2023 Webinar: Hepatology Care for Transgender and Gender Non-binary People-Webinar Recording

Webinar Recording

Video Transcription

Hi, everyone. Welcome to join the AASLD webinar. I'm Howard Lee and I have my co-moderator Elizabeth Goldschmidt here and this is really our honor to have all of you guys join us  at this webinar talking about hepatology care for transgender and gender non-binary people. We would like to thank AASLD to give us this opportunity to share this important topic  especially during the prime month but also want to thank the AASLD LGBTQ task force to organize this important webinar for us. So again, I am currently an assistant professor  in transplant hepatology in Baylor College of Medicine in Houston, Texas. I'm the member of the LGBTQ task force at AASLD, also the executive board member for Rambos and Gastro.  My pronouns, I, he, him, his, and you can find me on Twitter and my emails and also through email as well. I'm honored to introduce my co-moderator, Elizabeth Goldschmidt, who  is the director of the advanced practice and the lead APP in division of gastroenterology department of medicine in Duke University Medical Center in Durham, North Carolina.  She's also the member of LGBTQ task force of AASLD. Her pronouns are she, her, hers, and you can find her on Twitter and through her email account as well.  And we have our speakers, Dr. Sonali Paul, who is the assistant professor of medicine in section of gastroenterology, hepatology, nutrition, University of Chicago. She is also  the member of LGBTQ task force of AASLD and the executive board of Rambos and Gastro. Her pronouns are she, her, hers, and you can find her on Twitter and through email as well.  And last but not least, we have Dr. Tongonic, Laura Tongonic, as associate professor of medicine in University of Toronto. She was the past chair of diversity equity in the  Canadian Association of Gastroenterology, and she's the staff gastroenterologist in Mount Sinai Hospital in Toronto. Her pronouns are she, her, hers, and you can also find  her on Twitter and through email. This is quickly our learning objectives for today, and we're going to start our first talk by Elisabeth Goetscher, please.  All right. Thank you, Dr. Lee. Appreciate everybody's attendance at the webinar. I'm really excited to bring you the first segment, which is Transgender Care 101, Definitions, Pronouns, and the Transition Process.  I think it's important we walk through this because I don't know about you all, I'm probably older than most people attending right now, but I know for sure I didn't learn about these kinds of things in my training 30 years ago or so now.  So let's make sure that we're getting ourselves up to speed. As always, it's important to start at the beginning as we move forward gloriously, always gaily forward, never in a straight line.  Let's start with terminology, right? So terminology, important for us to remember that we are talking here about sex, which is a biological construct.  It is based upon chromosomes and gonads and how this differs from gender. Gender is a social construct. It is not based upon your biological orientation or your biology.  It's about societal norms and our understanding of who we are as a gender, not necessarily our biology.  And then gender identity, picking up from that same thing, is what is our internal sense of self and how a person fits into the world from the perspective of gender specifically.  In reference to the term transgender, this is the gender identity, which is different from their sex.  So if you are gender, transgender man, that means the female genitalia that you were born with are present, but you have a gender identity as a male.  It is a transgender woman biologically or male genitalia developed or present at birth, but with a female gender identity.  So transgender, trans woman, transgender man. Cisgender, some people have the same, they have alignment of cis coming from the Latin of same.  So there's an alignment of the gender and the biological identity. So those are cisgendered individuals.  Gender nonconforming is a term that encompasses the fact that gender identity is different from the sex at birth.  It is less fluid or defined as trans, but it's more of a broader term.  And then nonbinary, a term embracing the fact that there are gender identities that do not fit completely into a binary male-female system, but that the gender identity embraces components of both or outside.  Something broader than those defined categories. What we'll not be talking about here today, but just to remind us, is that sexual orientation is not the same as sex or gender.  Sexual orientation is our identity in terms of our relationship to others in romantic and sexual relationships, and that person's gender.  So not talking about that and remembering that those are separate entities. And additionally, just trying to go through the jargon of pronouns.  This is something that we advocate for, that we are using appropriate pronouns and not just assuming this. So identifying our pronouns based upon our gender identity.  This is our identified gender pronouns. They may be gender or they could be gender neutral. She, her, or he, him for gendered identity.  They, they're representative of a nonbinary or something beyond the constructs of male-female.  And it's easier to represent perhaps even beyond the concurrent social construct of gender at all.  Or there's other terms and other gender pronouns that people, other pronouns that people choose as well.  The definition then of gender-affirming care.  We're going to talk a little bit more about the hepatology specifics, but the broader term of gender-affirming care then are a definition of the interventions that have a goal of aligning biology with the external appearance and gender identity.  So bringing together the fact that the gender identity that a person has is different than their biological sex at birth.  Medical transitions would be the medical components of that.  So hormone therapy targeted towards either minimizing the external appearance of unwanted secondary sexual traits or boosting or amplifying those desired traits.  Surgical transition with the same goal, but with surgical approach.  Inclusive of both surgeries that may have a specific association or specific indication for gender affirmation or specific to this area.  Also procedures though that have other indications that are just in this area gender-affirming.  