Medical management of adult transsexual persons

Repurposing prescribed hydromorphone: Alternative uses of safer supply and tablet-injectable opioid agonist treatment to meet unaddressed health needs

BACKGROUND

In response to the ongoing overdose crisis in Canada, a number of opioid agonist treatment and safer supply programs provide people at high overdose risk with daily-dispensed tablet hydromorphone, with some requiring witnessed ingestion and others providing take-away doses. While these programs are intended to reduce overdose events by limiting people's use of the contaminated drug supply, the experiences of people receiving hydromorphone vary. In this article we explore the ways people repurpose hydromorphone to address unmet needs.

METHODS

This article draws on in-depth qualitative interviews from two studies evaluating hydromorphone tablet distribution programs in British Columbia, Canada. We used thematic analysis to identify themes related to repurposing hydromorphone. We compared themes across the two studies to identify any similarities or differences in relation to the ways study participants discussed repurposing hydromorphone tablets. We utilize vignettes - snapshots of participant experiences - to analyse and represent the data.

RESULTS

Four vignettes demonstrate how hydromorphone tablets are often being used to address and resolve unmet needs of people who use drugs. While most participants reported reducing their use of illicit drugs, a variety of instrumental uses of tablet hydromorphone were also discussed, including reducing anxiety, addressing sleep issues, withdrawal management, and managing chronic pain.

CONCLUSION

Our findings demonstrate how people who use drugs are maximizing the benefits of tablet hydromorphone distribution to address unmet needs. Hydromorphone distribution programs represent a public health and harm reduction intervention that is usefully addressing experiences related to structural vulnerabilities (such as inadequate pain management), which are often overlooked amongst stigmatized groups.

Sexual Satisfaction in Trans Masculine and Nonbinary Individuals: A Qualitative Investigation

The present study investigated the ways trans masculine and nonbinary individuals describe aspects of their sexual satisfaction. Sexual satisfaction refers to an individual's subjective evaluation of their sexual experiences, and is influenced by relational, contextual, and personal experiences. Prior research with sexual satisfaction among trans individuals utilized quantitative measures, restricting the ability for respondents to describe trans-related aspects. Further, the pervasive focus on the effects of medical transition on binary trans individuals' experiences in prior research limits our understanding of those who do not desire a medical transition or live outside of the gender binary. Participants represented a community sample of 358 trans masculine and nonbinary individuals who responded to the question: "In what ways are you satisfied with your sex life?" Thematic analysis revealed eight overarching themes that represented two categories: universal and trans-related. Discussion focuses on the ways in which clinicians and researchers can utilize the current findings to improve the sexual satisfaction of trans masculine and nonbinary individuals.

Pharmacists' role in transgender healthcare: A scoping review

BACKGROUND

Transgender patients have unique healthcare needs, providing pharmacists with the opportunity to play an important role in transgender care through addressing the healthcare disparities observed in this patient group.

OBJECTIVE

This scoping review aimed to explore the role of pharmacists in transgender healthcare.

METHODS

Six databases were searched from inception: Emcare, Informit, MEDLINE (Ovid), PubMed, Scopus, and Web of Science. The first author performed screening and data extraction in consensus with co-authors. Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) was utilised to report this review. Themes related to the role of pharmacists in transgender healthcare were identified.

RESULTS

A total of 356 studies were identified; however, only 15 studies, all from the USA met the selection criteria and were included in this review. Study types included empirical research, practice reports and opinion pieces such as commentaries, editorials, and reports. Pharmacists were found to practise in two different care settings: community and interdisciplinary clinics, performing various roles in transgender healthcare, including patient education and counselling, management of cross-sex hormonal therapy, patient advocacy and provision of preventative care. They were also responsible for the provision of culturally sensitive care in an inclusive and welcoming environment. Although pharmacists considered their role important, they lacked confidence in their knowledge to provide appropriate care to this patient group.

CONCLUSION

This review has highlighted that there is a need for education in transgender care for both pharmacists and pharmacy students, so that they are both confident and comfortable to play a meaningful role in transgender care. Pharmacists' involvement in addressing the health disparities experienced will contribute to improving the overall health outcomes for this group.

Prescribed drugs containing nitrogen heterocycles: an overview

Heteroatoms as well as heterocyclic scaffolds are frequently present as the common cores in a plethora of active pharmaceuticals natural products. Statistically, more than 85% of all biologically active compounds are heterocycles or comprise a heterocycle and most frequently, nitrogen heterocycles as a backbone in their complex structures. These facts disclose and emphasize the vital role of heterocycles in modern drug design and drug discovery. In this review, we try to present a comprehensive overview of top prescribed drugs containing nitrogen heterocycles, describing their pharmacological properties, medical applications and their selected synthetic pathways. It is worth mentioning that the reported examples are actually limited to current top selling drugs, being or containing N-heterocycles and their synthetic information has been extracted from both scientific journals and the wider patent literature.

