Caring for the Transgender Patient

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Caring for the Transgender Patient

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

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Objectives

• At the completion of the program attendees will
• Have an understanding of the history of the
  transgender movement
• Articulate the criteria for diagnosis of Gender
  Identity Disorder
• Be able to define common terms associated with
  the transgender movement
• Know the common procedures associated with gender
  change
• Know the hormones used in Gender Identity Disorder

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The Beginning

• Dr. 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
  childs beliefs.
• Introduced the term transsexualism in 1954.
• In 1966 wrote the book The Transsexual
  Phenomenon, the first book on the subject.

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Dr. Harry Benjamin

• In 1979 the
• Harry Benjamin International Gender Dysphoria
  Association
• was formed and named in honor of
• Dr. Benjamin
• The protocols in place currently for hormone
  replacement are based on his research.

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Definitions

• Transsexualism/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.

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Definitions (cont)

• 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

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Definitions (cont)

• 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 puberty
• D. Symptoms present for at least 6 months

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Definitions (cont)

• 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

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Definitions (cont)

• 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

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Definitions (cont)

• 2.) Persistent repudiation of male anatomical
  structures as evidenced by one of the following
• 1. an assertion that he will grow up to be
  a female
• 2. that his penis or testis are disgusting or
  will disappear
• 3. that it would be better not to have a
  penis or testes
• C. Has not yet reached puberty
• D. Symptoms present for at least 6 months

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Definitions (cont)

• 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.

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Definitions (cont)

• GG Genetic Girl
• TG Transgendered Girl
• MTF Male to Female
• FTM Female to Male
• GRS Gender Reassignment Surgery
• HRT Hormone Replacement Surgery
• Spiro Spironolactone

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Tim/Trina
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The Real Life Experience

• Undertake some Combination of
• Maintain FT or PT Employment
• Function as a Student
• Function as a Community Based Volunteer
• Acquire a new legal first or last name
• Provide documentation that persons other than the
  therapist know that pt functions in the new
  gender role.

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Hair Removal or Growth

• Electrolysis or Laser Hair Removal
• Can take up to 2 years of treatments
• Painful Expensive
• Rogaine on the Face/Chest
• Can have adverse systemic effects
• Must be maintained to be effective

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Breast Surgery

• Augmentation for Men
• Most wait until after starting hormones to see
  what growth HRT stimulates
• Reduction for Females
• Most wear binders for several years before
  surgery
• Difficult to find Plastic Surgeons who will go
  small enough

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Hormone Replacement Surgery

• Eligibility Criteria
• 18 years of age
• Demonstrate knowledge of what hormones can
  cannot do medically and what the risks are
  involved with HRT medical social
• Either 3 months of documented life experience OR
• Minimum of 3 months of psychotherapy after the
  initial evaluation has been completed

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HRT (cont)

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

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Biologic Effects of HRT

• Men
• Breast Growth
• Redistribution of body fat
• Decreased upper body strength
• Softening of skin
• Decrease in body hair/Stop loss of scalp hair
• Decreased fertility and testicular size
• Less frequent less firm erections

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Biologic Effects of HRT (cont)

• Females
• Permanent deepening of the voice
• Permanent clitoral enlargement
• Mild breast atrophy/decreased hip fat
• Increased upper body strength
• Increased facial body hair growth
• Male-pattern baldness
• Increased sexual arousability/interest

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Medical Side Effects of HRT

• Men
• Increased risk of DVT/PE
• Development of benign pituitary prolactinemias
• Infertility
• Weight Gain
• Liver Disease
• Emotional Lability

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Medical Side Effects of HRT

• Women
• Infertility
• Acne
• Shift in Lipid Profile
• Hepatic Dysfunction/Liver Tumor Development
• Emotional Lability
• Increase in Sexual Desire

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Relative Contraindications

• Known Cardiovascular Disease
• Strong Risk Factors for CVD
• Cigarette Smoking
• Obesity
• Clotting Disorders
• Some Endocrine Abnormalities

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Pre-Treatment Evaluation

• Must have the GID letter from psych
• Physical Examination w/ BP check
• Up to date on age appropriate screening tests
• Estrogen Therapy
• CMP, CBC, Free Testosterone Level
• Androgen Therapy
• Liver Profile, CBC,

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On-going Evaluations

• Repeat Baseline Labs Physical Exam w/ BP check
  at 6 12 months for both sexes then yearly
  thereafter
• Continue gender specific screening tests for
  pre-treatment gender
• For those receiving estrogen a prolactin level is
  needed at 1, 2, 3 years

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New Screening Tests Needed

• Males on Estrogen Need instructed in self
  breast exam need mammograms
• Females on Testosterone Need annual liver
  palpation

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Considerations after Gonadectomy

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

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HRT Dosing

• MTF
• Oral Estradiol (Estrace) 6-8mg PO or SL
• Oral Conjugated Estrogens (Premarin) 5mg PO
• Transdermal Estrogen (Vivelle) 2 0.1mg patches
  changed 2x/week.
• AND
• Spironolactone 200-400mg/d

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HRT Dosing

• FTM
• Testosterone Injectable 150-200mg q2weeks
• Transdermal Testosterone (Androderm) 5 7.5mg
  changed QD
• Testosterone Gel (Androgel) 5-10mg applied daily

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Gender Reassignment Surgery

• Mastectomy or Breast Augmentation
• Reduction Thyroid Condroplasty
• Rhinoplasty
• Liposuction of Waist
• Face Lift/Facial Bone Reduction
• Blepharoplasty
• Hysterosalpingo-oopherectomy

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Gender Reassignment Surgery

• Vaginoplasty by one of 3 methods
• Penile Skin Inversion
• Pedicles Rectosigmoid Transplant
• Free Skin Graft to Neovagina
• Phalloplasty including
• Vaginectomy
• Scrotoplasty
• Urethroplasty

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Conclusion

• Patients 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 PCPs must
  be familiar with the subtleties of this condition.