Welcome to the primary care for the transgender women module. My name is Zil Goldstein and I'm a nurse practitioner at the Center for Transgender Medicine and Surgery at Mount Sinai and an Assistant Professor of Medical Education at the Icahn School of Medicine. Today, we'll be talking about primary care for transgender women. First, we'll be understanding the need for primary care for transgender women, and then we'll get into some of the specifics of how to apply gender-specific health maintenance screening in this population. We'll describe finally how to conduct a sexual health interview and why this is important when working with transgender women. Part of why it is so important to provide health care to transgender people is because of the health disparities in this population. We see less frequent engagement in healthcare for routine and non-transition related needs. We also see 20 percent of transgender women being HIV positive. Primary care providers have a lot of opportunity to do important prevention and treatment work when it comes to HIV, and also a lot of suicide prevention work as we see 40 percent of transgender people having attempted suicide, and 39 percent of transgender people report severe psychological distress. So, there's a lot of work for primary care providers to do when it comes to prevention of suicide and improve them with mental health outcomes. We also see high rates of unemployment and underemployment in this population, which has a negative impact on their health because of lack of access to resources. Providing seamless access to hormone therapy is an important part of primary care for a transgender woman. We should think about this like diabetes, where primary care providers will start treatment with oral anti-diabetic agents, and then refer to endocrinology when they feel the care goes beyond their comfort level. Transgender patients are also not only seeking hormone therapy, but require primary care just like everyone else. It's important not to get caught up on the ins and outs of hormones, and really focus on the care of transgender people as whole people. Many transgender people expect to be treated poorly with 33 percent reporting a bad experience with a health care provider and two percent actually being assaulted in the health care setting. That's a very low number but it's important to remember that transgender people may be expecting this as a possibility when they come in for care. When working with transgender women, it is important to regularly discuss sexual health and the possibility of using pre-exposure prophylaxis to prevent HIV because of the high HIV burden in this population. We also want to routinely be screening for any mental health issues, and developing a network of trans-affirmative mental health providers to whom we can refer our patients when necessary. It's important to check in regularly about transition related means, how transition is going for a patient, and whether or not it's time to refer for any surgical related transition needs. While doing all of this, we are operating in a dearth of data. So, we have to take collaborative decision-making with our patients very seriously, reviewing what data are available, and deciding with the patient what the best choice is for their transition, and to keep them safe, and healthy. It is important to discuss what body parts are present by conducting what we call an organ inventory. For example, estrogen will cause the growth of memory and ductal breast tissue and the amount of time someone has been on estrogen therapy is a key consideration when discussing mammography screening with our patients. It's also important to remember that transgender women retain their prostates even after vaginoplasty. So, having a conversation with our patients about prostate cancer screening remains important. It's important to remember that the United States Preventive Task Force recommends an individual decision with each patient when it comes to prostate cancer screening. Most cases of prostate cancer in transgender women tend to be lesions that have occurred prior to the initiation of hormone therapy. Because we're blocking androgens in transgender women routinely, as a part of hormone therapy, we both see less prostate cancer, and also see a lower sensitivity with the Prostate-Specific Antigen screen. The upper limit of normal for the PSA tests should be considered 1.0. We should also consider digital exams. If a patient has had vaginoplasty, then the prostate will most likely be easily palpable through the anterior wall of the vagina. If a patient has not had vaginoplasty, then a digital rectal exam is still appropriate. It's important to remember that there are no evidence-based guidelines for breast cancer screening for transgender women. There are several factors that we consider when discussing this with our patient. For example, The United States Preventive Task Force recommends that women over 50 be screened for breast cancer using mammography. The University of California San Francisco Guidelines for Transgender Health, recommends screening people after five to 10 years of hormone therapy. Most experts then, consider patients over 50 with at least five years of experience on hormone therapy, to be those that need screening for breast cancer. When we are ordering these screenings, it's important to remember that about 60 percent of transgender women have dense breast tissue. This means that mammography alone may not be adequate screening for breast cancer, and we should consider ordering an ultrasound of the breast at the same time to make sure that we are adequately assessing the breasts for cancer. Clinical breast exams should also be a part of every annual physical for a transgender woman who is on hormone therapy. Current data do not endorse any differences for other routine screenings such as high cholesterol, colon cancer, or diabetes. Existing guidelines should be sufficient for most transgender patients. However, many health disparities in the transgender population stem from under-utilization of screening and preventive care. Building trusting relationships with our transgender patients is an important part of this care. Because people under-utilize screening and preventive care, it is important that they trust us when we recommend that they go for a colonoscopy or have blood work done to screen for diabetes. The general rule to go by is, "if you have it, screen it". When it comes to interpreting lab values in transgender women, there is some debate as to whether or not estrogen will affect HDL or good cholesterol. Some data show that HDL increases