Providing Care to LGBTQ Patients Erica M. Metz,

Providing Care to LGBTQ Patients Erica M. Metz,

Providing Care to LGBTQ Patients Erica M. Metz, MD Regional Medical Director for Transgender Health, Kaiser Permanente NCAL San Francisco Asthma Network Forum September 30, 2016 1 Disclosures No financial relationships Will discuss FDA off-label treatments 2 Objectives 1. Become familiar with definitions and terminology related to sexual orientation and gender identity. 2. Examine health care disparities that may affect LGBTQ patients and strategies to reduce them . 3. Develop skills to provide sensitive and respectful care to

LGBTQ patients. 4. Learn the basics of hormonal, surgical and preventive care for transgender patients. Fifth Agenda 3 Objectives 1. Become familiar with definitions and terminology related to sexual orientation and gender identity. 2. Examine health care disparities that may affect LGBTQ patients and strategies to reduce them . 3. Develop skills to provide sensitive and respectful care to LGBTQ patients. 4. Learn the basics of hormonal, surgical and preventive care for transgender patients. Fifth Agenda 4

Key Terms & Concepts| The Gender Unicorn Construct 5 Key Terms & Concepts| What is the Q? esbian LLesbian ay GGay isexual BBisexual ransgender TTransgender ueer or or Q Questioning uestioning QQueer 6 Key Terms & Concepts| Definitions Gender Identity

A persons innate perception (or sense) of their own gender; a persons gender identity may or may not be the same as that persons sex assigned at birth Transgender Describes an individual whose gender identity differs in some way from the sex they were assigned at birth Transman (Female to Male) Assigned Transwoman (Male to Female) Assigned Gender Non-Conforming Gender Non-Binary Gender Dysphoria Transition female at birth, has a male gender identity, may seek treatment to masculinize

To present, dress or act differently from what society expects of a person of a specific gender The discomfort or distress that is caused by a discrepancy between a persons gender identity and that persons sex assigned at birththat can in large part be alleviated by treatment. 7 male at birth, has a female gender identity, may seek treatment to feminize Identity does not conform to a binary understanding of gender as limited to male and female The process an individual takes to improve congruence between their outward appearance and their gender identity; which may including changing their gender expression, taking hormone therapy, and/or having surgery. Transgender Terms & Concepts | Terms to Use & Avoid Appropriate Terms

Inappropriate Terms (Avoid Use) Transgender individual / person Trans* community Transvestite Transsexual Transgendered Transgender Woman Transwoman Woman Male to Female/MTF (refers to treatments, not individuals) Transgender Man Transman Man Female to Male/FTM (refers to treatments, not individuals)

Transition Sex Change Gender Affirming Surgery Lower Body Surgery Sex Change Operation Sexual Reassignment Surgery (SRS) Bottom Surgery Assigned Female at Birth / Natal Female / Born Female Assigned Male at Birth / Natal Male / Born Male Cis-gender Normal Female, Real Female Normal Male, Real Male 8 Objectives 1. Become familiar with definitions and terminology related to sexual

orientation and gender identity. 2. Examine health care disparities that may affect LGBTQ patients and strategies to reduce them . 3. Develop skills to provide sensitive and respectful care to LGBTQ patients. 4. Learn the basics of hormonal, surgical and preventive care for transgender patients. Fifth Agenda 9 How many LGBT people are there? Gallup Daily tracking survey: Do you, personally, identify as lesbian, gay, bisexual, or transgender? US: 3.8% are LGBT, 29% are raising children 5.56 same sex couples per 1k households CA: 4.6%, 30% raising children, 7.8 couples/1k households Same-sex Couple and LGBT Demographic Data Interactive. (May 2016).

