Gender Affirming Care Flashcards

Question

When referring a trans individual to an physician, what should be confirmed?

Answer 1

If you are supporting youth with finding doctors, always make sure the doctor provides gender affirming care to patients under the age of 18 Can obtain care in SK if under the age of 18 and understand the risks (mature minor) Under 18, highest risk of suicide - BLockers are reversible

Answer 2

1) Wait list: 12-18 months (shorten, increase safety) (depends on clinic/doctor) 2) First visit: discuss medical history, transition goals, etc. 3) Follow ups: may be required for DR to asess readiness, physical and mental health (e.g. labs, requisitions, mental health) 4) Blood tests to asess risk 5) Prescription for HRT --> If injection: first shot(s) usually with pharmacist or doctor 6) Follow ups and blood work every 1-4 months, less frequent after dosing stable

Answer 3

Social - often before seeing a healthcare provider - Name - Pronouns - Clothing - Hair - Make up - Language - Voice training (feminine voice training at City Hospital) Medical (HCP territory here) - Puberty Blockers - Hormones (HRT) Surgical - Top - Bottom Other: - Tracheal Shave - Facial Feminization Surgery - Breast Augmentation - Laser Hair Removal (gendered pricing) ** Individualized goals mean any person may choose any combination of these or none at all **

Answer 4

Puberty blockers are medications used to pause or slow the effects of puberty These medications may be started soon after puberty begins They put puberty on pause and can prevent changes such as voice lowering, breast growth and periods Effects will vary, depending on how far puberty has progressed before starting the blockers SAFE - REVERSIBLE - can use when still on self discovery journey

Answer 5

Puberty blockers are typically started at Tanner stage 2 of puberty (10-16 years of age) On average: 11-12

Answer 6

If puberty blockers are stopped then puberty will begin again If youth begins hormone therapy than they will experience puberty related changes associated with the hormone prescribed

Answer 7

1) The idea or reality of developing secondary sex characteristics that do not fit with their gender can be very distressing 2) Can give youth time to think about gender, transition and goals without undergoing permenant or distressing puberty 3) Because puberty is slowed or paused this may eliminate the need for procedures like top surgery and hair removal

Answer 8

Puberty blockers stop breast enlargement - NOT EVEN TESTOSTERONE DOES THIS - Can be useful for preventing top surgery

Answer 9

Research indicates puberty blockers are safe and effective in supporting well being, reducing distress, and providing more time for trans youth to make decisions about gender affirming care

Answer 10

Leuprolide (Lupron)

Answer 11

REVERSIBLE EFFECTS AMAB: Blockers will stop or limit: - Growth of facial and body hair - Deepening of the voice - Broadening of the shoulders - Growth of the adams apple, coarsening of features - Growth of gonads (testes) and erectile tissue (penis) AFAB: Blockers will stop or limit: - Breast tissue development (THE ONLY MED THAT DOES) - Broadening of the hips - Monthly bleeding In both cases, blockers will temporarily stop or limit: - Growth in height and accumulation of calcium in the bones (EVIDENCE: will achieve height they would with natural hormones with exogenous hormones) - Development of sex drive Fertility Strong emotions of adolescence

Answer 12

Risks associated with prescribing blockers: - Not fully known - May impact bone development and final height - Sowed growth of erectile tissue which can limit procedures like vaginoplasty Risks associated with with-holding Blockers: - Distress - Dysphoria - Anxiety - Depression - Suicidal (higher for youth)

Answer 13

Feminizing Hormones: Estradiol and androgen blocker - USed in Tanner Stage 5 ot after puberty - NEED AN ANDROGEN BLOCKER - Daily pills of estradiol (and androgen blocker while they still have testes) - Benefit: STABLE LEVEL - Injection available, but not covered --> PMS every week - Patch available but not covered (> 50, smoker, 40 if risk for hypercoagulability) - No microdose option

Answer 14

1) Evaluate patient every 3 months in the first year and then one to two times per year (or more if adjusting doses) to monitor for appropriate signs of feminization and for development of adverse reactions 2) Measure midcycle serum testosterone and estradiol every 3 months a) Serum testosterone levels should be < 1.74 nmol/L b) Serum estradiol should not exceed peak physiologic range: 367-734 pmol/L 3) For individuals on cyproterone/spironolactone, serum electrolytes (particularily K+) should be monitored every 3 months in the first year and then annually there after 4) Routine cancer screening is recommended, as in nontrasngender indviduals (all tissues present) 5) Consider BMD testing at basleine (rare to get covered in SK) a) In individuals at low risk, screening for osteoporosis should be conducted at age 60 b) May need to be sooner in those who are inconsistent with hormone therapy

Answer 15

Testosterone

Answer 16

Injection every 1-2 weeks --> By self, pharmacist, doctor or nurse --> Subcutanous (MAIN form) and intramuscular Gel and patch forms available Microdose option available Testosterone is not birth control - Can still get pregnant and menstruate - Less spotting occurs with birth control if used along side testosterone - IUD can lead to dysphoria; nexplanon is a good go to birth control method Gel - Minimum of 30 mins (ideally 2 hours) with no clothing - Complex - Cost of needle phobia T bottle lasts 6-8 weeks

