10/3/2016 A PHARMACIST’S ROLE IN LEARNING OBJECTIVES CARING FOR TRANSGENDER AND GENDER NON- • De fine c urre nt a nd a ppro pria te vo c a b ula ry fo r CONFORMING PATIENTS disc ussing tra nsg e nde r a nd g e nde r no n-c o nfo rming (T GNC) pe o ple . • Re c o g nize b a rrie rs to he a lthc a re fa c e d b y T GNC J ES SIC A C O N KLIN , P HA R M D , P HC , B C A C P , A A HIV P , C D E V IS ITIN G A S S IS TA N T P R O FESSO R pe o ple P HA R M A C Y P R A C TIC E A N D A D M IN ISTR A TIV E S C IEN C ES UN M C O LLEG E O F P HA R M A C Y • Re c a ll c urre nt me dic a tio n the ra py o ptio ns fo r T GNC J EC O N KLIN @ SA LUD . UN M . ED U pe o ple • I de ntify o ppo rtunitie s fo r pha rma c ist to pro vide po sitive , a ffirming c a re fo r T GNC pa tie nts • L ist re fe re nc e s tha t re info rc e a ppro pria te T GNC c a re PREVALENCE OF TGNC PATIENTS IN BOSTON DEFINITIONS • Assigne d se x (natal se x) • Ge nde r a ssig ne d a t b irth, typic a lly b a se d o n e xte rna l g e nita lia Possible explanations for • Affir me d ge nde r inc r ease: • An individua l’ s g e nde r ide ntity; ma y o r ma y no t a lig n with na ta l g e nde r • Soc ial/ Cultur al ac c eptanc e • Ge nde r ide ntity • A c o mple x de ve lo pme nta l unde rsta nding o f o ne ’ s g e nde r se lf with • Gr eater medic al ac c ess psyc ho lo g ic a l, physio lo g ic a l, e nviro nme nta l a nd so c io c ultura l influe nc e s • Ge nde r be havior s: • Ho w a pe rso n ma y e xpre ss the ir g e nde r (dre ss, spe e c h, inte rpe rso na l style ) • Ge nde r r ole s: • Be ha vio rs, a ttitude s a nd pe rso na lity tra its so c ie ty de sig na te s a s “ma le ” o r “fe ma le ” Gender identity, behavior s and r oles do not always Re isne rSL e t a l. J U rban He alth . 2015 Jun; 92(3):584-92. 1. Re isne r, 2015 align GENDER PRONOUNS DEFINITIONS: GENDER SPECTRUM • Cisge nde r • Use pro no uns b a se d o n patient pr efer enc e • So me o ne who ide ntifie s with the ir a ssig ne d se x a t b irth • F • T e ma le : she / he r r ansge nde r • So me o ne who ide ntifie s a s a diffe re nt se x tha n the o ne a ssig ne d • Ma le : he / him a t b irth (ma y b e no n-b ina ry, the re is a spe c trum) • Ge nde r ne utra l: ze / ze r • T man : A pe rso n a ssig ne d fe ma le a t b irth who r ansge nde r ide ntifie s a s a ma n (tra ns-ma le ) • Ge nde r ne utra l: the y/ the m (c a n b e use d a s sing ula r) • T r ansge nde r woman : A pe rso n a ssig ne d ma le a t b irth who ide ntifie s a s a wo ma n (ta ns-fe ma le ) • Pa tie nt’ s ma y ide ntify a s o ne g e nde r b ut no t ye t • Ge nde r non-c onfor ming re a dy to use pro no uns fo r tha t g e nde r • A pe rso n who do e s no t e xpre ss the ir g e nde r in c ultura l o r so c io - typic a l wa ys • Pe rio dic a lly a sk a nd c he c k to ma ke sure the pa tie nt is still using the pro no uns yo u a re using 1
