Now that its 20011, we need to be prepared for the unusual in our offices. Assumptions like Mr Smith the handsome executive is not HIV positive or Mrs X the mother of three is not a lesbian, really don’t work now. Mrs Smith’s aunt Hilda could have been a man for the first 50 years of her life, and the sweet 25-year-old boy could have been raised in pink.
To be good doctors, we need to challenge ourselves to see beyond the obvious and understand/expect that nothing and no one is quite what they seem. This is particularly true when treating people of alternative genders and sexualities. We all have internal homophobia, and a fear of what is different or abnormal. Working from an anti-oppression framework means doing personal work, not just saying. :”Oh, im cool with gays. I have a friend that’s a ____________.”
A place to start: learning the language:
Gender: ones chosen expression of their identity. Usually on a male-female spectrum although may choose to be androgynous. Arbitrary of actual birth sex. Partly based on distinguishable characteristics such as shape, clothing, hairstyle as well as the behavioral, cultural, or psychological traits typically associated with one sex. Taking on the chosen gender….It may be appropriate to ask someone which pronoun they prefer using.
Examples of genders: M2F, Transwoman, F2M, Transman, transgendered, transsexual, two spirited, dyke, boi, butch, femme.
Transgender: * In these guidelines, transgender includes any person who: (a) has a gender identity that is different from their natal sex, and/or (b) who expresses their gender in ways that contravene societal expectations of the range of possibilities for men and women. This umbrella term includes crossdressers, drag kings/queens, transsexuals, people who are androgynous, Two-Spirit people, and people who are bi-gendered or multi-gendered, as well as people who do not identify with any labels.
Transsexual: one who begins life assigned as one biological sex and then implements a self-motivated transformation to have a lived consistent identity as another sex. They have an absolute conviction that they belong to that other sex and no amount of persuasion can change their mind. A transsexual undergoes a number of medical procedures to bring their physical body in congruence with their mind and spirit.
Sex = either of the two major forms of individuals that occur in many species and that are distinguished respectively as female or male especially on the basis of their reproductive organs and structures. Problematic. Better to use gender in a clinical setting. Actually a huge variance. As we work with neonates, fertility, and family care you may be, what would you do if the parents were deciding which of two sex’s to clearly define their baby, and they came to you?
Sex = the sum of the structural, functional, and behavioral characteristics of organisms that are involved in reproduction marked by the union of gametes and that distinguish males and females
Sexuality: gay, straight, queer, bisexual, dyke, etc: the quality or state of being sexual: a : the condition of having sex b : sexual activity c : expression of sexual receptivity or interest (ie, who you want to have sex with)
Transgender Primary Medical Care: Suggested Guidelines for Clinicians in British Columbia
Transphobia = the fear, hatred, disgust and discriminatory treatment of people whose perceived or real gender identity does not match, in a socially accepted way, the sex that they were assigned at both. Transgendered people, transsexuals, intersexed people, lesbians, gay men, and bisexuals are typically the target for transphobia. WE ALL HAVE IT: SEE CHILD GENDER ARTICLE.
Trans health care: trans people are just people too, but with an extra hormonal twist. And, often extra socio-economic stresses that go along with coming out, transitioning, and living at the edge of society
Patients best explore transgender issues in a setting of respect and trust. This requires:
1. referring to the transgender patient by their preferred name and pronoun,
2. reassuring the patient about confidentiality,
3. educating clinic staff and colleagues regarding transgender issues
4. respecting the patient’s wishes regarding potentially sensitive physical exams and tests (such as pelvic or breast examinations)
5. intake forms that reflect openness: use gender instead of sex, or male/female/trans, or leave a space to write own gender identity. Instead of marital status, use relationship status. Instead of just single/married add common-law/partnered.
Familiarity with commonly used terms and the diversity of identities (including fluid, non-binary identification) within the transgender community is essential.
