Sexual Health: Diversity in sex, gender and orientation

Question 1

Define the key terminology regarding diversity in gender and sexuality

Answer 1

• If in doubt, ask the patient!
• Gender identity: one’s internal sense of their own gender
• Gender non-conformity: person’s gender identity, role or expression differs from cultural norms prescribed for people of a particular sex
• Transgender: gender identity or expression differs from their assigned sex - independent of sexual orientation
• Non-binary: gender identities that sit within, outside of, across or between the spectrum of male and female binary
  
  • Might identify as gender fluid, trans masculine, trans feminine or bigender
• Gender dysphoria/Gender Identity Disorder: conflict between person’s physical or assigned gender and gender with which they identify
  
  • Experience significant discomfort or distress caused by a discrepancy between their identity and their birth-assigned sex (DSM-5)
  • Not all trans and gender diverse people experience gender dysphoria

Question 2

Describe the informed consent model of care

Answer 2

• Identify any history of migraines, liver disease, seizures, breast tissue lumps, and irregular bleeding, and decide whether these warrant further investigation prior to commencing hormone therapy.
• Consider current medications, allergies, alcohol or tobacco use, and what your patient’s support networks are like at home and at work.
• Discuss fertility goals and reproductive health needs. Provide information on fertility preservation process (many HealthPathways include fertility preservation referral pathways).
• Assess preventative health needs - last cervical screen, STI test, contraception methods, bowel cancer screen, etc.
• Conduct blood tests to establish baseline levels of FBC, E/LFT, fasting glucose/lipids, estrogen and testosterone, as well as blood pressure and weight.
• Provide the patient with informed consent paperwork, showing the patient has been provided with, and understands all the necessary information, and consents to the process.
• A sexual history is not required, but can be undertaken in an affirming manner if also providing sexual health care or screening.
• A genital exam is not required and is not recommended in any guidelines.

Question 3

Describe the assessment of mental health

Answer 3

• Assess mental health and screen for self-harming behaviors and suicidal ideation and intent. Also consider co-existing mental health difficulties, trauma, abuse, family conflict, and eating disorders. N.B. these conditions do not contraindicate access to gender-affirming hormones or surgery, but a referral to a mental health professional would be recommended.
• If referring for mental health assessment, support, or treatment, ensure this is done by an appropriately trained LGBTI-affirming professional.

Question 4

Describe the goals of treatment

Answer 4

• Discuss individual goals and needs. This will be different for each individual and may change over time. Not everyone wants hormonal treatment nor does everyone want surgery.
• Social transition i.e., changing or experimenting with gender presentation, including:
  
  • Personal appearance e.g., haircuts, clothing, genital tucking, breast binding.
  • Asking other people to use a different name and/or gender pronoun.
• Legal processes – amending names and birth certificates to reflect the person’s identity.
• Vocal and communication therapy.
• Hormonal treatments.
• Gamete cryopreservation.
• Genital and non-genital surgery.

Question 5

Describe the goals of treatment: surgical intervention

Answer 5

• Surgical interventions may include:
  
  • Genital surgical interventions:
    
    • Affirmed female: penectomy, orchidectomy, vaginoplasty, clitoroplasty, and vulvoplasty.
    • Affirmed male: hysterectomy/salpingo-oophorectomy, metoidioplasty or phalloplasty, vaginectomy, scrotoplasty, and implantation of erection and/or testicular prostheses.
  • Non-genital surgical intervention:
    
    • Affirmed female: augmentation mammoplasty, facial feminization surgery, hair removal (electrolysis, laser treatment, or waxing), voice surgery, thyroid cartilage reduction, liposuction, lipofilling, and gluteal augmentation.
    • Affirmed male: subcutaneous mastectomy and chest reconstruction, liposuction, lipofilling, and pectoral implants.

Question 6

List some other non-medical goals of treatment

Answer 6

1. Consider providing information on peer support and advocacy groups.
2. If the patient is self-medicating with hormones, sudden cessation is not recommended. Stopping hormones when they have experienced an improvement in mental health associated with therapy may be harmful.
3. Discuss lifestyle changes to address cardiovascular risk associated with hormonal treatments e.g. smoking cessation, weight loss, regular exercise, and managing drug or alcohol dependence. Address and manage other cardiovascular risk factors e.g. hypertension, hypercholesterolemia, and impaired glucose control.

