Transcript File - Ilford VTS The Home for Trainee GPs in Ilford

Gender Dysphoria
Dr Ashikur Rahman
GP-ST2
Definitions
 Gender identity – sense of fitting into the social categories of “male” or
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“female”
Cis-gender – when gender identity is consistent with phenotype at birth
Trans-gender – when gender identity is inconsistent with phenotype at birth
Other groups identify within the “transgender” umbrella term including those
who:
embrace aspects of both identities (“pan gender,” “polygender,” “gender
queer”)
are on a spectrum between sexes
are non-gender (“gender neutral” or “gender absent”)
 Separate entity to sexual orientation
 Gender diversity/variance – when trans individuals dress or behave in a
way that is perceived as by others as being outside cultural gender
norms
 Gender dysphoria – describes the distress experienced when gender
identity is not congruent with phenotypic appearance
 No longer regarded as a mental illness – evidence exists to suggest
genetic and physiological differences in the brain function of trans
individuals compared with the general population
Current Issues
 The numbers of trans people presenting for medical help are rising rapidly – 20% annual
growth in specialist referrals from GPs (26,000 in 2014)
 Accordingly, the waiting lists for access to specialist providers grow longer
 The mental health of those unable to access treatment is likely to deteriorate and selfmedication with products bought via the internet becoming more common
 The risk of self-harm and suicide in people unable to access treatments may be as much as
20 times greater than in the general population – 34% have attempted suicide at least once
 However, with the appropriate medical care, outcomes can be very positive – up to 96%
satisfaction over a 20-year period
 Often long wait for gender identity service appointment. May need referral to Community
Mental Health team for interim support
 Definitive management – DIRECT referral to Specialist Gender Identity Services
Referral Information
 How patient wishes to be named and what pronoun they are using
 Past and present gender experiences; how long patient has been aware of their gender differences; has it caused distress;
future hopes and expectations?
 Conflict between sex appearance and gender identity
 Conflict between sex appearance and gender role/expression
 Relationship with family; do they know?
 Have barriers, difficulties, loss of relationships been considered by the individual
 Present occupation
 Support or interaction with trans-groups?
 Any treatments including self medication been undertaken?
 Are hormones/surgery desired?
 Change of role anticipated?
 What are desired next steps?
Referral Centres
 Exeter GIC (The Laurels), Devon Partnership NHS Trust
 Leeds GIC (Newsome Centre), Leeds and York NHS Foundation Trust
 Northampton GIC, Northamptonshire Healthcare NHS Foundation Trust
 Nottingham GIC, Nottinghamshire Healthcare Trust
 Sheffield GIC (Porterbrook Clinic), Sheffield Health and Social Care NHS
Foundation Trust
 Northern Region Gender Dysphoria Services
 London GIC (Charing Cross), West London Mental Health Trust Gender Identity
Clinic
Treatment - Overview
 Psychological vs medical (hormonal) vs surgical
 GPs usually prescribe hormone therapy with guidance and support from the
specialist service
 Treatment induces beneficial physical and physiological effects by limiting
phenotypic sex hormones, while attaining physiological circulating levels of
testosterone or oestrogen appropriate for the target sex
 Patients must be counselled on effects, risks and side effects prior to treatment
 Must satisfy eligibility criteria - persistent, well-documented gender dysphoria,
competent to provide informed consent
Treatment - Trans Men
Products
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Testosterone as a transdermal gel or injection
Medications
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Transdermal testosterone e.g. Testim, Testogel, Tostran
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IM injection e.g. Nebido (3 monthly) or Sustain 250 (3 weekly)
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As per BNF and gender specialist advice
Baseline monitoring
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BP, FBC, U&Es, LFTs, fasting glucose, lipid profile, TFTs, prolactin, oestradiol, testosterone
Ongoing monitoring - as above excluding TFTs. Every 6 months for 3 years, then annually
Side effects/risks
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Beard/body hair growth, male pattern baldness, enlarged clitoris, heightened libido, acne, weight gain, sleep apnoea, reproductive
