10/3/2016 A PHARMACISTS ROLE IN LEARNING OBJECTIVES CARING FOR - - PDF document

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10/3/2016 A PHARMACISTS ROLE IN LEARNING OBJECTIVES CARING FOR TRANSGENDER AND GENDER NON- De fine c urre nt a nd a ppro pria te vo c a b ula ry fo r CONFORMING PATIENTS disc ussing tra nsg e nde r a nd g e nde r no n-c o nfo rming

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J ES SIC A C O N KLIN , P HA R M D , P HC , B C A C P , A A HIV P , C D E V IS ITIN G A S S IS TA N T P R O FESSO R P HA R M A C Y P R A C TIC E A N D A D M IN ISTR A TIV E S C IEN C ES UN M C O LLEG E O F P HA R M A C Y J EC O N KLIN @ SA LUD . UN M . ED U

A PHARMACIST’S ROLE IN CARING FOR TRANSGENDER AND GENDER NON- CONFORMING PATIENTS

LEARNING OBJECTIVES

  • De fine c urre nt a nd a ppro pria te vo c a b ula ry fo r

disc ussing tra nsg e nde r a nd g e nde r no n-c o nfo rming (T GNC) pe o ple .

  • Re c o g nize b a rrie rs to he a lthc a re fa c e d b y T

GNC pe o ple

  • Re c a ll c urre nt me dic a tio n the ra py o ptio ns fo r T

GNC pe o ple

  • I

de ntify o ppo rtunitie s fo r pha rma c ist to pro vide po sitive , a ffirming c a re fo r T GNC pa tie nts

  • L

ist re fe re nc e s tha t re info rc e a ppro pria te T GNC c a re

PREVALENCE OF TGNC PATIENTS IN BOSTON

  • 1. Re isne r, 2015

Re isne rSL e t a l. J U rban He alth. 2015 Jun; 92(3):584-92.

Possible explanations for inc r ease:

  • Soc ial/ Cultur

al ac c eptanc e

  • Gr

eater medic al ac c ess

DEFINITIONS

  • Assigne d se x (natal se x)
  • Ge nde r a ssig ne d a t b irth, typic a lly b a se d o n e xte rna l g e nita lia
  • Affir

me d ge nde r

  • An individua l’ s g e nde r ide ntity; ma y o r ma y no t a lig n with na ta l g e nde r
  • Ge nde r

ide ntity

  • A c o mple x de ve lo pme nta l unde rsta nding o f o ne ’ s g e nde r se lf with

psyc ho lo g ic a l, physio lo g ic a l, e nviro nme nta l a nd so c io c ultura l influe nc e s

  • Ge nde r

be havior s:

  • Ho w a pe rso n ma y e xpre ss the ir g e nde r (dre ss, spe e c h, inte rpe rso na l

style )

  • Ge nde r

r

  • le s:
  • Be ha vio rs, a ttitude s a nd pe rso na lity tra its so c ie ty de sig na te s a s “ma le ”
  • r “fe ma le ”

Gender identity, behavior s and r

  • les do not always

align

DEFINITIONS: GENDER SPECTRUM

  • Cisge nde r
  • So me o ne who ide ntifie s with the ir a ssig ne d se x a t b irth
  • T

r ansge nde r

  • So me o ne who ide ntifie s a s a diffe re nt se x tha n the o ne a ssig ne d

a t b irth (ma y b e no n-b ina ry, the re is a spe c trum)

  • T

r ansge nde r man: A pe rso n a ssig ne d fe ma le a t b irth who ide ntifie s a s a ma n (tra ns-ma le )

  • T

r ansge nde r woman: A pe rso n a ssig ne d ma le a t b irth who ide ntifie s a s a wo ma n (ta ns-fe ma le )

  • Ge nde r

non-c onfor ming

  • A pe rso n who do e s no t e xpre ss the ir g e nde r in c ultura l o r so c io -

typic a l wa ys

GENDER PRONOUNS

  • Use pro no uns b a se d o n patient pr

efer enc e

  • F

e ma le : she / he r

  • Ma le : he / him
  • Ge nde r ne utra l: ze / ze r
  • Ge nde r ne utra l: the y/ the m (c a n b e use d a s sing ula r)
  • Pa tie nt’ s ma y ide ntify a s o ne g e nde r b ut no t ye t

re a dy to use pro no uns fo r tha t g e nde r

  • Pe rio dic a lly a sk a nd c he c k to ma ke sure the

pa tie nt is still using the pro no uns yo u a re using

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GENDER PRONOUNS-HOW TO ASK

  • T

ry to no rma lize yo ur inte ra c tio n o f a sking pa tie nt’ s pre fe re nc e s