Why is all of this important? Why is talking about gender-affirming care important? The reason is it's gender dysphoria.  So gender dysphoria is fortunately the term that was coined in 2013 and replaced the antiquated and inappropriate pathological pathologizing term of gender identity disorder.  Recognition that gender dysphoria, as all DSM-5 criteria, all DSM-5s do, they give us lots of checkboxes to walk through.  But in essence, gender dysphoria can be summed up as the psychological distress resulting from an incongruence between the sex assigned at birth and one's gender identity.  So gender dysphoria then is not something that all trans or non-binary people experience.  But it is that when you do have that distress, that psychological distress between sex and gender identity can be coined gender dysphoria.  And then the downstream effects of any kind of distress or distressing condition then lead to potentially higher rates of mental illness and substance abuse.  Also certainly health behaviors and health outcomes can be impacted. There's a lot of literature about gender dysphoria and its impact.  What I chose to just here in our limited time is to highlight the fact that this is significantly impactful in our trans youth.  It has been well established that there are higher substance abuse rates and mental prevalence of mental illness among transgender people in general.  But youth seem to be even greater and have a higher disproportionate, have a higher impact in that area.  This is just a summary of a survey that was conducted online from June 2012 to 2015, so a significant time ago obviously, with 35,000 youth in the middle and public high schools.  And so the questions were aimed at identifying whether you were cis or trans or questioning or binary. And so respondents were able to categorize themselves as that.  But also one of the many questions was, have you ever attempted suicide?  And so this is the answers by male, female, cisgendered individuals with have yes, I have attempted suicide being present and alarming at 19 and 15%.  But when compared to their transgender respondents were significantly different and very concerning.  The highest rate of yes, I have answering yes to I have tried to commit suicide amongst transgender female to male participants in this survey.  And again, these are 13 to 24 year olds.  So we see that gender dysphoria downstream impact has significant health components and health impacts and alarming and need for us to address them.  I want to walk through the components of transitioning to make sure, again, we're having the jargon in our head about what it is that this involved.  The components of psychosocial transition then are the identification of the gender identity, identification of pronouns, the path toward actualization, deciding if a person is going to actually act on this and if they are, how are they going to do so to make this transaction possible?  The social components being talking with friends and revealing this change or sharing this change with employers and dating and intimate relationships.  Also, then, of course, navigating the stigma, bias, and discrimination associated with the destigmatization of this population. And then also thinking about the legal documents.  So it's a legal name change with a change of how that impacts all the other pieces that are attached to that driver's license, passport, medical license, teaching certificate.  All the things that go downstream from there are all a part of things that people who transition have to put into play.  Familiarity with some of the behaviors that people can adapt for as part of their transition include these.  These are ways to minimize the appearance of the unwanted secondary sexual traits or to create the presence of one.  In terms of packing, the wearing of a penile prosthesis to simulate the presence of a phallus, genital tucking to minimize the presence, the physical appearance of a phallus, or chest binding to minimize the presence of female appearing breast tissue.  Speaking specifically in medical transitioning, there's pre-pubertal and post-pubertal types of approaches.  And so there is some data, again, not time to go into today, about the pre-pubertal people who receive therapy prior to puberty and never experience their secondary sexual characteristics and significant reduction in gender dysphoria for those.  But in those pre-pubertal people, gonadotropin-releasing hormone blockers are used. And then in post-pubertal people with secondary characteristics are developed.  We want to feminize where we want to and bring down things that stimulate breast growth where we want it and block the anti-androgen effects or masculinizing hormone with testosterone.  It's important to note that in 2017 that the Endocrinology Society put out, since this was such a significant component of endocrinology therapy, there is now a practice guideline from the endocrinology societies about how to address this.  Some of the surgeries that you might consider are things that are intuitively make sense. Some of the masculinizing therapies are just what they sound like.  So getting rid of and removal of the unwanted secondary sexual characteristics, metoidioplasty not being a common term, but that's the creation of and specific to gender affirming surgical therapy with creation of a ballast from the vaginal tissues.  Things are not always so straightforward as a mastectomy. Masculinizing chest reconstruction is more than just a mastectomy with the actual plastic surgical reconstruction of a male-appearing chest.  Some of the feminizing therapies for male-to-female transitioning people are again, as they make sense, removal of the testes to reduce the testosterone production, vaginoplasty, breast augmentation.  Reduction thyrochondroplasty is a surgery to, as again is what it sounds, minimizing the tracheal cartilage to create a feminizing-appearing throat.  And then facial feminization surgery, which is an intense physical, it's a very intense ordeal to alter the bone structure of the face and realign so that there's a, when a person looks in the mirror to see the face that matches the person that they are on the inside is a very significant surgery and often one of the last done.  Why is this important? Gender-affirming care is protective.  There's been some data to show that when you ask people who, especially teenagers in this survey who are receiving gender-affirming hormone therapy, are you receiving it?  