TRANS-forming your practice FINAL · • Transvestite / Transvestic fetishism • Drag queen / king • Cross dresser • Gender role non-conformity • Body Dysmorphic Disorder •

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Acknowledge and pay tribute to the traditional territories of the peoples of Treaty 7, which include the Blackfoot Confederacy (comprised of the Siksika, the Piikuni, and the Kainai First Nations) as well as the Tsuut’ina First Nation, and the Stoney Nakoda (including Chiniki, Bearspaw, and Wesley First Nations). Together, we share this land, strive to live together, learn together, walk together, and grow together “in a good way.”

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THE BASICS

Objectives:

• Define “transgender”, the basics of transgender medicine and its challenges

• Select appropriate language and terminology in LGBTQ+ population

• Review social, medical and surgical transition

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PLANNING COMMITTEEChair

Ted Jablonski, MD CCFP FCFPClinical Assistant Professor, University of Calgary, Depart. of Family MedicineClinical Associate, Men’s Sexual Health Clinic, Southern Alberta Institute of UrologyMedical Director, Jablonski Sexual Health and Wellness Calgary, AB

Scientific committee

John Axler, MD CCFP FCFPAssistant Professor, Dept. of Family and Community Medicine,Director of Continuing Education for the Depart. of Community and Family Medicine, University of Toronto,Toronto, ON

Raymond Fung, MD FRCPCEndocrinologistMichael Garron Hospital, University of TorontoToronto, ON

Ed Kucharski, MD CCFPFamily Physician, South East Toronto Family Health TeamMichael Garron Hospital, Cancer Care Ontario, Toronto, ON

Joe Raiche, MD FRCPCAssistant Clinical Professor, Dept. of Psychiatry, University of CalgaryPsychiatrist, Foothills Medical CentreCalgary, AB

Reviewers

Brian Craig, MD CCFP FCFPAssistant Clinical Professor, Dept. of Family Medicine,Memorial University, Saint John Regional Hospital,Saint John, NB

Lydia Hatcher, MD CCFP FCFPAssociate Clinical Professor of Family Medicine,McMaster University, Chief of Family Medicine, St Joseph's Healthcare,Hamilton, ON

Larry McClure, MD CCFP FCFPFamily Physician,Parksville, BC

Daniel Ngui, MD CCFP FCFPClinical Associate Professor, University of British Columbia,Department of Family Medicine,Clinical Lead, Fraser Street Medical,Vancouver, BC

Kevin Saunders, MD CCFPRivergrove Medical Clinic, The Wellness Institute,Winnipeg, MB

Richard Ward, MD CCFP FCFP Clinical Associate Professor, University of Calgary,Medical Director, Primary Care, Alberta Health Services,Albert, BC

Special Thanks Jorge L. Pinzon, M.D., FRCPC, FAAP, FSAHMPediatrician - Adolescent Medicine - Alberta Children's HospitalClinical Associate Professor of Pediatrics and Psychiatry - University of Calgary

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Faculty/Presenter Disclosure• Faculty: Dr. Ted Jablonski, MD CCFP FCFP

• Relationships with financial interests:Principal Investigator (2016 – 2018)Principal Investigator in Clinical studies funded by Pfizer, Lilly, CortriaSpeaker’s Bureau, Advisory Board HonorariaAbbott Laboratories, Aralez (Tribute), AstraZeneca, Bayer, Boehringer‐Ingelheim, Bristol‐Myers Squibb, Eli Lilly, GlaxoSmithKline, Janssen‐Ortho, Lundbeck, Merck Frosst, Mylan, Novartis, Paladin labs, Pfizer, Sanofi‐Aventis, Schering, Servier, Shire, Solvay, Takeda, Valeant, Watson and media companies Antibody, CTC Communications, Edelman, mdBriefCaseMedPlan, Meducom, RxMedia , Science and Medicine

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PRESENTER DISCLOSURE

Dr. Ted Jablonski, MD CCFP FCFP #91934Conflict of Interest Declaration / Disclosure 2017

Principal Investigator (2015 – 2017)Principal Investigator in Clinical studies funded by Pfizer, Lilly, Cortria

Speaker’s Bureau, Advisory Board HonorariaAbbott Laboratories, Aralez (Tribute), AstraZeneca, Bayer, Boehringer-Ingelheim, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Janssen-Ortho, Lundbeck, Merck Frosst, Mylan, Novartis, Paladin labs, Pfizer, Sanofi-Aventis, Schering, Servier, Shire, Solvay, Takeda, Valeant, Watson and media companies Antibody, CTC Communications, Edelman, mdBriefCase MedPlan, Meducom, RxMedia , Science and Medicine

