Primary Care Protocol for Transgender Patient Care

This is an excellent document with links to many areas needed by transgender patients
www.transhealth.ucsf.edu

LINK TO: 
Primary Care Protocol for Transgender Patient Care


The Top 10 Things Trans People Should Know About the New Standards of Care

WPATH standard of care
The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People by the World Professional Association for Transgender Health (WPATH-SOC) are the most widespread SOC used by professionals working with transsexual, transgender, or gender variant people.
The latest revision was released September 25th, 2011. 
WIKIPEDIA ARTICLE

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The World Professional Association for Transgender Health (WPATH)
today (September 25th, 2011)released a newly-revised seventh edition of its Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 

The revised Standards of Care are a critical resource for providers, healthcare consumers, and advocates, and are a step forward in ensuring that transgender and gender non-conforming people receive high quality care individualized for their needs.
Significant features of the new edition include:
  • Recognition that gender nonconformity in and of itself is not a disorder.
  • Strong affirmation that attempts to change a person’s gender identity through “reparative” therapy are ineffective and unethical.
  • Strong affirmation that transition-related treatments such as hormone therapy and surgery are medically necessary for many individuals and should be covered by insurance.
  • Continued emphasis on the individual nature of transition-related care and the flexibility of treatment guidelines.
  • Additional guidance on the treatment of adolescents and children, including guidelines for puberty-delaying treatment.
  • Near elimination of the “real-life experience” requirement as a prerequisite criteria for medical transition in adults, with the exception of some genital surgeries.
  • Discussion of a wider range of treatment options, including voice and communication therapy.
  • Discussion of the preventive care needs of transgender people.
  • Clarification that the Standards of Care should be applied in their entirety to those who are incarcerated or otherwise living in an institutionalized setting.
  • A call for health professionals to advocate not only for their patients – for example by helping them obtain updated identity documents – but also for larger policy and legal reform promoting tolerance and equality.
The revised Standards of Care represent a step forward in ensuring that all transgender and gender nonconforming people have access to high-quality, respectful care responsive to their individual needs.

Transgender woman denied mammogram wins battle with health insurance company



Beth Scott was shocked when her insurance company denied coverage for her routine mammogram.
She soon figured out why.
Aetna, Scott’s health insurance carrier, stated that the procedure fell under her policy’s exclusion for treatments “related to changing sex.”
Scott, a 44-year-old transgender woman from New Jersey, had developed breasts after undergoing hormone therapy.
Her physician had advised her to seek the breast cancer check.
After exhausting her appeals process, she enlisted the help of the Transgender Legal Defense & Education Fund for help in her reimbursement.
Scott, who eventually won the fight and received an apology from Aetna, is just the latest person to struggle against the institutional medical discrimination that transgender people face.
Due to exclusionary clauses in certain insurance plans, not only are people denied coverage for the medical procedured needed to undergo the gender change, they are denied ordinary care.
These clauses make it impossible to receive coverage for any procedure that could conceivably be linked to their transgender status.
“I’ve heard of transgendered people being denied coverage for blood tests,” said Noah Lewis, a lawyer for the TLDEF in New York. “I heard a story about a transgender woman who was denied coverage for a broken arm after the insurance company determines the injury occured while playing on a all-female baseball team.”
Transgender women and men are often denied routine gynecological care and medically necessary surgeries, including fibroid removal and hysterectomies, said Lewis.
Scott’s victory was a personal win, but could also help others in her situation.

Healthy People 2020 Webinar: Transgender Health by Health & Human Services

This is a group of videos provided by the Dept of Health and Human Services. The Department of Health and Human Services (HHS) is the United States government's principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.
 LINK TO: Healthy People 2020 Webinar: Transgender Health

Prenatal Exposure to Diethylstilbestrol (DES) in Males and Gender-Related Disorders

For many years, researchers and public health specialists have been assessing the human health impact of prenatal exposure to the estrogenic anti-miscarriage drug, diethylstilbestrol (commonly known as DES or "stilbestrol"). The scope of adverse effects in females exposed to DES (often called "DES daughters") has been more substantially documented than the effects in males ("DES sons").

