Transgender medicine Flashcards
Transgender
an umbrella term for people whose gender is different from their ‘assigned’ sex at birth
o inclusive term describing all those whose gender expression falls outside the typical gender
norms
Transsexual
In law, a transsexual person is someone who ‘proposes to undergo, is undergoing or has
undergone gender reassignment (hormones/surgery)
o Somewhat outdated term => now refered to as “gender incongruence”
Trans*
umbrella term
o The expression‘trans’is often used synonymously with ‘transgender’ in its broadest sense.
o Recently the asterisk has become an additional symbol of inclusion of any kind of trans and non-binary gender presentation – hence trans* person
Transman
female assigned person at birth who is living as a man
Transwoman
male assigned person at birth who is living as a woman
Transvestite
someone who cross-dresses but does not want to alter their body
Non-binary gender identity
people are those who don’t feel male or female. They may feel like both or like something in
between. They may have a gender that changes over time or they may not relate to gender at all
Includes:
Gender Queer
Gender Fluid
Agender
Third Gender
a concept in which individuals are categorized, either by themselves or by society, as neither man nor woman.
Non-binary pronouns
Most non-binary persons use they, them, their, theirs, theirself
o Other variations: Ze, zey, zem, zeir, zeirs, zeirself Zie, zim, zir, zirs, zirself Ey, em, eir, eirs, eirself One
Ask the patient which pronouns they would like you to use
What is the WPATH standards of care
World Professional Association for Transgender Health
Worldwide association of multi-disciplinary practitioners working with trans patients
Strong emphasis on the individualization of care
What is the ICD-10 classification of transsecualism?
terminology to change to “gender incongruence”
o A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one’s anatomic sex, and a wish to have surgery and hormonal treatment to make one’s body as congruent as possible with one’s
preferred sex
What is the ICD-10 classification of Dual-role transvestism?
o The wearing of clothes of the opposite sex for part of the individual’s existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement
accompanying the cross-dressing
o NB: can be necessitated for work reasons
o Includes: gender identity disorder of adolescence or adulthood, non-transsexual type
o Excludes: Fetishistic transvestism
What is the ICD-10 classification of Gender identity disorder of childhood?
o A disorder, usually first manifest during early childhood (and always well before puberty),
characterized by a persistent and intense distress about assigned sex, together with a desire to
be (or insistence that one is) of the other sex.
o There is a persistent preoccupation with the dress and activities of the opposite sex and
repudiation of the individual’s own sex.
o The diagnosis requires a profound disturbance of the normal gender identity
Mere tomboyishness in girls or girlish behaviour in boys is not sufficient.
o Gender identity disorders in individuals who have reached or are entering puberty should not be
classified here
o Excludes: egodystonic sexual disorientation and sexual maturation disorder
What is the ICD-10 classification of GFetishistic transvestism?
o The wearing of clothes of the opposite sex principally to obtain sexual excitement and to create
the appearance of a person of the opposite sex.
o Fetishistic transvestism is distinguished from transsexual transvestism by its clear association
with sexual arousal and the strong desire to remove the clothing once orgasm occurs and sexual
arousal declines.
o It can occur as an earlier phase in the development of transsexualism
Describe the assessment for hormonal treatment
Medical history
o Especially migraine history (with aura) => red flag for oestrogen use
Family history
Blood pressure
Weight/BMI should be >35 => surgical restraints
Baseline bloods:
o U+E, LFT, Lipids, Glucose, Thyroid function
o FBC
o FSH, LH, Prolactin, Oestradiol, Testosterone, SHBG (Sex hormone-binding globulin - glycoprotein
that binds to the two sex hormones: androgen and oestrogen)
Describe fertility preservation in a female-to-male patient
o More difficult to harvest/store eggs o Intervention with an area of their anatomy that they may feel extremely uncomfortable about Can cause distress o collection and storage of oocytes o storage of embryo
Describe fertility preservation in a male-to-female patient
o collection of sperm
o storage of sperm
What are the crietia for hormone therapy?
persistent, well-documented gender dysphoria
o long history (2-3 years) of persistent thoughts about gender
capacity to make a fully informed decision and to consent for treatment
age of majority in a given country (if younger, follow the Standards of Care outlined in section VI)
o Start with hormonal treatments at age 16 on the UK
o Hormone blockers may be used in younger patients to delay the onset of puberty
if significant medical or mental health concerns are present, they must be reasonably well-controlled
o e.g. if gender identity issues are causing psychosis
o Treat mental illness first and see where they are then
What are the medical treatments given to transmen?
Sustanon
o intramuscular testosterone
o 125mg IMI 3 weekly
Alternatively => Testim gel o 1⁄2 tube daily o transdermal gel o provides continuous transdermal delivery of testosterone for 24 hours, following a single application
Increase to Sustanon 250mg 3 weekly/ Testim gel 1 tube daily
Nebido
o 1000mg 12 weekly
o Depot injection of testosterone
Aninjectionof a substance in a form that tends to keep it at the site ofinjectionso that
absorption occurs over a prolonged period
What treatments can be given for the supression of menstruation in transmen?
