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having/ maintaining physical arousal (erections) Consider maintaining testosterone at a higher level Trials of phosphodiaesterace Type 5 inhibitor (Cialis®, Viagra®) Elevated prolactin Common and typically benign with estrogen therapy. Some guidelines recommend routine measurement of prolactin while others do not Consider pituitary imaging if level is >80 mcg/L or if symptomatic (headaches, visual changes, excessive galactorrhea) Elevated transaminases Usually transient unless another cause of hepatic dysfunction identified Increase in and/or malodorous vaginal discharge post-vaginoplasty The lining of the vagina is created from inverted penile/scrotal skin (squamous epithelium) and oral antibiotics are therefore usually ineffective at treating bacterial overgrowth. Use intravaginal metronidazole gel bid and plain water douching until symptoms resolve See Appendix E - Sexual health screening for direction on how to assess vaginal symptoms post vaginoplasty Screening Cardiovascular risk Estrogen may increase cardiovascular risk. If using a risk calculator, use female scores if hormones were started early in life, male scores if hormones were started later (or both to estimate range) Breast cancer Average risk, estrogen use >5 years & ages 50-74: as per BC Cancer Breast Screening guidelines Higher risk (e.g. positive family history, BMI > 35, progestin use) - consider early or more frequent screening, refer to BC Cancer Breast Screening guidelines for higher than average risk Osteoporosis Screen as per national guidelines (ages 65 and up) or earlier if higher risk. For example: ● long-term low levels of estrogen post gonadectomy, or ● long-term use of androgen blocker without estrogen Encourage vitamin D and calcium intake and exercise. Maintain hormone therapy post-gonadectomy. Colon cancer Screen as per BC Cancer Colon Screening guidelines Prostate cancer Long term androgen suppression likely lowers the risk of prostate cancer but as per BC Cancer, providers should discuss the benefits and limitations of the PSA test with patients between the ages of 50-70. PSA may be less reliable/falsely low in low androgen settings. The prostate is not removed during vaginoplasty/vulvoplasty - if indicated, assess the prostate with a digital vaginal exam via lower aspect of anterior vaginal wall. Sexual health Some trans people may be at higher risk for sexually transmitted infections (STIs) including HIV and syphilis. Screen for STIs and consider HIV pre-exposure prohylaxis based on patient-specific risk factors. See Appendix E - Sexual health screening 12 Surgical readiness assessment Trans Care BC Primary Care Toolkit Surgical readiness assessment Some trans and gender diverse people benefit from gender-affirming surgery. Eligibility is based on the patient meeting WPATH criteria for the specific surgery and psychosocial readiness. To access publicly funded surgery, one or two assessments by qualified providers are required (the number of assessments depends on type of surgery). In private pay situations, surgeons set their own criteria regarding what type of assessment is required and by whom. Primary care providers may receive training and a period of clinical supervision to become qualified to provide these assessments. If you are not currently a qualified surgical assessor but are interested in becoming one, or if you require assistance with the completion of an assessment(s) for your patient, contact Trans Care BC’s Health Navigation team at 1-866-999-1514 or fillout the refferal form(s) for Surgical Readiness Assessment(s) for upper and lower surgeries, found on the surgery page at www.transcarebc.ca. Appendix F provides a description Trans Care BC’s Health Navigation team. Once the required assessments are complete, you can refer your patient for surgery. Please see the surgery page at www.transcarebc.ca for refferal options and documentation requirements for each surgery. WPATH criteria* Upper body (Chest/breast) Gonadectomy Genital construction Persistent, well-documented gender dysphoria One year of living congruently with gender identity ✓ * Note that these are only guidelines and clinicians should continue to apply clinical judgment. Surgery, especially upper body surgeries, may be appropriate for those under the age of the majority who have the capacity to consent as defined by the BC Infants Act. Please see the section on working with trans youth for further discussion. AMA Journal of Ethics® April 2018, Volume 20, Number 4: 403-413 SECOND THOUGHTS Exclusion of Medically Necessary Gender-Affirming Surgery for America’s Armed Services Veterans William M. Kuzon, Jr., MD, PhD, Emily Sluiter, and Katherine M. Gast, MD, MS Abstract Gender dysphoria, the term used in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) to describe distress at the incongruence between one’s gender and anatomy, affects approximately 0.6 percent of the population. It is estimated that there are 134,000 Armed Forces veterans in the United States with gender dysphoria. Although gender-affirming surgery is widely accepted as a medically necessary intervention for appropriately selected patients with gender dysphoria, the Veterans Health Administration (VHA) Health Benefits package and VHA Directive 2013-033 specifically prohibit genderaffirming
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