TARA JEANINE OLIVADIETETIC INTERN
BENEDICTINE UNIVERSITY, SPRING 2011
HIV, Hormones, Stress & Discrimination: Assessment &
Education with Transgender Patients
Introduction
According to the IOMClinicians are faced with incomplete
information about the health status of the LGBT population.
Each population has its own specific health needs and concerns.
Researchers face numerous challenges in understanding each populations including a lack of data.
Institute of Medicine,( March 2011)
Introduction Continued
For better understanding, the NIH needs to create an ample training program to raise awareness of health issues that the LGBT community is faced with.
The most pressing issues to focus on are:
1. Demographic research 2. Social Influences 3. Intervention Research 4. Transgender specific health needs
Institute Of Medicine,( March 2011)
Prevalence of Transgender
There is no reliable data on the number of transgender individuals in the United States.
Center for Disease Control and Prevention (2011)
You never know, you must have knowledge
Terminology
Terminology
Natal sex: Identified sex at birthGender: psychological, social & cultural aspects
of female & male. Transgender: a self selected term used to
describe an identity that transcend gender norms; an umbrella term.
Transition: a process from being perceived as one gender to another gender. Through : Name change or /and Hormones
and/or SurgeryTranssexual: a medical term used to describe a
transgender individual who has sought formal or informal medical intervention.
Alegria, (2011)
Other terminology
MTF :Male to Female, FTM(female to male), transman (FTM), transwomen (MTF),
Drag: someone who wears clothing of another gender, often involving the presentation of exaggerated, stereotypical gender characteristics.
Gender Queer: a term used by some people who may or may not fit on the spectrum of trans or be labeled as trans, but who identify their gender or orientation to be in-between or outside the binary gender.
Cross Dresser: a person who, on occasion wears clothing considered typical for another gender, but does not necessarily desire to change their gender.
Alegria, (2011)Howard Brown (n.d.)
Patient Information
Patient Information
Gender: MTF (male anatomy at present, w/hormones)Age: 40 Ethnicity: CaucasianHeight: 5’10”Weight: 182# (78kg) Wt Change: 27# gain in 5
years Usual Body Weight: 150-155 # ( as a male)IBW: F = 150# Deutsch, M.(2010) % IBW = 120%BMI: 26.1ABW: 158#
Patient Information
Current diagnoses: HIV+, severe depressionoHIV+ = diagnosed 2005oDepression: Childhood
Symptoms: depression
Patient Information
Medical tests planned: lipid panel, blood glucose, continuous CBC, estradiol levels, mammogram.
Previous Surgery: Breast ImplantsSurgery Planned: vaginoplasty.
Jenner, C.O. (2010)
Assessment of Nutrition Needs
Using the literature and ABW
Harris Benedict (stress 1.3) o 1931 kcals per day
1.0-1.4 grams protein/kg for maintenanceo 72 g-101g per day
MVI
(Coyne-Meyer, K., &Trombley, L., 2004)
Hormones & Surgeries
Hormone Therapy
Premarin .625 BIDoConjugated estrogen
Estraderm Transdermal: system patches
Delestrogen shot 40 mg o Increased or decreased weight, appetite changes,
decreased Ca+ bone loss, increase Ca+, increased TG, Increase HDL, Increased LDL
It is a Catch 22…..
Gender Identity Disorder
Diagnosis in the DSM A. evidence of a strong and persistent gross-
gender identification, which is the desire to be, or the insistence that one is of the other sex.
B. This cross-gender identification must not merely be a desire for any perceived cultural advantages of being the other sex. there must also be evidence of persistent discomfort about one’s assigned sex or a sense of inappropriateness in the gender role of that sex
Criteria for Hormones & Surgery
Psychiatric Evaluation before surgery or hormones
(A mental health diagnosis rules their life?)
Diagnoses of Gender Identity Disorder
Thinc: Trans Hormones-Informed Consent
(@Howard Brown)
p://lgbthealth.healthcommunities.com/transgender/gender-identity-disorder.shtml
Howardbrown.org
Hormones MTF
Estrogens Effects: Softer SkinReduced testicular volumeDecreased erectile functionDecreased hair growthDecreased libidoEnlargement of nipplesTestosterone to female levels
Labs: free testosterone, fasting chemistry panel, fasting lipid panel, CBC, estradiol levels, PSA, Pap (if vagina), mammogram
Algeria, (2011)
Hormones FTM
Androgen effects: Deepening of voice Increased aggression Increased libido Cessation of menses Hirtuism Clitorial growth Breast atrophy Redistribution of fat Laryngeal prominence
Labs: Fasting lipid profile, liver function tests, CBC, pap smear, mammogram (breast tissue present)Alegria, (2011)
Surgeries
MTFo Vaginoplastyo Augmentationo Facial Feminizationo Electrolysis
FTMo Chest reconstructiono Hysterectomyo Penis construction (phalloplasty)o Metoidioplasty (creation of penis from clitoris)
http://transgendersurgeries.com/
NUTRITION ASSESSMENT
Diet & Appearance
Trans persons may use food to help with their physical appearance Overeating to increase size Calorie Restriction
New gender after one year of successful hormone therapy Increase for FTM Do not overlook their needs
Deutsch, 2010Vancouver Coastal Health, 2010
The Literature
Lack healthy lifestyle patternMean nutrient intake below standard valueEat more or skip meals
Lead to malnutrition Obesity
Emotions had impact on food consumption Rejection Racism Lack of medical health care
The literature complements the patientSivakami, PL & Veena, K.V. (January, 2011)
HIV And Transgender
Rates among transgender
Estimated HIV infection rates among specific transgender populations range from 14-69%.
