Slide #1

The Cardiovascular & Metabolic Health of Transgender Persons:

Implications in Primary Care

The Cardiovascular & Metabolic Health of Transgender Persons:

Implications in Primary Care

PI - Madeline B. Deutsch, MDDirector

Transgender Health ProgramLA Gay & Lesbian Center

Assistant Clinical ProfessorUCSF Department of Family & Community Medicine

PI - Madeline B. Deutsch, MDDirector

Transgender Health ProgramLA Gay & Lesbian Center

Assistant Clinical ProfessorUCSF Department of Family & Community Medicine

Slide #2

Study Team• Madeline Deutsch, MD – PI

– LA Gay & Lesbian Center• Vipra Bhakri, MPH - Research Navigator

– Comm. Clinics Assoc of LA County• Katrina Kubicek, PhD – Collaborator

– USC CTSI• JoAnna Olson, MD – Co-Investigator

– CHLA• Special thanks to Marvin Belzer, MD

(CHLA)

Slide #3

Funding• CTSI – In kind funds (lab costs, incentives,

CASI equipment)• LAGLC – In kind PI time, overall project

support and management• CCALAC – 50% Research Navigator• CHLA – In kind co-investigator time

Slide #4

Background and Significance

• Body of research on transgender people is severely limited

• 2011 report from the IOM recommends funding research in all areas of transgender health

Slide #5

Trans Research –Why Important?

• 50% of transgender patients report having to teach their health provider about care– National Transgender Discrimination Survey 2011

• 11% report being refused care outright– State of Transgender California 2009

• Only 30% of medical school curriculae include content on transition-related care– Obedin-Mailver et al JAMA Sept 7, 2011

Slide #6

Transgender Care – Why Important?

• Hormone therapy reduces anxiety, depression and improves social functioning & QOL

• Surgery improves global functioning and quality of life

Newfield E, Hart S, Dibble S, Kohler L. Quality of Life Research. 2006 Jun 7;15(9):1447–57. Gómez-Gil E, Zubiaurre-Elorza L, Esteva I, Guillamon A, Godás T, Cruz Almaraz M, et al. Psychoneuroendocrinology [Internet]. 2011 [cited 2012 Dec 10];

Meier SLC, Fitzgerald KM, Pardo ST, Babcock J. Journal of Gay & Lesbian Mental Health. 2011;15(3):281–99.

Slide #7

Primary Aim

1) Collect metabolic and cardiovascular parameters on transgender patients before and after 6 months of cross-sex hormones

2) Collect information on transgender patient attitudes about primary care

Slide #8

Secondary Aims

• Develop infrastructure for future transgender research at the study site

• Test feasibility of conducting community-based transgender research and subsequent translation into clinical practice

• Explore research collaborations between the multiple involved institutions

Slide #9

Study Site (LA Gay & Lesbian Center)

• Oldest and largest (by budget) LGBT organization in the world

• Federally Qualified Health Center (Lookalike) & Ryan White Grantee

• Existing research programs focused primarily on HIV

• Transgender Health Program census = approx 500 individuals

Slide #10

Methods• Collect baseline and 6 month metabolic

data• Baseline and 6 month survey of attitudes

about primary care• Subjects receive covered lab costs and

$25 gift card incentives at enrollment and again at completion

• Planned N determined by budget (75)• Retention efforts include reminder calls &

texts

Slide #11

Study Population

• 18 years of age or older• Patient registered in LAGLC Transgender Health

Program• No prior cross-sex hormone treatment (csHT)• Intend to begin csHT• Transgender identified• No contraindication to csHT• Sequential patients enrolled

Slide #12

Initial Results

• 57 sequential patients enrolled– 34 FTM, 23 MTF

• Reasons for under-enrollment– Front office/scheduling difficulties– Shifting patient demographics (higher

percentage of new-to-LAGLC patients coming from another clinic already on hormones)

– Enrollment closed in January 2013 in order to allow completion of study within projected time frame of August 2013

Slide #13

White

Black

Native H

awain

Asian

Americ

an India

n

Oth

er 0

5

10

15

20

25

3027

3

0

31

0

Race Breakdown for FTM (N=34)