And then also ask about their at-risk behaviors. We saw lower depression and suicide in these children, people, excuse me, receiving gender-affirming hormone therapy.  So in summary, I hope that we can now appreciate that there's many facets to transitioning that is incredibly impactful on our health outcomes, especially in our youth, and that hormone therapy can be protective.  So with that, I'm going to turn it over to my friend Howie. Dr. Lee, you're up.  Thank you, Elizabeth, for that introduction. Sorry, I wasn't aware I was muted. And it's really good, a comprehensive introduction about the topics. And now I'm going to talk about  what are the impact on liver from the gender-affirming hormone therapy. So again, my name is Howard Lee and I am a transplant pathologist in Baylor College of Medicine.  My pronouns are he, him, his.  I have no financial disclosure. I would like to thank my friend, Dr. Ansenberg, who is an endocrinologist and specialize on transgender care, give me some feedback on the slides.  So Elizabeth kind of talk about the transgender hormone therapy and estrogen and testosterone are the most commonly used agent for gender-affirming hormone therapy. And then,  actually both estrogen and testosterone have a lot of impact on the liver. In fact, many experts actually call liver a very sexually dimorphic organ  because all the impact of all the sex hormones on the liver. So what I'm going to cover today about the possible effects of gender-affirming hormone therapy on liver,  which including drug-induced liver injury, also the old name is NAFL, but now metabolic dysfunction associated with the state of liver disease, hepatic tumors,  and how about the concern of using the gender-affirming hormone therapy with people with chronic liver disease.  So that start with the drug-induced liver injury from testosterone. If you look at liver tox, there are several pattern of delay that's been associated with testosterone.  Most common one is some transient serine enzyme elevation, usually two to three times upper liver normal,  and you can also have acute cholestatic syndrome, which also called bland cholestasis.  There's a third one that's rare, but kind of a pretty distinct entity. It's a chronic vascular injury, or they have a fancy name called pleiosis hepatis.  Basically, the liver will show dilated sinusoid with, and some of them will have a blood-filled cyst and sinusoid space as well.  The liver grossly can look enlarged and red and angry, and also that can have a potential of rupture as well. It's important to notice most of these cases  are linked to C17-alpha-oculated testosterone, and which is less commonly used now. How about estrogen?  Estrogen also can cause delay, and the pattern including the ALT or alkaline phosphatase elevation.  It's mainly reported in early formulation of oral contrastive pills, but much less with newer formulation. We all know that can also cause bilirubin elevation  by myoinhibition of bilirubin excretion, especially in those patients that have inherited form of bilirubin metabolism. Also can cause cholestatic liver injury as well,  usually arise during the first few cycles of therapy, and that can also cause the same complication of bleiosis hepatis.  But how about some real-world data about delay for gender-affirming hormone therapy? So this is a study that published in 2020, that it's a large cohort from Europe  that including almost 2,000 transgender individuals started gender-affirming hormone therapy between 2010 to 2020.  The primary outcome is liver test elevation within one year. The definition they use is two times upper-lipid normal of alkaline phosphatase, three times for ALT and AST.  They exclude alcohol use, other medication, and they also review the medical history throughout other cause of liver test elevation as well.  In this cohort, in the transgender man population, there's only six or 0.6% of them had liver test elevation that meet this criteria. Also in the transgender woman,  there's only one that meet this criteria. So you can see the percentages small for both transgender men and women.  They have around almost 400 patient that they have data extend to three years after starting gender-affirming hormone therapy. There is one transgender man  who has a liver test elevation from gender-affirming hormone therapy  in that cohort, one additional man. So, and I do have to say most of the case only have my elevation of a liver test.  Now, the second thing I'm going to talk about again is the NAFLD, or now the new name called MAFLD, metabolic dysfunction associated with state-of-the-art liver disease.  For the role of estrogen for MAFLD is likely protective. In the cisgender individual,  the man, we all know that men is more likely to have NAFLD or MAFLD compared to women. And in the cisgender women population, we all know that post-menopausal women  that are more likely to have MAFLD compared to pre-menopausal women. This is a study published in CGH about the risk.  You can see being a female, your risk is less to have MAFLD compared to men.  Also, how about role of androgen in MAFLD? It's quite interesting for androgen, the fact is kind of sex dependent. For cisgender women, the most data is,  we all know derived from patient with PCOS, that high testosterone increased risk of developing a state-of-the-liver disease is independently of obesity and insulin resistance.  Also same data showing in both pre-menopausal and post-menopausal cisgender women, that higher level of testosterone is associated with higher risk of state-of-the-liver disease.  For cisgender men, the effect is actually opposite  in some small studies showing that low testosterone is actually associated with a state-of-the-liver disease.  Here, I also want to mention not just the hormone and the sex like Elizabeth talked about, and even gender identity, which including the social and cultural characteristic  could also affect dietary patterns  and exercise patterns of the person, which could have impact on the risk factor of MAFLD as well, like showing on this BC cartoon. So, you know, I think it's just not sex,  the gender identity could also have impact on the risk of state-of-the-liver disease.  How about HCC?  HCC, we all know the incidence of HCC is higher in men than women,  in cisgender men and more than cisgender women. So androgen kind of, there's some hypothesis that saying that androgen maybe increase the risk and estrogen decrease the risk.  