Rn Continuing Education on Transgender Hormone Treatment

With the current media frenzy about Caitlyn Jenner,aka Bruce Jenner, questions about the transgender cohort have been moved to the forefront of society. Nurses sometimes struggle with the care and management of transgender patients.

Recent studies have documented the need for inclusion of the care of the LGBT population into general nursing education. Many nursing faculty members are still struggling with the notion of educating their students about this population.^{2, 5}A study showed that although nursing faculty was more comfortable teaching their students about the LGB (Lesbian, Gay, and Bisexual) community, these faculty members were perturbed about teaching their students about health issues concerning the transgender community.²

Who are Gender dysphoria/Transgender Patients?

Gender dysphoria or transgenderism refers to a person who is born with the genetic traits of one gender but has assumed the characteristics of another gender.^1,4,9 There are two categories of transsexuals-primary or secondary. Primary transsexuals usually show a consistent and extraordinary degree of gender dysphoria from an early age (four to six-years-old). Conversely, secondary transsexuals come to a full consciousness of their condition in their twenties and thirties. However, secondary transsexuals may not act out their dysphoria until they are much older. Characteristically, secondary transsexuals will go through the phases of being a "cross-dresser" or "transgenderist."⁸

Treatment Options for Gender Dysphoria/Transgender Patients

There are many therapeutic possibilities for people pursuing care for Gender Dysphoria. The type, order and quantity of treatments are contingent on the choice of different individuals. However, the ultimate goal of the treatments is to assist transgender people to transition to the gender that will represent their acceptable sense of self and promote quality life.^6,7,8

Some of these treatment options include but are not limited to:

• Transgender transformations in gender appearance and role. These changes may entail living wholly or partially in as another gender
• Feminizing or masculinizing of the body by using hormonal therapy
• Interventions to modify sex features, e.g., body shaping, such as padding of hips or buttocks, surgically modifying external and internal genitalia, such as genital tucking or penile prostheses, plastic surgery to change facial features, breast augmentation or reduction, and electrolysis, laser treatment, or waxing for hair removal
• Individual, couple, family, or group psychotherapy to explore the stigmatization and societal interpretations of gender dysphoria, improve body image and promote resilience, examine gender identity, role, and expression, and identify and develop peer and societal support systems
• Voice and communication therapy to develop verbal and non-verbal communication
• Changing name and gender markers on identification documents

Hormonal Therapy for Male-to-Female (MTF) Transgender Patients

The feminizing hormonal therapy for male-to-female transgender patient may include: Estrogen, Progesterone and Androgen antagonists such as Spironolactone and Finasteride.^6,8

SEE ALSO: Peer Support Lowers Distress in Transgender People

Estrogen

Desired effects: Estrogen therapy may lead to breast development, redistribution of body fat, reduction of body hair, stopping of scalp hair loss, softening of skin, testicular degeneration and loss of erections, and reduction of upper body strength.

Risk factors: Venous thrombosis/thromboembolism, weight gain, infertility, decreased glucose tolerance, decreased libido, hypertriglyceridemia, possible breast cancer, drug interactions, elevated blood pressure, gallbladder disease, and benign pituitary tumor or prolactinoma.⁸

Spironolactone

Desired effects: Spironolactone therapy may lead to modest breast development and the softening of facial and body hair. Spironolactone risk factors include hyperkalemia, hypotension, and drug interactions.

Progesterone: Progesterone use is controversial. To achieve full nipple development, progesterone is the hormone of choice. Potential adverse effects include depression, stroke, weight gain, increased risk of coronary artery disease, and lipid changes.⁸

Finasteride

Finasteride may decrease the overall incidence of prostate cancer. Nurses should educate patients on side effects, including ejaculatory or erectile dysfunction and reduction of libido, and the incidence of high-grade lesions. Encourage these patients to get an annual digital rectal exam. If patients opt for castration, side effects may include intensification of hot flashes, weight gain, loss of muscle mass, fatigue, blood cholesterol and memory problems, depression, anemia, reduced sexual desire and libido, and osteoporosis and risk of bone fractures.⁸

Hormonal Therapy for Female-to-Male (FTM) Transgender Patients

Testosterone

Testosterone is the hormone of choice for treatment of female-to-male transgender patients. Permanent changes include but are not limited to increased facial and body hair, clitoral enlargement, a deeper voice, and male pattern baldness. Temporary changes for testosterone hormonal treatment include cessation of menstruation, changes in sexual behavior, emotional changes, increased libido, acne, increased muscle mass and upper body strength, increased sweating, change sin body odor, weight gain, fluid retention, more appearance of veins, coarser skin, and mild breast atrophy.