Answer 17

1) Evaluate patient every 3 months in the first years and then one to two times per year (or more if adjusting doses) to monitor for appropriate signs of virilization and for the development of adverse reactions 2) Measure serum testosterone every 3 months until levels are in the normal phsyiologic male range a) For testosterone enanthate/cypionate injections, the testosterone should be measured midway between injections. The target levels is 13.9-24 nmol/dL. Alternatively, measure peak and trough levels to ensure levels remain in the normal male range b) For parenteral testosterone undecanoate (not widely available), testosterone should be measured just before the following injection. If the level is < 13.6 nmol/L, adjust the dosing interval c) For transdermal testosterone, the testosterone level can be measured no sooner than after one week of daily application (at least two hours after application) 3) Measure hematocrit or hemoglobin at baseline and every 3 months for the first year and then one to two times a year. Monitor weight, blood pressure (early onset HTN) and lipids at regular intervals 4) Screening for osteoporosis should be conducted in those who stop testosterone treatment, are inconsistent with hormone therapy or develop risks for bone loss 5) If cervical tissue is present, monitoring as recommended by SOGC (e.g. PAP smears, anal paps smears recommended if anal recpetive intercourse) 6) Ovariectomy can be considered after completion of hormone transition 7) Conduct sub and periareolar breast examinations if masectomy performed. If masectomy is not performed, then consider mammograms as recommended ** Gender markers; reminder for PAPS (any female on health card) ***

Answer 18

Taking on risks of the opposite gender * SAME RISKS WHEN PRESCRIBING HORMONES IN CISGENDER PEOPLE * Masculinizing: - Cardiovascular - Mood - Liver dysfunction - Polycythemia - Uterine bleeding (some continue to menstruate) - Infertility - Atrophy of the genitals** ** TX for atrophy to continue having penetrative sex (e.g. topical estrogen), Sildenafil (continue to have penetrative sex) Feminizing: - Venous thromboembolism - CV - Mood - Liver/kidney dysfunction - Lower libido - Infertility

Answer 19

Requires referrals, assessments and surgeon consultation Prepare for long wait times Must be mentally/physically ready, have recovery plan, and support network in place --> Down for many weeks and cannot do things on your own

Answer 20

Upper Surgery - 16+ years old - In Regina (with nipple grafts, masculinize and replace) and Saskatoon (nipple tattoo) - Costs covered for trans masc only (not travel) - Referral by any 1 doctor Lower Surgery - 18+ years old In SK (hysterectomy) or Montreal (vaginoplasty, phalloplasty, new genitalia) - costs covered (not travel or support person) Referral by 2 docs (1 "recognized authority")

Answer 21

Top Surgery AFAB: removal of breasts, chest contouring/liposuctioon masectomy-like) AMAB: breast implants/augmentation (not covered by the government)*** Bottom/Lower Surgery (Most frequently Montreal) AFAB: Phalloplasty, metoididioplasty, vaginectomy, scrotoplasty AMAB: vaginoplasty with or without canal Others: Hysterectomy with or w/o, or partial oophorectomy Orchiectomy Facial feminization surgery (FFS) (not covered by our gov't)*** Body sculpting, fat transfer, etc not covered by our gov't) *** LAser/electrolysis hair removal not covered by our gov't) *** May be covered through CanadaLife or Sunlife plans

Answer 22

Less things are covered for trans-fem individuals (more covered for trans-masc folks) Trans-fem have an increased risk of experiencing violence

Answer 23

1) HRT prescriptions and education about administration 2) Injection teaching/education at times 3) Syringe and sharps container (ALWAYSSS) - Keep a note of the needle size, some may use more than one needle (1 to draw up dose, 1 to inject 4) Communication with providers in care team 5) Advocate for patients 6) First line communication between patients and healthcare team

Answer 24

36% community pharmacists felt comfortable asking pt’s pronouns 40% pharmacists rated selves as “not at all prepared” to counsel on gender affirming therapy regimens 50% of trans people reported apprehension about experiencing discrimination at the pharmacy 54% percent perceived pharmacists had little to no knowledge of TNB (Trans/Non-Binary)-related health care ● Common coping actions: ○ Delayed seeking of healthcare ○ Non-disclosure of authentic gender identity ○ 13% avoided healthcare bc of perceived purposeful embarrassment experienced at a pharmacy. **New pharmacists have potential to improve the field and set new standards for care**

Answer 25

1) NIHB: covers HRT fully for registered First Nations and Inuit - Drugs and pharmacy benefits for First Nations and Inuit 2) Sask Health: partially covers HRT - Without job benefits/family coverage = 65-70 per vial of testosterone - With benefits/insurance = costs vary 0-50$ 3) Special Support Program: Depending on income, someone can apply Compounded HRT is not coveres: t-gel (covered by NIHB), injectable estrogen Many trans people have fears around using job benfits for HRT is not out or feel safe with employer ** Reassure clients that employers cannot view employees prescriptions through insurance companies

Gender Affirming Care Flashcards

(55 cards)