cessation of sperm production
define gender dysphoria in children
A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least six points …
associated with clinically significant distress or impairment in social, school or other important areas of functioning
define gender dysphoria in adolescents and adults
A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least 2 points …
gender identity disorder of childhood
The individual shows persistent and intense distress about being a boy, and has an intense desire to be a girl or, more rarely insists he is a girl
present for at least 6m and not yet reached puberty
define sexual maturation disorder
the patient suffers from uncertainty about his or her gender identity or sexual orientation
assc w/ or causes anxiety or depression
what is the difference between DSMV and ICD-10 in diagnoses
DSMV focuses on roles in childhood compared to physical sex characteristics in adults
ICD10 more focussed on physical sex characteristics even in childhood
an adult who considers themselves non-binary can meet the DSM-V criteria but not the ICD-10
ICD-11
will be published in Jan 2022 and will rename transsexualism as Gender Incongruence
and declassify it as a mental health disorder and classify it as a sexual health disorder
what is identity?
how they feel
what is expression?
how they communicate that feeling
history taking for gender identity
- describe your gender identity
- how + when did you realise that your experience is different to others?
- has your identity changed over time? Was there any significant life events that influenced your gender identity?
- How do you fell about your gender now?
- How does your gender impact work, relationships, family or other aspects of life?
- How do you feel about your physical sex characteristics above/below the waist? Have you any strong feelings about needing to change these?
history taking for gender expression
- Any activities you did as a child/adult that could be not typical for you assigned biological sex? How did other people view this?
- did you prefer to be around any particular gender as a child? Is that different now?
- Have you ever cross dressed? What was that experience like? What do you imagine it would be like?
- If you could change your appearance to more closely match how you feel, what would this look like?
- Have you ever taken any hormones or had any confirmatory surgery? What was this like?
perceptions of others history taking
- how do you want to be perceived? how important is it that how you feel and how others perceive you match?
- are there any social barriers to you expressing yourself in a way you feel comfortable
history taking structure
1) gender identity
2) gender expression
3) perceptions of others
4) physical and emotional
5) social stability
6) trauma
7) coercion/control/undue influence
8) paraphilias - fetishistic transvestitism as differential dx
9) self-harm suicide
10) harm to others, criminal record
what service is available?
U18 referred to a Gender Identity and Development Service (Tavistock/Portman clinics in London + Leeds)
approaching 18, they are transferred to an adult service e.g. Porterbrook Clinic in Sheffield
adult gender dysphoria care pathway: 0-6m
- 2x2 assessments (one must be with a medic
- MDT discussion if required
adult gender dysphoria care pathway: 6m
hormones and voice and communication therapy
adult gender dysphoria care pathway: 12m
facial hair depilation or mastectomy w/ chest wall reconstruction referrals
adult gender dysphoria care pathway: 18m
lower (genital reconstruction) gender confirmatory surgery pathway
adult gender dysphoria care pathway: 3-5yrs
transition complete (best case scenario)
will hormones irreversibly affect fertility
yes
patients can access fertility preservation services through their GP if their CCG funds for it
what are blockers?
they suppress levels of endogenous hormones to allow prescribed hormones to have a significant effect
sometimes needed in transmen if periods are not sufficiently supressed
name some ‘blockers’
- GnRH agonists: Leuprorelin, Triptorelin
- Anti- androgens: Finasteride, Cyproterone, Spironolactone
how do GnRH agonists work as blockers
blocks the hormone messaging between the brain and gonads
stop testosterone/oestrogen being produced in the first place
what are the side effects of GnRH
well-tolerated but andropause/menopause symptoms
how do anti-androgens works
reduce the effect of testosterone on the body
finasteride - minimise male pattern baldness
side effects of anti-androgens
less well tolerated
- liver/kidney impairment
- breast and liver carcinoma
- meningioma
what hormone is used for masculinisation?
testosterone IM or transdermal gel
in transmen, whose periods continue, what can be given in conjunction with testosterone?
GnRH agonist
name 9 effects of masculinising hormones
- skin oiliness/acne
- facial/ body hair growth
- scalp hair loss
- increased muscle mass/strength
- body fat redistribution
- cessation of menses
- clitoral enlargement
- vaginal atrophy
- deepened voice
how often should transdermal masculinising hormones be monitored?
6-8 weeks until levels stable
then every 6m for 3 years then yearly
how often should IM masculinising hormones be monitored
3 months until up-titrated to therapeutic levels
then every 6m for 3 years then yearly
why is Hb, haematocrit monitored yearly for masculinising hormone monitoring?
risk of polycythaemia
name some feminising hormones
- oestrogen (PO, gel, transdermal)
- GnRH agonists (Leuprorelin or triptorelin SC injections
- sometimes anti-androgens are required (Finasteride, Cyproterone, Spironolactone)
why are oestrogen gel and patches preferred to oral?
lower risk of thrombosis
why are GnRH agonists used as feminising hormones?
to reduce production of testosterone
why may oestrogens need stopping pre-operatively?
risk of VTE
name 11 effects of feminising hormones
1) body fat redistribution
2) decreased muscle mass/strength
3) softening of skin/decreased oiliness
4) deceased libido
5) decreased spontaneous erections
6) male sexual dysfunction
7) breast growth
8) decreased testicular volume
9) thinning + slowed growth of body + facial hair
10) decreased sperm production
11) male pattern baldness
when monitoring feminising hormones, how often are serum sex hormones levels checked
4-8 weeks for transdermal/oral
3m for injections
until up-titrated to therapeutic levels
when feminising hormone levels are stable, how often are they monitored?
every 6m for 3 years then yearly:
- BMI, BP
- U&Es
- LFTs
- HbA1c
- lipid profile
- TSH
- serum testosterone
- serum oestradiol
- serum prolactin
when are bloods taken after oral oestrogen
24hrs
when are bloods taken after oestrogen patch applied?