And study in cisgender men, there's some small studies showing that increased testosterone level is associated with high risk of HCC in some case control studies.  And most of the study are actually from Asia. So there's some hypothesis that there may be some interaction between hepatitis B and androgen. For cisgender women,  we think that estrogen likely protective according to some clinical studies. And then the thought is they may be related to estrogen receptors in the liver,  including ER alpha and beta.  How about HCC risk and people that use sex hormone?  So for HCC and androgen use, there's has been reported in patient with and without cirrhosis. Most of the HCC in this case are well differentiated  or they are hepatic edema with focal transformation. For estrogen, there's some case report in case control studies in the past has been reported that using oral contraceptive pills  is associated with HCC.  But in this meta-analysis published back in 2007 in Journal of Hepatology, showing that actually the fact was not statistically significant. So really we need more data  for gender affirming hormone therapy.  How about adenoma? We all know that for estrogen, we all know that cisgender women with long-term oral contraceptive, sorry, long-term OCP use does have increased risk of adenoma.  In androgen, for cisgender men that are using testosterone for hypogonadism or bodybuilding, there's some case report as well for hepatic adenoma.  Same thing in cisgender women using Denazol or hereditary angioedema also has been associated with hepatic adenoma. And I do want to mention  there is one case report out there from Japan that for transgender men, they're using testosterone and causing hepatic adenoma.  How about other hepatic tumors? There are some other hepatic tumors such as cholangiocarcinoma, angiosarcoma, and NRH-associated androgen, and estrogen has been associated  with FNH, hemangiomas, permatomas. Also, we all know that there's concerning for embolization, including butycarid syndrome, but I do have to mention most patient have other,  that has been reported have butycarid disease and other risk factor for thromboembolism. There's limited data for gender-affirming hormone therapy.  Lastly, I want to touch base about hormone use in chronic liver disease. And this is from the ASLD guidance in 2021  that mentioning androgen use for cisgender men with CLD.  The safety for testosterone is, we have some data showing that the most likely using testosterone is safe in patient with chronic liver disease in cisgender men population.  For estrogen, there is some concern, including a denoma that we talk about and thromboembolism risk, as we mentioned earlier. So ASLD guidance mentioned that HRT should not be used  in cisgender women with decompensated liver function, butycarid syndrome, or hepatocellular adenomas.  However, again, when we, every time we talk about gender-affirming hormone therapy, we're talking a little bit different population. A lot of them are younger population.  So really more data needed for using gender-affirming hormone therapy in this population.  Given the time, I'm going to mention  this ASLD reproductive health and liver disease practice guidance, again, published 2021. And I think they have a really good summarize about what we think about  using gender-affirming hormone therapy. So there's currently, as I showed you earlier as well, there's limited data suggest the effects  of hormone alteration and risk of hepatic steatosis and metabolic health in transgender patient. I also show you about the risk of tumor as well,  but actually there's really not that much data around the gender-affirming hormone therapy. So we kind of extrapolated data from cisgender patient  that using hormone for other reason. So ASLD put the guidance to say for masculinizing hormone therapy, we should screen for liver abnormalities and polycystemia before initiation.  For feminizing hormone therapy, we should consider co-management with hepatologists. I do love that you mentioned about welcoming a supportive environment  for transgender individuals. Seeking hepatology care is important and more data and research are really needed. And it's very important to mention  that gender-affirming hormone therapy can be life-saving for transgender and gender non-binary people as Elizabeth mentioned in her talk.  So we really, every time we think about this, we really need to balance the risks and benefits for our patients. So here are some more resources  and I'm pretty sure Laura will talk more about in her talk. And thank you guys for your attention. I do want to mention that we have this REMBO-Syngestro  work with all the major GI society have this survey. We're going to close out this month. So if you can take a screenshot of the QR code, finish this five minutes survey and tell us  what do you think and your experience taking care of this patient, we'll really appreciate it. Thank you again for joining my talk today and we'll take a question in the end.  Great, thanks so much. Let me just pull up my slides here.  Perfect, so I'm Sonali Paul and I'm very excited to be presenting today. And so thanks to the ASLD and Elizabeth and Howie for the opportunity.  I'll be talking about disparities and challenges for transgender patients in liver and organ transplant.  These are my disclosures not relevant to today's talk.  So in terms of objectives, we'll review a bit of the health disparities in relationship to organ transplant, review unique aspects of immunosuppression  and management, identify best practices and really reinforce that we can all provide gender affirming care.  Just a bit of looking at trends throughout the US. So the folks that identify as LGBT in the US, it's about 7%, of those about 10% identify as transgender.  But what's really interesting, if you look at Gen Z, it's about 20% of Gen Z identifies as LGBTQ. So there are going to be many more people  coming through the pipelines, not only as our patients, but also as our trainees that identify as LGBT. And of course, of those transgender and non-binary.  So I just want to start with a case. So this is a patient with cirrhosis, very high MELD. So she's a 35 year old transgender woman. She's currently on PO estrogen  and she has been for the last two years. She now has new alcohol related cirrhosis. She's quite decompensated or MELD is 30.  