  • “Hi, my na me is Je ssic a . I

’ m a pha rma c ist a nd I use fe ma le pro no uns. Ca n yo u te ll me a b o ut yo urse lf? ”

  • “L

a st time we ta lke d yo u we re using ma le pro no uns. Wha t pro no uns a re yo u using c urre ntly? ”

TYPES OF “TRANSITIONS”

  • Soc ial tr

ansition

  • Cha ng ing o ne ’ s so c ia l

g e nde r pre se nta tio n to b e tte r re fle c t a ffirme d g e nde r

  • Spe c ific to pa rtic ula r

c ultura l a nd so c ia l unde rsta nding s o f g e nde r b e ha vio rs a nd ro le s

  • Do e s no t ha ve to b e in

a ll e nviro nme nts

  • Physic al tr

ansition

  • Using me dic a l

inte rve ntio ns to c ha ng e se x tra its to b e tte r re fle c t a ffirme d g e nde r (ho rmo ne s, surg e rie s, e tc )

  • No n-me dic a l te c hniq ue s

inc lude e le c tro lysis a nd vo ic e tra ining

SEXUAL IDENTITY VERSUS GENDER IDENTITY

Sexual Identity

  • Stra ig ht
  • Bise xua l
  • L

e sb ia n

  • Ga y
  • Pa nse xua l
  • Ase xua l

Gender Identity

  • F

e ma le

  • Ma le
  • No n-b ina ry
  • Ag e nde r
  • T

wo -spirit

  • Ge nde rq ue e r
  • Ge nde rfluid

Se xua lity a nd g e nde r a re NOTthe sa me c o nc e pts

GENDER DYSPHORIA

GENDER DYSPHORIA

  • Clinic al sympto m
  • Disc o mfo rt, distre ss OR func tio na l impa irme nt c a use d

b y inc o ng rue nc e b e twe e n g e nde r a ssig ne d a t b irth a nd a ffirme d g e nde r

  • I

n 2013, g e nde r dyspho ria wa s a dde d to the Dia g no stic a nd Sta tistic a l Ma nual o f Me nta l Diso rde rs (DSM)-5th e ditio n No te DSM-I V dia g no sis o f ‘ g e nde r ide ntity diso rde r’ is no lo ng e r use d no r de e me d a c c e pta b le b y the T GNC c o mmunity

AUDIENCE RESPONSE

T rue o r F a lse : All T GNC pa tie nts e xpe rie nc e g e nde r dyspho ria .

1) T rue 1) F a lse

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10/3/2016 3

GENDER DYSPHORIA EXPERIENCE

  • 51% o f T

GNC yo uth a re b ullie d a t sc ho o l

  • T

GNC yo uth a re mo re like ly to ha ve lo we r GPAs, miss sc ho o l o r dro p o ut o f sc ho o l e a rly b e c a use o f ha ra ssme nt

  • 30% o f T

GNC yo uth a tte mpt suic ide a t le a st

  • nc e
  • (41% o f T

GNC a dults)

K

  • sc iw JG e t a l. 2010 Ne w Yo rk: GL

SE N. Ha a s AP a t a l. J Ho mo se x. 2011;58(1):10-51.

DISCRIMINATION FACED BY TGNC PEOPLE

DISCRIMINATION OF TGNC PEOPLE

  • I

n 2011, the Na tio na l L GBT Q T a sk F

  • rc e a nd the

Na tio na l Ce nte r fo r T ra nsg e nde r E q ua lity surve ye d 6,450 tra nsg e nde r a nd g e nde r no n- c o nfo rming individuals.

