Gender Affirming Care Flashcards
Describe the 2021 consensus regarding gender identity
The 2021 consensus was the first time that Canadians were given the option to identify as transgender or non-binary
Of the more than 30.5 million Canadians (aged 15+), 100, 815 of them identified as transgender or non binary (Large community in SK and in Canada)
–> 1/3 in people
Is gender the same as sexual orientation?
No - Distinct
Politicized to be synonymous
Define “assigned sex”
The biological classification of a person as female, male, or intersex
It is usually assigned at birth based on the visual assessment of the external anatomy
Define “gender identity”
A persons internal and indvidual experience of a gender
It is not necessarily visible to others and it may or may not align with what society expects based on assigned sex
Define “attraction”
Often referred to as sexual orientation, attraction describes a persons potential for emotional, spiritual, intellectual, intimate, romantic and/or sexual interest in other people and may form the basis for aspects of ones identity and/or behaviour
Not just sexual attracrion
Define “gender expression”
The way gender is presented and communicated to the world through clothing, speech, body lanaguage, hairstyle, voice and/or the emphasis or de-emphasis of body characteristics and behaviours
Define what is means to be transgender?
When someone’s gender identity is different than their sex assigned at birth
Being trans looks different for everyone (everyone’s journey is different)
Someone can realize they’re trans at any age
Identity and labels can change over time (people know themselves - should not be judged if changes)
May or may not include medical or legal changes (just as valid)
Being trans is not sad/bad/tragic
No criteria/expectation of what it means to be “trans”
Define cisgender/cis?
When a persons gender identity matches their sex assigned at birth (e.g. not trans)
NOT A SLUR
What are some ways to create an inclusive space for transgender individuals?
Avoid the “heterosexual/cisgender assumption”
You cannot tell if someone is trans or not (Do nit make assumptions)
Create space for patients and staff to be fully themselves
What are some ways to create a space for patients/staff to be fully themselves?
Train all staff and management –> Contact navigators for education
Take complaints of transphobia from staff and clients seriously - Do not make excuses
Gender neutral washrooms (IMPORANT) - Cannot be in the space for long otherwise
Have staff call out last name rather than first
Have staff ask for and add pronouns/chosen name as a note in file/chart
Patients have the right to set boundaries if something is uncomfortable
Inform patients why information is being collected
Be accepting when trans patients bring support persons
Know what medications are covered provincially and federally
What does it mean to create a safe space in the pharmacy?
A space where transgender individuals feel safe and welcome; however, also includes the people that love someone who is trans whether family, friends, partners, etc.
What are some ways that medical trauma can present for the trans community in healthcare?
Being turned away from medical facilities (many conditions do not require gender for treatment - irrelevant)
Misgendering/dead naming
Asking unnecessary/invasive questions
Only focusing on hormones and gender identity for diagnoses
Holding referrals/prescriptions hostage (demanding info that is irrelevant and not safe)
Why does trans healthcare matter? Study?
Medical Trauma: psychological and physiological responses to pain, injury, serious illness, medical procedures, and negative treatment experiences
Mitigation of harm is the goal in healthcare; rates of asthma, uncontrolled diabetes, and CHF are higher –> Not safe to get care –> avoidance –> Increased risk
1/3 of trans and gender diverse (TGD) people report a negative healthcare experience in the last year
44% of TGD report having an unmet health concern in the past year
71% can obtain necessary care in an emergency department, 52% report negative experiences, 21% report avoiding emergency departments because of negative expectations
Describe the ethical consideration of HCP in gender affirming care
Cannot decline to make care available
Can decide to not provide reproductive/gender affirming care; however, need to ensure individual is aware of where to seek care
Describe the population health impacts of being trans and gender diverse (TGD)? Study? Why has this occurred?
In ON and PQ, trans adults compared to cis gender controls:
42% more likely to live in the lower income neighbourhoods
Have higher rates of chronic disease:
- Asthma: 20.5%
- DM II - 61.8%
- COPD - 60%
- HIV- 1600%
In the US, HIV affects women who are trans disproportionately
- 14% of trans women who have HIV
- 19% of black trans women have HIV
Less than 10% of trans adults who meet criteria for PrEp are on it
Higher mortality due to AIDs, suicide, and drug related death
** The historical and ongoing structural oppression of 2SLGBTQIA+ people has created health disparities **
What is trans broken arm syndrome? How to manage?
When healthcare providers assume all medical issues relate to being trans
Includes discussing trans status and HRT at unnecessary length
Applies to mental health as well
Asking about surgeries, partners, and genitals
Applies to all healthcare
Explain why you need to know the information
What is gender dysphoria?
