WPATH 2018: Primary Care Updates

It has been more than a month since the WPATH Conference closed in Buenos Aires, Argentina. One of the best sessions I attended was a panel by 4 trans identified health care providers  РNathan Levitte NP, Zil Golstein NP, Maddie Deutch MD and Asa Radix MD. I will summarize some of their presentation here as it was excellent in both content and relevance.

Nathan Levitte is a NYU Langone Health surgical NP and spoke on the surgical experience. The first issue reviewed was the practice of stopping estradiol pre-surgery. Many surgeons request that this be stopped 4 weeks prior to surgery for DVT prophylaxis; however, this is not an evidence based practice and could lead to withdrawal symptoms including depression and hot flashes. One recommendation was to switch to a transdermal therapy during the pre and post surgical window to maintain blood levels while decreasing risk of thrombosis.

“Surgery itself is a trauma. Being hospitalized as a trans person is traumatic. Dilation is also traumatic.”

A surgical screening for PTSD, sexual abuse, latent health issues, home support systems, medication cost, and food resources is important to maintain patient safety and reduce the risk of postoperative complications. For this reason, peer navigators are crucial to create trusted collaborations between surgeons and patients and improve outcomes.

Due to this likelihood of resurfacing trauma, most surgery programs require pre and post surgical appointments with mental health providers to build this safety net for vulnerable patients. Patient communication is crucial to reduce stigmatization and promote healing models.

Dr. Madeline Deutch from the University of California San Francisco reviewed and critiqued a 2018 cohort study from the Annals of Internal Medicine on Cross Sex Hormones and Acute Cardiovascular Events.  She illustrated the pitfalls of research that does not include Number Needed to Treat and Number Needed to Harm in evaluating evidence.

The study results declared : “Transfeminine participants had a higher incidence of VTE, with 2- and 8-year risk differences of 4.1 (95% CI, 1.6 to 6.7) and 16.7 (CI, 6.4 to 27.5) per 1000 persons relative to cisgender men and 3.4 (CI, 1.1 to 5.6) and 13.7 (CI, 4.1 to 22.7) relative to cisgender women. The overall analyses for ischemic stroke and myocardial infarction demonstrated similar incidence across groups. More pronounced differences for VTE and ischemic stroke were observed among transfeminine participants who initiated hormone therapy during follow-up.” However, using NNT/NNH statistical analysis for myocardial infarction, for every 166 transfeminine patients treated, 1 would experience MI.

Using this kind of statistical analysis ensures that evidence is being used properly to make informed consent decisions and properly reflect the evidence gathered.