This case study focuses on the transgender population and the discrimination that they face in the medical community. It also focuses on nutrition and medications and how they play an part in the management of HIV.

1. HIV, Hormones, Stress &
Discrimination: Assessment &
Education with Transgender Patients
TARA JEANINE OLIVA
DIETETIC INTERN
BENEDICTINE UNIVERSITY, SPRING 2011

2. Introduction
According to the IOM
 Clinicians are faced with incomplete information
about the health status of the LGBT population.
 Each population has its own specific health needs
and concerns.
 Researchers face numerous challenges in
understanding each populations including a lack of
data.
 Institute of Medicine,( March 2011)

3. Introduction Continued
 For better understanding, the NIH needs to create an
ample training program to raise awareness of health issues
that the LGBT community is faced with.
 The most pressing issues to focus on are:
 1. Demographic research
 2. Social Influences
 3. Intervention Research
 4. Transgender specific health needs
Institute Of Medicine,( March 2011)

4. Prevalence of Transgender
 There is no reliable data on the number of transgender
individuals in the United States.
Center for Disease Control and Prevention (2011)

5. You never know, you must have knowledge

6. Terminology

7. Terminology
 Natal sex: Identified sex at birth
 Gender: psychological, social & cultural aspects of female
& male.
 Transgender: a self selected term used to describe an
identity that transcend gender norms; an umbrella term.
 Transition: a process from being perceived as one gender
to another gender.
 Through : Name change or /and Hormones and/or
Surgery
 Transsexual: a medical term used to describe a
transgender individual who has sought formal or informal
medical intervention.
 Alegria, (2011)

8. Other terminology
 MTF :Male to Female, FTM(female to male), transman (FTM),
transwomen (MTF),
 Drag: someone who wears clothing of another gender, often
involving the presentation of exaggerated, stereotypical gender
characteristics.
 Gender Queer: a term used by some people who may or may
not fit on the spectrum of trans or be labeled as trans, but who
identify their gender or orientation to be in-between or outside
the binary gender.
 Cross Dresser: a person who, on occasion wears clothing
considered typical for another gender, but does not necessarily
desire to change their gender.
Alegria, (2011)
Howard Brown (n.d.)

9. Patient Information

10. Patient Information
 Gender: MTF (male anatomy at present,
w/hormones)
 Age: 40
 Ethnicity: Caucasian
 Height: 5’10”
 Weight: 182# (78kg) Wt Change: 27# gain in 5 years
 Usual Body Weight: 150-155 # ( as a male)
 IBW: F = 150# % IBW = 120%
Deutsch, M.(2010)
 BMI: 26.1
 ABW: 158#

11. Patient Information
 Current diagnoses: HIV+, severe
depression
o HIV+ = diagnosed 2005
o Depression: Childhood
Symptoms: depression

12. Patient Information
 Medical tests planned: lipid panel, blood
glucose, continuous CBC, estradiol levels,
mammogram.
 Previous Surgery: Breast Implants
 Surgery Planned: vaginoplasty.
Jenner, C.O. (2010)

13. Assessment of Nutrition Needs
Using the literature and ABW
 Harris Benedict (stress 1.3)
o 1931 kcals per day
 1.0-1.4 grams protein/kg for maintenance
o 72 g-101g per day
 MVI
(Coyne-Meyer, K., &Trombley, L., 2004)

14. Hormones & Surgeries

15. Hormone Therapy
 Premarin .625 BID
o Conjugated estrogen
 Estraderm Transdermal: system
patches
 Delestrogen shot 40 mg
o Increased or decreased weight, appetite changes,
decreased Ca+ bone loss, increase Ca+, increased TG,
Increase HDL, Increased LDL

16. It is a Catch 22…..

17. Gender Identity Disorder
Diagnosis in the DSM
A. evidence of a strong and persistent gross-gender
identification, which is the desire to be, or the
insistence that one is of the other sex.
B. This cross-gender identification must not merely
be a desire for any perceived cultural advantages of
being the other sex. there must also be evidence of
persistent discomfort about one’s assigned sex or a
sense of inappropriateness in the gender role of
that sex

