Summary
Highlights
The session begins with an introduction to UCSF Family and Community Medicine Grand Rounds and housekeeping reminders. Dr. Maddie Deutsch and Dr. Sen Wynn are introduced as the speakers. Dr. Deutsch provides an overview of the UCSF Gender Affirming Health Program, its services, patient demographics, and team, highlighting its reach and the UCSF care guidelines.
Dr. Deutsch shares her personal journey from emergency medicine to founding a gender affirming health program, driven by a desire to address limited access to quality healthcare for the queer community. She emphasizes how her family medicine background prepared her for this comprehensive care.
The Williams Institute at UCLA provides key demographic data, estimating that 0.5% of the US adult population and 1.4% of youth identify as transgender. Dr. Deutsch explains that the perceived increase in trans youth is due to increased societal acceptance and language availability, not a 'trend.' She discusses the pervasive impact of discrimination, stigma, shame, and trauma on trans people's health, leading to issues like unstable housing, lack of legal protection, and behavioral health challenges.
Dr. Deutsch addresses the current political landscape, describing the rapid legislative changes targeting trans healthcare as political machinations. She provides resources like the Movement Advancement Project and the Federation of State Medical Boards for tracking these developments, emphasizing that trans people are often made scapegoats.
The importance of collecting Sexual Orientation and Gender Identity (SOGI) data is stressed, including gender identity, birth-assigned sex, chosen name, and pronouns. This dual-step approach helps accurate data collection for population health and research. Dr. Deutsch advocates for taking a sexual history from all patients and proposes an "onion model" for a patient-centered approach, highlighting that misgendering in medical records erodes trust.
Dr. Deutsch introduces the World Professional Association for Transgender Health (WPATH) and its comprehensive Standards of Care (SOC-8) guidelines. Regarding youth care, she clarifies that medical interventions (like pubertal suppression with GnRH analogs) only begin at Tanner stage two. Hormone therapy starts when developmentally appropriate (typically 13-16 years old), and surgery under 18 is rare, with chest surgery being the most common exception.
Preliminary data from a multi-center study shows improved appearance congruence, positive affect, and life satisfaction, along with reduced depression and anxiety, for youth receiving hormone therapy. A separate study indicates a significant reduction in suicidal ideation and severe psychological distress among young adults who received pubertal suppression. Dr. Deutsch discusses detransition, noting its rarity and that most reasons are external rather than changes in gender identity.
Concerns about bone density in trans youth are addressed, with data suggesting lower baseline bone density, possibly linked to reduced physical activity and vitamin D deficiency. This is presented as a challenge to understand and address, not a reason to withhold care. For trans elders, qualitative studies reveal fears of mistreatment, isolation, financial stressors, and lack of agency in healthcare, compounded by their trans identity.
Data from Medicare databases indicate increased rates of nearly every health issue in the trans population compared to cisgender individuals. Dr. Deutsch presents research on cervical cancer screening among transmasculine people, highlighting a significant disparity in high-risk HPV infection rates related to receptive penile-vaginal sex. This underscores the need for patient-centered screening, including alternative approaches like self-swabbing for HPV.
Hormone therapy is described as a straightforward, patient-oriented process. For binary transition, estrogen and androgen blockers are used to target female hormone ranges, or testosterone for male ranges. For sub-maximal effects, an individualized approach with careful monitoring is recommended. Regarding cardiovascular risks, while a slight increase in thromboembolic disease is noted for trans women, the number needed to harm is high, making hormone therapy generally safe from a cardiovascular perspective. No significant cardiovascular risks were found for trans men.