Hormonal, Medical, and Nonsurgical Aspects of Gender Affirmation

Although the acronym LGBTQ is often used as a catchall label for sexual and gender minorities, transgender people have unique and individual health needs and unfortunately experience significant health disparities. This article reviews essential terminology and concepts relevant to discussions of gender and gender identity, practical tips for changes that can be made on the clinical and institutional levels in order to create a welcoming and safe environment for transgender patients, as well as current recommendations for the provision of gender-affirming medical therapy.

Addressing transgender patients' barriers to access care

The transgender population faces several barriers to accessing quality medical care in the US healthcare system. This article examines the challenges that prevent this marginalized group from obtaining high-quality healthcare services and discusses how NP advocacy can help create a welcoming environment for transgender patients.

The current status of transgender health education in doctor of pharmacy curricula in North America

Doctor of pharmacy programs across the country strive to prepare culturally competent pharmacy professionals who are trained to provide compassionate and evidence-based care to a variety of patients. Within the Accreditation Council for Pharmacy Education 2016 Standards and Key Elements for the Doctor of Pharmacy Degree, pharmacy schools are charged with the task of developing professionals who can identify and diminish health care disparities. Transgender persons represent one of the most underrepresented and underserved communities within the modern health care system, yet very little information is available for training future pharmacists to care for the transgender community. A literature search using the MeSH terms transgender persons or trans-sexualism and pharmacy education was conducted, and it revealed 1 article published by Parkhill and colleagues in the American Journal of Pharmacy Education. A Google® search of the phrase “transgender education in pharmacy school” was conducted and produced 1 additional published article as well as an online transgender education program launched in November 2016. The following commentary outlines the current literature and practices that involve integration of transgender health education into pharmacy schools in North America and a discussion on areas for future study.

Disease screening and prevention for transgender and gender-diverse adults

Primary care clinicians have an important role in the health and wellness of transgender and gender-diverse (TGD) adults and need to know best practices of health maintenance and disease prevention interventions. This article focuses on how exogenous use of sex steroids provided as hormone therapy and gender-affirming procedures affect screening and prevention. Hormone therapy can affect the heart, liver, lipids, bones, brain, skin, and reproductive organs; likewise, behaviors and gender-affirming procedures may alter the risks, prevalence, and screening techniques of sexually transmitted infections. Where applicable, modifications accounting for those differences should be incorporated into the primary care of TGD adults.

Evaluation and Treatment of Gender Dysphoria to Prepare for Gender Confirmation Surgery

BACKGROUND

Gender dysphoria is the experience of marked distress due to incongruence between genetically determined gender and experienced gender. Treatment of gender dysphoria should be individualized and multidisciplinary, involving a combination of psychotherapy, social gender transition, cross-sex hormone therapy, gender-affirming surgery, and/or ancillary procedures and services. The goal of all treatment modalities is to alleviate distress and affirm the patient's experienced gender identity. This article is the first in a 3-part series focused on the diagnostic assessment and non-operative treatment of gender dysphoria. Parts 2 and 3 focus on operative aspects of gender dysphoria treatment.

AIM

To summarize the recommendations of the World Professional Association for Transgender Health (WPATH) and the Endocrine Society (ES), as well as review published literature regarding the non-operative treatment of gender dysphoria.

METHODS

A review of relevant literature through January 2017 was performed via PubMed.

OUTCOMES

WPATH guidelines regarding diagnosis and non-surgical treatment of gender dysphoria, specifically regimens and risks of cross-sex hormone therapy were reviewed.

RESULTS

Few physicians have experience with the diagnosis or treatment of gender dysphoria, although the number of patients seeking treatment has risen substantially in recent years. As a result, clinicians have turned to published recommendations from WPATH and ES, both of which promote high-quality, evidence-based care for patients with gender dysphoria. Successful treatment requires an individualized multidisciplinary approach. Non-operative treatment is both safe and effective for the majority of patients with gender dysphoria.

CONCLUSIONS

Guidelines from WPATH and ES, along with published literature pertaining to the diagnosis and non-operative treatment of gender dysphoria, were reviewed and summarized. Hadj-Moussa M, Ohl DA, Kuzon WM. Evaluation and Treatment of Gender Dysphoria to Prepare for Gender Confirmation Surgery. Sex Med Rev 2018;6:607-617.