Los Angeles, CA: The Williams Institute, UCLA School of Law. Link: 10 How Many Transgender People Are There? UCLAs William Institute estimate: 0.6% of US population (1.4 million) May 2015 Census Bureaus analysis of name change since 1936 135,367 people changed name to opposite gender 30,006 also changed their sex 65% transgender men, 35% transgender women Surgery no longer required for legal gender change as of 2013 Kaiser Permanente NCAL employee survey: 2% self-identify as transgender Link: 11 Effects of Stigma Interpersonal Stigma Intrapersonal Stigma Structural

Stigma Inequities and Health Disparities Hatzenbeuler, ML, Link BG. Introduction to the special issue on structural stigma and health. Soc Sci Med 2014; Feb 103: 1-6. 12 Stress Intersectionality

13 Race Class Gender Identity Sexual Orientation Age Religious background Level of education Culture Housing Legal status Mental and physical health Native language Why Focus on this Population? Increased visibility and awareness, more patients out Medically underserved and at risk 19% report being refused care; high levels of postponing care due to fear of discrimination or inability to pay (less likely to be insured) Highest rates of tobacco, alcohol and drug use MSM and transwomen at high risk of HIV infection, particularly people of color

High rates of homelessness (20-40% of homeless youth are LGBT) Nearly 50% of transwomen in one study reported using hormones not prescribed by a physician 50% of transgender people report needing to educate their doctor about how to care for them Elderly LGBT patients have more isolation, fewer family supports and a lack of social services 14 Why Focus on this Population? High rates of suicidality and mental health disparities LGBT youth 2-3x more likely to commit suicide Dane County Survey: 17% of transgender teens with h/o suicide attempt vs 3% of non-trans National Transgender Discrimination Survey found 41% of respondents had attempted suicide 54% of transgender people reported having depression symptoms; LGB people 13%, significantly higher than the general population (6.6%) launched Aug, 2015 -- 20,000 respondents Treatment leading to increased gender congruency results in reduction of medical and psychiatric comorbidities and improvements in well-being and social functioning 15

Lambda Legal, 2010, New York. Available at 16 Smoking 2004 California tobacco use survey: lesbian women 70% more likely to smoke than other women gay men were 50% more likely to smoke than other men The LGBT National Tobacco Control Network estimates that the LGBT community is 50% to 200% more likely than others to be addicted to tobacco Bisexuals with highest rates on state surveys (>30%) LGBT adolescents: 47% of females and 36.7% of males reporting same-sex attraction or behavior smoked (compared to 29%) 17 Factors affecting tobacco use

High stress related to stigma and discrimination Bar culture (social bonding, safe spaces) Lack of access to health care and treatment Tobacco industry targeting, normalizing in ads 18 Objectives 1. Become familiar with definitions and terminology related to sexual orientation and gender identity. 2. Examine health care disparities that may affect LGBTQ patients and strategies to reduce them . 3. Develop skills to provide sensitive and respectful care to LGBTQ patients. 4. Learn the basics of hormonal, surgical and preventive care for transgender patients. Fifth Agenda 19

Build Trust| Key Principles Understand Self-Designation & Use Inclusive Language Be Respectful Avoid assumptions about sexual orientation and gender identity based on appearance Use preferred name (regardless of legal name on medical record) If you are unsure how to address ask, How would you like to be called? or What are your pronouns? If you make a mistake, apologize and correct yourself promptly, and refrain from making an excuse Not all gender non-conforming people are transgender

Ask relevant questions only Provide warm handoffs Alert staff about discrepancies in legal and preferred name and gender marker Only disclose sexual orientation or transgender status if necessary for care Keep conversations with colleagues professional (avoid gossip or jokes) 20 Taking a Sexual History| Best Practices & Examples Ironically, it may require greater intimacy to discuss sex than to engage in it. The Hidden Epidemic, Institute of Medicine 1997 Instead of Ask Do you have a wife/husband or boyfriend/girlfriend?

Do you have a partner? Are you in a relationship? Do you have sex with men, women or both? What is(are) the gender(s) of your sexual partners? Do you use birth control? Do you have sex that could result in pregnancy? What are your future plans/wishes for fertility? Make it routine, normalize, practice! Get to know your patient as a person Ask about behaviors to assess risk (focus on body parts) Protect confidentiality 21