She was deemed an acceptable candidate for liver transplant, but was told to stop her estrogen for the risk of thromboembolism with a very unclear restart date.  And unfortunately we had no guidelines. And this isn't our institution, but it was a case I had heard of. And there are no guidelines with respect to this.  And really it becomes a matter of life and death. Obviously for transplant, it's if the patient doesn't get a transplant, they'll most likely die.  But if you have to stop someone's estrogen or testosterone, that also is just a huge part of their identity. So weighing that into the decision as well as really important.  So in terms of consideration, so we want to think about when we approach why disparities exist in this population. So we think about the minority stress model.  So we all have stresses that are everyday stressors, but the stress related to,  minority identity in this case, trans and non-binary, it really influences health behaviors. And as Elizabeth had mentioned, there's increased rates of psychiatric illness  and mental health, and not so much because of the people, but because of the society that we live in. And so this may increase rates of alcohol and smoking.  And these are often key factors for transplant evaluations, especially in liver transplant.  Trans folks also have less access to health insurance because they're more often uninsured and then have either less access  or actually do not go and get preventative health services. So things like breast, cervical, colon cancer screening. And again, these are also things that we all ask  our patients to get prior to transplant. Thinking about chosen family is quite important. The psychosocial eval and having social supports is such a huge part of transplant,  but many folks in the LGBT community and in the trans community don't have, their biological families have actually rejected them.  So they have a close network of family and friends,  or rather friends who have become their chosen family. And so knowing that that, approaching the patient from that lens and not being judging why they don't have actually  any biological family with them, they may just have really close friends. And then just having a very thorough psychiatric evaluation,  but in the setting of knowing that there are increased rates of suicide and depression and anxiety in this population and looking at it from that lens as well.  So in terms of liver transplant, when you PubMed it, this is what comes up. There is really no data on liver transplant with regards to transgender and non-binary folks.  There is a case series coming out of Penn that was done in 2020. This looked at kidney transplant and donation in the transgender population.  And really the most important thing that I took away, two important things, but one of the most important was really discussing either a prior history of surgical therapy  or hormone therapy or any future plans for either of those, because that's going to really dictate the transplant course and future options as well.  So they looked at, there were four recipients and two donors  and they looked at kind of hormone therapies if they've had any surgeries, infectious disease issues, and then psychiatric diseases as well.  What they found was that, and again, this is very obviously very anecdotal, that feminizing vaginoplasty and phalloplasty can increase the risk for potentially anatomic issues  in kidney transplant. So things like urethral strictures, recurrent UTIs, fistulas, acute kidney injury.  In terms of medications, so there are interactions that we worry about. So estrogen, so feminizing drug therapy. There is a risk of venous thromboembolism,  so especially with PO, estradiol, less with transdermal applications. So the recommendation is to potentially avoid PO and hold any other formulations  for two to four weeks pre and post transplant. Anti-androgens like spironolactone are also used and this can cause hyperkalemia and interact as we know with our CNIs and Bactrim.  Vascularizing drug therapy is testosterone in many different forms. So perioperative cessation is really not needed per this paper. There is an increased risk of alopecia  because it increases the risk of tachyclolimus and then also an increased risk of acne with testosterone and that also kind of synergizes with mTOR inhibitors and steroids.  For transgender men that have persistent menses, aromatase inhibitors are often used. This can increase risks of osteoporosis with CNI and steroids.  And then progestin in general can be inhibited by mycophenolate. So those are important things to know. But unfortunately, as I always said, we don't have very much data.  So we have no long-term effects on graft and patient survival in folks that are receiving gender-affirming hormone therapy.  So what we really need is, transplant is already multidisciplinary, but this even kind of speaks to how much further it really needs to be integrated.  So thinking about the surgical issues, the hormonal issues, the infectious disease issues, and then really having a really great psychosocial eval as well.  And someone had said,  I'd heard someone say that, and this is in relationship to a trans patient who is undergoing a transplant eval, how can someone have so many psychiatric issues and suicide attempts?  Does he have a family history? And when we think about that comment,  it's really not, right, it's not the person. There's a lot of hate out there and there's a lot of bathroom downs going on. There's a lot of things going on,  mainly at the state levels  that are targeting LGBTQ folks, specifically trans and non-binary folks. So if this is the culture that you're living in, it's easy to be very depressed. So it's not our patients.  So just thinking about MELD score and creatinine. So the current version of the MELD score, as we know, looks at INR, serum bilirubin, creatinine, and sodium.  There is a growing concern though that women are disadvantaged. Serum creatinine actually overestimates renal function in women, so it can underestimate the risk of mortality.  There is a push and it's going to go live, I think, soon, or it is already live. So MELD 3.0 now actually includes female sex to address the existing sex disparity.  And UNOS actually now has their forms changed to include birth sex instead of gender, and then sex for purposes of adult MELD calculation.  