Low estrogen doses normalize testosterone and estradiol levels to the female range in transgender women

OBJECTIVE

The ideal dosage of cross-sex hormones remains unknown. The aim of this study was to evaluate the luteinizing hormone, follicle-stimulating hormone, testosterone, estradiol and prolactin levels after low-dose estrogen therapy with or without cyproterone acetate in transgender women.

METHODS

The serum hormone and biochemical profiles of 51 transgender women were evaluated before gonadectomy. Hormone therapy consisted of conjugated equine estrogen alone or combined with cyproterone acetate. The daily dose of conjugated equine estrogen was 0.625 mg in 41 subjects and 1.25 mg in 10 subjects, and the daily dose of cyproterone acetate was 50 mg in 42 subjects and 100 mg in one subject.

RESULTS

Estrogen-only therapy reduced the testosterone, luteinizing hormone and follicle-stimulating hormone levels from 731.5 to 18 ng/dL, 6.3 to 1.1 U/L and 9.6 to 1.5 U/L, respectively. Estrogen plus cyproterone acetate reduced the testosterone, luteinizing hormone and follicle-stimulating hormone levels from 750 to 21 ng/dL, 6.8 to 0.6 U/L and 10 to 1.0 U/L, respectively. The serum levels of luteinizing hormone, follicle-stimulating hormone, testosterone, estradiol and prolactin in the patients treated with estrogen alone and estrogen plus cyproterone acetate were not significantly different. The group receiving estrogen plus cyproterone acetate had significantly higher levels of gamma-glutamyltransferase than the group receiving estrogen alone. No significant differences in the other biochemical parameters were evident between the patients receiving estrogen alone and estrogen plus cyproterone acetate.

CONCLUSION

In our sample of transgender women, lower estrogen doses than those usually prescribed for these subjects were able to adjust the testosterone and estradiol levels to the physiological female range, thus avoiding high estrogen doses and their multiple associated side effects.

Outcome and preferences in male-to-female subjects with gender dysphoria: Experience from Eastern India

CONTEXT

Gender dysphoria (GD) is an increasingly recognized medical condition in India, and little scientific data on treatment outcomes are available.

AIMS

Our objective is to study the therapeutic options including psychotherapy, hormone, and surgical treatments used for alleviating GD in male-to-female (MTF) transgender subjects in Eastern India.

SUBJECTS AND METHODS

This is a retrospective study of treatment preferences and outcome in 55 MTF transgender subjects who were presented to the endocrine clinic.

STATISTICAL ANALYSIS USED

Descriptive statistical analysis is carried out in the present study, and Microsoft Word and Excel are used to generate graphs and tables.

RESULTS

The mean follow-up was 1.9 years and 14 subjects (25.5%) were lost to follow-up after a single or 2-3 contact sessions. Rest 41 subjects (74.5%) desiring treatment had regular counseling and medical monitoring. All 41 subjects were dressing to present herself as female and all of them were receiving cross-sex hormone therapy either estrogen only (68%), or drospirenone in combination with estrogen (12%) or gonadotropin-releasing hormone agonist (GnRH) in combination with estrogens (19.5%). Most of the subjects preferred estrogen therapy as it was most affordable and only a small number of subjects preferred drospirenone or GnRH agonist because of cost and availability. 23.6% subjects underwent esthetic breast augmentation surgery and 25.5% underwent orchiectomy and/or vaginoplasty. Three subjects presented with prior breast augmentation surgery and nine subjects presented with prior orchiectomy without vaginoplasty, depicting a high prevalence of poorly supervised surgeries.

CONCLUSIONS

Standards of care documents provide clinical guidance for health professionals about the optimal management of transsexual people. The lack of information among health professionals about proper and protocolwise management leads to suboptimal physical, social, and sexual results.

Survey of community pharmacy residents' perceptions of transgender health management

OBJECTIVES

1) To measure the general perceptions and attitudes of community pharmacy residents toward transgender patients and health; 2) to identify gaps in didactic education regarding transgender health care among residents; and 3) to evaluate residents' level of support for pharmacists receiving education in transgender health care.

METHODS

This study was a cross-sectional survey delivered online. Community residency directors were e-mailed a cover letter and a 34-question online survey. The directors were asked to forward the survey to their residents for completion within 4 weeks. Responses were anonymous with no identifiers collected on the survey. Survey responses used a combination of open-response, multiple-choice, and Likert-scale questions aimed at gathering respondents' demographic information, perceptions of managing transgender patients and the need for receiving additional education in transgender health care.