Risks of testosterone therapy include hepatotoxicity, increased likelihood of sleep apnea, lower HDL cholesterol, polycythemia, insulin resistance, elevated triglycerides, and unknown effects on breast, endometrial, ovarian tissues.

Nurses should teach the patients the importance of continuing hormones after the removal of the ovaries. This continuation may uphold the desired effects and maintain bone health. It is important to teach patients that a high dose of testosterone converts to estrogen. Additionally, the route of testosterone has different effects. For instance, transdermal testosterone will have a slower masculinizing effect. Furthermore, patients could pass on the impact of the testosterone to other people they come in skin-to-skin contact with.⁸

Continued Nursing Care of Transgender Patients

• Assess patient's well-being with transition
• Assess social effect of transition
• Assess the progression and the degree of masculinization or feminization
• Monitor mood cycles and adjust medication as indicated
• Discuss any family issues
• Counsel regarding sexual activity
• Review and reconcile medication use
• If post-surgery, keep the surgical site clean and follow-up exams to monitor healing and assess for s/s of infection.
• Monitor function of genitals and donation sites (forearm, leg, etc.)
• Encourage health care maintenance, including pap smear, breast exam, mammogram, STD screening, and prostate screening
• Monitor loss of neo-vaginal depth/length if dilation isn't done
• Assess for skin tears and pain with rough dilation or sexual penetration
• Teach MTF patients that they can still get their opposite sex partners pregnant. To make enough sperm, patients should stop taking feminizing hormones for at least 3-6 months. Likewise, FTM pateints can get pregnant whether they are taking hormones or not.
• Teach transgender patients to use birth control without hormones. Advise the patients to be aware that unprotected sex not only leads to unwanted pregnancies, but also puts them at risk for STDs.

Nurses should consistently provide culturally competent and current care to the transgender population. Nursing professionals should be knowledgeable about how to address this cohort. They should use transgender-specific terminology such as "transgender" as an adjective and not a noun. For instance, it is incorrect to say, "Adam is a transgender," or "Many transgenders came to the clinic today." The correct way is, "Adam is a transgender man," or "Many transgender people came to the hospital today." Nurses should avoid defamatory words such as "tranny," "she-male," "he/she," "it," "shim," or "trans."³

With the increasing acceptance of this cohort in society, nurses should ensure that they are up-to-date with all the current research and information on how to care for and educate their gender dysphoria patients.

References

1.Beidel, D. C., Bulk, C. M., & Stanley, M. A. (2014). Gender dysphoria, sexual dysfunctions, and paraphilic disorders. Abnormal Psychology (pp. 278-285). New Jersey: Pearson Education, Inc.

2. Echezona-Johnson, C. (2014). Equitable Obstetrical Care for the Lesbian, Gay, Bisexual, and Transgender Community (Doctoral dissertation, WALDEN UNIVERSITY).

3. James, A. (2015). Glossary of transgender terms. Retrieved from http://www.tsroadmap.a.com/start/tgterms.html

4. Kamens, S. R. (2011). On the proposed sexual and gender identity diagnoses for DSM-5: History and controversies. The Humanistic Psychologist, 39, 37-59. doi:10.1080/08873267.2011.539935

5. Lim, F., Johnson, M., & Eliason, M. (2015). A national survey of faculty knowledge, experience, and readiness for teaching lesbian, gay, bisexual, and transgender health in baccalaureate nursing programs. Nursing Education Perspectives, 36(3), 144-152.

6. Ross, C. A. (2009). Ethics of gender identity disorder. Ethical Human Psychology and Psychiatry 11, 165-170. doi: 10.1891/1559-4343.11.3.165

7. Vanderburgh, R. (2009). Appropriate therapeutic care for families with pre-pubescent transgender/gender-dissonant children. Child Adolescent Social Work Journal, 26, 135-154. doi: 10.1007/s10560-008-0158-5

8. The World Professional Association for Transgender Health (WPATH) (2011). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7 edition. Retrieved from http://www .thisishow.org/ Files/soc7.pdf

9. Zucker, K. J. (2010). The DSM diagnostic criteria for gender identity disorder in children. Archives of Sexual Behavior, 39(2), 477-498. doi:10.1007/s10508-009-9540-4

Chinazo Echezona-Johnson is Director of Nursing/Women and Children Nursing Education, at Metropolitan Hospital Center in New York, NY.

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