Testosterone alone
Depo-Provera (contraceptive injection) => prevent menstruation
Occasionally, use of GNRH analogues is necessary o Triptorelin (Decapeptyl) 11.25mg 12 weekly o These flood gonadroptropin pathways and blocks oestrogen production/ovarian cycle
Contraception is indicated: o If sexual contact with male partner o Testosterone alone is not sufficient o Progestagen only method >Depo-Provera >Implant/IUS
What are the effects of testosterone therapy on transmen?
Lower voice
Facial and body hair growth
Increased muscle bulk
Amennorrhoea
Clitoromegaly created into a micro phallus
Increased libido
Tendency to be more aggressive “roid rage”
What are the risks of testosterone therapy in transmen?
Polycythaemia – bone marrow is stimulated to produce more RBC
o May need to start taking blood off patient to reduce Hb
Liver dysfunction – occasionally seen
Increased risk for cardiovascular disease
Increased weight
Diabetes
Mental health disturbance
What medical treatment can be given to transwomen?
Tablets => Oestradiol valerate
o 1-2mg daily
o Disadvantage => hepatic first pass metabolism
Transdermal patch => Oestradiol 50mcg/day
o Fewer side effects
o Used in patients >40yrs
Increase to Oestradiol valerate 4-6mg daily
Increase to 100mcg-200mcg patch
What is the use of anti-androgen therapy in transwomen?
block testosterone
GNRH analogues o Triptorelin (Decapeptyl)11.25mg 12 weekly)
Cyproterone Acetate 50mg daily
o an antiandrogen and progestogen
Finasteride 5mg daily
o 5α-reductase inhibitor => prevents conversion of testosterone to dihydrotestosterone
o Promotes hair growth
Spironolactone 50mg daily
o Significantly depresses plasma testosterone levels
o Often used by patients with self-medication
o Can cause electrolyte disturbances
What are the effects of oestrogen therapy in transwomen?
breast growth softer skin less facial and body hair fat redistribution to hips more emotional
What are the risks of oestrogen therapy in transwomen?
Increased risk for VTE (venous thromboembolism)
Increased weight
Increased Blood Pressure
Increased risk for Breast Cancer
What surgical treatment is available for transmen?
Bilateral mastectomy and male chest reconstruction
Hysterectomy and oophorectomy
Metoidioplasty - hypertrophied clitoris is released and urethra redirected through
o surgeon separates the enlargedclitorisfrom thelabia minora, and severs itssuspensory
ligamentin order to lower it to the approximate position of the penis
Phalloplasty
o Radial artery flap skin from the forearm is removed together with the radial artery and nerves
Artery is hooked up to femoral artery in the groin
Nerves are hooked up to clitoral nerve
o Pubic and thigh area are alternative sources of skin
Tend to have less sensation, so the arm is preferred
o Surgeons implant erectile tubes into the phallus, put a reservoir of fluid in the abdomen with a
pump in the scrotum
What surgical procedures are available for transwomen?
Thyroid chondroplasty (Adam’s apple)
Penectomy, orchidectomy, clitoroplasty, vulvoplasty and penile inversion vaginoplasty
o Lubrication necessary for sex
o Regular dilation necessary to prevent body from closing it
Colovaginoplasty => surgical procedure that involves using a section of the end of the large intestine (the sigmoid colon) to create a neovagina
Breast augmentation
Describe urinary tract problems in female-to-male patients after gender reassignment surgery
o Neo-urethral stenosis
o Urethral fistula
Describe urinary tract problems in male-to-female patients after gender reassignment surgery
o Urinary spraying
o Increased risk for UTI due to shortened urethra
Describe problems in female-to-male patients after gender reassignment surgery
dislodgement of erectile cylinders
mechanical failure of erectile mechanism- may need 10-yearly replacement
hysterectomy and oophorectomy usually with one of phalloplasty procedures, as well as vaginal ablation
Describe urinary tract problems in male-to-female patients after gender reassignment surgery
granulation tissue – may need to be treated with silver nitrate cautery
neovaginal hair growth hairballs
vascular occlusion of arterial supply to neo-clitoris
o blood supply may become cut off
o post surgery, there may be a loss of function with orgasm/no penetrative sex possible
neovaginal stricture
ongoing need for dilation
Which patients require smear tests following gender reassignment surgery?
FTM
o Still recommended if cervix still present
o Remove from SCCRS after hysterectomy
MTF
o Ensure not on SCCRS recall system
What cancer screening services are required following gender reassignment surgery
Prostate:
o MTF less risk due to oestrogen and anti-androgen
o FTM Screen as for non-trans males
Breast:
o FTM - still some breast tissue, self-examination, refer breast lumps as usual
o MTF - offer breast screening