Incongruence between experienced/expressed gender and assigned gender
- Access to hormones, clothes, etc. does not mean dysphoria
What does gender dysphoria look like?
Dysphoria is different for every trans person
There is no “cure”
Level of dysphoria does not indicate someone is “more” trans
Some people do not experience dysphoria
Describe the DSM-5 criteria diagnosis of gender dysphoria and its role in trans care? ICD-11?
Traditionally required for hormones and surgery - moving away from this definition
ICD-11 - Gender incongruence instead of gender dysphoria
- de-patholoigize trans identities
What are the implications on health of gender dysphoria?
The condition is associated with clinically significant distress or impairment in social, occupational and or other important areas of functioning
Define gender euphoria. What does it refer to?
Satisfaction and joy caused by the congruence between one’s gender identity and their features, expression, or experiences
1) External. internal, or social
2) Term created by and for trans people, unlike “gender dysphoria”
3) Often how trans youth know they are the correct gender
What is a practice point regarding gender euphoria?
Practice Point: Strive to enable gender euphoria rather than just treating dysphoria
1) focus on ways to affirm transgender peers/clients/youth/etc.
2) Help them find what feels good, rather than finding what feels bad
3) Be a cheerleader, not a coach in their transition - Priorities can change - Let them know what is reversible and what isnt but do not impede on their decision
What is the number 1 determination of health for trans people?
Family support is the number 1 determination of health for trans people
What are some of the ways that a trans individual can access medical transition? Describe them?
1) Discuss transition with family physician
- All doctors can prescribe HRT, not all do; many worry about getting it wrong
- Many trans people do not have a family physician (4x higher for trans people in SK) or one they feel safe with (HUGE BARRIER in our system)
2) Connect with doctor who specializes in trans care
- Self-refer or physician referral depending on the clinic
- NOT ALL doctors take self-referral
- Long wait times - Effects are significant and negative
3) Self-prescribe supplements and street HRT
- Unsafe, but quite common
- Harm reduction approach required here - DO NOT SHAME
- Rapidly switch and monitor
When referring a trans individual to an physician, what should be confirmed?
If you are supporting youth with finding doctors, always make sure the doctor provides gender affirming care to patients under the age of 18
Can obtain care in SK if under the age of 18 and understand the risks (mature minor)
Under 18, highest risk of suicide - BLockers are reversible
Describe the process/steps of transition
1) Wait list: 12-18 months (shorten, increase safety) (depends on clinic/doctor)
2) First visit: discuss medical history, transition goals, etc.
3) Follow ups: may be required for DR to asess readiness, physical and mental health (e.g. labs, requisitions, mental health)
4) Blood tests to asess risk
5) Prescription for HRT
–> If injection: first shot(s) usually with pharmacist or doctor
6) Follow ups and blood work every 1-4 months, less frequent after dosing stable
Describe the terminology that should be used to create a safe/inclusive environment
What are some of the components of transition? Describe the relation to one’s goals of transition?
Social - often before seeing a healthcare provider
- Name
- Pronouns
- Clothing
- Hair
- Make up
- Language
- Voice training (feminine voice training at City Hospital)
Medical (HCP territory here)
- Puberty Blockers
- Hormones (HRT)
Surgical
- Top
- Bottom
Other:
- Tracheal Shave
- Facial Feminization Surgery
- Breast Augmentation
- Laser Hair Removal (gendered pricing)
** Individualized goals mean any person may choose any combination of these or none at all **
Describe the use of puberty blockers in transition
Puberty blockers are medications used to pause or slow the effects of puberty
These medications may be started soon after puberty begins
They put puberty on pause and can prevent changes such as voice lowering, breast growth and periods
Effects will vary, depending on how far puberty has progressed before starting the blockers
SAFE - REVERSIBLE - can use when still on self discovery journey
Describe the Tanner Stages of Puberty
When are puberty blockers commonly started?
Puberty blockers are typically started at Tanner stage 2 of puberty (10-16 years of age)
On average: 11-12
What occurs if puberty blockers are discontinued?
If puberty blockers are stopped then puberty will begin again
If youth begins hormone therapy than they will experience puberty related changes associated with the hormone prescribed
What are some of the common reasons why puberty blockers are prescribed?
1) The idea or reality of developing secondary sex characteristics that do not fit with their gender can be very distressing
2) Can give youth time to think about gender, transition and goals without undergoing permenant or distressing puberty
3) Because puberty is slowed or paused this may eliminate the need for procedures like top surgery and hair removal
What is a unique effect of puberty blockers?