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DISCLOSURE OF COMMERCIAL SUPPORT

• This program has received financial support from the Alliance for Best Practices in Health Education (ABPHE) not-for-profit organization

• This program has received in-kind support from liV Medical Communications & Training Agency

• Potential for conflict(s) of interest• Ted Jablonski has received support from ABPHE

• Ted Jablonski has not received funding from any commercial organization which may benefit from the content of this program

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MITIGATING POTENTIAL BIAS

• The information presented in this CME program is based on the literature available – evidence or expert opinion

• This CME program and its material is peer reviewed and all the recommendations involving clinical medicine are based on evidence that is accepted within the profession; and all scientific research referred to, reported, or used in the CME/CPD activity in support or justification of patient care recommendations conforms to the generally accepted standards

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TRANSGENDER HEALTH

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Q&A

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What is Gender?1

What is the best description of gender identity?2

GENDER

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WHO definition

Gender refers to the socially constructed characteristics of women and men – such as norms, roles and relationships of and between groups of women and men. It varies from society to society and can be changed.

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GENDER IDENTITY

• Inherent sense of being male, female, or along gender non-binary spectrum

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Q&A

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What does the mnemonic LGBTQQIP2SAA stand for?1

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LGBTQQIP2SAA

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Lesbian

Gay

Bisexual

Transgender

Queer

Questioning

Intersex

Pansexual

2 Spirited

Asexual

Ally

Q&A

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What is the definition of TRANSGENDER?1

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TRANSGENDER

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A marked incongruence between one’s experienced / expressed gender and assigned gender at birth

Q&A

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Then what is Gender Dysphoria?1

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GENDER DYSPHORIA

• Previously called Gender Identity Disorder (GID)

• Gender dysphoria involves a conflict between a person's physical or assigned gender and the gender with which he/she/they identify

• People with gender dysphoria may often experience significant distress and/or problems functioning associated with this conflict

• Gender dysphoria is not the same as gender nonconformity (Gender variance, or gender nonconformity, is behavior or gender expression by an individual that does not match masculine and feminine gender norms)

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DSM 5 CRITERIA

A marked incongruence between one’s experienced/expressed gender and

assigned gender, of at least 6 months’ duration, as manifested by at least

two of the following:

1. Incongruence between preferred gender and natal sex characteristics

2. Wish to prevent or remove natal sex characteristics

3. Desire for sex characteristics of alternative gender

4. Desire to be an alternative gender

5. Wants to be treated as an alternative gender

6. Have feelings and reactions of alternative gender

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. (Arlington, Va. : American Psychiatric Publishing, c2013., 2013) 20

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Q&A

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What is NOT Transgender?1

TRANSGENDER IS NOT…..

• Transvestite / Transvestic fetishism

• Drag queen / king

• Cross dresser

• Gender role non-conformity

• Body Dysmorphic Disorder

• Dissociative Disorders

• Psychosis

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Q&A

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How many transgender people do you have in your practice? (Are you sure?)

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PREVALENCE

US 0.3 – 0.5% of population reported Transgender (2004-09)

UK 1% reported gender variant (2012)

Historic stats quoted in past “International estimate” (grossly underestimated) • F to M (Female to Male) 1 in 30,000• M to F (Male to Female) 1 in 7 - 12,000

• In the United States, it is estimated that roughly 1.4 million adults identify as transgender

24https://williamsinstitute.law.ucla.edu/category/research/census-lgbt-demographics-studies/

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Q&A

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What names and pronouns should I use for my transgender patients?

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WHAT NAMES AND PRONOUNS TO USE WITH YOUR PATIENT?

JUST ASK!

• What is your legal name?

• What name would you prefer to be called?

• What pronouns would you prefer for yourself (e.g. he, him, his / she, her, hers / they, them, theirs / other) Please specify:

• If not sure calling someone in from the waiting room, just use their last name.

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GENDER IDENTITY

What is your current gender identity? (Check all that apply)

• Male

• Female

• Female-to-Male (FTM)/Transgender Male/Trans Man

• Male-to-Female (MTF)/Transgender Female/Trans Woman

• Genderqueer, neither exclusively male nor female

• Additional Gender Category/(or Other), please specify

• Decline to Answer

• What sex were you assigned at birth on your original birth certificate?

(Check one) MALE FEMALE

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Q&A

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Is defining sexual orientation needed to determine if my patient is transgender?1

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GENDER VS SEXUALITY

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Q&A

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To what degree does transition impact the overall life of transgender patients?1

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OUTCOMES

Meta analysis of 28 studies with 1833 trans patients. Overall regret rate is 2.2% *

Murad, M. H. et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin. Endocrinol. (Oxf) 72, 214–231 (2010)

Level of significant improvement following hormone therapy and/or gender reassignment surgery (GRS)

Gender dysphoria 80%

Psychological symptoms (depression, anxiety, etc.)

