Transgender Medicine Flashcards
What is assigned sex?
biological classification of a person as female, male, or intersex
assigned at birth based on anatomy
What is sexual orientation?
a persons potential for emotional, spiritual, intellectual, intimate, romantic, and/or sexual interest in other people
Differentiate gender identity and gender expression.
gender identity:
-a persons internal and individual experience of gender
-not necessarily visible to others
-may or may not align with assigned sex
gender expression:
-the way gender is presented and communicated to the world through clothing, speech, body language, hairstyle, voice, and body characteristics and behaviors
What does it mean to be transgender?
when someones gender identity is different than their sex assigned at birth
-may or may not include medical transition or legal changes
What is cisgender?
when a persons gender identity matches their sex assigned at birth
-not a slur
What is medical trauma?
psychological and physiological responses to pain, injury, serious illness, medical procedures, and negative treatment experiences
What does medical trauma look like for the trans community?
being turned away from medical facilities
misgendering/deadnaming
asking unnecessary/invasive questions
only focusing on hormones & gender identity for diagnoses
holding referrals/prescription hostages
What are the population health impacts of being transgender?
higher rates of chronic disease
-asthma
-type 2 diabetes
-COPD
-HIV
higher mortality due to AIDS, suicide, drug-related deaths
What is trans broken arm syndrome?
when HCPs assume all medical issues relate to being trans
-include discussing trans status and HRT at unnecessary length
-applies to mental health as well
What is gender dysphoria?
incongruence between experienced/expressed gender and assigned gender
-associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning
-some do not experience dysphoria
What is gender euphoria?
satisfaction and joy caused by the congruence between ones gender identity and their features, expression, or experiences
-practice point: strive to enable gender euphoria rather than just treating dysphoria
How can trans people access medical transition?
option 1: discuss transition with family physician
-all doctors can prescribe HRT, not all do
option 2: connect with doctor who specializes in trans care
-self-refer (not all) or physician referral
option 3: self-prescribe supplements & street HRT
-unsafe, but quite common
What does the transition process look like?
- wait list: 12-18 months
- first visit: discuss medical history, transition goals, etc.
- follow-ups: for MD to assess readiness, physical/mental health
- blood tests required to assess risk
- prescription for HRT
- follow-ups & bloodwork q1-4 mo, less when dosing stable
What is some terminology to avoid and the terminology to use instead?
homosexual –> gay, lesbian, queer
transsexual –> transgender
sex change –> bottom/lower surgery
gender reassignment surgery –> gender affirming surgery
mastectomy –> top surgery
FTM, MTF –> AFAB, AMAB
real name –> legal name/name on healthcard
preferred pronouns/name –> pronouns/name
What are the components of transition?
social:
-name, pronouns, clothing, hair, makeup, language, voice
medical:
-puberty blockers, HRT
surgical:
-top, bottom, others
individualized goals mean any person may choose any combination of these or none of these
What are puberty blockers?
medications used to pause or slow the effects of puberty
-may be started as soon as puberty begins
-they put puberty on pause and can prevent changes such as voice lowering, breast growth and periods
When are puberty blockers typically started?
Tanner stage 2 of puberty (10-16 yrs)
What happens when puberty blockers are stopped?
puberty will begin again
What happens when hormone therapy is started in youth?
if youth begin hormone therapy than they will experience puberty related changes associated with the hormone prescribed
What are some common reasons why puberty blockers are prescribed?
idea or reality of developing secondary sex characteristics that do not fit their gender can be distressing
gives youth time to think about gender, transition, & goals without undergoing permanent or distressing puberty
may eliminate need for surgical procedures
What does research indicate regarding puberty blockers?
safe and effective in supporting wellbeing, 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
What are the reversible effects of puberty blockers in AMAB?
blockers will stop or limit:
-growth of facial and body hair
-deepening of voice
-broadening of shoulders
-growth of Adams apple. coarsening of features
-growth of gonads and erectile tissue
What are the reversible effects of puberty blockers in AFAB?
blockers will stop or limit:
-breast tissue development
-broadening of hips
-monthly bleeding
What are the reversible effects of puberty blockers in AFAB and AMAB?
blockers will temporarily stop or limit:
-growth in height & accumulation of calcium in bones
-development of sex drive
-fertility
-strong emotions of adolescence
What are the risks associated with puberty blockers?
not fully known
may impact bone development and final height
slowed growth of erectile tissue which can limit procedues like vaginoplasty
What are the risks associated with withholding puberty blockers?
distress
dysphoria
anxiety
depression
suicidality
What are the drugs used for feminizing features?
androgen blocker: leuprolide or spironolactone
estradiol
How long does it take to see changes from HRT?
it takes time
-up to 5 years
Describe the monitoring parameters for feminizing hormone therapy.
- evaluate patient q3mo in year 1 and then 1-2x/yr (more if adjusting doses) to monitor for appropriate signs of feminizing and ADRs
- measure midcycle serum testosterone and estradiol q3mo
-serum testosterone should be < 1.74 nmol/L
-serum estradiol should not exceed 367-734 pmol/L - if on cyproterone/spironolactone: serum elytes (K+) q3mo in year 1 and then annually
- routine cancer screening
- consider baseline BMD:
-low risk consider screening at age 60
-sooner in those who are inconsistent with hormone therapy
What is the hormone used for masculinizing features?
testosterone
How is testosterone typically given?
injection every 1-2 weeks (SC or IM)
-by self, pharmacist, MD, or nurse
-preferred option
gel & patch forms available but gel needs 30min-2h of no contact with clothes
microdose option available
True or false: testosterone is birth control
false
Describe the monitoring parameters for masculinizing hormone.
- evaluate patient q3mo in year 1 and then 1-2x/yr (more if adjusting doses) to monitor for appropriate signs of virilization and for ADRs
- measure serum testosterone q3mo until in normal physiologic range
-for testosterone enanthate/cypionate injections, the level should be measured midway between injections with a target of 13.9-24 nmol/dL
-for parenteral testosterone undecanoate, measure just before the following injection, if < 13.6 nmol/dL adjust interval
-for transdermal testosterone, measure no sooner than after one week of daily application (at least 2h after application) - measure hematocrit or HgB at baseline and q3mo for year 1 then 1-2x/yr, monitor BP/lipids/wt at regular intervals
- screening for osteoporosis if stopped testosterone treatment, inconsistent with hormone therapy or at risk
- if cervical tissue present, monitoring as per SOGC
- ovariectomy can be considered after completion of hormone transition
- conduct sub and peri areolar annual breast examinations if mastectomy performed, mammograms if no mastectomy
What are the risks of masculinizing hormone therapy?
cardiovascular
mood
liver dysfunction
polycythemia
uterine bleeding
infertility
What are the risks of feminizing hormone therapy?
VTE
cardiovascular
mood
liver/kidney dysfunction
lower libido
infertility
What are some key notes regarding upper surgery?
16+ yrs old
in Regina or Saskatoon
costs covered for trans masc only
referral by any 1 doctor
What are some key notes regarding lower surgery?
18+ yrs old
in SK & Montreal
costs covered
referral by 2 doctors (1 recognized authority)
Which surgical transitions are covered by the government?
top surgery:
-AFAB: removal of breasts, chest contouring
bottom surgery:
-AFAB: phalloplasty, metoidioplasty, vaginectomy, scrotoplasty
-AMAB: vaginoplasty with or without canal
others:
-hysterectomy with or without oophorectomy
-orchiectomy
Describe HRT coverage.
NIHB: covers HRT fully
Sask Health: partially covers HRT
depending on income can apply for Special Support
compounded HRT not coverred
