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MFSRH Part 2 (2023) > Transgender Health Problems > Flashcards

Transgender Health Problems Flashcards

1
Q

What trans rights are mentioned in the Equality Act 2010?

A
  • 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
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2
Q

What should a trans man receiving hormone therapy be told re. contraception?

A
  • 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
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3
Q

What considerations are there for using a copper IUD for a trans man for contraception?

A
  • Effect of having an intimate examination
  • Safe and do not interfere with any hormones
  • May be associated with increased vaginal bleeding and IMB
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4
Q

What considerations are there for progestogen-only methods of contraception for trans men?

A
  • 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
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5
Q

What considerations are there for using CHC as contraception for trans men?

A
  • Could use continuously / extended regime to improve length of time of amenorrhoea / reduce unscheduled bleeding
  • Not recommended if taking testosterone due to the estrogen
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6
Q

Does testosterone replacement affect emergency contraception?

A

No

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7
Q

What contraceptive advice should be given to a trans woman on estradiol treatment?

A
  • 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
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8
Q

What advice should be given to a trans woman receiving GnRH analogues / finasteride / cyproterone acetate?

A
  • 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
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9
Q

Does PEP or PrEP interact with hormones used in gender transitioning?

A

No

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10
Q

Which CT/GC NAAT testing should/can be performed in a trans man who still has a vagina/uterus?

A
  • 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
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11
Q

Which CT/GC NAAT testing should/can be performed in a trans woman with a neo vagina?

A
  • Urine NAAT is appropriate for all trans and non-binary people
  • Can also do VVS NAAT
  • Consider whether needs throat or rectum swab
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12
Q

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?

A
  • 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
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13
Q

What negative effects on the body can occur in trans people? (testosterone and estrogen)

A

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

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14
Q

What gender surgery can be performed for someone who was assigned male at birth?

A
  • 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
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15
Q

Name some complications of gender reassignment surgery performed for people who were assigned male at birth

A

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

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16
Q

What gender surgery can be done for individuals assigned female at birth?

A
  • Hysterectomy +/- salpingoophorectomy
  • Colpoplasty/colpoclesis/colpectomy (closure, fusion or removal of vagina)
  • Scrotoplasty
  • Metoidioplasty (creation of a small penis from enlarged clitoral tissue)
  • Phalloplasty
17
Q

What complications can arise from gender reassignment surgery for individuals who were assigned female at birth?

A
  • Urethral stenosis / urination difficulties
  • Urethral fistulae
  • Sexual function problems
  • Need for multiple revisions
  • Infection or explantation of penile implants
18
Q

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?

A

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?
19
Q

What are the 7Ps in taking a sexual history from a trans individual?

A
  • 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)
20
Q

Describe first- and second-line hormone regimens for transgender men

A

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

21
Q

What monitoring is required for testosterone therapy?

A
  • 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
22
Q

What are the clinical goals for treatment with testosterone to achieve physical virilisation?

A
  • 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
23
Q

What are the biochemical goals for treatment with testosterone?

A
  • 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
24
Q

What are first-, second- and third-line hormone regimes for transgender women?

A

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

25
Q

What monitoring is required for transgender women receiving estrogen therapy?

A
  • 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
26
Q

What are the clinical treatment goals for physical feminisation?

A
  • 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
27
Q

What are the biochemical treatment goals for physical feminisation?

A
  • 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

28
Q

What is a gender recognition certificate?

A
  • 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
29
Q

What is the standard application track to applying for a gender recognition certificate?

A

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

30
Q

Describe gender non conformity

A

The extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex

31
Q

Describe gender dysphoria

A

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)

32
Q

How long can someone store their eggs, sperm or ovaries for, as per the Human Fertilisation and Embryology Authority?

A
  • Up to max 55 years
  • Renewed consent needs to take place every 10 years

MFSRH Part 2 (2023) (22 decks)

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