And so I think this is, from my perspective, I think the terminology could be a little bit different, but I think this is amazing first step,  and really, really kudos and congratulations to UNOS, because not many folks that come out with calculators that are binary think about this specifically.  I think there are still questions, I think that still remain in terms of just testosterone. So what happens to folks that are transitioning or have transitioned?  We know that testosterone increases muscle mass, unclear effects of estrogen, so what sex is going to be listed, and then also what sex is going to be listed  for our non-binary patients. But again, I'm just very happy to see that. So how do we move beyond the binary? And I said transplant really in medicine,  and this is not an inclusive, exhaustive list, but just increasing education, having webinars like this across the medical continuum. And I know in medical school,  I learned very little about LGBTQ health and nothing about transgender health. And then capturing sexual orientation and gender identity data in UNOS and SRTR databases.  I mean, I think we're doing a really good first step looking at gender identity now, but I think going that step further and looking at sexual orientation,  because that's really the only way we're going to figure out where the disparities are.  In terms of having inclusive language, just thinking about your intake forms, not saying other father, saying parent, or not saying husband, wife, saying partner.  Just having inclusive spaces. We know that LGBTQ folks, when they walk into a room, they scan the room looking for any sign that that space is safe for them.  So just having a simple rainbow flag or a progress pride flag in the room or on the door to the clinic really goes a long way. And then just having transplant teams  with diverse backgrounds.  And then I just want to end with talking about gender-affirming care. This has been kind of a buzzword recently. We talk a lot about it. And when you look at the WHO definition,  it's the range of social, psychological, behavioral, and medical interventions designed to support and affirm an individual's gender identity. So my point is that we can all provide  gender-affirming care. We don't have to be endocrinologists or folks that prescribe or perform surgeries. It's way more than hormones and surgery.  So it's like listening, building understanding, creating an environment to safety. And I think safety is such an important thing for all patients, especially our trans  and non-binary patients. And it's really recognizing the patient's gender and using the correct name and pronouns. That is really it. And so we affirm one's name and gender  all the time on a daily basis, but we do it in our cisgender folks. There's no reason we can't also do that in our transgender folks.  And then just be an ally, wear a pin. You really have no, no idea who it's gonna help. I can tell you for my own journey, if I had seen folks wearing rainbow pins  like going through training, I think my training journey would have been a bit different.  So just to conclude, so again, we can all provide gender-affirming care.  Prior to transplant, we wanna discuss a prior history and future plans for gender-affirming therapy. Multidisciplinary teams are incredibly important,  specifically when we look at transplant and thinking about chosen family and in that psychosocial eval and then capturing SOGI data, so sexual orientation and gender identity data  in all of our databases and just the need for more research.  So good morning and good afternoon, everybody. My name is Laura Tergonak. I'm an Associate Professor of Medicine at the University of Toronto  in the Division of Gastroenterology and Hepatology. And I'm gonna give our last talk about sort of some pointers on how to best provide gender affirming care to your patients.  And I wanna thank Dr. Paul for her introduction about gender affirming care isn't just providing hormones or providing surgical services, but it's how to care for your patients  who are living with liver conditions and liver diseases and how to do it in a way that affirms their identity.  So in terms of my conflict of interest, I just wanna focus on the right on my cognitive conflicts of interest. I think it's important to mention, I'm not a hepatologist,  so this is gonna be fairly general. I am trans though. And so I'm pretty engaged in what's going on in the world of in sort of the, in society and in culture.  And that a lot of my talk, both as a provider of many patients who are trans and gender non-conforming as well as my own personal experience,  my lived experience informs how I interpret data and informs about how I wanna be treated if I'm seen as a patient and what I try to do when I'm delivering care  in my clinical practice.  So in terms of the objectives for today's talk, I think it's important that we all be aware of the barriers that are faced by the transgender and gender non-conforming community  to understand what is meant by gender affirming care in the context of providing that care by non-specialists. So by people who are not necessarily experts  in providing a gender-based, in providing transition care, but to understand how to treat your patients with respect and to do it in a way that they'll feel comfortable  coming to you for their liver care.  So as was alluded to earlier,  we are seeing an increasing prevalence of people who identify as transgender or gender non-conforming, particularly among adolescents and young adults.  And what we do see is that in the most recent assessment of this from 2022, that 1.4% of young adults and adolescents identified as transgender or gender non-conforming  and about one in 200 of all adults identify that this way.  We also know that people who are gender non-conforming do face significant challenges. And this is looking at the US poverty rate in 2020 and 2021.  And what we see is that among people who are on the LGBT, who identify as members of the LGBTQ plus community, that they have experienced higher rates of deprivation and poverty.  And this is highest among people who are transgender. We also know that the concept of intersectionality where other factors that may be,  that may such as racial factors, immigration status,  living with disability, those things tend to magnify the impacts of having an LGBTQ identity. And we see that among the, in this chart on the right, people of color who are LGBT  face higher levels of deprivation  than their counterparts who are white.  