Welcome to the module on Primary Care for Transgender Men. My name is Zil Goldstein, and I'm a family nurse practitioner at the Center for Transgender Medicine and Surgery at Mount Sinai, as well as an Assistant Professor of medical Education at the Icahn School of Medicine. Today, we're going to be talking about the need for primary care for transgender men, and understand how to apply gender-specific health maintenance recommendations to transgender men. Finally, we'll discuss how to conduct a sexual health interview with transgender men to screen appropriately for sexually transmitted infections. Transgender men experience many health disparities. For example, we see less frequent engagement in routine and non-transition related care. We also see very high rates of suicide attempts with 40 percent of transgender people having attempted suicide, and 39 percent reporting severe psychological distress. Growing rates of HIV infection are also very important to consider in transgender men, and highlight the need for regular discussions about sexual health. Lastly, we see high rates of unemployment and underemployment in the transgender population, which has a negative effect on health by keeping people from having access to the resources they need to stay healthy. Providing seamless access to hormone care in the primary care setting is an important part of transgender primary care. For example, with diabetes, we don't simply refer someone to an endocrinologist as primary care providers. We first treat their diabetes with agents such as metformin or other oral anti-diabetic agents, and we'll refer to the endocrinologist only when it becomes beyond our comfort level to treat and control their diabetes. Transgender patients are not just transgender however, and require the same primary care, preventive care, and routine health maintenance screenings as any other patient engaged in primary care. It's important to remember when conducting this care that many transgender people expect to be treated poorly with 33 percent of transgender people reporting a bad experience with a health care provider, and two percent reporting being assaulted in a healthcare setting. While this is a very low number, it is important to remember that this is a possibility in a transgender person's mind when seeking care. Taking all of these points into consideration, it is vital that we routinely screen for mental health disruptions in our transgender patients, and also maintain a network of sensitive and informed mental health providers who can help address these concerns. Some evidence shows that transgender men have a hard time talking to their providers about risky sexual behaviors, and have a hard time getting educated on how to have safer sex. So it's important that we proactively ask our patients about their sexual practices, and we'll discuss how to do that more later. We also want to be asking regularly about transition-related needs, satisfaction around transition, and the need to refer to surgeons for procedures such as chest masculinization or genital surgery. While doing all of these, we have to keep in minds that we're operating in a relative dearth of evidence. So shared decision-making with our patients is vital, where we can review what information is available, and make a decision together based on that information and the patient's comfort level. It is important to discuss what body parts are present with our transgender patients by conducting what we call an organ inventory. For example, does the person have a cervix? Do they have a uterus? Do they have memory tissue? In the absence of chest masculinization surgery, mammary tissue should be screened according to guidelines for cisgender women when we're working with transgender men. It's also important to remember that chest masculinization surgery does not remove all mammary tissue, and some may still be present. Transgender men also have very low rates of engaging in cervical cancer screening, so we may have to modify how we do this in order to adequately screen for cervical cancer. When considering mammary cancer screening in transgender men, it is important to remember that chest masculinization surgery is an aesthetic surgery. The goal is not necessarily to remove all of the mammary tissue, so some may remain after surgery. Palpating our transgender men's chests regularly after chest masculinization surgery is an important measure to screen for any changes that may occur in their chest wall that could be indicative of cancer. By palpating their chest regularly, we'll get to know their chest, and be able to tell if there are any changes as there may be some baseline swollen lymph nodes after surgery. When it comes to cervical cancer screening for transgender men, anyone with a cervix needs to be screened. However, transgender men engage in cervical cancer screening at much lower rates than cisgender women. Transgender men also have higher rates of unsatisfactory Pap smears, meaning it's difficult to collect enough cells for someone to make an accurate assessment of whether or not they're a cervical cancer. Keeping all of these in mind, providers should consider offering self-swabs for HPV, which many transgender men prefer. The one drawback of offering a self-swab, is that any positive results of HPV need to go directly to colposcopy which is a much more invasive procedure that many transgender men would prefer to avoid. It is important to offer both options for cervical cancer screening to our transgender male patients, and also keep in mind that self-collected HPV swabs are just as