  • 90% re po rte d ha ra ssme nt o r mistre a tme nt o n the jo b
  • 26% lo st a jo b due to b e ing tra nsg e nde r
  • 53% ha d b e e n ve rb a lly ha ra sse d in a pla c e o f pub lic

a c c o mmo da tio n

Gra nt JM e t a l. Wa shing to n: Na tio na l Ce nte r fo r T ra nsg e nde r E q ua lity. 2011

TGNC DISCRIMINATION IN HEALTHCARE

  • 33% ha ve de la ye d o r did no t a c c e ss

he a lthc a re due to disc rimina tio n

  • 50% re po rt ha ving to e duc a te the ir me dic al

pro vide rs

  • 28% po stpo ne c a re due to fe a r o f

disc rimina tio n

  • 48% c a nno t a ffo rd me dic al c a re
  • 19% re po rt b e ing re fuse d me dic a l c a re
  • 30% re po rt ha ving a disa b ility o r me nta l he a lth

c o nditio n (po pula tio n a ve ra g e is 20%)

Gra nt JM e t a l. Wa shing to n: Na tio na l Ce nte r fo r T ra nsg e nde r E q ua lity. 2011

IMPACTS ON HEALTH DUE TO DISCRIMINATION

  • Da ily stre ss o f disc rimina tio n, stig ma a nd a dve rsity
  • I

nc re a se d ra te s o f sub sta nc e use , a nxie ty, de pre ssio n, suic ide a tte mpts

  • Hig he r tra uma ra te s in c hildho o d e q ua te to hig he r ra te s
  • f po o r he a lth o utc o me s in a dultho o d
  • Hig he r ra te s o f HI

V

  • 28% o f tra nsg e nde r wo me n in the US ha ve HI

V

  • 56% o f tra nsg e nde r Afric a n-Ame ric a n wo me n ha ve HI

V

Gra nt JM e t a l. Wa shing to n: Na tio na l Ce nte r fo r T ra nsg e nde r E q ua lity. 2011 Ba ra l SD e t a l. L anc e t. I nfe c t Dis. 2013 Ma r;13(3):214-22.

OVERVIEW OF HORMONE THERAPY

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10/3/2016 4

GOALS OF PHARMACOLOGIC INTERVENTIONS

T

  • induc e physic a l c ha ng e s tha t a re mo re c o ng rue nt

with g e nde r ide ntity

  • I

ndividualize b a se d o n pa tie nt’ s g o a ls

  • Ma ximum ma sc uliniza tio n/ fe miniza tio n
  • Minima l ma sc uliniza tio n/ fe miniza tio n fo r a mo re a ndro g yno us

pre se nta tio n

FEMINIZING HORMONE THERAPY

  • Go a ls
  • T
  • de ve lo p fe ma le se c o nda ry se x c ha ra c te ristic s
  • T
  • suppre ss/ minimize ma le se c o nda ry se x c ha ra c te ristic s
  • Ge ne ra l a ppro a c h
  • Co mb ine e stro g e n with a ndro g e n b lo c ke r

ANTI-ANDROGENS

  • Spiro no la c to ne
  • Dire c tly inhib its te sto ste ro ne se c re tio n a nd a ndro g e n

b inding to the a ndro g e n re c e pto r

  • GnRH a g o nist
  • Blo c k the re le a se o f fo llic le stimulating ho rmo ne a nd

lute inizing ho rmo ne

ESTROGENS

  • Ora l e stro g e n
  • T

ra nsde rma l e stro g e n

  • Pa tie nts a t risk o f VT

E

  • E

le va te d trig lyc e ride s

  • I

nje c ta b le e stro g e n

E ST ROGE N

T

  • pic a l
  • T

ra nsde rma l (Pa tc h)

  • Ge l, spra y
  • Co mpo unde d to pic a l c re a ms

Inje c tio n

  • E

stra dio l Va le ra te

  • E

stra dio l Cypio na te Ora l:

  • 17-b e ta e stra dio l (e stra dio l)

Sub ling ua l ta b le t:

  • (mic ro nize d e stra dio l)

F e minizing Hor mone s E xpe c te d Onse t E xpe c te d Maximum E ffe c t Bo dy fa t re distrib utio n 3-6 mo nths 2-5 ye a rs De c re a se d musc le ma ss/ stre ng th 3-6 mo nths 1-2 ye a rs So fte ning o f skin/ de c re a se d

  • iline ss

3-6 mo nths unkno wn De c re a se d lib ido 1-3 mo nths 1-2 ye a rs De c re a se d spo nta ne o us e re c tio ns 1-3 mo nths 3-6 ye a rs Ma le se xua l dysfunc tio n Va ria b le Va ria b le Bre a st g ro wth 3-6 mo nths 2-3 ye a rs De c re a se d te stic ula r vo lume 3-6 mo nths 2-3 ye a rs Ma le pa tte rn b a ldne ss No re g ro wth, lo ss sto ps 1-3 mo nths 1-2 ye a rs