Addressing transgender patients| Best Practices & Examples Best Practices Examples When addressing patients, avoid using gendered terms like sir or maam How may I help you today? When talking about patients, avoid pronouns and other gender terms, or use gender neutral words such as they. Never refer to someone as it. Your patient is here in the waiting room They are here for their 3 oclock appointment Politely ask if you are unsure about a patient's preferred name What name would you like us to use? I would like to be respectfulhow would you

like to be addressed? Ask respectfully about names if they do not match what is in your records. Could your chart be under another name? What is the name on your insurance? Only ask information that is required. Ask yourself: What do I know? What do I need to know? How can I ask in a sensitive way? We all make mistakes. If you do make a mistake: I apologize for using the wrong pronoun. I am sorry I used the wrong name, Sarah I meant she. I am sorry

Apologize and correct yourself promptly Once you apologize, do not continue to tell the person how bad you feelit puts them in a position of needing to comfort you Refrain from giving reasons or excuses for the mistake Do not continue to make the same mistake 22 Document| Preferred Name 23 Document| Gender Identity New Sexual Orientation & Gender Identity SmartForm to document sex assigned at birth, gender identity, pronouns, organ inventory, transition treatment/plans and surgical history

If the SOGI tab is not present, click More Activities and add it 24 Online Resources| Information for patients KP My Doctor Online Transgender Care Multi-Specialty Transitions Clinic Oakland Medical Center Gender Pathways Clinic San Francisco Medical Center 25

Objectives 1. Become familiar with definitions and terminology related to sexual orientation and gender identity. 2. Examine health care disparities that may affect LGBTQ patients and strategies to reduce them . 3. Develop skills to provide sensitive and respectful care to LGBTQ patients. 4. Learn the basics of hormonal, surgical and preventive care for transgender patients. Fifth Agenda 26 Evolving Health Care Environment Kaiser Transgender Benefits DMHC: Insurers Cannot Deny Care to Transgender Patients Friday, April 12, 2013 The California Department of Managed Health Care this week issued guidance reminding

health plans that discrimination against transgender individuals violates anti-discrimination laws. DMHC urged insurers to review health plan documents -- including coverage limitations based on gender -- to ensure they are in compliance with the laws. Federal health board rules Medicare can pay for transgender recipients' sex-change surgeries Friday, May 30, 2014 SAN FRANCISCO (AP) Medicare can no longer automatically deny coverage requests for sex reassignment surgeries, a federal board ruled Friday in a groundbreaking decision that recognizes the procedures are medically necessary for some people who don't identify with their biological sex. Medical care, hormones and mental heath all covered Gender affirming surgery (lower body surgery) and male chest reconstruction (upper body surgery) covered by all commercial plans, the ACA and MediCal Medicare has removed coverage

exclusion, but payment infrastructure remains undeveloped and few surgeons are certified Reconstructive evaluations to determine medical necessity of other procedures 27 Transgender Care| Multidisciplinary Clinic Services Mental Health Medicine Support for patients who are questioning or who have mental health needs related to their gender identity or transition Mental health evaluation for readiness to start

hormones (optional in informed consent model) Mental health evaluation for readiness for gender affirming surgeries Group therapy, support groups and patient education sessions Social Work & Nursing Hormone initiation and management Follow-up and assistance with any medical issues related to transition, including lab monitoring and appropriate health care maintenance screenings

Medical case consultations and pre-operative assessments Gynecology Case management and care coordination Pre- and post-operative planning Addressing insurance, social and financial concerns and arranging for assistance Education about treatment options Referrals to trans* knowledgeable providers 28 Cervical cancer screening and routine gynecologic care for transmen in a gender neutral setting Counseling on fertility preservation Consultations for hysterectomy/oophorectomy

for gender transition Transgender Care| Surgical Services Transwomen Gender Affirming (Lower Body) Surgery Transmen Vaginoplasty Labiaplasty Metoidioplasty (with or without urethral lengthening) Phalloplasty (free flap)

Hysterectomy / Oophorectomy Revision procedures and/or treatment of post-operative complications Orchiectomy Revision procedures and/or treatment of post-operative complications Upper Body Surgery Feminizing mammoplasty (breast augmentation)*

Bilateral mastectomy with chest reconstruction (top surgery) Other Procedures Chondrolaryngoplasty (tracheal shave)* Facial feminization procedures* Speech therapy Voice surgery* Facial hair removal* Speech therapy

