Transgender Health Problems Flashcards
What trans rights are mentioned in the Equality Act 2010?
- Trans and non-binary people are protected from discrimination, harassment and victimisation
- Intentionally misgendering someone could be unlawful harassment
- A right to confidentiality about their birth-assigned sex - disclosing this without consent of the patient (or clear clinical need) is unlawful
What should a trans man receiving hormone therapy be told re. contraception?
- Testosterone is not contraception, even if amenorrhoeic
- GnRH analogues are not contraception, even if amenorrhoeic
- Pregnancy is an absolute contraindication to testosterone therapy due to masculinisation of the fetus
What considerations are there for using a copper IUD for a trans man for contraception?
- Effect of having an intimate examination
- Safe and do not interfere with any hormones
- May be associated with increased vaginal bleeding and IMB
What considerations are there for progestogen-only methods of contraception for trans men?
- Not thought to interfere with hormone regimens
- Injection and LNG IUD may be of particular benefit due to rates of amenorrhoea
- LNG IUD would involve having and intimate examination
What considerations are there for using CHC as contraception for trans men?
- Could use continuously / extended regime to improve length of time of amenorrhoea / reduce unscheduled bleeding
- Not recommended if taking testosterone due to the estrogen
Does testosterone replacement affect emergency contraception?
No
What contraceptive advice should be given to a trans woman on estradiol treatment?
- Estradiol results in impaired spermatogenesis, but it does not provide effective contraceptive cover
- If not undergone orchidectomy yet are still at risk of conceiving with a partner with a uterus and ovaries
What advice should be given to a trans woman receiving GnRH analogues / finasteride / cyproterone acetate?
- These cannot be relied upon to completely reduce sperm or block sperm production, therefore could still conceive with a partner who has a uterus/ovaries
Does PEP or PrEP interact with hormones used in gender transitioning?
No
Which CT/GC NAAT testing should/can be performed in a trans man who still has a vagina/uterus?
- Urine NAAT is appropriate for all trans and non-binary people
- If has penetrative vaginal sex can offer a VVS
- Consider whether needs throat or rectum swab
- If vagina still present but also has undergone neopenis surgery, BASHH guidelines state FVU plus possibility of VVS depending on sexual history
Which CT/GC NAAT testing should/can be performed in a trans woman with a neo vagina?
- Urine NAAT is appropriate for all trans and non-binary people
- Can also do VVS NAAT
- Consider whether needs throat or rectum swab
What speculum considerations should be considered for examining either a trans man who has not yet had surgery or a trans woman who has had vaginoplasty / neo vagina?
- Trans man on testosterone therapy may have a lot of vaginal atrophy and so consider using a small speculum. The patient may feel more comfortable inserting himself.
- Trans woman with a neovagina may benefit from a proctocope instead of a speculum
What negative effects on the body can occur in trans people? (testosterone and estrogen)
Testosterone
- Skin thinning or vaginal atrophy, making penetration uncomfortable or painful
- Clitoris can enlarge and become more sensitive / painful
Estrogen and androgen blockers
- Erectile difficulties
- Lowered libido
- Delayed / reduced ejaculation
What gender surgery can be performed for someone who was assigned male at birth?
- Orchidectomy + reshaping penis/scrotum to form a vagina/vulva
- Penile inversion technique: forming a vagina from penile tissue
- Colovaginoplasty: forming a vagina from a section of bowel
- Other vaginoplasty possible is a combination of the above and other grafted skin
- All of the above require regular dilation by the patient
- Surgery tends not to remove the prostate
- In colovaginoplasty, symptoms of proctitis could occur and should be managed as such
Name some complications of gender reassignment surgery performed for people who were assigned male at birth
Complications can be as high as 32%
- Vaginal canal stenosis
- Urethral meatus stenosis / urination difficulties
- Hair growth within the vagina
- Vaginal discharge
- Vaginal or vulval pain
- Vaginal bleeding
- Vaginal tissue prolapse
- Sexual function difficulties e.g. anorgasmia
What gender surgery can be done for individuals assigned female at birth?
- Hysterectomy +/- salpingoophorectomy
- Colpoplasty/colpoclesis/colpectomy (closure, fusion or removal of vagina)
- Scrotoplasty
- Metoidioplasty (creation of a small penis from enlarged clitoral tissue)
- Phalloplasty
What complications can arise from gender reassignment surgery for individuals who were assigned female at birth?