WPAT H Sta nda rds o f Ca re , 7th Ve rsio n

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10/3/2016 5

MASCULINIZING HORMONE THERAPY

  • Go a ls
  • T
  • de ve lo p ma le se c o nda ry se x c ha ra c te ristic s
  • T
  • suppre ss/ minimize fe ma le se c o nda ry se x c ha ra c te ristic s
  • Ge ne ra l a ppro a c h
  • T

e sto ste ro ne mo no the ra py

T E ST OST E RONE

Inje c ta b le (IM)

  • Cypionate
  • E

na ntha te

  • Pro pio na te

T

  • pic a l
  • Andro de rm (Pa tc h)
  • Andro g e l (g e l)
  • Ointme nt (pe tro la tum b a se )

Sub c uta ne o us Impla nt

  • T

e sto pe l Inje c ta b le (Sub Q)

  • Cypio na te

E xpe c te d Onse t E xpe c te d Maximum E ffe c t Skin o iline ss/ a c ne 1-6 mo nths 1-2 ye a rs F a c ia l/ b o dy ha ir g ro wth 3-6 mo nths 3-5 ye a rs Sc a lp ha ir lo ss >12 mo nths Va ria b le Inc re a se d musc le ma ss/ stre ng th 6-12 mo nths 2-5 ye a rs Bo dy fa t re distrib utio n 3-6 mo nths 2-5 ye a rs Ce ssa tio n o f me nse s 2-6 mo nths n/ a Clito ra l e nla rg e me nt 3-6 mo nths 1-2 ye a rs Va g ina l a tro phy 3-6 mo nths 1-2 ye a rs De e pe ne d vo ic e 3-12 mo nths 1-2 ye a rs

IM TESTOSTERONE FOR SUBQ ADMINISTRATION

  • Co mmo nly use d
  • NOT

F DA a ppro ve d

  • I

s it sa fe ?

  • I

s it e ffic a c io us?

  • Ho w is it g ive n?

EFFICACY AND SAFETY

Study Population (age ) Dose E ffic ac y Safe ty

Olso n e t a l. 2014 36 pa tie nts (13-24 y/ o ) Sub Q 25mg b iwe e kly fo r 8 we e ks, the n inc re a se d to 25mg we e kly fo r 4 we e ks, the n 50mg we e kly 91.4% a c hie ving to ta l te sto ste ro ne le ve ls WNL

  • Sta tistic a lly

sig nific a nt in HCT

  • 2 lo c a lize d

re a c tio ns

  • No dissa tisfie d

pa tie nts Bo h e t a l. 2015 26 pa tie nts (16-50 y/ o ; me a n 27) *14 lo st to fo llo w-up Sub Q 50mg we e kly fo r 4 mo nths the n titra te d to te sto ste ro ne le ve ls (a ve ra g e we e kly do se 57.9mg ) 100% a c hie ve d to ta l te sto ste ro ne le ve ls WNL

  • 1 pa tie nt

re po rte d mino r irrita tio n a t the inje c tio n site , whic h re so lve d Olsha n e t a l. 2013 5 tra nsme n 2 hypo g o na da lme n (18-58; me a n 28.2 y/ o ) Sub Q 50-60mg we e kly 100% a c hie ve d to ta l te sto ste ro ne le ve ls WNL

  • No a dve rse drug

e ffe c ts we re re po rte d

OPPORTUNITIES FOR PHARMACISTS TO PROVIDE QUALITY CARE TO TGNC PEOPLE

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10/3/2016 6

PHARMACIST ROLE

  • Be a wa re o f the issue s T

GNC pe o ple fa c e

  • Stig ma a nd disc rimina tio n
  • L

imite d a c c e ss to c a ring a nd c o mpe te nt he a lth c a re pro fe ssio na ls

  • L

imite d re so urc e s

  • Diffic ultie s na vig a ting the he a lth c a re syste m
  • i.e . Me dic a tio n a c q uisitio n
  • Pro vide a g e nde r a ffirming e xpe rie nc e
  • E

sta b lish na me / pro no un pre fe re nc e

  • Pre sc riptio n dro p o ff a nd pic k up
  • E

nte ring ho spita l pa tie nt’ s ro o m

  • Clinic c he c k in/ disc ha rg e

Co le ma n E ., e t. a l. Sta nda rds o f Ca re fo r the He a lth o f T ra nsse xua l, T ra nsg e nde r, a nd Ge nde r-No nc o nfo rming Pe o ple , Ve rsio n 7. I nte rna tio na l Jo urna l o f T ra nsg e nde rism, 13:165–232, 2011.