RESULTS

Overall, the results of the survey indicated that community pharmacy residents support integrating transgender health management into pharmacy education and recognize that the overwhelming barriers to care for these patients include discrimination and lack of provider knowledge. Significant findings include: 82.7% of community residents think that community pharmacists play an important role in providing care for transgender patients; 98.2% think that they have a responsibility to treat transgender patients; and 71.4% were not educated about transgender patient issues in pharmacy school. Only 36.2% of community residents felt confident in their ability to treat transgender patients.

CONCLUSION

Community pharmacy residents list discrimination and lack of provider knowledge as the major barriers to care for transgender patients. Residents do not feel confident in their ability to treat and manage transgender patients. The majority of residents were not educated about transgender patient issues while in pharmacy school and think that community pharmacists need more education in this area. Residents support integrating transgender health education into continuing education programs and pharmacy school curricula.

Outcome and preferences in female-to-male subjects with gender dysphoria: Experience from Eastern India

CONTEXT

Awareness of gender dysphoria (GD) and its treatment is increasing. There is paucity of scientific data from India regarding the therapeutic options being used for alleviating GD, which includes psychotherapy, hormone, and surgical treatments.

AIM

To study the therapeutic options including psychotherapy, hormone, and surgical treatments used for alleviating GD.

SETTINGS AND DESIGN

This is a retrospective study of treatment preferences and outcome in 18 female-to-male (FTM) transgender subjects who presented to the endocrine clinic.

RESULTS

The mean follow-up was 1.6 years and only one subject was lost to follow-up after a single visit. All subjects desiring treatment had regular counseling and medical monitoring. All FTM subjects were cross-dressing. Seventeen (94.4%) FTM subjects were receiving cross-sex hormone therapy, in the form of testosterone only (61.1%) or gonadotropin-releasing hormone (GnRH) agonist in combination with testosterone (11.1%) or medroxyprogesterone acetate (MPA) depot in combination with testosterone (22.2%). FTM subjects preferred testosterone or testosterone plus MPA; very few could afford GnRH therapy. Testosterone esters injection was preferred by most (72.2%) subjects as it was most affordable while 22.2% chose 3 monthly injections of testosterone undecanoate for convenience and better symptomatic improvement, but it was more expensive. None preferred testosterone gels because of cost and availability concerns. About 33.3% of our subjects underwent mastectomy, 38.9% had hysterectomy with bilateral salpingo-oophorectomy, and only one subject underwent phalloplasty. About 16.7% of FTM subjects presented with prior mastectomy depicting a high prevalence of unsupervised or poorly supervised surgeries not following protocol wise approach.

CONCLUSION

Notwithstanding of advances in Standards of Care in the Western world, there is lack of awareness and acceptance in the FTM subjects, about proper and timely protocol-wise management options leading to suboptimal physical, social, and sexual results.

Endocrine care of transpeople part I. A review of cross-sex hormonal treatments, outcomes and adverse effects in transmen

Gender dysphoria (GD) is characterized by discomfort with the assigned or birth gender and the urge to live as a member of the desired sex. The goal of medical and surgical treatment is to improve the well-being and quality of life of transpeople. The acquisition of phenotypic features of the desired gender requires the use of cross-sex hormonal therapy (CHT). Adult transmen are treated with testosterone to induce virilization. In adolescents with severe and persistent GD, consideration can be given to arresting puberty at Tanner Stage II and if dysphoria persists, CHT is generally started after 16 years of age. Currently available short- and long-term safety studies suggest that CHT is reasonably safe in transmen. Monitoring of transmen should be more frequent during the first year of cross-sex hormone administration reducing to once or twice per year thereafter. Long-term monitoring after sex reassignment surgery (SRS) includes annual check-ups as are carried out for natal hypogonadal men. In elderly transmen, special attention should be paid to haematocrit in particular. Screening for breast and cervical cancer should be continued in transmen not undergoing SRS.

Endocrine care of transpeople part II. A review of cross-sex hormonal treatments, outcomes and adverse effects in transwomen

The treatment of transwomen relies on the combined administration of anti-androgens or GnRH analogues to suppress androgen production and thereby reduce male phenotypic characteristics together with oestrogens to develop female characteristics. In transwomen, synthetic oestrogens such as ethinyl oestradiol, as well as conjugated equine oestrogens (CEE), should be avoided to minimize thromboembolic risks especially in older transwomen and in those with risk factors. Currently, available short- and long-term safety studies suggest that cross-sex hormonal therapy (CHT) can be considered safe in transwomen improving the well-being and quality of life of these individuals. Long-term monitoring should aim to decrease cardiovascular risks and should include prostate and breast cancer screenings.