78%

Quality of Life 80%

Sexual functioning 72%

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Q&A

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Are there any unique health risks seen with transgender patients prior to and during transition?

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MEDICAL COMORBIDITIES

Physical

• PCOS (40% of transmen pre-

transition)

• HIV and STIs (3X higher risk)

• Illegal drug use (3X higher

risk)

Psychiatric

• Mood disorders (27%)

• Anxiety disorders (17-31%)

• Personality disorders (15%)

• Substance use disorders (8%)

• Autism spectrum disorder (~5%)

• Suicidal ideation (35%); self-harm (37%); suicide attempts (8X higher)

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PSYCHOSOCIAL COMORBIDITIES

Socioeconomic

• Higher risk of poor social supports

• Lack of income

• Lower education

• Overrepresented in the homeless population (25-40%)

• More likely to face school victimization (40%)

34Claes, L. et al. Non-suicidal self-injury in trans people: associations with psychological symptoms, victimization, interpersonal functioning, and perceived social support. J Sex Med 12, 168–179 (2015)

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Q&A

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How do patients transition?1

Very individualized approach

SOCIAL TRANSITION

MEDICAL TRANSITION – Hormonal / Surgical

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Feminizing MasculinizingHormonal Blockade Leuprolide (GnRH agonist) Leuprolide (GnRH agonist)

Spironolactone

Cyproterone

Finasteride

Hormonal Estradiol Testosterone

? Progesterone

Surgical AugmentationBreast reduction / Male chest

contouring

Tracheal shaving Hysterectomy +/- BSO

Facial feminization

Vaginoplasty Phalloplasty

Orchiectomy Metoidioplasty

OPTIONS FOR MEDICAL TRANSITION

CRITERIA FOR HORMONE THERAPY

Longstanding pattern of gender non-conformity or dysphoria

No confounding psychological, medical, or social problems that would affect treatment

Informed consent

Age of majority in given country

If significant medical or mental health concerns, they must be reasonably well controlled

For adolescents

Gender dysphoria emerged or worsened with puberty

38Coleman, E. et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism 13, 165–232 (2012)

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BEFORE STARTING HORMONES…

• Ask if they know if anyone who has transitioned and if they had any challenges?

• Assess if patient has adequate social supports? Who have they disclosed to? How to they plan on disclosing?

• Need help with connecting patient to community resources, support groups, etc.

• Counsel patient about anticipated hormone effects and risks of hormones

• Assess and counsel on fertility preservation options – if patient is interested

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Suppress:

Anti-androgen• Androgen receptor blocker

• GnRH agonists

− Decrease testosterone

production by suppressing

GnRH-LH- testosterone axis

No prospective randomized

controlled trials on effectiveness

of different regimens

HORMONAL THERAPY: FEMINIZING

Hembree, Wylie et al, Endocrine treatment of Transsexual Persons: An Endocrine Society Clinical practice guideline. Journal Clin Endocrinology and metabolism; 94:3132-3154, 2009. 40

Enhance:

Estrogen− (Progesterone)

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VANESSARequesting to be a new patient in your practice

− 31 year old, Accountant

− Marital status: separated

Past Medical History:

− Major depression / generalized anxiety

− Substance abuse

MEDS: Zoplicone 7.5mg at hsSertraline 150mg OD

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VANESSA

Hormonal therapy

− Estradiol 2 mg

− Spironolactone 200mg

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VANESSA

LAB REPORT (brought in by patient)

• Estradiol 188 pmol/L (female range follicular: 77 – 921, midcycle 139- 2382)

• Testosterone 5.7 nmol/L (female range < 1.8)

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http://www.rainbowhealthontario.ca/TransHealthGuide/pdf/fem-ht-expectedeffectsguide.pdf 44

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Q&A

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What are the most common challenges with hormonal feminization?

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CHALLENGES

Lack of clinical therapeutic effect

Mood / libido

sexual function

side effects

increased risks in older patient

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VANESSA (REVISITED)

You have taken her into your practice, hormones have been titrated and you have started referral for gender transition related surgery

HORMONES

− Estradiol titrated to 4mg

− Spironolactone titrated to 300mg

LAB

− Estradiol 302 pmol/L (female follicular: 77–921, midcycle 139-2382)

− Testosterone 0.9 nmol/L (female < 1.8)

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LET’S REALLY TRANSITION….