Question 7

Describe medication for transgender patients

Answer 7

• Manage expectations of hormonal therapy. Physical changes occur gradually, and most reach maximum around 1 to 2 years.
• Hormonal therapy is off-license.
• MtF-oestrogens, androgen antagonists, progestogens.
• FtM-androgens.
• Precautions to hormonal treatment:
  
  • Current or recent smoker.
  • Heart failure, cerebrovascular disease, coronary artery disease, AF.
  • History, or family history of VTE – consider screening for causes of thrombophilia.
  • Cardiovascular risk factors: BMI > 30, hyperlipidemia, hypertension.
  • Migraine.
  • Past history of hormone-sensitive cancers e.g., breast, prostate, uterine, testicular.
  • Possible drug interactions.
  • Sleep apnea.

Question 8

Descriibe feminising treatment

Answer 8

• With androgen blockers, use spironolactone 100-200 mg daily. Check electrolytes, urea, and creatinine (EUC) after 1 to 6 weeks. Or use Cyproterone acetate 12.5mg up to 50mg. Titrate doses up to achieve a low testosterone (<2nm/L).
• Transdermal estrogen has lower risks of thromboembolic disease and cardiovascular disease.
• Sandrena estradiol 0.1% gel (1mg/g) 1 mg a day (maximum 5 mg) not applied to the breast area. Measure estradiol level 4 hours after application.
• Estradot or Estraderm 50 micrograms (up to 100mcg) / 24 hours (change patch twice a week). Measure estradiol 48 hours after application and before the new patch.
• Progynova 1 mg daily increasing gradually (up to 8 mg daily dose). Measure estradiol level 4 hours after the dose.
• Estradiol implants are available from special compounding pharmacies. Usually, a 100mg implant is used and it lasts approximately 12 months.
• Estradiol injections are starting to be used in Australia. They have to be ordered from special compounding pharmacies, and the dose is 5-10mg every 1-2 weeks.
• These are suggested starting doses, which may need to be increased according to the patient context, and biochemical levels achieved with therapy. All these medications are available as General Schedule items on the Pharmaceutical Benefits Scheme (PBS).
• Biochemical targets:
  
  • Estradiol approximately 400 to 600 pmol/L after 6 to 9 months (adjusted according to the patient’s biological response). After menopausal age, 200 to 400 pmol/L.
  • Testosterone < 2 nmol/L.
• The standard advice is that progesterone therapy is not recommended as it is associated with cardiovascular disease, breast cancer, weight gain, and depression, and there is no evidence that it enhances breast development.
• However, a lot of trans women ask for natural micronized progesterone, i.e., Prometrium.

Question 9

Describe masculinising treatment

Answer 9

• Injections.
• Primoteston Depot (testosterone enanthate 250 mg/mL). Administer 250 mg intramuscularly every 2 to 4 weeks (or 50% dose subcutaneously weekly).
• Aim for target serum total testosterone levels of 14 to 25 nmol/L (measured just before the next injection) target of 8 to 12 nmol/L.
• Or
• Reandron (testosterone undecanoate 1g/4 mL). Initial dose of 1 g injection followed by another at six weeks, then maintain maintenance dosing approximately every 10 to 15 weeks (average 12 weeks).
• Aim for target testosterone levels of 15 to 20 nmol/L (before giving the next injection). If the level is below 15 nmol/L, consider adjusting dosing level to more frequent dosing intervals.
• Testosterone is not currently available on the PBS without authority. Must be treated by a specialist general pediatrician, specialist pediatric endocrinologist, specialist urologist, specialist endocrinologist, or a Fellow of the Australasian Chapter of Sexual Health Medicine; or in consultation with one of these specialists; or have an appointment to be assessed by one of these specialists.
• Use “Patient must have an established pituitary or testicular disorder” when calling Medicare.
• Testosterone can also be prescribed on a private script.
• A 2015 systematic literature review of hormone therapy found transgender hormone therapy to be safe with no increase in mortality or cancer prevalence. The greatest health concern for transgender women was venous thromboembolism and for transgender men was polycythemia.