Transsexuals are the
T in GLBT. But their needs in assisted living go far beyond the issues of discrimination and social affirmation. Transsexuality is primarily a medical diagnosis, not a cultural concern. They have unique health care needs that must be addressed.
About one in a thousand women is born transsexual-with about the same number of men. The situation results from a switch in fetal hormones between weeks 3-6 of gestation-a switch caused by maternal stress, sickness or medications. The brain develops one way before the switch; the gonads develop another way after the switch. The result is an infant with a sexual biology that doesn't match their innate personality (ie, their Gender Identity).
Each transsexual responds to the mismatch in a different way depending on their circumstances:
-- They may have been forced to live an entire lifetime in a wrong-gender lifestyle
-- They may have adopted a right-gender lifestyle without changing their biology
-- But most live a right-gender life after some form of biologic correction: hormones, surgery or both. The exact hormone regimen and the extent of the surgery differ from individual to individual.
NOT FOR ANDROGYNES
Before proceeding any further, it's important to note that transsexuals form only a small segment of the greater transgender population. Androgynes make up the remainder. Male-androgynes were once known as "
Cross-dressers", even though it's not about clothes at all. Butches are the biologic-female equivalent.
Androgynes have a mixed Gender Identity-part "
male" and part "
female" (although the terms begin to lose their meaning at this point.) Butches and male-androgynes are quite happy with their biology; they don't need or want surgery or hormones.
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HORMONES
EVERY senior is concerned about hormones, regardless of gender or sexual orientation. One universal effect of aging is a waning hormone output from the gonads. The result can be a wide range of symptoms including hot flashes, physical atrophy, weakness, fatigue, skeletal pain and a loss of sexual interest.
Hormone replacement can certainly relieve these symptoms, but numerous studies have shown harmful effects, such as increased cardiovascular & cancer risk (breast & prostate cancer). The current recommendation is to use the lowest dose of hormone replacement for the shortest time, with regular screening.
Transsexuals are no different. If transsexual therapy is to mirror natural physiology, hormonal treatment would be gradually withdrawn between 50 and 70 years of age. ...With resulting symptoms and patient dissatisfaction.
"
You need to suffer like the rest of the senior population." --Not a very compelling argument.
Long-term habits of hormone use can be hard to break:
"
You're telling me hormones were necessary & beneficial for 40 years, but now they're harmful?"
But for transsexuals the treatments also play a symbolic role:
"
If I stop my estrogen, won't I go back to being a male?"
Transsexual hormone management is complex and must be addressed by a physician on an individual basis. However the basics are:
Female transsexuals add estrogen and remove testosterone.
Male transsexuals add testosterone and remove estrogen.
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ESTROGEN for female transsexuals comes in 3 forms: daily oral, weekly patch or monthly injectable. Oral forms increase clotting risk but improve cholesterol levels --at a price of increased gall bladder disease.
ESTROGEN COMPLICATION --BLOOD CLOTS: All women -- transsexual or not -- have a significant risk of Deep Vein Thrombosis (clots in the legs-- DVT) with subsequent pulmonary embolism, heart attack or stroke. The risk is increased by estrogen treatment. Care must include:
-- Education & monitoring for DVT symptoms
-- Regular lower-extremity exercise is absolutely essential
-- Women should avoid long periods of sitting (eg driving & airplane trips)
-- Consider wear of pressure stockings
-- Surgery must include DVT precautions and early ambulation
-- Daily ASA doesn't affect DVT but does reduce heart attack risk
ESTROGEN CONCERN --CALCIUM: Both testosterone & estrogen prevent calcium spillage from the kidneys. As hormone levels drop, both male & female seniors need calcium & Vitamin D supplementation to replace the loss (and to protect against subsequent development of osteoporosis).
Women lose calcium during pregnancy, so they enter the senior years already behind the power curve-depending on how many pregnancies they had. Vitamin D is a necessary adjunct for calcium processing by the body.
Remember that some MALE transsexuals have had pregnancies, and need the higher doses of calcium. ...Unless they're on calcium-sparing levels of testosterone.
RECOMMENDED CALCIUM DOSE: 1000 -1300 mg per day
-- 1 cup of milk (8 oz) contains approximately 300 mg Calcium
-- An ultra-strength Tums(r) tablet contains 400 mg Calcium
RECOMMENDED VITAMIN D DOSE: 800 IU's / day (over 50 yrs old)
-- Fortified Milk usually contains about 100 IU's per cup
-- Most multivitamins contain 400 IU's
-- Excessive Vitamin D intake causes liver toxicity
ESTROGEN COMPLICATION --CHOLELITHIASIS (Gall Stones): People taking estrogens (esp oral) have a 2-3x risk of cholelithiasis with subsequent cholecystitis. Patients need to be alert for the symptoms:
-- Intermittent abdominal pain, jaundice, and elevated liver enzymes
-- Dietary fat intolerance
PREVENTION: Avoidance of obesity, high-fiber diet, adequate calcium intake, frequent small meals
TESTOSTERONE REMOVAL for female transsexuals Anti-testosterone is an essential part of a female transsexual's hormonal regimen. Remember that estrogen has virtually no anti-testosterone effect; the two hormones have different-not opposing-effects on the body.
