Prescribing for transgender patients

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My name is Ashlea Broomfield and I'm here with Louise Tomlins talking about transgender hormonal prescribing. Welcome to the podcast Louise.

It's great to be here.

So, I thought we would start talking a little bit about how to approach a conversation with someone who is transgender and what are the right terms to use and how we can be sure that we're having a consultation that's sensitive and appropriate for that particular person?

Language can be key and I guess it's important to be respectful when talking with transgender people because there's a lot of discrimination and stigma that they have experienced. So, there is some nomenclature that's important to kind of know about. Transgender I guess in general is used to describe people whose gender identity or experience of their gender doesn't wholly fit with what's usually associated with the sex that they're assigned at birth, and so people can be either transgender male, so their assigned female sex at birth but they identify as male, and transgender females are assigned male sex at birth but identify as females. There is everyone in between as well. So, we can also talk about people who identify as non-binary. That's an umbrella term I suppose for people whose concept of gender is not necessarily either all-male or all-female but perhaps somewhere in between and it can include people who experience their gender as a meld of both masculine and feminine or people who don't kind of buy into the binaryness of gender and that doesn't mean anything to them. Or people can use it to identify themselves where their gender is actually a sort of fluid state and can change from one to the other. So, I think that's absolutely fine to ask people how they identify, what term they like to use to refer to themselves, what pronouns they like to use. That's extremely important as well. Whether it's he, him, she, her, or they, them. That's always good to just ask to begin with and also to ask what name people would like to go by because often for transgender people their preferred name may not be what's actually on their Medicare card.

It can be really difficult particularly if someone's coming to your practice with a different name and a different pronoun and we unintentionally refer to them as their non-identified gender or name and in my experience I have found that even if I stumble a little bit and they go I'm actually known as this and I can sit back and go I'm really sorry that we've got that mistake on the record let's fix that up, how would you like to be called and what kind of ways would you like me to refer to you and please let me know if I don't use the right one because I don't have a lot of transgender patients or you know I won't be seeing you very regularly so sometimes I can slip up and please let me know and correct me if I say something wrong.

I think that's absolutely perfect. I mean sometimes these things happen and as long as you apologise and I guess try and make things clear on the file, perhaps for a next doctor who comes on that their preferred name is different from the Medicare name, making it clear in the file, but that's absolutely the best way to go just to apologise and try and work out for the next visit what the appropriate language to use is for that particular person.

One of the most common things that people will come in with is a request for hormonal transition. What kind of things do we need to take into account in terms of the process before somebody can start the hormonal transition?

There our standards-of-care guidelines that are published by the World Professional Association for Transgender Health and they recommend that before commencing gender-affirming hormone therapy that people should have a mental health assessment carried out by the psychiatrist or psychologist who's got experience in looking after transgender people. And the idea of that is just to confirm the persistence of the gender dysphoria, to work out obviously with the patient and what the best way forward is to manage that, whether that be hormone therapy, and I guess also to identify other mental health diagnoses that may be there as well and that is important to work out a management plan so that those sorts of things are as stable as possible prior to commencing hormone therapy. There is actually a second model of care which is called the Informed Consent Model of Care where that step can actually be carried out by a physician, whether it's the GP or whoever is prescribing the hormone therapy, that they can carry out that mental health assessment themselves. For most cases with transgender people that idea of persistence is fairly well documented, and the patient can tell you that very easily themselves so it's a matter of taking a bit of a history about that person's particular journey with their gender and how they felt about it over the years. And then it's also important to take a full medical history and identify any potential comorbidities or risk factors that may either be made worse or increase the risk of the gender-affirming hormone. Then we would do baseline blood pressure, weight, baseline blood tests, full blood count, EUC baseline hormone levels. Things like lipids, blood sugar level.

Is there any limitations on who can prescribe and any legal implications of prescribing medication in terms of the use of the medication for hormonal transition?

There are no specific limitations to who can prescribe. The standards-of-care guidelines recommend that it should be someone who's experienced. So that could be either a GP who's got experience with prescribing for transgender, it could be an endocrinologist, it could be a sexual health physician. The number of practitioners who are experienced is limited in Australia and this I guess puts a number of barriers in front of transgender people trying to access hormone therapy. So, it's fairly straightforward. If you don't feel comfortable in actually initiating hormone therapy for transgender people that's fine, by all means refer them on to endocrinologists, sexual health physicians, other GPS who have experience. GPs have the skill set when it comes to prescribing for postmenopausal women, hypogonadal men, so it's very similar kind of medicine.