Some trans health care specifics:
Issues in my practice:
- Preparation for surgeries and recovery
- Health care not related to gender issues
- Reproductive stuff, hormone effects, etc
- Mental health & depression
- Basic nutrition and wellness
Hormonal and surgical treatment can profoundly increase quality of life for transgender individuals who desire to bring their bodies into greater congruence with their gender identity. If medical concerns emerge regarding hormonal interventions or planned surgeries, efforts should be made to try to control them where possible through behavior/lifestyle change or medication. Reduction or discontinuation of hormones should be a last rather than first resort and is not to be undertaken lightly as there can be serious psychological consequences. It is vital for primary care providers to understand the diversity of the transgender community and to avoid a narrow idea of “transgender health”.
Many trans people have started hormones and stopped them because they reached the level of transition they were interested in. Each person has his/ her own story. Ask it.
The primary care provider should be comfortable inquiring about gender concerns on a regular, if not routine, basis. For example:
• “Because so many people are impacted by gender issues, I have begun to ask everyone about it. Anything you do say about gender issues will be kept confidential. If this topic isn’t relevant to you, tell me and I’ll move on.” • “Out of respect for my clients’ right to self-identify, I ask all clients what gender pronoun they’d prefer I use for them. What pronoun would you like me to use for you?” • You can ask (after framing the question as mentioned above): “Do you identify as transgender?” • if you use an intake form, asking a question about gender on the form can be a way to encourage disclosure of transgender identity. Some agencies use “Gender: __________”
Male to Female aka TRANSWOMEN
Rx: estrogen and anti-androgen Rx.
May have breast implants
Can support with ground flax seeds, phytoestrogens
Breast exam not deemed necessary due to very low breast cancer risk. However, may be good to teach transwomen about breast care
ie) coffee and methylxanthines lead to fibrocystic breasts etc
Many transwomen have fibrocystic breasts from silicone injections.
Mammography after age 50 with hormone use
“In applying knowledge from the non-transgender setting to transgender patients, the primary care provider should look for rigorous studies that are highly relevant to the clinical context. For example, a large prospective study involving non-transgender women on postmenopausal hormone therapy may be relevant for MTFs over age 50 who are taking similar types of hormones for feminizing purposes.”
Consider vaginal pap smear with hx of HPV
Prostate: no need to test PSA. Studies show feminizing hormone therapy appears to decrease risk of prostate cancer.
Digital rectal prostate exams still suggested.
Regular screening of cardiac events or symptoms suggested while undertaking hormonal therapy.
Patients taking estrogen may be at higher risk for type 2 diabetes especially with family risk factors.
All cardiovascular, clotting disorder, diabetes, hypertension screening applicable to all genders.
Female to Male aka TRANSMEN
Often on testosterone
May have had hysterectomy and/or mastectomy
Support liver, adrenals (site of testosterone production in XX)
May need to address acne, alopecia
Breast exams: still recommended if have not had chest surgery.
May have rash or candida yeast under breasts if have been binding them.
Still need annual PAP if cervix remains intact
Testosterone therapy can result in atrophic changes mimicking dysplasia. Inform pathologist of clients hormonal status. If PAP smears are intolerable, or with high grade dysplasia, total hysterectomy is suggested. (and no more paps)
Increased incidence of PCOS is documented among FTM’s. Consider screening even without hormone use.
Monitor blood pressure Q 3 months
Most requisition forms for laboratory tests ask for the sex of the patient to provide the primary care provider with normal ranges for the results (which are often sex-dependent) and to flag abnormal results. Normal values specifically for transgender persons who are undergoing or have completed gender transition have not been established for any laboratory test, and there is no consensus about how sex should be recorded on lab requests for the transgender patient
Queer health issues that intersect all genders
Higher smoking rates, alcohol use, coffee, populations under extra psychological stressors: coming out, family, constant disclosure of difference, social stigma, street harassment, poverty issues
– liver health is important, but not only treatment for addictions
– stress management
– anger management, address grief, refer to psychotherapy if necessary
– acupuncture for addictions: LI4, PC6, LV3, HT7, SHEN MEN, GV20
– SMOKING: RAINBOW TOBACCO INTERVENTION PROJECT; free group quit smoking specific to LGBT community. Health Canada studies have shown that LGBT community smokes more than straight counterpart
– Lung support; all modalities apply (also grief)
– Elimination: large intestine.lungs
– Harm reduction: reduction of amount better than nothing
Coping skills: meditation, exercise, time in nature, time spent alone, journaling
Supplements: relora, adrenal support, 5HTP/triffonia
Massage, acupuncture, craniosacral therapy – help people to connect to their bodies in a non-threatening way
Referral for counseling: must be trans/queer/LGBT positive and probably free
GYNECOLOGY/ REPRODUCTIVE HEALTH
Lesbians much less likely to get yearly paps, especially more androgynous butches and women. Leaves women prone to more advanced dysplasia and GYN cancers.
