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 twista@howardbrown.org 

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.