We also know that transgender people face higher rates of victimization, both for transgender women and transgender men, experience victimization at significantly higher rates  than cisgender women and cisgender men. And 25% of trans people who've experienced victimization feel it was hate related. In other words, related to their gender identity  or expression. When it comes to the healthcare environment,  I know a lot of us like to think of ourselves as being progressive culturally and that we strive to provide excellent care for all our patients,  but this isn't necessarily what is perceived by people who are transgender and gender non-conforming. And what I show here is that two thirds  of transgender adults worry that their health evaluations, the quality, the diagnostic plan, how they're being managed is influenced negatively by their trans identity.  So people often worry that they're not going to get lead examinations. I know a lot of trans people feel that once their trans status is disclosed, that whatever the symptom is,  it becomes ascribable either to their being trans or to trans identity. So it's sort of like what's often followed is that the trans broken arm syndrome  or the trans shoulder syndrome, where no matter what symptom you have that has no causal association, people will say, well, it might be have something to do with your hormones  or might have something to do with your stress from being trans. In addition, nearly half of trans individuals report having a negative or discriminatory experience  with a healthcare provider. So once again, this is not necessarily people providing transition care, but any providers providing any care.  So we see that about half of the population has experienced at least one form and these can include things like patients believing  that their care provider has intentionally misgendered them by using the wrong name or a wrong pronoun, that they believe that they've been refused healthcare  because or refuse an appointment because of their trans status or that physicians were physically or emotionally abusive to them in the course of providing care  or that they just refuse to be seen. And as you can imagine, these kinds of experiences may be caught more common in areas of the country  where the level of anti-trans rhetoric is at its highest. And so I think it's incumbent upon us in wanting to provide quality care for all of our patients  to exhibit and to demonstrate principles  of gender affirming care, no matter what disease we're treating. So when I talk about gender affirming care, as stated before, I'm not only talking about aspects of transition,  such as the social transition, medical interventions and surgical interventions that our previous speakers alluded to, but also how do we affirm someone's gender  in the rest of their life through affirmation and acceptance, through demonstrating willingness to learn and through kindness and support of people.  And so what I wanted to conclude with were some basic best practices providing care to transgender non-conforming individuals.  So the first principle is you want to have an affirming office, which also includes not just people who are attending the seminar being aware  or people who may be watching this later, but how do we train or also involve our front office staff who are often managing the paperwork and insurance  and often are the face of your office, but they're often the first people who are talking to your patients on the phone or who they're seeing when they walk into the clinic.  I think it's important to do things like ask non-judgmental questions what means of address. So you might say things like, it says your name is Christine on your health card.  Is this how you would like us to call you if someone appears to be more male presenting? Ask about preferred pronouns and don't be shy about it.  Are you okay if we use she, her pronouns or do you have another preference? Make sure your phone visit protocols and intake sheet reflect pronouns  and use a visible field in your EMR, even if your EMR doesn't let you to display preferred names and pronouns so that they're front and center when you address a patient.  It's also important to express, explain legal limitations. We know that many insurers  might require your legal name and your gender to match what's on your birth certificate or on your health card. So saying something like our insurer requires  that our official submission matches the gender on your ID. So just letting you know that that isn't our choice and also let your transgender non-conforming patients know  why they might see this different and that it's not necessarily coming from you. And also to let you know when this status might change. So let us know right away  if you get your legal name status changed.  During the patient encounter, it's important to acknowledge new information about gender identity to your patient. You might know your patient by a previous name  and in a different gender expression and it may be at their next visit that they're expressing that differently. So you might say something like, I see you're going by Max now.  Thanks for letting us know. Ask about medications and procedures that you, as you would about other past medical history. So it's important to know, is someone using estrogen?  Is someone using testosterone? But don't be period. If it's not, you know, knowing someone's surgical status or knowing what genitals or gonads they might have between their legs  may not necessarily be as important to how you provide care for them. And also acknowledge the limitations. I think as Dr. Hall alluded to,  there's a lot we don't know about the influence of hormones or surgical management on patients who have other liver diseases. So it's okay to say, I don't know about this.  I don't know what effect your estrogen is going to have on your IBS or on your liver disease, but I'm interested in learning about your experiences. So express curiosity.  And then I know this may be not as germane to people practicing liver disease as opposed to general GI, but I think it's important to incorporate principles of trauma-informed care  when it comes to intimate area examinations. So these patients may have had discomfort around discordant genitals. They may be having a female gender expression,  but still have typically male genitalia. And some other people may present female,  but not publicly share, or even share with their closest friends that they have a past that included a gender transition.  