48hrs
when are bloods taken after gel applied?
4-6hrs
what are the likely risks of feminising hormones?
- VTE
- gallstones
- elevated liver enzymes
- weight gain
what is the possible risk of feminising hormones
cardiovascular disease
what is the possible risk of feminising hormones in the presence of additional RFs
T2DM
what other treatment and support can the NHS offer?
- SALT referral (posture post-chest surgery + voice)
- facial hair depilation
- occupational therapy (social transitioning support)
- counselling
what can the NHS offer in terms of facial hair depilation
- NHS can fund 8 sessions
- electrolysis or laser depending on type of hair
- creams that slow growth of hair
what can private healthcare offer as other treatments and support?
- facial feminisation surgery
- breast augmentation
- laryngeal shaving
what is required for a mastectomy and chest wall reconstruction?
- persistent gender dysphoria
- physical, emotional, social stability or plan in place to optimise
- BMI <31.5
- non-smoking for at least 6m
- ideally after 6m on testosterone - development of chest wall muscles
- only one opinion needed
risks of mastectomy and chest wall reconstruction
- loss of nipple viability
- loss of sensation along scar line
- keloid scarring
- dog-ear skin tags
- fat necrosis
- ongoing risk of breast cancer
how many opinions are needed for lower surgery?
a 2nd independent clinical opinion needed unless pt has a gender recognition certificate
what is the criteria for lower surgery?
- persistent, well-documented gender dysphoria
- capacity
- > 17yrs
- well-controlled physical + mental health
- 12m of continuous hormone therapy
- 12m of living in a full-time gender role congruent with their gender identity
- BMI<31.5
- non-smoking for at least 6 months
what are the options for masculinising gender confirmatory surgery?
- hysterectomy, salpingo-oopherectomy + vaginectomy
- metoidioplasty (extending the clitoris into a micro-penis) or phalloplasty (creation of penis), and urethroplasty (creating a longer urethra)
- erectile implants + scrotoplasty (creation of scrotum w/testicular prostheses)
why after a salpingo-oopherectomy, will a pt no longer need any blocker medication?
the body’s natural source of oestrogen will be stopped
and testosterone may also need to be lowered
name some disadvantages of masculinising gender confirmatory surgery
- very complicated
- long recovery time
- may not what they imagined
- loss of sensation
- failure of skin grafts (inc loss of neophallus)
- urine stream/urinary obstruction
what are the options of feminising gender confirmatory surgery?
- Penectomy (removal of penis)
- orchidectomy (removal of testicles)
- vaginoplasty (creation of vagina)
- clitoroplasty (creation of clitoris)
- labioplasty (creation of labia)
- repositioning of urethra
why will the pt no longer need any blocker medication after an orchidectomy?
the body’s natural source of testosterone will be stopped
oestrogen can be lowered
name some disadvantages to feminising gender confirmatory surgery
- very complicated set of surgeries
- long recovery time
- may not what pt imagined
- urine stream/obstruction
- loss of sensation
- damage to bowel or bladder
- after surgery, strict regime for washing + dilating the neovagina 3x/day gradually reduced but up to 12m
describe a transwoman
male to female
describe a transman
female to man
which screening can a transwoman have?
- breast (if breast tissue present)
- NOT cervical
- abdominal aortic aneurysm
- bowel
which screening can a transman have?
- breast (if breast tissue present)
- cervical (if cervix present)
- AAA?
- bowel
- if pregnant: the same antenatal + newborn screening
what is a cis-woman?
someone who identifies as a woman and was identified as female at birth
why are feminising hormones changed after 50 years old
in a cis-woman, oestrogen lowers after menopause so levels must be lowered to 300-450 and transdermal preparation to minimise risk of VTE
define Q+ in LGBTQ+
Queer+: not experiencing a ‘binary’ identity/role
not limited in sexual preference to biological sex, gender or gender identity
define asexual
romantically but not sexually attracted
define polyamarous
romantic or physical attachment to >1 partner
define non-binary gender
identifying with a proportion of male and female identity in varying degrees
define gender fluidity
gender identifying fluctuating over time and place
define gender non-conforming
expression/role
define agender
not strongly identifying with any gender
define hate in relation to hate crime/incidence
any incident or crime motivated by prejudice or hostility (or perceived to be so) against a person’s:
- race
- religion
- sexual orientation
- transgender identity
- disability
what is the difference between a hate crime and a hate incident?
crime: the law is broken
incident: not a criminal offence
what is the Rainbow Badge Scheme?
an initiative that gives staff a way to show the SHSC NHS Foundation Trust offers open, non-judgemental + inclusive care for pts and their families who identify as LGBT+
what you are signing up to if you join the Rainbow Badge Scheme
- wear badge
- use inclusive language in all discussions
- positively affirming the identity that a person chooses to use
- assuring confidentiality
- initiating safeguard when required
- escalating concerns regarding discriminatory behaviour
- a listening ear
