Transcript What is gender?

HIV in Transgender
Patients
Anita Radix, MD MPH
Callen Lorde Community
Health Center
Learning Objectives
At the conclusion of this presentation,
participants should be able to:
• Adapt and implement HIV prevention
strategies for persons of transgender
experience
• Modify evaluation and treatment
approaches to ensure culturally
competent delivery of HIV-related health
services for your patients
Off Label Disclosure
This presentation will include discussion
of the following non-FDA-approved or
investigational uses of products/devices:
• Cross gender hormone therapy
Case
27 y/o HIV-infected transgender
(male-to-female) woman transferring
care from California.
• 6 months ago CD4 420 cells/mm3
HIV RNA level of 16,000 copies/ml.
• ARV naïve
• PMH: HIV+ 2005, started CGHT at
age 20
• Meds: spironolactone 100mg tid,
Premarin 2.5mg bid
The Basics
• Basic terminology - what does
transgender mean?
• Gender vs. sexual orientation
• What pronoun to use
• HIV & Primary care issues
• Risks/benefits hormone therapy
• Creating a welcoming space
Background information
Terminology
What is gender?
6
Gender vs. Sex
Traditional
• Gender is binary (M/F)
• Synonymous with sex (chromosomes,
genitalia)
New
• Gender is a spectrum
• Defined by several criteria
• Separate from sex
Gender
Return
Trans-terminology
•Transgender
• umbrella term used to group the many gender
different communities
• people who transcend typical gender
paradigms
•Transsexual
• biological men and women whose gender
identity most closely matches the other
gender
• Sometimes used to describe persons who
have undergone genital surgery
Trans-terminology
Transition
• The process from living
and being perceived as the
gender assigned at birth
according to the
anatomical sex (M or F) to
living and being perceived
as the individual sees and
understands themselves
Trans-terminology
Common terms to describe transition:
• MTF, male-to-female (trans women)
• FTM, female-to-male (trans men)
Medical Terms
• Gender Dysphoria (DSM III) or Gender
Identity Disorder (DSM IV)
• Often perceived as pathologizing
• DSM-V revising definition to Gender
Incongruence (APA, 2010)
• Sex Reassignment Surgery (SRS) or
Gender Confirming Surgery (GCS)
Sexual Orientation
• Part of, but not the same as, gender
identity
• Trans-women attracted to men and transmen attracted to women may identify as
heterosexual
• Trans-women attracted to women may
identify as lesbian
• Trans-men attracted to men may identify as
gay
What is the Correct Pronoun?
• How do I know which pronoun to
use?
• Ask politely
• What’s the presenting gender?
• Echo the language you hear; listen for
new pronouns (hir, zie, s/he)
• Make an effort to use the correct
pronoun consistently
Transgender Epidemiology
Demographics
No reliable data:
Prevalence rates of MTF transsexualism
• 1:500 – 1:20001
• 1/11,900, based on medical/surgical
treatment2
• 1:2,900 surgical treatment3
• Transgender prevalence higher
HIV Prevalence
• No national surveillance data
• Transwomen designated as MSM
• Meta-analysis - HIV prevalence estimated at 11.8
(self report) to 27.7% (confirmed) among MTF4
• Higher rates among transgender sex workers 68%5
• African American MTFs 41-63%6,7
• HIV prevalence in transgender men was found to
be 3% in Washington, DC 8 and 2% in San
Francisco7
HIV Incidence
• High HIV incidence 3.4-7.8% per 100
person-years9,10
• African American transwomen 18.1%
per 100 person-years10
