September 11, 2017
Author: Katie Chung
Co-Editor: Dr. Rebecca Barron
Case Overview
The transgender population has very specific medical needs. Gender played a central role in this otherwise routine adolescent wellness visit.
Patient History
Patient AB is a pleasant 18 year old transgender female who presents for a routine follow up visit for hormone management. She has been taking estradiol and spironolactone for about 1 year. During her last visit, the estradiol dose was increased from 6mg to 8mg daily and she continues to take 200 mg spironolactone daily. Patient AB was pleased with the dose change. She reports breast enlargement of one-cup size since her last visit. She reports occasional mood swings, but does not feel that they interfere with her life. No reports of anxiety or depression.
AB reports being sexually active with 1 cis male partner for 5 months. She reports receiving anal sex with 100% condom use and performing oral sex without condoms. She denies a history of sexual trauma. Her last HIV test was negative. She is interested in routine STI and HIV screening during her visit. She is not currently experiencing any symptoms.
In addition to her hormone therapy, she is interested in pursuing gender affirmation surgery. She plans to pursue facial feminization surgery, breast augmentation, and vaginoplasty in the near future.
During her last visit, she mentioned interest in voice training. She was also interested in changing her legal name and gender markers.
PMH:
Hospitalizations: none
Surgical History: none
Medications: Estradiol 8mg daily, sublingual, Spironolactone 200mg daily
Allergies: NKDA
Family History: Mother (44) and Father (45) are both healthy. No siblings or children.
Social History: Patient AB reports living with a roommate and her roommate’s father in Providence. She did not have any concerns about her health and safety at home. AB is a freshman in college. She is planning to take some time off from school to work and save money. She is considering switching to cosmetology school in order to become a makeup artist.
No concerns about diet, nutrition, or exercise.
No tobacco use. Alcohol: 1-2 drinks on weekends (socially) No recreational or prescription drug use (for non-prescription reasons)
Review of Systems:
General/Constitutional: Positive for 5 lb weight gain since her last visit. Negative for fever, chills, change in appetite, fatigue, night sweats.
HEENT: Negative for head injuries, hearing loss, tinnitus, use of hearing aid, epistaxis, rhinorrhea, loss of smell, bleeding gums, odynophagia, dysphagia, sore throat, hoarseness, sores in mouth or nose, tooth pain
GU: Negative for dysuria, hematuria, urinary retention, swelling of testes, penile discharge.
Psychiatric: Negative for poor concentration, depression, anxiety, anhedonia, suicidal or homicidal ideation.
Endocrine: Negative for polydipsia, polyphagia, E or cold intolerance.
Allergic/immunologic: Negative for food or environmental allergies
Integumentary: Negative for rash, skin changes, or hair loss.
Physical Exam:
General Appearance: Feminine appearance. Well-developed and well-nourished; resting comfortably and in no acute distress. No skin lesions or rash.
Vitals Signs: HR: 78 (regular), RR: 14, unlabored, BP: 122/74, BMI: 30.1
Head: Normocephalic, atraumatic, long hair in a braid, normal distribution and texture.
Eyes: No conjunctival injection or pallor, sclera white
Oral Cavity: moist mucous membranes, good dentition. Oropharynx without evidence of erythema, tonsillar enlargement, or exudates. Uvula midline.
Neck: supple. No lymphadenopathy, masses, or tenderness. No thyromegaly. Trachea midline.
Abdomen: Soft and non-distended, positive bowel sounds. Spleen and liver non-palpable.
Genitourinary: Patient declined exam as she is not currently experiencing symptoms.