Orchiectomy (castration) is of course the best method of testosterone removal-the problem is solved, with a bonus of reduced cancer risk. Prolactin excess (breast milk production) is an occasional complication of the surgical solution.
However if surgery isn't an option, oral anti-androgens are the alternative:
Spironolactone (Aldactone(r)) was used as an anti-testosterone during the 1960 &1970's and unfortunately continues to be widely prescribed even though far safer and more effective medications have become available. It's a potassium-sparing diuretic which was found to have weak anti-testosterone effects. Risks are significant and include postural hypotension and hyperkalemia with associated cardiac arrhythmias-a particular concern for seniors. Anyone on the medication should have regular electrolyte monitoring.
F Seniors on spironolactone should be referred to their provider for medication change.
The newer and more-effective anti-androgens are bicalutamide (Casodex(r)) and flutamide (Eulexin(r)). However the latter requires 3x per day dosing. Any anti-androgen use requires liver enzyme screening at least yearly.
F Finasteride (Proscar(r)) is sometimes considered to be an "anti-testosterone", though its effects are limited to the prostate. Finisteride should never be used for managing transsexuality.
ANTI-TESTOSTERONE COMPLICATIONS
-- Reversible hepatitis (abdominal pain, jaundice, dietary fat intolerance, high liver enzymes)
-- Nausea & diarrhea (flutamide has 2x incidence compared to bicalutamide)
-- Paradoxical masculinization (hair growth, voice deepening, etc)
-- Displaces coumadin (a "blood thinner" medication) from binding proteins, increasing bleeding risk
ANTI-ANDROGEN ASSISTANCE
A major reason orchiectomy is preferred over oral anti-androgens is that the body responds by boosting testosterone production (not possible if the testicles are gone). Anti-testosterone masculinization can be prevented by administering Leuprolide (Lupron(r)), which stops brain pituitary regulatory functions.
F Leuprolide is an expensive medication with serious potential side effects. Usually the medication should stopped after age 60, if not sooner.
LEUPROLIDE COMPLICATIONS primarily involve pituitary suppression; ie hypo- / hyper-thyroidism, prolactin excess (milk production), or growth hormone deficiency
The average woman on leuprolide loses 2-4% of total bone calcium per year
LEUPROLIDE MONITORING
-- Liver enzyme screening every 3-6 months
-- Yearly testosterone level to adjust leuprolide dosage
-- Yearly pituitary screening: T3, T4, TSH, prolactin, parathyroid hormone, growth hormone levels
-- Osteoporosis screening every 2 years
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TESTOSTERONE for male transsexuals is by injection every 2-4 weeks (most patients self-administer the dose). A patch is available, but it lasts only one day and is prohibitively expensive. Testosterone has many possible effects on the body including hypertension, increased risk of cardiovascular disease (heart attacks, atherosclerosis, etc), acne and mood changes (irritability, anger, aggressiveness, short temper).
TESTOSTERONE COMPLICATION --HEPATITIS: Dose-related and reversible. Usually treated by lowering the dose. Common symptoms include abdominal pain, jaundice, and dietary fat intolerance. Patients on testosterone should be careful about excessive alcohol use. Hepatic injury may also increase clotting time, with associated bruising.
TESTOSTERONE COMPLICATION --POLYCYTHEMIA: Having too many red blood cells results in blood that's thick and doesn't flow well through the arteries. This complication occurs most frequently as an interaction between testosterone and smoking.
TESTOSTERONE MONITORING
-- Liver enzyme profile every 6 months
-- Annual CBC, lipid profile
-- Blood pressure monitoring
-- Appropriate CAD screening
-- Yearly testosterone & Sex Hormone Binding Globulin (SHBG) level (SHBG-bound testosterone is inactive)
ESTROGEN REMOVAL for male transsexuals Usually male transsexuals undergo hysterectomy and oophorectomy, which stops menstruation, eliminates risk of ovarian cancer and reduces the risk of cervical cancer. If surgery hasn't been done, Tamoxifen (Nolvadex(r)) or clomiphene are occasionally given to younger transsexuals for control of menstruation, cramping, etc. However there would be no indication for its use in seniors. Tamoxifen triples the risk of deep vein thrombosis.