Predictors of HIV infection
among Transgender Women
•
•
•
•
•
•
African-American race 5,7
Syphilis5
High number of sex partners7
Less than high school education7
History of sex work8
Unemployment8
Sexual
Assault
Poverty
Hate
Crimes
Harassment
Discrimination
Wrongful
Incarceration
Police
Brutality
Domestic
Violence
Homelessness
Return
Transphobia – an irrational fear of
gender-different people leading to
systematic discrimination
Tyra Hunter (19701995)
Died in Washington DC
after paramedics
withdrew treatment at
scene of car accident.
Robert Eads (19451999)
Care for ovarian cancer
delayed for one year
because more than two
dozen doctors refused to
treat him.
Brandon Teena (19721993)
Raped and murdered by
John Lotter and Marvin
Nissen after they
discovered he was
anatomically female.
Initial Assessment
Medical History
Ask about:
• Hormone use, dose, duration, obtained
“on the street” or prescription
• Silicone injections, pump parties
• Needles for injection (shared)
• Psychosocial issues: depression, PTSD,
support network, employment, sex
work and substance use
Initial Assessment
Exam
Keep in mind:
•Transgender patients may have had previous
negative healthcare experiences
•Developing trust and rapport may take longer than
you are used to
•Avoid genital and rectal exams on first visit, if
possible.
•Be sensitive to disassociation from genitals
•Discuss choice of language to describe anatomy
Avoid using “pre-op” and “postop”
Initial Assessment
Counseling
• Counseling on minimizing modifiable
risk factors
• Smoking cessation
• Alcohol and drug use harm reduction
• STI prevention
• Needle use and sharing
• Silicone use
Silicone
• >25% of transgender women inject silicone
to create “feminine” appearance4
• May be industrial grade and mixed with
paraffin or cooking oil
• Pump Parties - venue for sharing and
injecting silicone
• Risks – pulmonary embolism, ARDS, local
infections, disfigurement, Hepatitis C, HIV
Case cont.
• Labs: CD4 count of 322 cells/mm3 and an
HIV RNA level of 82,000 copies/ml.
• She is interested in antiretroviral therapy
and there are no major concerns with
adherence. Genotype is fully sensitive.
• What about interactions with her CGHT
(Premarin 2.5mg BID, spironolactone
100mg TID)?
HIV Medications That Increase
Estradiol and Ethinyl
Estradiol Levels
HIV Medications That Decrease
Estradiol and Ethinyl
Estradiol Levels
amprenavir (Agenerase)
atazanavir/ritonavir
atazanavir (Reyataz) ↑ 48%
darunavir/ritonavir (Prezista)
↓44%
delavirdine (Rescriptor)
fosamprenavir/ritonavir (Lexiva)
↓37%
efavirenz (Sustiva) ↑ 37%
lopinavir/ritonavir (Kaletra) ↓ 42%
etravirine (Intelence) ↑22%
nelfinavir (Viracept)
fosamprenavir (Lexiva)
nevirapine (Viramune) ↓20%
indinavir (Crixivan)
ritonavir (Norvir)
saquinavir (Invirase)
tipranivir (Aptivus)
Ethinyl estradiol may decrease levels of:
amprenavir (Agenerase), fosamprenavir (Lexiva)
Selzentry (Maraviroc) – no significant effect on ethinyl estradiol levels
DHHS, 2009
Adherence
• Lower adherence rates noted among
HIV+ MTF 12
• Negative provider interactions
• Perceived negative effects of ARVs on hormones
• Selling ARVs to purchase hormones
• Psychosocial
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•
•
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•
↑
↑
↑
↑
↑
4,5,8,12
Homelessness
Unemployment
Substance use
Incarceration
Social isolation
What hormones are used and
what do they do?
Gender Confirming Hormone Therapy
Estrogens

