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Gender Affirming Care

Lauren Waskowicz

Documentation:

  • Always ask the patients preferred names and pronouns, document preferred name in eSTAR (see below) and document pronouns, sexual orientation and gender in “Gender and Sexuality” tab found in the drop down menu on the right side of upper dashboard
  • Patient’s legal name and sex should be reflected in the chart, if patient legally changes sex and gender marker, epic officially can reflect that
  • If not, document preferred name in the patient header as below:
    • Click Patient’s Name on eSTAR header to pull up demographics
    • In the box with the patient’s name there is this symbol N, clicking this will bring up a box that will allow you to enter a “preferred name” which will then populate to the patient header
    • Edit your outpatient schedule preferences to show preferred name as a column, click on the cogwheels in your whiteboard, move “pref name” over to the right for selected columns
  • Sexual History: Ask the patient's permission to discuss sexual history, be sure to normalize it and make it a part of every new patient visit.
    • 6 Ps:
      • Partners: How many partners in the past 6 months and how do partners identify (male, female, non-binary etc.)
      • Practices: Type of sex (oral, anal, vaginal). If anal sex, does the patient participate in receptive, penetrative or both practices
      • Protection: Protection from STI (abstinence, monogamy, barrier)
      • Past History of STI: Was STI treated and was a test of cure performed
      • Pregnancy Intention/Prevention: Is patient/partner trying to conceive, if not, what methods are they using for contraception
      • Plus: History of sexual trauma/violence, concerns/satisfaction

Starting Gender Affirming Hormones: (John Hopkins Quick Guide: https://bit.ly/GAHT-QUICK-GUIDE)

  • First 1-2 Visits:
    • Collect Gender History:
      • Ask patient goals - what do they hope to achieve with Gender Affirming Hormone Therapy
      • Are they interested in surgery ➔ Refer as appropriate (see below for referrals)
      • Fertility goals? Recommend sperm banking for trans women, evidence less clear that testosterone affects future fertility in transmen, but egg harvesting still recommended
      • Contraceptive needs (Gender Affirming Hormone Therapy IS NOT birth control) ➔ consider progesterone only options in transmen
      • Interest in hair removal (required for most bottom surgeries), speech therapy
    • Comprehensive History and Physical:
      • Assess health conditions which might be influenced by GAHT: e.g. smoking (VTE risk for AMAB), DM, HTN, HLD, CAD, polycythemia, OSA
      • Medication reconciliation for interactions (can contact VIVID PharmD Dylan Hughes on eSTAR with questions)
      • Assess social and sexual health needs
      • Obtain Baseline Labs (CBC, CMP, estradiol, total testosterone, lipids, a1C)
    • Assess capacity for consent, start informed consent process:
      • Consent may be verbal or written (MedEx Consent form - “Consent Estrogen Hormone Therapy” OR “Consent Testosterone Hormone Therapy”)
    • Write first prescription (3-6 month supply) & needles (if needed)
  • Follow Up Visits: (first year q3m, second year q6m then yearly)
    • Ask about physical and emotional changes (see chart for expected time course)
    • Assess for side effects
      • Injection site reactions
      • Transgender Male: acne, hair loss (consider finasteride), genital dryness 2/2 atrophy (consider topical E)
      • Transgender Female: dizziness/hypotension from spiro (consider alternate blocker)
    • Check Blood pressure and CBC, CMP, estradiol, total testosterone (check hormone levels midcycle if using injections)
  • There are varying opinions on the actual importance/relevance of monitoring hormone levels (the following recommendations are from Endocrine society)
  • For Feminizing hormones: Estradiol goal of 100-200pg/mL, testosterone <55
  • For Masculinizing hormones: Testosterone goal of 400-700ng/dL
    • Adjust hormone doses as needed (see table below)
    • Revisit gender affirming goals ➔ Refer as appropriate

Gender Affirming Hormone Dosing:

Feminizing Hormones: AFAB Masculinizing Hormones: AFAB
ANTI-ANDROGEN:
Spironolactone (most common) 50mg bid to start. Titrate up by 50 mg q3 months PRN. Max dose 200mg bid
Alternatives: finasteride (adjuvant only), leuprolide (expensive), bicalutamide (rarely 2/2 hepatotoxicity risk)
PLUS ESTROGEN:
Estradiol: Topical has lowest VTE risk.
PO: 2 mg daily to start. Max 6-8 mg/day. Split bid for 4+ mg. Titrate by 2 mg q3m. Topical: patch 0.1mg 2x/week. Titrate 0.1mg q3m. Max 0.4mg 2x/week.
Injectable (IM or sub Q): E cypionate or E valerate 2-10 mg/wk or 5-30 mg/ 2 weeks
(optional) Progesterone for breast development; mixed evidence. May add-on at 1-2 yrs. Prometrium 100-200 mg daily. 		TESTOSTERONE:
Injectable (IM or subQ)*: typical starting: 50 mg/wk. Low dose (nonbinary): 25 mg/wk. Max dose 100 mg/wk
OR
Transdermal gel Androgel 50 mg daily to start (low dose 25 mg daily) other options: fortesta 2%, axiron, testim
OR
Transdermal patch Androderm 2-4 mg daily to start (1-2x2mg patches). Titrate by 2mg q3m. Max 8mg/day
*Injectable testosterone is usually most affordable option
  • FYI: Needles for IM/SQ injections: 18G 1 ½” to draw up AND 1 mL 25G ⅝” to inject (subQ) OR 3 mL 23G 1-1.5” to inject (IM)
  • See John Hopkins Quick Guide: https://bit.ly/GAHT-QUICK-GUIDE for further information including expected time course for physical changes after starting hormone therapy

Referrals:

  • Gender Affirming Care is primary care and can be managed in resident clinic without referral
  • VIVID Health is a department at VUMC providing comprehensive and affirming care tailored to meet the needs of LGBTQ+ identifying adults. Services include primary care, hormone therapy, electrolysis, voice care, surgical consults and other related transition services.
  • There is now a VIVID health referral work queue. To refer patients to the VIVID network of providers, type “Ambulatory Referral to Transgender Clinic” into EPIC orders and in the comments indicate what services you are hoping to connect the patient to.
  • If the patient is interested in gender affirming surgery there is Transgender health option in the Ambulatory Referral to Plastic Surgery order.
  • Questions regarding referrals can be routed to “VIVID Health ADMIN pool” for review

Resources:

  • Quick Guide to GAHT: https://bit.ly/GAHT-QUICK-GUIDE
    • Has information on starting/monitoring hormones, timeline on when to expect physical/emotional changes, and other resources
  • Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People: https://transcare.ucsf.edu/guidelines
    • More comprehensive guide to hormone therapy, gender-affirming care surgery, hair removal, tucking, binding, fertility, etc
  • WPATH Standards of Care (Version 8): https://www.wpath.org/publications/soc
    • Most comprehensive, international standards of care for Transgender and Gender Diverse people