Puberty blockers stop breast enlargement
- NOT EVEN TESTOSTERONE DOES THIS - Can be useful for preventing top surgery
Describe the research on puberty blockers
Research indicates puberty blockers are safe and effective in supporting well being, reducing distress, and providing more time for trans youth to make decisions about gender affirming care
What is an example of a puberty blocker?
Leuprolide (Lupron)
Describe the effects of Leuprolide (leupron)
REVERSIBLE EFFECTS
AMAB: Blockers will stop or limit:
- Growth of facial and body hair
- Deepening of the voice
- Broadening of the shoulders
- Growth of the adams apple, coarsening of features
- Growth of gonads (testes) and erectile tissue (penis)
AFAB: Blockers will stop or limit:
- Breast tissue development (THE ONLY MED THAT DOES)
- Broadening of the hips
- Monthly bleeding
In both cases, blockers will temporarily stop or limit:
- Growth in height and accumulation of calcium in the bones (EVIDENCE: will achieve height they would with natural hormones with exogenous hormones)
- Development of sex drive
Fertility
Strong emotions of adolescence
What are the risks associated with puberty blockers?
Risks associated with prescribing blockers:
- Not fully known
- May impact bone development and final height
- Sowed growth of erectile tissue which can limit procedures like vaginoplasty
Risks associated with with-holding Blockers:
- Distress
- Dysphoria
- Anxiety
- Depression
- Suicidal (higher for youth)
What are the feminizing hormones? When are they used? Formulations and coverage?
Feminizing Hormones: Estradiol and androgen blocker
- USed in Tanner Stage 5 ot after puberty - NEED AN ANDROGEN BLOCKER
- Daily pills of estradiol (and androgen blocker while they still have testes) - Benefit: STABLE LEVEL
- Injection available, but not covered –> PMS every week
- Patch available but not covered (> 50, smoker, 40 if risk for hypercoagulability)
- No microdose option
What are the physical effects of feminizing hormones and the reversibility?
Describe the monitoring for feminizing hormones
1) Evaluate patient every 3 months in the first year and then one to two times per year (or more if adjusting doses) to monitor for appropriate signs of feminization and for development of adverse reactions
2) Measure midcycle serum testosterone and estradiol every 3 months
a) Serum testosterone levels should be < 1.74 nmol/L
b) Serum estradiol should not exceed peak physiologic range: 367-734 pmol/L
3) For individuals on cyproterone/spironolactone, serum electrolytes (particularily K+) should be monitored every 3 months in the first year and then annually there after
4) Routine cancer screening is recommended, as in nontrasngender indviduals (all tissues present)
5) Consider BMD testing at basleine (rare to get covered in SK)
a) In individuals at low risk, screening for osteoporosis should be conducted at age 60
b) May need to be sooner in those who are inconsistent with hormone therapy
What is the masculinizing hormone?
Testosterone
Describe the duration, route/formulation, administration and in general testosterone therapy
Injection every 1-2 weeks
–> By self, pharmacist, doctor or nurse
–> Subcutanous (MAIN form) and intramuscular
Gel and patch forms available
Microdose option available
Testosterone is not birth control
- Can still get pregnant and menstruate
- Less spotting occurs with birth control if used along side testosterone
- IUD can lead to dysphoria; nexplanon is a good go to birth control method
Gel - Minimum of 30 mins (ideally 2 hours) with no clothing - Complex - Cost of needle phobia
T bottle lasts 6-8 weeks
Describe the physical effects and reversibility of masculinizing hormone testosterone
Describe the monitoring of masculinizing hormone testosterone
1) Evaluate patient every 3 months in the first years and then one to two times per year (or more if adjusting doses) to monitor for appropriate signs of virilization and for the development of adverse reactions
2) Measure serum testosterone every 3 months until levels are in the normal phsyiologic male range
a) For testosterone enanthate/cypionate injections, the testosterone should be measured midway between injections. The target levels is 13.9-24 nmol/dL. Alternatively, measure peak and trough levels to ensure levels remain in the normal male range
b) For parenteral testosterone undecanoate (not widely available), testosterone should be measured just before the following injection. If the level is < 13.6 nmol/L, adjust the dosing interval
c) For transdermal testosterone, the testosterone level can be measured no sooner than after one week of daily application (at least two hours after application)
3) Measure hematocrit or hemoglobin at baseline and every 3 months for the first year and then one to two times a year. Monitor weight, blood pressure (early onset HTN) and lipids at regular intervals
4) Screening for osteoporosis should be conducted in those who stop testosterone treatment, are inconsistent with hormone therapy or develop risks for bone loss
5) If cervical tissue is present, monitoring as recommended by SOGC (e.g. PAP smears, anal paps smears recommended if anal recpetive intercourse)
6) Ovariectomy can be considered after completion of hormone transition
7) Conduct sub and periareolar breast examinations if masectomy performed. If masectomy is not performed, then consider mammograms as recommended
** Gender markers; reminder for PAPS (any female on health card) ***
Compare the risks of hormone therapy: Masculinizing and Femininzing
Taking on risks of the opposite gender
- SAME RISKS WHEN PRESCRIBING HORMONES IN CISGENDER PEOPLE *
Masculinizing:
- Cardiovascular
- Mood
- Liver dysfunction
- Polycythemia
- Uterine bleeding (some continue to menstruate)
- Infertility
- Atrophy of the genitals**
** TX for atrophy to continue having penetrative sex (e.g. topical estrogen), Sildenafil (continue to have penetrative sex)
Feminizing:
- Venous thromboembolism
- CV
- Mood
- Liver/kidney dysfunction
- Lower libido
- Infertility
What is surgical transition?