*medical necessity determined based on reconstructive surgery statute 29 Clinical Criteria for Transgender Surgery Persistent, well-documented gender dysphoria Two mental health evaluations by therapists trained in gender evaluation (one for chest surgery and other feminizing procedures) Capacity to make a fully informed decision and to consent for treatment Age of a majority in a given country Well-controlled medical or mental health concerns, if present 12 continuous months of hormone therapy (not a prerequisite for male chest reconstruction) 12 continuous months of living in a gender role that is congruent with the patients identity for gender affirming surgery From WPATH Standards of Care, 7th version

30 Prescribe Hormones| Goals of Medical Therapy Give cross-sex hormones to induce physical changes more congruent with a patients gender identity Gradual physical and psychological process taking approximately 5 years to complete (most changes occur 3 mos-2 yrs) Provide patient education regarding options, benefits and risks Expectation setting Fertility goals Importance of monitoring/follow up Individualize treatment to patients goals Use the lowest effective dose to minimize risk of side effects Consider harm reduction (TD estrogen for smokers, encourage cessation) Continue appropriate primary care preventative screenings for organs present

31 Prescribe Hormones| Testosterone options IM injections SC injections Topical Testosterone cypionate 200mg/mL, 100-200mg every 2 weeks Start low dose and increase for desired effect and physiologic level (300-1000ng/dL) Weekly dosing common, reduces fluctuations in energy Generally of IM dose (50mg weekly) Much smaller needle so easier to self inject

Pilot studies and clinician experience suggest equivalent to IM shots Can form inflamed nodules under the skin Gel 12.5mg/pump, 2-8 pumps to skin daily 32 Can transfer to partners Slower, subtle Transdermal patch 24mg/24 hour, applied weekly Limited by rash, rotate sites Hormones in Primary Care| Follow Up for Transmen Refill stable testosterone prescriptions Check testosterone level (treatment monitoring), lipids, FBS,

ALT/AST, CBC every 6 months; HIV/STD screening as appropriate Total testosterone level at midway point between injections more useful than peak or trough (goal 300-1000ng/dl) Encourage smoking cessation Ask about sexual practices; advise pregnancy prevention if at risk Continue routine breast and cervical cancer screening if not surgically removed (some breast tissue remains after top surgery consider screening if high risk) Bone density screening at age 60 or earlier if risk factors or inconsistent testosterone use after oopherectomy 33 Prescribe Hormones| Estrogen Options Estradiol tablets 2-6mg daily Dividing dose bid can reduce nausea Take sublingually instead of swallowing Topical Estradiol Estrogen injections

Weekly transdermal patch 0.1-0.4mg/day Estradiol valerate 2040mg/mL Preferred for patients over 40, who smoke, or who have medical comorbidities Dose 20-60mg IM every 2 weeks Non-formulary biweekly patch (better adhesive) Non-formulary Variable levels Estradiol cypionate 5mg/mL alternative Any of above with Anti-androgen Spironolactone 25-100mg bid, titrate as tolerated until testosterone suppressed to <50ng/dL or

patients goal is met 34 Hormones in Primary Care| Follow Up for Transwomen Refill stable estrogen and spironolactone prescriptions Check lipids, glucose or A1C, Cr/K, ALT, estradiol (goal 50-200pg/mL), total testosterone (suppression monitoring, goal <50) every 6 months; HIV/STD screening as applicable Encourage smoking cessation Ask about sexual practices; consider PrEP if at risk Mammograms recommended starting at age 50 for patients on estrogen for 5 years or more Remove cervical cancer screening prompt: click No Cervix button in PROMPT tab Bone density screening at age 60, consider sooner if risk factors or inconsistently on estrogen (encourage Vitamin D supplements) Prostate cancer screening controversial (PSA typically suppressed) 35 Prescribe Hormones| Literature Review 36 Outcomes in Transwomen on Estrogen