18. Criteria for Hormones & Surgery
 Psychiatric Evaluation before surgery or
hormones
(A mental health diagnosis rules their life?)
 Diagnoses of Gender Identity Disorder
 Thinc:
Trans Hormones-Informed Consent
(@Howard Brown)
p://lgbthealth.healthcommunities.com/transgender/gender-identity-disorder.shtml
Howardbrown.org

19. Hormones MTF
 Estrogens Effects:
 SofterSkin
 Reduced testicular volume
 Decreased erectile function
 Decreased hair growth
 Decreased libido
 Enlargement of nipples
 Testosterone to female levels
 Labs: free testosterone, fasting chemistry panel, fasting
lipid panel, CBC, estradiol levels, PSA, Pap (if vagina),
mammogram
Algeria, (2011)

20. Hormones FTM
 Androgen effects:
 Deepening of voice
 Increased aggression
 Increased libido
 Cessation of menses
 Hirtuism
 Clitorial growth
 Breast atrophy
 Redistribution of fat
 Laryngeal prominence
 Labs: Fasting lipid profile, liver function tests,
CBC, pap smear, mammogram (breast tissue
present)
Alegria, (2011)

21. Surgeries
 MTF
o Vaginoplasty
o Augmentation
o Facial Feminization
o Electrolysis
 FTM
o Chest reconstruction
o Hysterectomy
o Penis construction (phalloplasty)
o Metoidioplasty (creation of penis from clitoris)
http://transgendersurgeries.com/

22. NUTRITION ASSESSMENT

23. Diet & Appearance
 Trans persons may use food to help with their
physical appearance
 Overeating to increase size
 Calorie Restriction
 New gender after one year of successful hormone
therapy
 Increase for FTM
 Do not overlook their needs
Deutsch, 2010
Vancouver Coastal Health, 2010

24. The Literature
 Lack healthy lifestyle pattern
 Mean nutrient intake below standard value
 Eat more or skip meals
 Lead to malnutrition
 Obesity
 Emotions had impact on food consumption
 Rejection
 Racism
 Lack of medical health care
 The literature complements the patient
Sivakami, PL & Veena, K.V. (January, 2011)

25. HIV And Transgender

26. Rates among transgender
 Estimated HIV infection rates among
specific transgender populations range
from 14-69%.
 Highest among MTF sex workers
 Center for Disease Control and prevention (2011)

27. Prevalence of HIV
High Rate of HIV+
o Lack of HIV education
o Lack of medical access
o SES – social isolation
o Mental Health concerns
o Stress
o Many barriers
**LEAD TO ↑ RISKY BEHAVIORS

28. Behavioral Risks for HIV
o Unprotected receptive anal intercourse
o Multiple casual partners
o Sex work
o IV drug/street hormones
o Herbst, J.H. (2008)

29. Lack of education of HIV/AIDS
o Providers lack adequate knowledge to care
for patients.
o Do not lend themselves to “caring”
environments.
o Do not understand their needs
o Lack any formal education of this population
o May see this population as having a
diagnosed “Gender Identity Disorder
o Butler, R. (2010)

30. Health Disparities

31. Discrimination Affects Health
o Families : isolation
o Employers : loss of job, loss of health insurance
o Homelessness: lack of support system,
increased risk of HIV.
o Healthcare: uncaring environment, unknowledgeable
staff, lack of care
o Williamson, (2010)

32. Homeless
Lack of
unemployment
homeless insurance
Lack of meds
TRANSGENDER
Lack of
nutrition
Lack of medical care
Risky Poor health status
Behaviors
Operario, D & Nemato, T. (2010)

33. COMMUNITY RESOURCES

34. Howard Brown Health Center
Howard Brown exists to eliminate the disparities in health care
experienced by lesbian, gay, bisexual and transgendered people
through research, education and the provision of services that
promote health and wellness.
o Medical center
o Behavioral Services
o Youth Services
o Fund raising events
o Substance abuse programs
o Many, many, more
o www.howardbrown.org
http://www.howardbrown.org/hb_services.asp?id=37