This paper contributes three areas of important research on DES exposure in males:
(1) an overview of published literature discussing the confirmed and suspected adverse effects of prenatal exposure in DES sons;
(2) preliminary results from a 5-year online study of DES sons involving 500 individuals with confirmed (60% of sample) and suspected prenatal DES exposure;
(3) documentation of the presence of gender identity disorders and male-to-female transsexualism reported by more than 100 participants in the study.

During the 1970s and 1980s an increased amount of public and scientific attention was paid to the health and medical problems of individuals whose mothers were prescribed diethylstilbestrol (DES). A potent synthetic nonsteroidal estrogen, DES was first developed in 1938 and initially became available in the U.S. for treating a range of gynecologic conditions in 1941 (Apfel and Fisher, 1984). A few years later its approval by the FDA was broadened to include treatment of pregnant women for the purpose of preventing miscarriages. Though its efficacy had long been questioned by some in the medical community (Bambigboye and Morris, 2003; Dieckmann, 1953), DES remained popular with doctors until discovery in the early 1970s of an apparent association between prenatal exposure to DES and a rare form of vaginal cancer in females whose mothers used DES (Heinonen, 1973; Herbst and Bern, 1981). Subsequent research confirmed the transplacental mechanism of DES transmission (Maydl, et al., 1983) and classified DES as a carcinogen and teratogen (Mittendorf, 1995) as well as a mutagen (Roy and Liehr, 1999; Stopper et al., 2005).

While DES usage with pregnant women was banned by the FDA in 1971, the drug continued to be used in several European countries into the early 1980s (Schrager and Potter, 2004). DES remained a popular option for treatment of advanced prostate cancer in aging males due to its ability to inhibit luteinizing hormone secretion by the pituitary and thus inhibit testosterone secretion (Scherr and Pitts, 2003; Whitesel, 2003), despite reports that adverse effects from this treatment could include feminization in males (B. C. Cancer Agency, 2005). Through the 1970s DES was also prescribed as an estrogen supplement for treatment of male-to-female transsexuals (Kwan, 1985; Ober, 1976).

It has been estimated that as many as four to five million American women were prescribed DES during pregnancy. Estimates of the numbers of "DES daughters" and "DES sons" born in the U.S. are between one million and three million of each (Edelman, 1986). Hundreds of thousands of DES sons and daughters were also born in Canada, Europe and Australia between the 1940s and 1980s. Efforts to determine exact numbers of prenatally exposed individuals, and the dosage and exposure patterns, particularly during the years of prime DES popularity, 1947-55 in the U.S., have been largely unsuccessful (Duke, et al., 2000; Heinonen, 1973). Because DES proved popular as a growth-stimulant in the cattle industry (Raun and Preston, 2002) for more than forty years (McLachlan, 2001), many consumers have also been exposed to unknown amounts of DES as it entered the food chain through beef consumption.

Among the most significant findings from this study is the high prevalence of individuals with confirmed or strongly suspected prenatal DES exposure who self-identify as male-to-female transsexual or transgender, and individuals who have reported experiencing difficulties with gender dysphoria.

In this study, more than 150 individuals with confirmed or suspected prenatal DES exposure reported moderate to severe feelings of gender dysphoria across the lifespan. For most, these feelings had apparently been present since early childhood. The prevalence of a significant number of self-identified male-to-female transsexuals and transgendered individuals as well as some individuals who identify as intersex, androgynous, gay or bisexual males has inspired fresh investigation of historic theories about a possible biological/endocrine basis for psychosexual development in humans, including sexual orientation, core gender identity, and sexual identity (Benjamin, 1973; Cohen-Kettenis and Gooren, 1999; Diamond, 1965, 1996; Michel et al, 2001; Swaab, 2004).