on estrogen therapy, and some data show no change. Some data also show weight gain on estrogen therapy, and some data show no change in weight. So there is some debate whether or not there's a benefit to HDL and there's further debate as to whether or not the benefits of a higher HDL are canceled out by the increase in weight when it comes to cardiovascular outcomes. With the suppression of testosterone, we also expect hemoglobin and hematocrit levels to be lower in transgender women after starting hormone therapy. We should consider that the male scale may not be the right scale to use in transgender women when considering these lab values. For example, if a patient has a hemoglobin level of 12.5, they will be considered anemic on most male scales, but not anemic on most female scales. It's important to remember however, that if a transgender woman is anemic on a female scale, then they should be worked up for anemia like any other patient. It's important to remember that there are no data discussing creatinine levels in transgender women. We often see decrease in muscle mass after the initiation of hormone therapy. However, we don't know if this correlates to a lower creatinine level, as muscles when they break down, are processed through the kidneys and excreted as creatinine. When dosing medication for someone who has kidney disease, it's important to consider that there may be changes in the normal level of creatinine. However, there are no guidelines at this time that help guide that decision. Many transgender women choose to undergo genital surgery to change their primary sex characteristics from those of the male, to those of a female. The most common complications with these procedures are what's called granulation tissue or excessive and aggressive healing of that area by the body. Sometimes this granulation tissue needs to be removed and cauterized using silver nitrate to make sure it doesn't grow back. However, the main role of the primary care provider is preparing patients for surgery and preparing them for the post-operative recovery period. Primary care providers should be offering speculum exams to people with vaginas. However, these exams should not occur until three months after surgery. It is vital to find out what technique was used to create a patient's vagina, as different surgeons use different techniques, and this may influence what they need to do post-operatively. It's also important to connect patients to resources locally such as urologists and gynecologists prior to surgery, so they have a relationship with someone who can help take care of them if there are any post-op complications. Most surgical techniques line the inside of the vagina with skin tissue, but other tissues such as colon or abdominal peritoneum may also be used. There is no squamocolumnar junction, or the area where two types of cells meet where HPV usually lives. So, there's little chance of HPV-related cancers. Vaginal skin cancer has been reported in the literature in transgender women after vaginoplasty. So it's important to regularly, visually examine the inside of our patients vaginas. Vaginal strictures, rectovaginal fistulae, or abnormal connections between the vagina and rectum, as well as urinary issues should be evaluated by a specialist. We do see increased rates of smoking and drug use in the transgender population. It's generally believed that this is due to a concept called minority stress, or the stress that transgender people feel being marginalized from society. Many transgender people use substances or tobacco in order to cope with this stress. So it is important to screen trans people for tobacco and substance use, as well as keep in mind that when we are counseling people to stop using substances and to stop smoking, it can be important to take a harm reduction approach, and first focus on reducing use before stopping altogether. Connections with mental health resources are vital to make sure that our patients have the support they need to help stop using these substances. We need to be offering other coping skills for our patients, and not just taking away the techniques that they use to cope with their minority stress. Many transgender patients report an inability to discuss sexual health issues with their providers, due to both their own discomfort discussing their body and their providers discomfort. Given the high rates of HIV among transgender women, it is necessary to discuss sexual health on a regular basis. Transgender people may not be comfortable using medical terms to refer to their body. So, it's important to use general broader terms like private parts or genitals, then listen for the words that the patient uses to describe their body and echo those words back to them throughout the discussion. When working with this population, understanding the specific sex acts someone has engaged in is an important part of offering sexual health care. Rather than using identity as a proxy for how someone engages in sex, we need to understand specifically how someone likes to have sex. Transgender patients may be engaging in sex with cisgender or non-transgender men, cisgender women, or other transgender people. So, it's very important to understand that identity does not dictate how someone has sex. I use two questions to open this discussion. I ask, what are the gender or genders of your partner or partners? And I ask, how do you like to have sex? This way, we can open the conversation generally, and focus in on the specific acts someone engages in. I'll use words like genitals, private parts, or front of genitals and backup genitals to determine exactly what someone is doing, so we can screen appropriately. There are no differences in the vaccine schedule for this population. However, transgender women do not require pregnancy testing prior to the administration of vaccines that could harm a developing fetus, because they do not have a uterus and cannot get pregnant. Hormone therapy does not interact with any vaccines, so the regular pediatric and adult vaccines schedules can be used. In summary, the main points to take away from this module are to take an organ inventory with transgender patients, to screen the body parts that they have, to provide hormone therapy as a part of primary care to help keep transgender patients engaged, to start with broad open questions and narrow down to specific sex acts when discussing sexual health, and to stay up-to-date on the latest data available. Thank you so much for your participation in this module. I hope you found it useful in understanding how to provide primary care to transgender women.