So perhaps if someone or a GP was out there and was keen to start looking at helping people transition hormonally it might be a good start to link in with the sexual health physician or a psychiatrist who's got an interest in transgender health and then work out a way where they can work together as a team and perhaps down the track can work in liaison once they're more experienced in terms of how the process happens.

Yeah absolutely. ANZPATH is our branch of the WPATH Professional Association and they have got training days once per year and they also have an excellent training module on their website at the moment that goes through all aspects of initiation, maintenance and so on.

What are the ways that regional or rural GPs can link in with people that are more experienced in managing this area?

The good place to start is the ANZPATH websites. They do have a list of different medical practitioners, psychologists state by state, and also in each state there is generally support for transgender people. So in New South Wales there's the Gender Centre, in Victoria I think there's Transgender Victoria, Queensland definitely has one and South Australia, and they are always good places to go to get information about providers in the area.

Is there anything you wanted to say in relation to children who are presenting with gender dysphoria on specific things that we as GPs need to be mindful of in terms of timing of puberty and the success of hormonal transition?

Before they hit puberty there is no role for any medication but certainly there may be a role for kids to socially transition. So, to be presenting as the gender with which they most feel comfortable and that can be a difficult time. If kids are wanting to access gender-affirming hormone therapy what usually happens is that once they do hit puberty and sort of at Tanner Stage 2 they can take blockers to block puberty. So, it's GnRH agonists and what that does is it stops the surge of estrogen or testosterone as it may be so that there's no further masculinisation or feminisation of the child at that stage. There's a halt pretty much on puberty happening and that then gives the child a time to mature emotionally and cognitively so that they're at the stage where they can then give informed consent to what then can become potentially irreversible treatment. So, whilst they're taking the puberty blockers if they change their mind at that stage they can you know puberty just goes on as normal. And I guess doing nothing is sort of not an option for kids either. It's really important to help kids who are in that situation to do the thing that is right for them.

Yeah because like the downside of that is there's quite a high suicide risk.

Yeah that's right. It's astounding the correlation between anxiety and depression in trans kids and the rates of suicide and other eating disorders and that sort of thing, it's kind of up above 50% for most of those different mental health issues.

So, in that setting discussing with the family about the blockers aren't actually changing the gender at all, they're just stopping the development of the gender while the brain can continue to develop into a more adult brain and then they can make a decision further down the track on what they want to do.

Yeah.

Does it have any effect on height at all?

Apparently linear growth does still continue and it's actually, you need estrogen or testosterone to fuse your end plates. So, in fact particularly for transgender females they can end up taller than they would be normally which can be an issue for them as adults as well. So, there's also definitely an effect on bone density during that time as well. You need a sex hormone and that's the time when you're laying down your peak bone mass as well.

So making sure that the explanation to the person in their family is from the perspective of this allows us time to make decisions but once we've made the decision it's useful to go on with it but it's useful to have in-depth discussions with the people who are really skilled and specialised in this area so that you've got all the information but if we leave it and wait till later then we're at higher risk of mental health outcomes.

Yes, a balancing act, a fine balancing act. As I say a lot of transgender people will approach health professionals and come up against a brick wall because people are a bit frightened, don't know about it and that can be really harmful for transgender people. So great if you can refer on to people who are more experienced, even better if you can get some information and yourself some education and know a little bit about it and be able to help people along their journey.

And at the very least if somebody comes to see us then saying look I don't know much about this area but I'm really willing to work with you and see what we can do. Do you have any information that you're aware of or if not, why don't we catch up again in a week and I'll have a read about it and see what I can do.

Yeah and that just absolutely acceptable to trans people. Don't want to speak for them but from my experience a lot of people have said you know as long as doctors, you know are respectful and happy to learn and want to ask things it's usually okay if it's done in a respectful way.

Excellent. So, I think we'll finish it there.

Okay.

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The views of the hosts and guests on the podcasts are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm Ashlea Broomfield and thanks for joining us on the Australian Prescriber Podcast.