This study’s findings provide fresh evidence of psychiatric disturbances among individuals exposed to DES. It is hopeful that future research on human health effects of exposure to endocrine disrupting chemicals (i.e., assessing neurotoxicity) can include psychiatric disturbances such as major depression, anxiety disorders, eating disorders, and psychoses as potential endpoints for analysis of the long-term effects from prenatal exposure. Additional questions may be explored as to whether psychiatric conditions such as increased depression and/or anxiety disorders in DES sons have a foundation in primary endocrine system disorders.

Endocrine system disorders such as hypogonadotropic hypogonadism in DES sons have been among the more common reported adverse health effects in this research study. Although the prevalence of endocrine system disorders among DES sons has not been discussed in any of the existing published epidemiological research on DES-exposed populations, both the Endocrine Society and the American Association of Clinical Endocrinologists (2002) have recognized prenatal DES exposure as a risk factor for endocrine disorders including hypogonadism. This study confirms that this issue needs further attention in future studies of DES sons.

Relative infrequency of reported cancer among the DES sons in this research is consistent with most existing long-term studies demonstrating limited cancer prevalence in males with prenatal DES exposure. While the rate of total cancer occurrence among members of the DES Sons International Network is uncertain, numerous efforts have been made to generate discussion about cancer risks and in particular, to encourage dialogue regarding testicular cancer experiences. Approximately seven members of the network between the study years of 1999 and 2004 indicated some past or present experience with testicular cancer. It appears that overall cancer outcomes among network members have been low, a finding consistent with research by Strohsnitter et al. (2001).

Based on the findings in this study, research into the human health effects of exposure to endocrine disrupting chemicals needs to focus on additional behavioral toxic endpoints besides those historically investigated.
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Diethylstilbestrol a 5-Year Study: Gender Dysphoria, Transsexualism

During the 1970s and 1980s an increasing amount of public and scientific attention was paid to the health and medical problems of women and men whose mothers and grandmothers took diethylstilbestrol (DES) for prevention of miscarriage. A potent estrogenic chemical, DES was first developed in 1938 and initially became available in the U.S. for treating a range of gynecologic conditions in 1941 (Apfel and Fisher, 1984). A few years later its approval by the FDA was broadened to include treatment of pregnant women for the purpose of preventing miscarriages (spontaneous abortions). Though its efficacy had long been doubted by some in the medical community (Bambigboye and Morris, 2003; Dieckmann, 1953; Edelman, 1986), DES remained popular until publication of research in the early 1970s identifying an apparent association between prenatal exposure to DES and a rare form of vaginal cancer in females (commonly called “DES daughters”) whose mothers used DES (Giusti, Iwamato, and Hatch, 1995; Heinonen, 1973; Herbst and Bern, 1981).

It is estimated that as many as five to ten million Americans received DES during pregnancy or were exposed to the drug in utero between the late 1940s and early 1970s (Giusti, Iwamoto, and Hatch, 1995). The numbers of male offspring exposed in utero to DES (“DES sons”) have been estimated at between one and three million in the U.S. (Laitman, Jonler, and Messing, 1997) and similar estimates exist for the numbers of American females exposed in utero (Edelman, 1986). Hundreds of thousands of DES sons and daughters were also born in Canada, Europe and Australia during a similar period.

Compared with the history of research on the range of health effects of DES daughters, there are relatively few published medical research studies conducted with DES sons. And yet, the finding that prenatal DES exposure also led to detrimental effects for a number of exposed males has existed since the 1970s (Andonian and Kessler, 1979; Bibbo et al., 1977; Gill et al., 1979; Gill, et al., 1988; Laitman et al., 1997). These effects include a variety of structural abnormalities of the reproductive system such as epididymal (benign) cysts, hypoplastic testes or undescended testes (chryptorchidism), microphallus or underdeveloped penis which may be associated with an intersex condition, and hypospadias (opening of the penis is on the underside rather than at the end). Although DES exposure has been suspected as a possible source of male infertility and testicular cancer (Giusti, Iwamato, and Hatch, 1995, it is still uncertain whether prenatal DES exposure has led to increased risk of infertility (Wilcox et al., 1995) or increased rates of testicular cancer as well as other types of cancer in males (Strohsnitter, et al. 2001).
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