Venous Thromboembolism Driven by hypercoagulable risk factors and type of estrogen Gooren, et al, 2008: NO increase in clot in 2,236 MTF patients on HT from 1976-2006 compared to controls Except for ethinyl estradiol 6-8% Asscheman, et al, 2014: 1% in 1,076 MTF patients over average 5.4 years Wierckx, et al, 2013: 5% of 214 pts in 1st 3 years, but 10/11 had at least one VTE risk factor (smoking, surgery, hypercoaguable disorder) Ott, et al, 2010: no clot in 162 transwomen followed for mean 64.2 months on TD estrogen Cardiovascular risk similar or slightly higher compared to male controls (higher than female controls), also closely tied to smoking One study (Asscheman, et al, 2011) showed increased mortality of 51%, but secondary to substance use, HIV and suicide 37 Outcomes in Transwomen on Estrogen Increased insulin resistance and type 2 diabetes No clear increase in cancer possible prostate cancer incidence 0.04% (Gooren, et al, 2013) no change in breast cancer risk compared to male breast cancer incidence (10

case reports since 1968) Bone density: Wierckx, et al, 2010: 25% of 100 transwomen had osteoporosis after 10 years of hormone therapy Treated with anti-androgens for 1 year prior to starting estrogen Estrogen non-adherence Mueller, et al, 2011, no osteoporosis in 84 transwomen European data suggests transwomen have lower bone density than male controls at baseline 38 Outcomes in Transmen on Testosterone Polycythemia (no adverse outcomes) Increased incidence of type 2 diabetes No increased cardiovascular events

No increased thromboembolism No proven increase in cancer incidence Gooren, et al, 2013 breast cancer incidence 5.9 per 100,000 person years ?slight increase in ovarian cancer but rates still very low No decrease in bone density (may rise) No increased mortality 39 Special considerations for asthma care PFTs in transgender patients Need to know birth gender to accurately interpret results Reference values may be inaccurate if affirmed gender is on medical record Requires sensitivity to explain discrepancy to patients Chest binding for transmen May affect comfort/compliance with spirometry assessments Can affect asthma symptoms No published studies 40 References

American Lung Association, The LGBT Community: A Priority Population for Tobacco Control, de Haan Gene, Santos Glenn-Milo, Arayasirikul Sean, and Raymond Henry F. Non-Prescribed Hormone Use and Barriers to Care for Transgender Women in San Francisco. LGBT Health. December 2015, 2(4): 313-323. doi:10.1089/lgbt.2014.0128. Dejun Su, et al. Mental Health Disparities Within the LGBT Population: A Comparison Between Transgender and Nontransgender Individuals. Transgender Health. Volume 1.1, 2016. DOI: 10.1089/trgh.2015.0001 Erickson, Doug, New transgender research filling in gaps, Wisconsin State Journal, January 26, 2014 Gooren, Louis J, Care of Transsexual Persons, NEJM 2011; 364:1251-7 Gorton, R. Nick, Medical Therapy & Health Maintenance for Transgender Men: a Guide for Health Care Providers, 2005

Healthy People 2020 Topics and Objectives: Lesbian, Gay, Bisexual and Transgender Health, Hembree, Wylie C., et al, Endocrine Treatment of Transsexual Persons: an Endocrine Society Clinical Practice Guideline, J Clin Endocrinol Metab, September 2009; 94(9):3132-3154 Makadon, Harvey J, Achieving Health Equity for Lesbian, Gay, Bisexual and Transgender People, presentation from National LGBT Education Center, a program of Fenway Health Murad, MH, et al, Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes, Clin Endocrinol (Oxf). 2010;72(2):214. NCAL Transgender Benefit Clinician Advisory Group, Kaiser Permanente Transgender Hormone Therapy Practice Resource, September 2012 Tang H, Greenwood GL, Cowling, DW, Lloyd, JC, Roeseler AG, Bal, DG. Cigarette Smoking among lesbians, gays, and bisexuals: how serious a problem? (2004) Cancer Causes and Control. Vol. 15, Number 8. Pages 797-803. UCSF Primary Care Protocol for Transgender Patient Care ( Weinand, JD, Safer, JD, Hormone therapy in transgender adults is safe with provider supervision; A review of hormone therapy sequelae for transgender individuals, J Clin & Translational Endo, June 2015; 2(2):55-60. World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version, 2011 41

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