Conjugated Estrogens : 1.25-10mg po qd or divided as bid

Estradiol: 2-8 mg po qd or divided as bid

Estradiol Patch : 0.1-0.3mg q3-7 days

•
Estradiol Valerate injection : 20-60mg IM q2wks
Ethinyl estradiol (OCP) 50-100g qd
Anti-androgen
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Spironolactone 100-400mg daily, divided doses
Finasteride 1-5mg po daily
Cyproterone Acetate (Androcur)
5--reductase inhibitors:
•
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Finasteride: 1-5mg daily; Dutasteride: 0.5mg daily
Flutamide (Eulexin) 50-750mg daily
Adverse Effects of Hormone
Therapy
Risks (anecdotal):
• Thromboembolism
• Increased risk of breast cancer?
• Hyperprolactinemia/pituitary adenoma
• Hepatotoxicity
• Cardiovascular risk?
• Infertility
• Anxiety/depression
• Gallstones
• Hypertension
Safety of Hormone Therapy
• Very few published studies of long-term
safety of MTF or FTM regimens
• Prospective study from The Netherlands
13
• 30 years follow-up 2236 MTF, and 876 FTM.
• MTF: ethinyl estradiol, 6–8% increase venous
thrombosis
Appropriate Follow-up
• Routine screening on all organs as
long as they are present:
• Testicular and prostate exam
• Pap smear
• Breast exams and mammograms
[Evidence level C, consensus opinion]
Appropriate Follow-up
• Periodic laboratory testing:
• MTF - q6-12 mos: fasting glucose, lipid
profile, liver function, prolactin; as needed:
testosterone, potassium, hemoglobin
• FTM - q6-12 mos: fasting lipids, liver
function, hemoglobin
[Evidence level C, expert opinion]
STI Screening
•
•
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Assess the risk of STI’s for all
transfemale patients
Offer Hepatitis B immunization
Screen at least annually* (3-6 months
for highest risk) for
•
•
Syphilis
Urethral & rectal N. gonorrheoeae and C.
trachomatis testing
[Evidence level C, expert opinion]
*MTFs who have sex with men
Creating a Welcoming Space
• Use language that is sensitive to
transgender identities
• Trans-sensitive intake forms – allow clients
write in their gender
• Become familiar with the gender pronoun
your patient prefers
• Cultural competency training for staff
• Have trans-sensitive brochures, prevention
information available
• Be familiar with local resources available to
assist with name/gender change
Thank you!
References
1. Olyslager F, Conway L. On the Calculation of the Prevalence of Transsexualism. WPATH 20th
International Symposium. Chicago, Illinois, 2007.
2. Bakker, A, et al. (1993) The prevalence of transsexualism in the Netherlands Acta Psychiatrica
Scandinavica Volume 87 Issue 4, Pages 237 - 238
3. Tsoi WF.The prevalence of transsexualism in Singapore. Acta Psychiatr Scand. 1988 Oct;78(4):501-4.
4. Herbst, J., et al. (2007). Estimating HIV prevalence and risk behaviors of transgender persons in the
United States: A systematic review. AIDS and Behavior.
5. Elifson, K., et al. Male transvestite prostitutes and HIV risk. (1993 Feb). American Journal of Public
Health;83(2):260-2.
6. Nemoto, T., et al. (2004) HIV risk behaviors among male-to-female transgender persons of color in San
Francisco. American Journal of Public Health;94 (7):1193-1199.
7. Clements-Nolle, K et al (2001) HIV prevalence, risk behaviors, health care use, and mental health
status of transgender persons: implications for public health intervention. (2001 Jun). American
Journal of Public Health.;91(6):915-21.
8. Xavier, J.M. (2000). The Washington, DC. Transgender Needs Assessment Survey Final Report for
Phase Two. Washington, DC: Administration for HIV/AIDS of the District of Columbia. at:
http://www.gender.org/
9. Simon, P., et al. HIV prevalence and incidence among male-to-female transsexuals receiving HIV
prevention services in Los Angeles County. (2000 Dec). AIDS, 14, 2953-2955.
10. Kellogg, 2001) Kellogg, T., Incidence of human immunodeficiency virus among male-to-female
transgendered persons in San Francisco. (2001 Dec). Journal of Acquired Immune Deficiency
Syndromes;28(4):380-4.
11. DHHS 2009 http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.
12. Sevelius, J et al. Antiretroviral Therapy Adherence among transgender women living with HIV.(2010)
JANAC 21(3):256-264
13. Gooren, L. Long-Term Treatment of Transsexuals with Cross-Sex Hormones: Extensive Personal
Experience. (2007) J. Clin. Endocrinol. Metab. 93:19-25