Requires referrals, assessments and surgeon consultation
Prepare for long wait times
Must be mentally/physically ready, have recovery plan, and support network in place
–> Down for many weeks and cannot do things on your own
What are the two different types of surgical transition? Describe the availability of these surgeries?
Upper Surgery
- 16+ years old
- In Regina (with nipple grafts, masculinize and replace) and Saskatoon (nipple tattoo)
- Costs covered for trans masc only (not travel)
- Referral by any 1 doctor
Lower Surgery
- 18+ years old
In SK (hysterectomy) or Montreal (vaginoplasty, phalloplasty, new genitalia)
- costs covered (not travel or support person)
Referral by 2 docs (1 “recognized authority”)
Describe the surgical transition coverage
Top Surgery
AFAB: removal of breasts, chest contouring/liposuctioon masectomy-like)
AMAB: breast implants/augmentation (not covered by the government)***
Bottom/Lower Surgery (Most frequently Montreal)
AFAB: Phalloplasty, metoididioplasty, vaginectomy, scrotoplasty
AMAB: vaginoplasty with or without canal
Others:
Hysterectomy with or w/o, or partial oophorectomy
Orchiectomy
Facial feminization surgery (FFS) (not covered by our gov’t)**
Body sculpting, fat transfer, etc not covered by our gov’t) **
LAser/electrolysis hair removal not covered by our gov’t)
*** May be covered through CanadaLife or Sunlife plans
Describe the coverage of surgeries for trans individuals
Less things are covered for trans-fem individuals (more covered for trans-masc folks)
Trans-fem have an increased risk of experiencing violence
Describe the role of the pharmacist in trans health care
1) HRT prescriptions and education about administration
2) Injection teaching/education at times
3) Syringe and sharps container (ALWAYSSS)
- Keep a note of the needle size, some may use more than one needle (1 to draw up dose, 1 to inject
4) Communication with providers in care team
5) Advocate for patients
6) First line communication between patients and healthcare team
Describe the current state of pharmacy and trans care
36% community pharmacists felt comfortable asking pt’s pronouns
40% pharmacists rated selves as “not at all prepared” to counsel on gender
affirming therapy regimens
50% of trans people reported apprehension about experiencing discrimination at the pharmacy
54% percent perceived pharmacists had little to no knowledge of TNB (Trans/Non-Binary)-related health care
● Common coping actions:
○ Delayed seeking of healthcare
○ Non-disclosure of authentic gender identity
○ 13% avoided healthcare bc of perceived purposeful embarrassment experienced at a pharmacy.
New pharmacists have potential to improve the field and set new standards for care
Describe the coverage of HRT in Saskatchewan
1) NIHB: covers HRT fully for registered First Nations and Inuit
- Drugs and pharmacy benefits for First Nations and Inuit
2) Sask Health: partially covers HRT
- Without job benefits/family coverage = 65-70 per vial of testosterone
- With benefits/insurance = costs vary 0-50$
3) Special Support Program: Depending on income, someone can apply
Compounded HRT is not coveres: t-gel (covered by NIHB), injectable estrogen
Many trans people have fears around using job benfits for HRT is not out or feel safe with employer
** Reassure clients that employers cannot view employees prescriptions through insurance companies
Describe NIHB coverage for gender affirming products
What are some of the available practice guidelines for trans health care?