- Urethral stenosis / urination difficulties
- Urethral fistulae
- Sexual function problems
- Need for multiple revisions
- Infection or explantation of penile implants
What are two good phrases to use when asking a trans person about the type of sex they have or whether they have had any gender reassignment surgery?
Make sure you explain first why you are asking the question
- I need to ask specific questions about the type of sex you have, so that I can understand what sexual health tests I can recommend. Is that okay?
- For me to understand which sexual health tests I can recommend for you, I need to ask specific questions about any previous surgeries you may have had to your genitals. Is that okay?
What are the 7Ps in taking a sexual history from a trans individual?
- Pronouns
- Partners
- Parts (‘bottom’ surgery)
- Practice (what sex do they engage in? insertive/receptive/both/neither? Do they use and/or share sex toys?
- Past history (of STIs)
- Prevention strategies (condoms, PrEP, vaccinations)
- Pregnancy prevention (for AFAB)
Describe first- and second-line hormone regimens for transgender men
First line
- IM or SC testosterone (Nebido) or transdermal testosterone (gel 2% Tostran or patch)
Second line
- GnRH analogues, such as decapeptyl/triptorelin
Oral testo not recommended because of variability in absorption
Testosterone implants not recommended due to risk of supraphysiological serum testo levels
What monitoring is required for testosterone therapy?
- Monitor for virilising and adverse effects
- Monitor serum testo
- Monitor haematocrit and lipid profile before initiation and also at follow-up
- Testo can cause polycythaemia
- BMD screening for those at risk of osteoporosis
- Breast and cervical screening
What are the clinical goals for treatment with testosterone to achieve physical virilisation?
- Relief of gender dysphoria
- Cognitive change
- Amenorrhoea
- Skin and hair changes, facial and body hair growth
- Deepening of voice
- Increased upper body muscle development
- Redistribution of body fat
- Breast atrophy
What are the biochemical goals for treatment with testosterone?
- Serum total testo around 18nmol/L
- Haematocrit, LFTs, fasting glucose and lipids within reference ranges
- Suppression of estradiol and LH/FSH is not included in routine lab monitoring, unless the patient does not become amenorrhoeic within 3 months
- Additional GnRH analogues are rarely necessary
What are first-, second- and third-line hormone regimes for transgender women?
First-line
- Transdermal estrogen (Estradiol patches Evorel 100, or Sandrena gel 2mg, or estrogel)
Second-line
- Oral estrogens in addition to TD estrogen (micronised estradiol preparations such as Zumenon)
Third-line
- GnRH analogues in addition to estrogens - treatment can be continued until gonadectomy or indefinitely
Anti-androgens such as spironolactone or cyproterone acetate can be used, but more adverse effects
Estrogen implants not recommended because of supra-physiological serum estradiol levels
What monitoring is required for transgender women receiving estrogen therapy?
- Monitor for feminising and adverse effects
- Monitor serum testo and estradiol
- Monitor prolactin and triglycerides
- Monitor potassium if on spironolactone
- BMD screening for those at risk of osteoporosis
What are the clinical treatment goals for physical feminisation?
- Relief of gender dysphoria
- Cognitive change
- Skin and hair changes
- Breast growth
- Redistribution of body fat
- Reduction in body hair growth
- Cessation of erections
- Shrinkage of testes
What are the biochemical treatment goals for physical feminisation?
- Serum testo <3.0nmol/L
- Serum estradiol with range of 200-600pmol/L
- Prolactin, LFTs, fasting glucode and lipids within reference ranges
2/3 will achieve treatment goals with estradiol alone
1/3 will require additional GnRH analogues
What is a gender recognition certificate?
- Gender Recognition Act 2004 allows people to apply to the Gender Recognition Panel to receive a Gender Recognition Certificate
- With a full GRC, this person will legally be the gender that is documented on the certificate, and will be entitled to all the legal rights as per that gender
- Allows the person to obtain a new birth certificate in their ‘new’ gender
What is the standard application track to applying for a gender recognition certificate?
Three criteria
1. Evidence of gender dysphoria
2. Lived fully the past 2 years in their acquired gender and will continue to do so
3. Intend to live permanently in their acquired gender until death
Describe gender non conformity
The extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex
Describe gender dysphoria
Discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role
and/or primary and secondary sex characteristics)
How long can someone store their eggs, sperm or ovaries for, as per the Human Fertilisation and Embryology Authority?
- Up to max 55 years
- Renewed consent needs to take place every 10 years