10/3/2016 TYPES OF “TRANSITIONS” GENDER PRONOUNS-HOW TO ASK • Soc ial tr • Physic al tr • T ansition ansition ry to no rma lize yo ur inte ra c tio n o f a sking • Cha ng ing o ne ’ s so c ia l • Using me dic a l pa tie nt’ s pre fe re nc e s g e nde r pre se nta tio n to inte rve ntio ns to c ha ng e • “Hi, my na me is Je ssic a . I ’ m a pha rma c ist a nd I use b e tte r re fle c t a ffirme d se x tra its to b e tte r re fle c t fe ma le pro no uns. Ca n yo u te ll me a b o ut yo urse lf? ” g e nde r a ffirme d g e nde r (ho rmo ne s, surg e rie s, • Spe c ific to pa rtic ula r • “L a st time we ta lke d yo u we re using ma le pro no uns. e tc ) c ultura l a nd so c ia l Wha t pro no uns a re yo u using c urre ntly? ” • No n-me dic a l te c hniq ue s unde rsta nding s o f g e nde r b e ha vio rs a nd inc lude e le c tro lysis a nd ro le s vo ic e tra ining • Do e s no t ha ve to b e in a ll e nviro nme nts SEXUAL IDENTITY VERSUS GENDER IDENTITY Gender Identity Sexual Identity • Stra ig ht • F e ma le • Bise xua l • Ma le • L • No n-b ina ry e sb ia n GENDER DYSPHORIA • Ga y • Ag e nde r • T • Pa nse xua l wo -spirit • Ge nde rq ue e r • Ase xua l • Ge nde rfluid Se xua lity a nd g e nde r a re NOT the sa me c o nc e pts GENDER DYSPHORIA AUDIENCE RESPONSE • Clinic al sympto m T rue o r F a lse : All T GNC pa tie nts e xpe rie nc e • Disc o mfo rt, distre ss OR func tio na l impa irme nt c a use d g e nde r dyspho ria . b y inc o ng rue nc e b e twe e n g e nde r a ssig ne d a t b irth a nd a ffirme d g e nde r 1) T rue • I n 2013, g e nde r dyspho ria wa s a dde d to the Dia g no stic a nd Sta tistic a l Ma nual o f Me nta l 1) F a lse Diso rde rs (DSM)-5 th e ditio n No te DSM-I V dia g no sis o f ‘ g e nde r ide ntity diso rde r’ is no lo ng e r use d no r de e me d a c c e pta b le b y the T GNC c o mmunity 2
10/3/2016 GENDER DYSPHORIA EXPERIENCE DISCRIMINATION FACED BY TGNC PEOPLE • 51% o f T GNC yo uth a re b ullie d a t sc ho o l • T GNC yo uth a re mo re like ly to ha ve lo we r GPAs, miss sc ho o l o r dro p o ut o f sc ho o l e a rly b e c a use o f ha ra ssme nt • 30% o f T GNC yo uth a tte mpt suic ide a t le a st o nc e • (41% o f T GNC a dults) K o sc iw JG e t a l. 2010 Ne w Yo rk: GL SE N. Ha a s AP a t a l. J Ho mo se x. 2011;58(1):10-51. DISCRIMINATION OF TGNC PEOPLE TGNC DISCRIMINATION IN HEALTHCARE • 33% ha ve de la ye d o r did no t a c c e ss • I n 2011, the Na tio na l L GBT Q T a sk F o rc e a nd the he a lthc a re due to disc rimina tio n Na tio na l Ce nte r fo r T ra nsg e nde r E q ua lity • 50% re po rt ha ving to e duc a te the ir me dic al surve ye d 6,450 tra nsg e nde r a nd g e nde r no n- c o nfo rming individuals. pro vide rs • 90% re po rte d ha ra ssme nt o r mistre a tme nt o n the jo b • 28% po stpo ne c a re due to fe a r o f • 26% lo st a jo b due to b e ing tra nsg e nde r disc rimina tio n • 53% ha d b e e n ve rb a lly ha ra sse d in a pla c e o f pub lic • 48% c a nno t a ffo rd me dic al c a re a c c o mmo da tio n • 19% re po rt b e ing re fuse d me dic