[“academic half day”, “transgender”, “primary care”]
Shayne Taylor, MD
Insurance often won't cover the visit if the primary dx is e.g. “Gender Dysphoria,“ have to bill it as “HTN”, “Endocrine Disorder NOS”, “Therapeutic Monitoring,“ etc.
Insurance problems even problematic for procedures.
Also, transgender people need two letters of mental health support for any procedures below the belly-button (e.g. TVH). Also, wtf.
Knowledge gaps for patients, providers, insurance as above. Even if well-meaning, physicians typically know too little or are uncomfortable.
½ trans women in the South is HIV+, and of those, outcomes are worse compared with the cis population.
Introducing ourselves with pronouns normalizes the process.
Ask directly, “Hi Emily, nice to meet you, what pronouns do you use?“
Documentation in Epic is getting better, will hopefully be part of the standard intake soon.
Use functional terms that have medical meaning -
“people who menstruate,“ “people with a cervix,“
Regarding the act of sex, think about:
Bottom line is medical therapy for gender dysphoria is life-saving.
Secondarily, regarding risk reduction, many people will buy hormones online if no provider will rx, so better part of valor is to have open conversation, rx meds with appropriate mitigations as possible, monitor closely.
(assigned female at birth, identifies as male)
Essentially, one drug: testosterone.
Forms: Testosterone cypionate/enanthate
Overall strategy:
Reassess every few years to see if the permanent changes are where they'd like, if they're ok with the temporary changes reverting, would like hysterectomy, etc.
Generally FDA approved for MSK injection, but subQ works and is easier for pts (may have to talk to pharm about getting the right needles).
Main issue with gel is the expense, coupons exist (good for needlephobes). Secondary concern is transfer to close contacts.
Birth control: prefer progesterone-only, IUD, Nexplanon
(for unknown reasons, IUDs in people who are on T therapy are associated with pelvic pain, pain w orgasm, so Nexplanon is a great option)
(assigned male at birth, identifies as female)
Two goals: block T, add E2
Block T: - spironolactone @ 100mg daily typically, can go to BID (keep an eye on K, etc.) - bicalutamide @ 50mg - designed for metastatic prostate cancer, monitor CMP - goal T < 50 (may have higher goal if still wants to have sex)
Add E2: - estradiol, prefer patches d/t lowest risk of CVA - patch: vivelle dot (0.05 2x/wk, 0.1 2x/wk, 2x0.1 2x/wk, can go higher but becomes logistically difficult) - pills: 2mg, 4mg, 6mg, 8mg max. Can take SL, but will have to take more often. Careful with lab checking, variability is high. - injections: estradiol valerate/cypionate, q7d 0.2-0.3mL (3-6mg) - level: society guidelines 100-200, practical 200-300 may be more effective, but overall go by symptoms
?progesterone - expert opinion varies - online opinion is pro - may help w breast development - 200mg (PO vs PR) qHS (causes some somnolence) - try for 6mo, reassess (cont if good, d/c if equivocal)
Cancer screening: pap smears (atrophic, let the pathologist know this is a transgender pt), get HPV co-test, mammograms as indicated
Also consider sperm banking (expensive, not always desired, but worth discussing).
Breast removal, very helpful. Usually requires 1 letter from mental health specialist. Cash price is $8500 at VUMC if insurance won't cover.
TVH: prefer keeping ovaries for long-term bone protection, etc.
Metoidioplasty - release the clitoris enlarged by T therapy, can reroute urethra (frequent complications, but can urinate standing up), not large enough for penetrative sex.
Phalloplasty - TVH first, graft from forearm skin, urethral lengthening (also frequent complications, e.g. require I/O cath, SPC), penile implants possible for penetrative sex.
Breast augmentation - well-tolerated, few downsides
Orchiectomy - well tolerated, will also need lifelong HRT
Vaginoplasty - shallow depth, cosmetic but no penetrative depth, few downsides - full depth, needs full electrolysis of scrotum to create vaginal shaft, then needs dilation forever (prevent spontaneous closure, immediately post-op 3-4x/day for 30-45 minutes)
Unless clear indication to stop, which would be rare (?estrogen iso CVA, but even then probably ok to continue), continue their hormones inpatient.