SPECIFIC PHARMACY SETTINGS

  • Re ta il
  • Me dic a tio n la b e l ve rsus insura nc e c la im
  • E

sta b lish/ K no w pre fe rre d na me / pro no uns whe n c a lling pa tie nts a b o ut re fills, pic k-up, insura nc e , e tc .

  • Va c c ina tio ns
  • Disc ussio n b a se d o n b e ne fits to o rg a n syste m (HPV & c e rvic a l b e ne fits)
  • Use disc re e t la ng ua g e
  • Ho spita l/ Clinic
  • E

sta b lish/ K no w pre fe rre d na me / pro no uns b e fo re e nte ring a pa tie nt ro o m

  • Aid in inte rpre ting la b o ra to ry re sults
  • Do se o f me dic a tio n
  • CrCl diffe re nc e s
  • Risk Ca lc ula tio ns
  • ASCVD risk
  • Re se a rc h
  • Add to the b o dy o f lite ra ture

PHARMACIST ROLE

  • Me dic a tio n E

duc a tio n

  • Pro viding a n in-de pth disc ussio n re g a rding the me dic a l risks,

b e ne fits a nd a lte rna tive s o f c ro ss se x ho rmo ne the ra py (c sHT )

  • Disc ussing time line s o f physic a l o utc o me s o f c sHT
  • Disc ussing a pa tie nts e xpe c ta tio ns a nd g o a ls o f c sHT
  • Disc ussing the diffe re nt fo rmula tio ns o f the c sHT
  • T

a ilo ring c sHTto the pa tie nt’ s ne e ds

  • Impro ve a c c e ss to me dic a tio ns
  • He lping the te a m with prio r a utho riza tio ns fo r the c sHT
  • Co -ma na g e me nt a nd risk re duc tio n
  • Smo king c e ssa tio n
  • Ob e sity
  • E

le c tro nic Me dic a l Re c o rds (E MR) a nd syste ms o f c a re

  • T

ro ub le sho o t ho w to re c o rd na ta l g e nde r ve rsus a ffirme d g e nde r

EVOLVING ACCESS TO CARE

INCREASED ACCESS TO CARE

  • I

n Ma y 2016, the De pa rtme nt o f He a lth a nd Huma n Se rvic e s a dde d pro te c tio ns fo r tra nsg e nde r pe o ple to the Affo rda b le Ca re Ac t

  • No w tra nsg e nde r pa tie nts in a ll 50 sta te s will b e

g ua ra nte e d a c c e ss to he a lth se rvic e s a nd insura nc e to c o ve r tho se se rvic e s

  • E

nsure tra nsg e nde r pa tie nts still ha ve c o ve ra g e fo r ne c e ssa ry he a lth se rvic e s (ie tra nsg e nde r ma n will ha ve insura nc e fo r ma mmo g ra ms a nd g yne c o lo g ic a l se rvic e s)

  • I

nsura nc e c o mpa nie s c a nno t de ny c o ve ra g e to the ra pie s, surg e rie s o r o the r pro c e dure s re la te d to g e nde r tra nsitio n

RESOURCES

  • Wo rld Pro fe ssio na l Asso c ia tio n fo r T

ra nsg e nde r He a lth (WPAT H)

  • E

duc a tio n/ tra ining

  • Wo rld Pro fe ssio na l Asso c ia tio n fo r T

ra nsg e nde r He a lth (WPAT H.o rg )

  • T

he E ndo c rine So c ie ty Guide line s

  • F

e nwa y Na tio na l L GBT Q He a lth E duc a tio n Ce nte r

  • UCSF

Ce nte r o f E xc e lle nc e fo r T ra nsg e nde r He a lth

  • Ge nde r Spe c trum.o rg
  • GL

AAD.o rg

  • Co nse nt fo rms, e xa mple le tte rs fo r insura nc e s, e xa mple le tte rs fo r

g e nde r ma rke r c ha ng e s, e tc .

  • UCSF

Co Efo r T ra nsg e nde r He a lth

  • WPAT

H

  • F

e nwa y He a lth

  • Sa n F

ra nc isc o De pa rtme nt o f He a lth, T ra nsg e nde r He a lth Se rvic e s