implications
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Polycythaemia, elevated liver enzymes, hyperlipidaemia, CVD, HTN, T2DM
Treatment - Trans Women
Products
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Oestradiol as a gel or patch +/- GnRHa via depot to downregulate testicular function
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DHT inhibition to prevent MPB
Medications
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Transdermal oestradiol e.g. Estragel, oestradiol patch – present least risk of thrombosis
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Oral oestradiol
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Levels reduced by enzyme inducers e.g. anti-epileptics, anti-fungals
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May be stopped prior to surgery as per specialist advice
Baseline monitoring
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BP, FBC, U&Es, LFTs, fasting glucose, lipid profile, TFTs, prolactin, oestradiol, testosterone
Ongoing monitoring - as above excluding TFTs. Every 6 months for 3 years, then annually
Side effects/risks
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Modest feminisation including breast development within 2 years, slowed rate of hair loss, reduced muscle bulk, male sexual
dysfunction, weight gain, reproductive implications
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Thrombosis, gallstones, elevated liver enzymes, hypertriglyceridaemia, CVD, HTN, T2DM
Surgical Options
Trans Men
 TAH + BSO – requires 2 opinions, usually from the gender clinic team, but second opinion can
come from GP
 Vaginectomy, phallopasty, metatoidioplasty, urethroplasty, scrotoplasty, testicular and
erectile prostheses
 Chest reconstruction
Trans Women
 Penectomy, orchidectomy, vaginoplasty,cliteroplasty, labioplasty - requires 2 opinions,
usually from the gender clinic team, but second opinion can come from GP
 Breast augmentation if insufficient development after 2 years oestradiol treatment – only 1
opinion required
 Phonosurgery
 Hair removal
Long Term Care
Trans Men
 Cervical smears for those who retain their cervix
Trans Women
 Prostate gland is retained so remember to consider prostate pathology as a differential for
symptoms. Prostate cancer possible but unlikely due to testosterone suppression
Both
 Breast screening should be offered in accordance with national guidelines
 Osteoporosis may an issue if patients have been hypogonadal for prolonged periods where
hormone replacement has been insufficient – consider whether DEXA scan is indicated
 More likely to smoke, drink excess alcohol and abuse illicit substances compared to the
general population. In conjunction with hormone treatments this exposes them to higher
cardiovascular risk.
 Higher rates of depression and suicide
Funding
 Gender reassignment treatment is commissioned by NHS
England (specialised service)
 Applies to psychological treatment, SALT, limited
facial/genital hair removal, chest surgery and genital
surgery
 CCGs responsible for funding prescription of hormone
treatment in primary care
The Role of the GP
“GPs are responsible for prescribing, administering and monitoring hormone treatment set out by the specialist service”
What does this mean and why?
Growing problem
Consequent delays in specialist appointment
Increased mental health risk and sourcing unreliable products from the internet
Current GMC guidelines for The Assessment And Treatment Of Adults With Gender Dysphoria:
“…the GP or other medical practitioner involved in the patient’s care may prescribe ‘bridging’ endocrine treatments as part of a
holding and harm reduction strategy while the patient awaits specialised endocrinology or other gender identity treatment
and/or confirmation of hormone prescription elsewhere or from patient records”
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For those self-medicating the GMC guidance:
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advise against internet medications
if on established treatment advise against suddenly stopping medication as can lead to significant detriment to
psychological well being due to reversal of physical and physiological changes. This increases risk of depression and suicide
consider offering bridging prescription if benefits outweigh risk of stopping internet medication and there are no
contraindications
seek guidance from SGIS to whom one has/will refer for prescription
assess current regimen for safety and drug interactions
Points of Contention
 Are GPs experienced enough and competent in providing
bridging hormone treatments?
 Is there a formal shared care protocol for providing
ongoing treatment and routine monitoring?
Thank You