Cross-sex hormone therapy for gender dysphoria

PURPOSE

Gender identity is the sense one has of being male or female. Gender dysphoria (GD) refers to the distress caused by the incongruence between gender identity and biological sex in gender-nonconforming individuals. Cross-sex hormone therapy (CHT) aims at easing GD, improving well-being, and quality of life of gender-nonconforming individuals. This can be achieved by inducing and maintaining the desired-sex characteristics in accordance with the specific aspirations and expectations of each individual. Nevertheless, CHT can be associated with potentially serious long-term complications.

METHODS

Here, we review when, how, and how long to prescribe CHT to adult transsexuals as well as what to expect and monitor once it has been initiated.

RESULTS

In recent years, transsexualism has become more and more recognized and depathologized. To manage GD, National and International Standards of Care have been established. Nevertheless, the needs of transgender patients can still be ignored or dismissed. Moreover, some questions remain unanswered because of the lack of specific retrospective or prospective studies on CHT.

CONCLUSION

Education and culturally sensitive training must be supplied to healthcare professionals to overcome the existing issues on GD management and change the perspectives of transsexual people.

A transgender health care panel discussion in a required diversity course

OBJECTIVES

To examine the impact of a panel discussion on transgender health care on first-year (P1) pharmacy students' knowledge and understanding of transgender experiences in an Introduction to Diversity course.

DESIGN

The panel consisted of both transgender males and females. After panelists shared their healthcare experiences, students asked them questions in a moderated setting. Students completed evaluations on the presentation and learning outcomes. They also wrote a self-reflection paper on the experience.

ASSESSMENT

Ninety-one percent of students agreed that they could describe methods for showing respect to a transgender patient and 91.0% evaluated the usefulness of the presentation to be very good or excellent. Qualitative analysis (phenomenological study) was conducted on the self-reflection papers and revealed 7 major themes.

CONCLUSION

First-year students reported that they found the panel discussion to be eye opening and relevant to their pharmacy career. Our panel may serve as model for other pharmacy schools to implement.

Safety of hormonal treatment in transgenders

PURPOSE OF REVIEW

Discussion of short and long-term issues of cross-hormone treatment of transgender individuals in the light of recent literature.

RECENT FINDINGS

Gender nonconformity has been depathologized and replaced by gender dysphoria in the Diagnostic and Statistical Manual of Mental Disorders version V.Safety of cross-sex hormone treatment is still a matter of debate, but the latest findings in literature are quite reassuring about short-term and long-term effects. No dramatic changes in recommendations for treatment have emerged in the past years, and for the most part, clinical work is based on Endocrine Society Clinical Guidelines published in 2009.

SUMMARY

Most recent findings agreed on the importance of maintaining cross-sex hormone serum concentration within the physiological range, avoiding or limiting maximum peaks and troughs.Treatment must be highly individualized and transitioning patients need to be engaged in a 'clinical contract' with the physician in order to ensure compliance with prescribed treatments.Although overall mortality appears to be higher among transgender individuals, this in not attributed to hormonal treatment but to other causes mostly related to lifestyle habits.

Hormone and genetic study in male to female transsexual patients

BACKGROUND

Data of the literature demonstrated controversial results of a correlation between transsexualism and genetic mutations.

AIM

To evaluate the hormone and gene profile of male-female (M-F) transsexual.

SUBJECTS AND METHODS

Thirty M-F transsexuals aged 24-39. Seventeen had already undergone sex reassignment surgery, 13 were awaiting. All subjects had been undergoing estrogen and antiandrogen therapy. We studied hormones of the hypothalamus- pituitary-testicular axis, thyroid and adrenal profile, GH basal and after GHRH stimulation, IGF-I. The gene study analyzed SRY, AR, DAX1, SOX9, AZF region of the Y chromosome.

RESULTS

Pre-surgery subjects had elevated PRL, reduced testosterone and gonadotropins. Post-surgery subjects showed reduced androgens, a marked increase in LH and FSH and normal PRL. Cortisol and ACTH were similar to reference values in pre- and post-surgery patients. There was a marked increase in the baseline and post-stimulation GH values in 6 of the 13 pre-surgery patients, peaking at T15. IGF-I was similar to reference values in both groups except for one post-surgery patient, whose level was below the normal range. There were no polymorphisms in the amplified gene region for SOX9, and a single nucleotide synonimous polymorphism for DAX1. No statistically significant differences were seen in the mean of CAG repeats between controls and transsexual subjects. SRY gene was present in all subjects. Qualitative analysis of the AZFa, AZFb, and AZFc regions did not reveal any microdeletions in any subject.

CONCLUSIONS

This gender disorder does not seem to be associated with any molecular mutations of some of the main genes involved in sexual differentiation.