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SAM

24 year old Transman healthy, construction worker in relationship

Past Medical History

• Smoker, just quit

• MDD / GAD in past

MEDS

• Started TESTOSTERONE (bought at gym)

• OTC bodybuilding supplements49

Q&A

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What are the hormonal options available to MASCULINIZE a transgender patient?1

How do you chose between options?2

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TESTOSTERONE

http://www.rainbowhealthontario.ca/TransHealthGuide/pdf/rho_transprimarycare_masculinizinghtguide.pdf 51

TESTOSTERONE OPTIONS

• ORAL

• TRANSDERMAL

• INTRANASAL

• INJECTABLE

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http://www.rainbowhealthontario.ca/TransHealthGuide/pdf/masc-ht-expectedeffectsguide.pdf 53

Q&A

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What are the most common challenges with hormonal masculinization?1

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CHALLENGES

• SUPRAPHYSIOLOGIC EFFECTS

• Testosterone side effects − ACNE− MALE PATTERN BALDNESS− MOOD/LIBIDO

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SAM (REVISITED)

• Testosterone 100mg IM weekly

• Testosterone trough level 20.5 nmol/L ( male range 8 – 29 nmol/L)

• Hematocrit 52% L/L

• HDL dropped approx. 30% - remains just above 1.0 mml/L

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Q&A

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Do all transgender patients get surgery?1

SOME ESTIMATES…..

• “Top surgery” /mastectomy >95%,

• TVH/BSO (Total vaginal hysterectomy with or without bilateral salpingoorphorectomy) 50-60% (maybe more??)

• Phallo/metoidioplasty ~15%

• FFS (Facial feminization surgery including tracheal shave) ~5% (likely more would do if public coverage)

• BA (Breast augmentation) 5-10% (again, more would likely consider if not private)

• Vocal chord surgery 1%

• Orchiectomy 5-10%

• Vaginoplasty >75%

• Hair removal (laser) ?50%

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Q&A

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What are possible surgeries for gender transition?

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GENDER TRANSITION SURGERIES “MENU”

Masculinizing surgeries

• Bilateral mastectomy with chest reconstruction

• Hysterectomy with/without bilateral salpingoophorectomy

• metoidioplasty

• phalloplasty

Feminizing surgeries

• Breast surgery / augmentation

• Orchiectomy

• Vaginoplasty

• Facial Feminization Surgery (FFS)

• Cricothyroid shaving / Cricothyroidectomy

• Vocal chord

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GENDER TRANSITION SURGERIES MASCULINIZING (FTM)

Bilat mastectomy with chest “contouring” / reconstruction

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GENDER TRANSITION SURGERIESMASCULINIZING (FTM)

• Hysterectomy with/without bilateral salpingoorphorectomy

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• Metoidioplasty (meto, meta)

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• Phalloplasty (phallo)

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GENDER TRANSITION SURGERIESFEMINIZING (MTF)

• Breast surgery / augmentation

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• Orchiectomy

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• Vaginoplasty

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• Facial Feminization Surgery (FFS)

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• Cricothyroid shaving / Cricothyroidectomy

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• Vocal chord surgeries

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Q&A

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What is the typical post-op course / experience?

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What are the typical complications, if any?2

• Cosmetic appearance (less than ideal – mastectomy/ chest contouring, phallo)

• Multiple procedures to accomplish (phallo)

• Post op wound care / infections

• Elaborate post op care (dilatations)

• Poor functionality (vaginoplasty, phallo)

• Surgical complications – e.g. urethral stricture - phallo

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DISCUSSION

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THANKS!c o n t a c t @ d r t e d j a b l o n s k i . c o m

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RESOURCES

LOCAL

• Organizations, on line support groups

• Specialized clinics, FP “champions” with special interest /specialists with interest

PROVINCIAL

• www.sherbourne.on.ca

• www.rainbowhealthontario.ca/resource-search

• http://www.rainbowhealthontario.ca/TransHealthGuide/

• www.transhealth.vch.ca

NATIONAL

• C-path www.cpath.ca

INTERNATIONAL

• W-path www.wpath.org

• www.transhealth.ucsf.edu

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GUIDELINES - CANADIAN

• www.cpath.ca

• www.transhealth.vch.ca

• http://www.rainbowhealthontario.ca/TransHealthGuide/#guidelines

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ONLINE TRAINING

• http://www.rainbowhealthontario.ca/training

• http://www.rainbowhealthontario.ca/introduction-to-lgbt

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OTHER USEFUL WEB LINKS

• http://www.rainbowhealthontario.ca/about-lgbtq-health/

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TRANS-forming your practice FINAL · • Transvestite / Transvestic fetishism • Drag queen / king • Cross dresser • Gender role non-conformity • Body Dysmorphic Disorder •

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