White

Black

Native H

awain

Asian

Americ

an India

n

Oth

er 0

5

10

15

20

25

30

18

1 1 2 0 1

Race breakdown for MTF (N=23)

Slide #14

Hispanic 32%

Non-Hispanic

68%

Ethnicity breakdown for FTM (N=34)

Hispanic45%

Non-Hispanic

55%

Ethnicity Breakdown for MTF(N=23)

Slide #15

18-25 26-35 36-45 46-55 >550

2

4

6

8

10

12

14

16

18

20

18

11

5

00

12

6

1

3

1

Age Distribution for FTM and MTF

FTMMTF

# o

f P

ati

en

ts

Slide #16

  FTM  MTF 

BP Systolic     

Mean ±SD 119.8±13.3 130.8±15.3

Median 120.0 130.0

BP Diastolic 

Mean ±SD 74.1±10.9 77.6±12.1

Median 73.0 77.0

Height

Mean ±SD 65.2±3.3 68.3±4

Median 65.0 68.0

Weight

Mean ±SD 183.1±56.1 174.8±55

Median 173.0 153.0

Waist Circumference

Mean ±SD 98.9±19.9 92.5±17.8

Median 96.0 86.0

BMI

Mean ±SD 30±8.4 25.9±5.8

Median 69.6 5.8

Slide #17

FTM  MTF Cholesterol Total     Mean ±SD 175.8±31.6 177.9±29.5Median 172.5 186.5HDL 

Mean ±SD 60±16.9 53.2±17.6Median 57.0 53.0LDL (Calc) Mean ±SD 95.5±26.7 100.7±26.8Median 92.0 109.5Triglycerides Mean ±SD 102±94.3 130.5±120.4Median 79.0 88.0

Estradiol Mean ±SD 109.4±65.8 32.4±22.4Median 141.9 28.9

Testosterone , Total  Mean ±SD 38.8±17.8 410.7±192.9Median 35.5 399.0Testosterone , Free Mean ±SD 0.8±0.5 11.6±5.5Median 0.7 11.4

Slide #18

< 3 mths21%

3-6 mths23%

6-12 mths14%

12-18 mths16%

18-24 mths7%

2-3 yrs3%

> 3 yrs16%

Time since last routine primary care visit

Slide #19

Very Likely Likely Somewhat Likely

Unlikely Very Unlikely0%

5%

10%

15%

20%

25%

30%

25%

18%

23%

28%

7%

How likely are you to see a primary care provider for routine care?

Slide #20

Anxiety

about g

oing to

the d

octor

No health

insu

rance

Distance

/ Tra

nsporta

tion is

sues

Difficu

lt to g

et an a

ppointm

ent

Healthca

re is

not a

prio

rity

for m

e right n

ow

0%

10%

20%

30%

40%

50%

60%

24%

12%

50%

21%

12%

15%

6%

18%

9%

27%

Barriers that may exist to accessing Care

Slide #21

Very Important75%

Somewhat Important23%

Neither important nor unimportant

2%

How important is it for you to recieve medical care of any kind at an LGBT-

oriented clinic?

Slide #22

Very Important16%

Somewhat Important25%Neither important nor

unimportant47%

Somewhat unimportant2%

Very Unimportant9%

How important is it for you to have a primary care provider who is trans-

gender themself?

Slide #23

Much more com-fortable

44%

Somewhat more comfortable

26%

Does not make a dif-ference

30%

Does having a transgender medical provider make you feel more or less comfortable in the health-

care setting?

Slide #24

Very Likely Likely Somewhat Likely

Unlikely Very Unlikely0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

77%

18%

4% 2% 0%

How likely is it that you would make future changes to your lifestyle, diet or exercise routine

if recommended to do so by your provider?

Slide #25

Study - Next Steps

• Complete 6 month exit visits• Conduct rigorous data analysis in

collaboration with CTSI• Prepare and submit manuscripts for

publication

Slide #26

Lessons Learned

• More resources needed to support scheduling of study patients (front office)

• Areas for improvement in EMR data abstraction at study site

• Collaborative, community based research appears to feasible in the study of transgender patients