Neurologic: CNII-XII intact
Labs:
BUN: 12 mg/dL, CO2: 25mmol/L, Creatinine: 1.1 mg/dL, Glucose: 81mg/dL, Serum chloride: 105mmol/L, Serum potassium: 4.5mEq/L
Serum sodium: 143 mEq/L, Estrogen: 103 pg/mL, ALT: 20 U/L, AST: 18 U/L, ALP: 75 U/L, Albumin: 4.0 g/dL, Bilirubin: 1.3mg/dL
GGT: 25 U/L, LD: 150 U/L
Assessment:
AB is an 18 year old transgender female who presents for her 1 year hormone management follow up. She has been doing well since increasing her estradiol to 8mg at her last visit. She has been on estrogen and spironolactone for about 1 year. She has also been sexually active with a new male partner and is interested in routine STI and HIV screening.
Plan:
Labs ordered:
Basic Metabolic Panel, Estrogen, Prolactin, Testosterone, Liver Function Test, HIV, GC/Chlamydia swab (rectal, self-administered)
Syphilis, Hep C
1. Her estrogen level was slightly low during her last visit. Pending today’s lab results, we may consider increasing her estradiol dose if her levels continue to be low.
2. We discussed options and a timeline for surgery. AB was given resource packets for feminizing surgery and an information packet on legal name and gender marker changes.
Discussion:
Transgender patients experience significant barriers to health, which include a lack of healthcare providers who are competent in LGBTQ health, lack of health insurance coverage, and financial barriers [1]. This particular case highlights the fact that, despite significant barriers and health disparities in the transgender population, gender dysphoria can be treated safely and effectively with counseling, hormones and possible surgery [3]. Withholding treatment in this population has significant demonstrable negative health consequences, particularly regarding mental health problems, self-injury, and bullying [4].
This case demonstrates that these barriers, while pervasive and systemic, are possible to overcome through providing adequate treatment and training staff and providers in culturally-competent care [2,5].
One intervention particularly worth mentioning is the use of leuprolide (Lupron), which is a gonadotropin releasing hormone (GnRH) agonist. It functions to prevent further testosterone or estrogen production, effectively putting a “pause” on pubertal progression. Commonly used at Tanner stage 2, it can safely delay the development of secondary sex characteristics in adolescents and give them time to explore their gender identity without the pressure of an imminent undesired pubertal process [6].
References:
1. Qureshi RI, Zha P, Kim S, Hindin P, Naqvi Z, Holly C, Dubbs W, Ritch W. Healthcare Needs and Care Utilization among Lesbian, Gay, Bisexual and Transgender Populations in New Jersey. J Homosex. 2017 May 8. doi: 10.1080/00918369.2017.1311555. [Epub ahead of print] PubMed PMID: 28481718.
2. Cannon SM, Shukla V, Vanderbilt AA. Addressing the healthcare needs of older Lesbian, Gay, Bisexual, and Transgender patients in medical school curricula: a call to action. Med Educ Online. 2017;22(1):1320933. doi: 10.1080/10872981.2017.1320933. PubMed PMID: 28468575.
3. Joseph A, Cliffe C, Hillyard M, Majeed A. Gender identity and the management of the transgender patient: a guide for non-specialists. J R Soc Med. 2017 Apr;110(4):144-152. doi: 10.1177/0141076817696054. Epub 2017 Apr 6. Review. PubMed PMID: 28382847.
4. Nahata L, Quinn GP, Caltabellotta NM, Tishelman AC. Mental Health Concerns and Insurance Denials Among Transgender Adolescents. LGBT Health. 2017 Apr 12. doi: 10.1089/lgbt.2016.0151. [Epub ahead of print] PubMed PMID: 28402749.
5. Bidell MP, Stepleman LM. An Interdisciplinary Approach to Lesbian, Gay, Bisexual, and Transgender Clinical Competence, Professional Training, and Ethical Care: Introduction to the Special Issue. J Homosex. 2017 May 2. doi: 10.1080/00918369.2017.1321360. [Epub ahead of print] PubMed PMID: 28463093.
6. Olson J, Garofalo R. The Peripubertal Gender-Dysphoric Child: Puberty Suppression and Treatment Paradigms. Pediatr Ann. 2014; 43: e132-e137. doi: 10.3928/00904481-20140522-08.
Key Words: Case Study, Sex and Gender Based Medicine, transgender medicine
