Transgender health

Question 1

How does one access gender clinic

Answer 1

GP referral to adult services when aged 17 or 18
GP referral to GIDS if younger than this
Can be transferred from GIDS to adult services when turn 18
Self-referral available at some clinics
Current waiting times are very long - 4 years +

Question 2

Gender identity clinics in the uk

Answer 2

Newcastle
Leeds*
Sheffield
Nottingham
Northampton
Tavistock and Portman (London)*
Exeter
* Gender Identity Development Service (GIDS)
CMAGIC - Merseyside
Indigo - Manchester
TransPlus at 56 Dean Street - London
East of England Gender Service - Cambridge and Norfolk

Question 3

How does the process work at Sheffield?

Answer 3

0 - 6 months: Initial assessment - Diagnosis - MDT discussion if required
6 months: Home assessment + start - Voice and communication therapy
12 months: Medical review - Facial hair removal (TF) - Referral for top surgery (TM)
18 months: Lower (genital reconstruction) gender confirmatory surgery pathway
After this: Named professional reviews, peer support workers, psychological therapy, Gendered intelligence

Question 4

Terminology for transgender health

Answer 4

Cisgender
Transgender
Trans man
Trans woman
AFAB
AMAB
Non-binary
Transitioning
Dysphoria
Deadnaming
Misgendering
Gender affirmation surgery
Pronouns
Titles (Mr, Ms, Mrs, Mx)

Question 5

Hormone therapy features

Answer 5

Masculinising hormone therapy - testosterone
Intramuscular - varies from every two weeks to every twenty weeks
Transdermal - daily application
Monitoring of serum testosterone, FBC, LFT (+ others)
Blockers sometimes required for maximum suppression of female 2° sexual characteristics

Question 6

Effects and timescales for masculising hormone therapy

Answer 6

Slide of 19 transgender health

Question 7

Risks of testosterone

Answer 7

Likely increased risk: Polycythemia*, weight gain, acne, androgenic balding, sleep apnoea, emotional instability

Possible increased risk: Altered lipid profiles, liver dysfunction*

Possible increased risk with presence of additional risk factors: T2DM, HTN, mania and psychosis in patients with pre-existing disorders, CVD

Inconclusive/Possible: Breast cancer, osteoporosis, cervical cancer, ovarian cancer, uterine cancer

Close monitoring of FBC + LFT alongside serum testosterone
**Recommended to have TV/TA USS Uterus every 2 years

Question 8

Testosterone Therapy - Monitoring

Answer 8

FBC, U+Es, LFTs, TFTs, prolactin, glucose, HbA1c, lipids serum oestradiol, serum testosterone (FSH + LH if oestradiol not supressed) + BMI & BP
Desired level 8-12nmol/L for injectables and 14-20 nmol/L for gels
Blood tests: 4-6h after gel; trough for injectables
Every 3 months/every 6 months/every year

Question 9

Features of man to woman hormone therapy

Answer 9

Feminising hormone therapy - oestrogen
Transdermal - gels or patches
Oral - tablets
Monitoring of serum estradiol (+ other bloods)
Blockers usually required for maximum suppression of male 2° sexual characteristics
Anti-androgens sometimes also required

Question 10

Effects and timescales of feminising hormone therapy

Answer 10

Slide 13 of transgender health

Question 11

Risks of oestrogen

Answer 11

Likely increased risk: VTE*, gallstones, elevated liver enzymes, weight gain, hypertriglyceridemia, emotional instability

Likely increased risk with presence of additional CVS risk factors including age: Cardiovascular disease

Possible increased risk with presence of additional risk factors including age: T2DM*

Inconclusive/Likely: Breast Cancer

Question 12

Monitoring of Oestradiol therapy

Answer 12

FBC, U+Es, LFTs, TFTs, prolactin (risk of hyperplasia of subclinical microadenoma), glucose, HbA1c, lipids serum oestradiol, serum testosterone (FSH + LH if testosterone not supressed) + BMI & BP
Desired level 350pmol/L – 750pmol/L
Blood tests: 4-6h after gel; 24h after tablet; 48h after patch
Every 3 months/every 6 months/every year

Question 13

Hormone blockers

Answer 13

GnRH analogues (leuproreline) – 3.75mg s/c x 2 then 11.25mg s/c every 12 weeks (T<1.8 nmol/L; E2< 70 pmol/L)
Initial flair up
QTc prolongation
Diabetes and cardiovascular disorders, oedema, liver dysfunction
Antiandrogens (finasteride, cyproterone acetate, spironolactone) not recommended due to SEs

Question 14

Surgical options

Answer 14

Nationally commissioned (NHS England Specialist Gender Affirming Surgery)
Mastectomy with chest wall reconstruction
Phalloplasty
Metoidioplasty
Vaginoplasty
Vulvoplasty

Standalone
Hysterectomy (and bilateral salpyngo-ophorectomy)
Orchidectomy

Question 15

Screening for trans

Answer 15

Breast: Both
Cervical: Trans man only
AAA screening: Both
Bowel screening: Both