Caring for the Transgender Patient Lorraine W. Bock, MSN, CRNP Bock CRNP Services, PC.

Caring for the Transgender Patient

Lorraine W. Bock, MSN, CRNPBock CRNP Services, PC

ObjectivesAt the completion of the program attendees will:Have an understanding of the history of the

transgender movementArticulate the criteria for diagnosis of Gender

Identity DisorderBe able to define common terms associated with the

transgender movementKnow the common procedures associated with

gender changeKnow the hormones used in Gender Identity

Disorder

The BeginningDr. Harry Benjamin (1885-1986) – German born physician trained in Germany with a special interest in research.In 1941 was asked to see a child who “assured to be a girl” whose parent wished to support the child’s beliefs. Introduced the term transsexualism in 1954.In 1966 wrote the book The Transsexual Phenomenon, the first book on the subject.

Dr. Harry BenjaminIn 1979 the Harry Benjamin International Gender Dysphoria Associationwas formed and named in honor of

Dr. BenjaminThe protocols in place currently for hormone replacement are based on his research.

DefinitionsTranssexualism/Transgendered - Person who aspires to or actually lives in the anatomically contrary gender role. The transexual identity has been present for at least 2 years. This is not a symptom of another mental disorder or chromosomal abnormality.

Dual Role Transvestite/Cross Dresser – An individual that wears the clothes of the opposite sex in order to experience temporary membership in that sex. There is no sexual motivation for the dressing. There is no desire to permanently change to the opposite sex.

Definitions (con’t)Gender Identity Disorder (GID) of Childhood

Different Criteria for Boys/Girls

Girls A. Persistent & Intense distress about

being a girl and has expressed desire to be a boy or insists that she is a boy

Definitions (con’t)B. Persistent repudiation of female anatomical structures as evidenced by one of the following

1. an assertion that she has or will grow a penis

2. rejection of urination in a sitting position

3. assertion that she does not want to grow breasts or menstruate

C. Has not yet reached pubertyD. Symptoms present for at least 6 months

Definitions (con’t)Gender Identity Disorder (GID) of Childhood

Different Criteria for Boys/Girls

Boys A. Persistent & Intense distress about

being a boy and has expressed desire to be a girl or insists that he is a girl

Definitions (con’t)B. Either of the following must be present

1.) Pre-occupation with stereotypic female activities as evidenced by cross-dressing or simulating female attire, or by intense desire to participate in games and past-times of girls and rejection of stereotypical male toys, games, & activities

Definitions (con’t)2.) Persistent repudiation of male anatomical

structures as evidenced by one of the following1. an assertion that he will grow up

to be a female2. that his penis or testis are

disgusting or will disappear3. that it would be better not to have

a penis or testesC. Has not yet reached pubertyD. Symptoms present for at least 6 months

Definitions (con’t)Gender Identity Disorder NOS – One

with a strong persistent identification with the cross-gender identity. A persistent discomfort with his or her sex. Sense of inappropriateness in the gender role he/she is currently in. Symptoms present for at least 2 years.

Definitions (con’t)GG – Genetic GirlTG – Transgendered GirlMTF – Male to FemaleFTM – Female to MaleGRS – Gender Reassignment SurgeryHRT – Hormone Replacement SurgerySpiro – Spironolactone

Tim/Trina

The Real Life Experience

Undertake some Combination of:Maintain FT or PT Employment Function as a StudentFunction as a Community Based Volunteer

Acquire a new legal first or last nameProvide documentation that persons other than the therapist know that pt functions in the new gender role.

Hair Removal or Growth

Electrolysis or Laser Hair Removal Can take up to 2 years of treatmentsPainful & Expensive

Rogaine on the Face/ChestCan have adverse systemic effectsMust be maintained to be effective

Breast SurgeryAugmentation for Men

Most wait until after starting hormones to see what growth HRT stimulates

Reduction for FemalesMost wear binders for several years before surgeryDifficult to find Plastic Surgeons who will “go small enough”

Hormone Replacement Surgery

Eligibility Criteria – 18 years of ageDemonstrate knowledge of what hormones can & cannot do medically and what the risks are involved with HRT – medical & socialEither 3 months of documented life experience ORMinimum of 3 months of psychotherapy after the initial evaluation has been completed

HRT (con’t)Readiness Criteria

Pt has had further consolidation of gender identity during the real life experiencePt has made some progress in mastering other problems leading to or improving stable mental healthHormones are likely to be taken in a responsible manner

Biologic Effects of HRTMen

Breast GrowthRedistribution of body fatDecreased upper body strengthSoftening of skinDecrease in body hair/Stop loss of scalp hairDecreased fertility and testicular sizeLess frequent & less firm erections

Biologic Effects of HRT (con’t)

FemalesPermanent deepening of the voicePermanent clitoral enlargementMild breast atrophy/decreased hip fatIncreased upper body strengthIncreased facial & body hair growthMale-pattern baldnessIncreased sexual arousability/interest

Medical Side Effects of HRT

MenIncreased risk of DVT/PEDevelopment of benign pituitary prolactinemiasInfertilityWeight GainLiver DiseaseEmotional Lability

Medical Side Effects of HRT

WomenInfertilityAcneShift in Lipid ProfileHepatic Dysfunction/Liver Tumor DevelopmentEmotional LabilityIncrease in Sexual Desire

Relative ContraindicationsKnown Cardiovascular DiseaseStrong Risk Factors for CVDCigarette SmokingObesityClotting DisordersSome Endocrine Abnormalities

Pre-Treatment EvaluationMust have the GID letter from psychPhysical Examination w/ BP checkUp to date on age appropriate screening testsEstrogen Therapy

CMP, CBC, Free Testosterone Level

Androgen TherapyLiver Profile, CBC,

On-going EvaluationsRepeat Baseline Labs & Physical Exam w/ BP check at 6 & 12 months for both sexes then yearly thereafterContinue gender specific screening tests for pre-treatment genderFor those receiving estrogen a prolactin level is needed at 1, 2,& 3 years

New Screening Tests Needed

Males on Estrogen – Need instructed in self breast exam & need mammogramsFemales on Testosterone – Need annual liver palpation

Considerations after Gonadectomy

Estrogen can be reduced by 1/3 to 1/2 after removal of the testes and still maintain feminizationTestosterone can be reduced by 1/2 after oopherectomy due to risk of osteoporosis

HRT DosingMTF

Oral Estradiol (Estrace®)– 6-8mg PO or SLOral Conjugated Estrogens (Premarin®) – 5mg PO Transdermal Estrogen (Vivelle®) – 2 0.1mg patches changed 2x/week.

ANDSpironolactone 200-400mg/d

HRT DosingFTM

Testosterone Injectable – 150-200mg q2weeksTransdermal Testosterone (Androderm) – 5 – 7.5mg changed QDTestosterone Gel (Androgel) – 5-10mg applied daily

Gender Reassignment Surgery

Mastectomy or Breast AugmentationReduction Thyroid CondroplastyRhinoplastyLiposuction of WaistFace Lift/Facial Bone ReductionBlepharoplastyHysterosalpingo-oopherectomy

Gender Reassignment Surgery

Vaginoplasty by one of 3 methodsPenile Skin InversionPedicles Rectosigmoid TransplantFree Skin Graft to Neovagina

Phalloplasty includingVaginectomyScrotoplastyUrethroplasty

ConclusionPatients who have GID and undergo treatment whether it is mental health therapy, HRT or surgical interventions go through rigorous events in order to “change.” They have a right to unbiased, holistic, primary care and PCP’s must be familiar with the subtleties of this condition.