accurate as those collected by a provider. When it comes to routine health maintenance, current data do not endorse any changes in how we screen for colon cancer, diabetes, cholesterol or many other conditions. Existing guidelines suffice for most other routine care, but it's important to remember that many health disparities in the transgender population stem from underutilization of these screenings. That means it's important to build trusting relationships with our patients. So when we say, if you have a screen it, they will actually follow through. Many transgender men also choose to undergo genital surgery. Genital surgery varies widely for transgender men with many options available. So it's important to discuss specifically what procedure the patient is seeking. The most common complications with all of these procedures are; urinary fistulae holes in the urethra leading to the outside of the body, or urinary strictures that close off the urethra and make it difficult for men to pee. The role of the primary care provider however, is preparing patients for surgery and helping to manage any complications that arise post-operatively. Because there are high rates of complication with these procedures, it is important to consider connecting patients with resources locally prior to surgery if they are traveling out of the area. This way if someone does have a complication from a genital surgery, they may already know a urologist or gynecologist who can help take care of it. When interpreting laboratory values for transgender patients, evidence is split on the effects of testosterone therapy on lipid profiles. Some data show an increase in triglycerides and LDL or bad cholesterol, while some data show no change. Testosterone therapy will cause an increase in hemoglobin and hematocrit levels, which is a measure of how many red blood cells someone has. The upper limit of normal in the male range is the most accurate for interpreting this data, and it is important to monitor hemoglobin and hematocrit as testosterone can cause a condition where people have too many red blood cells called erythrocytosis or polycythemia, which should be treated according to guidelines for cisgender people when it arises. Increased muscle mass from testosterone therapy may also cause an increase in creatinine levels as muscle is processed by the kidneys into creatinine, and we may have a falsely elevated creatinine level. However, there are currently no data to help guide our decisions in interpreting these results. In the transgender population, we see higher rates of tobacco, alcohol, and drug use. This is thought to be due to minority stress, or the excessive stress someone feels due to the stigma of being transgender. People then cope with this excessive stress by using substances, and it is important to use a harm reduction approach when discussing this with our patients, as we need to reduce the amount that they use before quitting. It is also important to connect people with other mental health resources, so they can learn better modes of coping with their excessive stress than using substances. Now moving on to sexual health, many transgender people report an inability to discuss sexual health concerns with health care providers due to both provider and patient discomfort discussing these sensitive topics. When having these conversations, it's important to open the conversation broadly, and wait for a patient to identify their body parts before then echoing that language when discussing sexual practices. Many transgender men don't like to hear the word vagina, and instead may use terms like front hole to refer to that part of their body. When discussing sexual health, it is also important to keep in mind that identity does not serve as a proxy for sexual behaviors. Transgender people may be having sex with cisgender or non-transgender men, cisgender women, or other transgender people. So it's important to ask open-ended questions to determine how people are having sex. I like to ask, what are the gender or genders of your sexual partner or partners? I also ask people how they like to have sex? I'll use generic terms like genitals, private parts, "front,'' ''back,'' and ''mouth'' to open the conversation, and again then echo the language my patients use if there are other ways they prefer to refer to their body. Once we identify the specific sex acts that someone engages in, we then have to screen appropriately to make sure that people are getting tested according to the acts that they perform. When discussing vaccines with transgender men, we have to consider many of the concepts we have discussed today. Many vaccines can harm a developing fetus. So if someone still has a uterus and is having sex in a way that puts them at risk for pregnancy, we then need to be offering pregnancy testing prior to administering these vaccines. There are no side effects however, from hormone therapy, and the regular adult and pediatric vaccines schedules can be followed. In summary, when working with transgender patients, it is important to take an organ inventory to remember if you have it, screen it, to learn how to provide hormone therapy to help keep transgender patients engaged in care, to start with broad, open questions about sexual health and then ask about specific sex acts to get the necessary information you need to take care of someone, and also to stay up to date on the latest data. Thank you so much for your time and attention with this module. I hope it gives you the tools that you need to take care of transgender men in your primary care practice.