35. TWISTA
Trans Women Informing Sister Trans Women on
AIDS
TWISTA is a group designed to celebrate the strength and
resiliency of transgender women of color (ages 16-24)
Support to deal with struggles like harassment, relationships,
and health.
o Role models
o Love and support
o Education
o Sponsored through Howard Brown –Chicago
twista@howardbrown.org

36. Community Interventions
 AIDS Foundation of Chicago
o Supportive Housing
o Food pantries, soup kitchens, and meal
programs
o Prevention Events
o Syringe Programs
o Medication Programs
o Advocacy
o Grantmaking

37. What Can We Do?
 Proper gender on questionnaires
 Proper pronoun/proper name
 Gender neutral restrooms
 Work as a multidisciplinary team, know your part
 Understand hormones/ART interactions
 Understand eating disorders/refer if necessary
 Know the risks in this community
 Know your patient, do not make assumptions.
 Create a caring environment

38. Angelique

39. Works Cited
 Butler, R. (2010)An assessment of lesbian, gay, bisexual, and transgender curriculum
infusion in U.S. medical schools. Retrieved on May 05, 2011 from
http://www.indiana.edu/~spea/pubs/undergrad-honors/volume-4/butler_rachel.pdf
 Center for Disease Control and Prevention. (2011) HIV in the United States. Retrieved from
May 4, 2011 from http://www.cdc.gov/HIV/resources/factsheets/us.htm.
 Coyne-Meyers, K., & Trombley, L. (2004). A review of nutrition in Human
Immunodeficiency Virus infection in the era of highly active antiretroviral therapy.
Nutrition in Clinical Practice, 19, 340-355.
 Deutsch, M. (2010). Primary care for transgender patients. Proceedings of the 13th Annual
Clinical Conference for the Ryan White HIV/AIDS Program,
http://www.iasusa.org/keyslides/hrsa/2010/index.html
 Health Communities.(2011) Gender Identity Disorder. Retrieved on May 06, 2011 from
http://lgbthealth.healthcommunities.com/transgender/gender-identity-disorder.shtml.
 Herbst, J.H. (2008). Estimating HIV prevalence and risk behaviors of transgender
persons in the United States: A system review. AIDS and Behavior, 12(1), 1-17.
 Howard Brown Health Center Publication. (2009) TWISTA
 Institute of omedicine of the national Acadamies. (March, 2011). The health of lesbian, gay,
bisexual and transgender People; Building a foundation for better understanding.
Retrieved on April 15, 2011 from http://www.iom.edu/Reports/2011/The-Health-of-
Lesbian-Gay-Bisexual-and-Transgender-People.aspx.
 Jenner, C.O. (2010). Transsexual primary care. Journal of the American Academy of Nurse
Practitioners, 22(8), 403-408.

40. Works Cited
• Jenner, C.O. (2010). Transsexual primary care. Journal of the American
Academy of Nurse Practitioners, 22(8), 403-408.
• Lawrence A. (2001) Vaginal Neoplasia in a Male-to-Female Transsexual:
Case Report, Review of the Literature, and Recommendations for
Cytological Screening. International Journal of Transgender.5,(1).
• Nerad, J., et al. (2003). General nutrition management in patients with
Human Immunodeficiency Virus. Clinical Infectious Diseases, 36(2), S52-
62
• Operario, D. & Tooru, N. (Dec 15, 2010) HIV in Transgender Communities:
Syndemic dynamics and a need for multicomponent interventions. Journal
of Acquired Immune Deficiency Syndromes, 55, p 91-93.
 Pribram, V. (2010). Nutrition and HIV. Singapore: Blackwell Publishing
Ltd
 Willliamson, C. (2010). Providing care to transgender persons: A clinical
approach to primary care, hormones, and HIV management. Journal of the
Association of Nurses in AIDS Care, 21(3), 221-229
 Vancouver Coastal Health. (2011) Transcare medical issues. Retrievedd on
May 5, 2011 from http://vch.eduhealth.ca/pdfs/GA/GA.100.F55.pdf.