a l c a re • 30% re po rt ha ving a disa b ility o r me nta l he a lth Gra nt JM e t a l. Wa shing to n: Na tio na l Ce nte r fo r T ra nsg e nde r E q ua lity. 2011 c o nditio n (po pula tio n a ve ra g e is 20%) Gra nt JM e t a l. Wa shing to n: Na tio na l Ce nte r fo r T ra nsg e nde r E q ua lity. 2011 IMPACTS ON HEALTH DUE TO DISCRIMINATION • Da ily stre ss o f disc rimina tio n, stig ma a nd a dve rsity • I nc re a se d ra te s o f sub sta nc e use , a nxie ty, de pre ssio n, suic ide a tte mpts • Hig he r tra uma ra te s in c hildho o d e q ua te to hig he r ra te s OVERVIEW OF HORMONE o f po o r he a lth o utc o me s in a dultho o d • Hig he r ra te s o f HI V THERAPY • 28% o f tra nsg e nde r wo me n in the US ha ve HI V • 56% o f tra nsg e nde r Afric a n-Ame ric a n wo me n ha ve HI V Gra nt JM e t a l. Wa shing to n: Na tio na l Ce nte r fo r T ra nsg e nde r E q ua lity. 2011 Ba ra l SD e t a l. L anc e t. I nfe c t Dis. 2013 Ma r;13(3):214-22. 3
10/3/2016 GOALS OF PHARMACOLOGIC FEMINIZING HORMONE THERAPY INTERVENTIONS • Go a ls T o induc e physic a l c ha ng e s tha t a re mo re c o ng rue nt • T with g e nde r ide ntity o de ve lo p fe ma le se c o nda ry se x c ha ra c te ristic s • I • T ndividualize b a se d o n pa tie nt’ s g o a ls o suppre ss/ minimize ma le se c o nda ry se x c ha ra c te ristic s • Ma ximum ma sc uliniza tio n/ fe miniza tio n • Ge ne ra l a ppro a c h • Minima l ma sc uliniza tio n/ fe miniza tio n fo r a mo re a ndro g yno us • Co mb ine e stro g e n with a ndro g e n b lo c ke r pre se nta tio n ANTI-ANDROGENS ESTROGENS • Spiro no la c to ne • Ora l e stro g e n • Dire c tly inhib its te sto ste ro ne se c re tio n a nd a ndro g e n • T ra nsde rma l e stro g e n b inding to the a ndro g e n re c e pto r • Pa tie nts a t risk o f VT E • GnRH a g o nist • E le va te d trig lyc e ride s • Blo c k the re le a se o f fo llic le stimulating ho rmo ne a nd • I nje c ta b le e stro g e n lute inizing ho rmo ne F e minizing Hor mone s E xpe c te d Onse t E xpe c te d Maximum Ora l: E ffe c t • 17-b e ta e stra dio l (e stra dio l) Bo dy fa t re distrib utio n 3-6 mo nths 2-5 ye a rs Sub ling ua l ta b le t: • (mic ro nize d e stra dio l) De c re a se d musc le 3-6 mo nths 1-2 ye a rs ma ss/ stre ng th So fte ning o f skin/ de c re a se d 3-6 mo nths unkno wn o iline ss De c re a se d lib ido 1-3 mo nths 1-2 ye a rs T o pic a l • T ra nsde rma l (Pa tc h) E ST ROGE N • De c re a se d spo nta ne o us 1-3 mo nths 3-6 ye a rs Ge l, spra y • e re c tio ns Co mpo unde d to pic a l c re a ms Ma le se xua l dysfunc tio n Va ria b le Va ria b le Bre a st g ro wth 3-6 mo nths 2-3 ye a rs Inje c tio n De c re a se d te stic ula r vo lume 3-6 mo nths 2-3 ye a rs • E stra dio l Va le ra te • E stra dio l Cypio na te Ma le pa tte rn b a ldne ss No re g ro wth, lo ss 1-2 ye a rs sto ps 1-3 mo nths H Sta nda rds o f Ca re , 7 th Ve rsio n WPAT 4
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