Highest among MTF sex workers
Center for Disease Control and prevention (2011)
Prevalence of HIV
High Rate of HIV+ oLack of HIV educationoLack of medical accessoSES – social isolationoMental Health concernsoStressoMany barriers
**LEAD TO ↑ RISKY BEHAVIORS
Behavioral Risks for HIV
o Unprotected receptive anal intercourse
o Multiple casual partners
o Sex work
o IV drug/street hormones
o Herbst, J.H. (2008)
Lack of education of HIV/AIDS
o Providers lack adequate knowledge to care for patients.
o Do not lend themselves to “caring” environments.
o Do not understand their needso Lack any formal education of this
populationo May see this population as having a diagnosed “Gender Identity Disorder
o Butler, R. (2010)
Health Disparities
Discrimination Affects Health
o Families : isolation
o Employers : loss of job, loss of health insurance
o Homelessness: lack of support system, increased risk of HIV.
o Healthcare: uncaring environment, unknowledgeable staff, lack of care
o Williamson, (2010)
Homeless
TRANSGENDER
homeless
unemployment
Lack of meds
Lack of nutrition
Lack of insuranc
e
Poor health status
Lack of medical care
Risky Behavior
sOperario, D & Nemato, T. (2010)
COMMUNITY RESOURCES
Howard Brown Health Center
Howard Brown exists to eliminate the disparities in health care experienced by lesbian, gay, bisexual and transgendered people through research, education and the provision of services that promote health and wellness.
o Medical centero Behavioral Serviceso Youth Services o Fund raising eventso Substance abuse programso Many, many, more
o www.howardbrown.org
http://www.howardbrown.org/hb_services.asp?id=37
TWISTA
Trans Women Informing Sister Trans Women on AIDS
TWISTA is a group designed to celebrate the strength and resiliency of transgender women of color (ages
16-24) Support to deal with struggles like harassment,
relationships, and health.o Role modelso Love and supporto Educationo Sponsored through Howard Brown –Chicago [email protected]
Community Interventions
AIDS Foundation of Chicagoo Supportive Housingo Food pantries, soup kitchens, and meal
programso Prevention Eventso Syringe Programso Medication Programso Advocacyo Grantmaking
What Can We Do?
Proper gender on questionnairesProper pronoun/proper nameGender neutral restroomsWork as a multidisciplinary team, know your
partUnderstand hormones/ART interactionsUnderstand eating disorders/refer if
necessaryKnow the risks in this communityKnow your patient, do not make assumptions.Create a caring environment
Angelique
Works Cited
Butler, R. (2010)An assessment of lesbian, gay, bisexual, and transgender curriculum infusion in U.S. medical schools. Retrieved on May 05, 2011 from http://www.indiana.edu/~spea/pubs/undergrad-honors/volume-4/butler_rachel.pdf
Center for Disease Control and Prevention. (2011) HIV in the United States. Retrieved from May 4, 2011 from http://www.cdc.gov/HIV/resources/factsheets/us.htm.
Coyne-Meyers, K., & Trombley, L. (2004). A review of nutrition in Human Immunodeficiency Virus infection in the era of highly active antiretroviral therapy. Nutrition in Clinical Practice, 19, 340-355.
Deutsch, M. (2010). Primary care for transgender patients. Proceedings of the 13th Annual Clinical Conference for the Ryan White HIV/AIDS Program, http://www.iasusa.org/keyslides/hrsa/2010/index.html
Health Communities.(2011) Gender Identity Disorder. Retrieved on May 06, 2011 from http://lgbthealth.healthcommunities.com/transgender/gender-identity-disorder.shtml.
Herbst, J.H. (2008). Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A system review. AIDS and Behavior, 12(1), 1-17.
Howard Brown Health Center Publication. (2009) TWISTA Institute of omedicine of the national Acadamies. (March, 2011). The health of lesbian,
gay, bisexual and transgender People; Building a foundation for better understanding. Retrieved on April 15, 2011 from http://www.iom.edu/Reports/2011/The-Health-of-Lesbian-Gay-Bisexual-and-Transgender-People.aspx.
Jenner, C.O. (2010). Transsexual primary care. Journal of the American Academy of Nurse Practitioners, 22(8), 403-408.
Works Cited
• Jenner, C.O. (2010). Transsexual primary care. Journal of the American Academy of Nurse Practitioners, 22(8), 403-408.
• Lawrence A. (2001) Vaginal Neoplasia in a Male-to-Female Transsexual: Case Report, Review of the Literature, and Recommendations for Cytological Screening. International Journal of Transgender.5,(1).
• Nerad, J., et al. (2003). General nutrition management in patients with Human Immunodeficiency Virus. Clinical Infectious Diseases, 36(2), S52-62
• Operario, D. & Tooru, N. (Dec 15, 2010) HIV in Transgender Communities: Syndemic dynamics and a need for multicomponent interventions. Journal of Acquired Immune Deficiency Syndromes, 55, p 91-93.
Pribram, V. (2010). Nutrition and HIV. Singapore: Blackwell Publishing Ltd Willliamson, C. (2010). Providing care to transgender persons: A clinical
approach to primary care, hormones, and HIV management. Journal of the Association of Nurses in AIDS Care, 21(3), 221-229
Vancouver Coastal Health. (2011) Transcare medical issues. Retrievedd on May 5, 2011 from http://vch.eduhealth.ca/pdfs/GA/GA.100.F55.pdf.