– HASSLE FREE CLINIC (Toronto): great resource: also HIV HEPC testing: 416 922 0566
– SHERBOURNE HEALTH CENTER (Toronto): primary medical care for LGBT community. Also referral for counseling support
– Never assume a lesbian is not pregnant
– Genital warts extremely common: best fx in my practice: antisycotic homeopathy.
– Herpes very common: lysine in high doses, tea tree/lavender oils. Increase vitamins A & E.
– Syphilis has been on the rise for gay men. Know key signs and symptoms
BODY MODIFICATION: very common in queer community/ Includes cuttings, brandings tattoos, piercing, stretching ear lobes.
– Genital piercing. Don’t need to ask about unless long standing inguinal lympadenopathy or recurrent infections that could be linked to jewelry.
– Cutting/ self harm. Also very prominent in queer community. Psychological response to stress, effort to control uncontrollable situations. Need to establish trust and rapport with person to see what underlying psychology is. Usually related to a need for perfection from parents (carc.) may need referral to a qualified therapist.
– Self harm: look at the environment it was done in. was it hasty? Planned? Ritualistic? Did it impart a sense of empowerment or one of shame? Not necessarily a sign of pathological psychology. . has social and personal significance. Rituals, visioning, rites of passage compared to a religion for some. “leather family.”
– Client may have unusual bruising, lacerations, etc. traumeel cream. Arnica, basic first aid and wound care generally enough.
– S/M is quite common in the queer community. Originally a part of gay male history, women have been more and more included and organized since the 1980’s
BREAST HEALTH: many people in queer community have nipple piercing – constant source of infection and discharge. If do have jewelry, follow up on its health – it can become something so “normal” never think of addressing it as health care.
Nipple Ring health:
– paint nipple with betadine daily –if absorbs quickly could also help FCB
– sea salt water soaks – standard protocol. Add tea tree or lavender
– internal lymphatic and antibacterial support: cleavers, iris, burdock, Echinacea, phytolacca, cheladonium plex, goldenseal plasters if needed,
– St johnswort oil topically: excellent for painful infected piercings anywhere
– Comfrey salves topically. Avoid calendula for granular healing
– Ledum homeopathic if painful. Arnica. Hypericum.
Wait until have established trust and rapport with FTM before approaching breast exams. Many will have had mastectomies, and will have obvious scarring.
Very common in queer community
Myth of gay male perfection
Coming out stress
Restricted diets may trigger anorexic or bulemic episodes
Constitutional homeopathy: Milk Rx, Insect Rx esp Spiders
Binge eating disorders from stress / emotional eating
Address serotonin levels with 5HTP.
Consider relora to address cortisol levels and stress
Could be eating very little due to low income, money goes to booze, drugs, social activities bills. Address priorities.
As providers of health care for a diverse population we must examine our own internal prejudices and belief systems. Referral may be necessary
All LGBTT people need to be screened for depression
17 yo Portuguese Catholic girl was brought in by her sister. CC stomachaches, nausea, and menstrual cramps. Didn’t give out much information. Vague non-specific IBS-like complaints. Eventually I reassured her that the visit was completely confidential, and unless she had killed someone, I was not going to disclose any information. Eventually told me she was questioning her sexuality, and had been very depressed for the past 2 years about it. She knew her stomach aches were related to stress about her family and her coming out process. She was about to head to U of T and wasn’t feeling as depressed anymore, so didn’t need depression support now.
TX: focused on stress management and emotional support, mag-carb 30c, acidophilus and dairy elimination. Was able to get to core of issue instead of just focusing on supplements and diet.
Do not underestimate the mental/emotional distress that can be associated with coming out. Do not overestimate it either – every person will have their own story.