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SURGERY POST-OP MAINTENANCE CARE
FEMALE TRANSSEXUAL GENITAL SURGERY: Years after the genital surgery site has healed, female transsexuals must still perform vaginal dilation at least twice a week. (More often if tightness is encountered.) The patient assumes the trendelenberg position: lying on back with feet below hips, knees raised, and relaxed apart (no wider than 45 degrees). A 28-38 mm diameter stent is lubricated with KY Jelly(r) or Surgilube(r), then inserted full-depth into the vagina (usually about 6 inches, depending on what surgery was done) for several minutes.
Whenever a vaginal stent is inserted, it should be pointed anteriorly, toward the public bone. The tip should be felt to slide underneath the bone and upward, toward the chest-NOT toward the back.
Sometimes lubrication is inadequate deep inside the vagina, resulting in discomfort or tightness during dilitation. Unfortunately gel on the surface of the stent doesn't make its way deep inside. Lubrication of the vaginal depths is best accomplished by using an intra-vaginal applicator-for example, Gyne-Moistrin(r), a spermacide applicator or a douche kit.
If dilatation isn't performed regularly the patient's vagina will constrict, atrophy, and eventually close-trapping debris and secretions inside (a possible site for infection, discharge or odor). If dilatation is performed incorrectly, perforation may occur-most commonly a recto-vaginal fistula in the posterior wall. The most common reason for fistula formation is inserting the stent pointed toward the backbone. This damages or weakens the posterior vaginal wall.
If a fistula HAS formed, fecal matter will leak out of the vagina, along with symptoms of vaginal infection.
INTRA-VAGINAL HAIR GROWTH is another relatively common surgical complication, usually with only cosmetic relevance.
MALE TRANSSEXUAL GENITAL SURGERY: Unfortunately the surgical options for male transsexuals are totally inadequate and non-functional. Most patients are still unable to use a urinal afterward. One result is that male transsexuals can be very sensitive about their genital appearance. The other is that most don't bother with surgery.
If surgery HAS been done, there are a wide variety of prosthetics available to allow urination while standing, in addition to various approaches to assist penetration during sexual intercourse.
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ROUTINE WELLNESS SCREENING
Transsexuals have a unique schedule for wellness screening, but it depends on the extent of their surgical intervention. Note that the following screening schedule applies to the senior population only (>55 years old). Individuals may have special health risks (suggested by family or occupational history) that require additional screening, as determined by their medical provider.
EVERYONE, whether they're transsexual or not, needs to maintain a healthy active lifestyle throughout the senior years. This includes a balanced diet, regular exercise, no smoking, and moderation in alcohol consumption.
BREAST CANCER SCREENING: Both MALE and FEMALE transsexuals
-- Monthly breast self-examinations; yearly medical breast examinations
FEMALE TRANSSEXUALS ONLY (including male transsexuals without mastectomy):
-- Mammogram every 4 years after 10 years of estrogen exposure
-- Every 1-2 years if:
Family history of breast cancer
Positive genetic screening (contra-indication for estrogen therapy)
History of smoking
Hi-dose estrogen use (>0.3 mg daily for >3 years)
CERVICAL CANCER SCREENING Male transsexuals over age 65 can stop pap smears if they've had 3 normal smears in a row over the previous 10 years. -Or if they had a total hysterectomy and don't have other risk factors. HPV immunization is not recommended for seniors.
Female transsexuals likewise don't need pap smears or HPV immunization.
COLONIC CANCER SCREENING Yearly testing for fecal blood, in addition to colonoscopy every 10 years. Some methods of surgical vaginal construction use segments of colon. If that was done be sure to include vaginal colon screening along with the bowels.
Alternatives to colonoscopy include:
-- Sigmoidoscopy every 5 years
-- Double contrast barium enema every 5 years
-- CT colonography every 5 years
RISK FACTORS
-- Family history of colon cancer or polyps below the age of 60
-- Personal history of polyps or inflammatory bowel disease
PROSTATE CANCER SCREENING Female transsexuals still have a prostate regardless of any surgery they might have had. However current public health recommendations (2010) are moving away from routine digital exams & serum PSA levels: routine screening appears to trigger more unnecessary biopsies than it changes the outcome of dangerous cancers. Being transsexual further reduces the risks from the prostate.
INDICATIONS THAT SCREENING SHOULD BE DONE:
-- Afro-American ethnicity
-- Positive family history
-- Age >75
-- Pelvic pain or signs of urinary obstruction (urinary hesitance, frequency; interrupted or weak stream; incomplete emptying)