And they may not necessarily even wanna share this with you. So when I'm approaching an examination, I'll say things like,  I don't necessarily need to expose your genitals to do a colonoscopy or to do a rectal examination. And I think it's important to address why you're doing it.  So if I'm doing a rectal examination, I may see things like I'm doing this because I'm curious about why you're having bleeding,  and I'm gonna do it in a way that maintains your dignity. Last, acknowledge your missteps. Be humble when you make mistakes. Sorry, I just realized I called you by your old name.  Let me slow down a bit, make sure I catch myself so I don't do this again. And may take an effort to educate yourself on issues of your population. So say things like, I realize,  I don't know as much as I'd like to, but I'm gonna keep on learning. It's not your patient's responsibility to educate you, just like it's not their duty  to educate you about their disease. You have to take the responsibility to do it yourself. And with that, I just want to end and just remind you  that, as I mentioned earlier in my talk, I do have a trans background. I know we often talk about the hardships that trans people face, but there's also a lot of joy  in being able to live as your true self. And I just think it's important when we're seeing our patients to remind ourselves that they have.  Thank you very much for your, thank you very much for your attention. And I'd like to thank the ASLD and our hosts for giving me the opportunity to share with you today.  All right. Thank you. Thank you, Laura. That was a great wrap up. I appreciate, and I appreciate  you bringing it all together and reminding us of, again, I'd like to not let off, that it's a lot  more than surgeries and hormones. Gender affirming care is something we all have the ability to  provide just with our voices and our presence. So I appreciate that. Thanks for being with us.  We love having GEI colleagues with us in hepatology. Come on over. So we have,  let's see, we'll pull the chat or pull the Q&A up to see if there are any questions from our  attendees. I don't see any questions from attendees, Elizabeth. So for now, but I want to  encourage everyone, this is a really want to, I know a lot of you probably have some questions after hearing talk and please just type in the Q&A box so we can answer for you.  All right. So maybe before we waiting people entering question, I want to start the first  question. We all know, I think that's been mentioned in multiple talks today that collecting  SOGI data, the sexual orientation, gender identity data is important. And I would like to ask our  panelists, how do you do it in your own institution? Do you have a patient fill out a  form, you have front desk ask, or is the provider that mainly doing it? And then ideally, what would  you think the best way to do this? Sorry, is that to me? Sure. So I'll let you start. Okay. So I think, I mean, we have Epic, I think as a lot of people do. And so there's a SOGI  data capture space for that. I think the way different institutions have rolled it out, I think it's very different in the training is different, but I think, I mean, that's one way  of definitely doing it. Okay, good. And Laura, do you? Yeah. So we use any, we aren't on Epic  and our EMR does not have a field to specifically capture this data, but I've sort of set one up for  my own practice. So I recorded, in terms of, like a lot of the education I do, or at least in terms  of providing a GI practice, I mean, in terms of GI practice is mostly focused on front of office,  because on how to sort of, you know, annotate the chart in a way that is easily accessible so that  people know, you know, I brought up that issue, like in my province of Ontario, we have to use  the name that's on the birth card in order to process all our things. So just, you know,  reminding patients about, you know, you know, we're gonna call you this, you know, confirming  how they want their pronouns to be used, but reminding them that, you know, unfortunately,  because of the nature of the larger world out there, that sometimes we are going to show documents,  or it's going to be documented. And, you know, the other challenge I have is we refer patients,  let's say for radiologic procedures, or for endoscopies, is making sure that we inform that  this is a preferred name, this for pronouns, I find I can do all I want. But if I send someone  to get a CT scan, and they get referred to by their old name, you know, that can be a demeaning  and demoralizing experience that may cause the next time to be like, I'm done with this hospital.  So it's important to convey those messages as well, when you're referring to allied health  professionals, or for other procedures where you may not necessarily be in the room, in the room,  or where you may be working with a different staff, like the endoscopy team at the hospital  you practice at. So it's important to take this, not just, you know, within your own personal space,  but try to share this and in all the places where you may practice and also places where your patients may come into contact more. Great, thank you both. And I think we have  a question coming in regarding the other resources that are there about education. I think  this is an important question, you know, and I do want to mention that one of the bigger reasons that  we have this webinar is when we started the ASLD LGBT Task Force, you know, and all of us identify  as LGBTQ community, but none of us feel super well educated about how to really taking care of  transgender and gender non-binary people. So I think this is an important question. I'm going  to share one of my slides in my talk that I didn't have time to share today, and so I hope you can  see this. So there's a CERBL organization that's been doing this, as I show here, WPATH, the World  Professional Association for Transgender Health, is one of the major ones, and also GLAMA, Gay and  Lesbian Medical Association, also have some guidance as well. There's from American Underground  Society also have one guidance out there as well. And American Academy of Family Physicians also  have a caring for transgender, gender diverse person, what clinicians should know. So, and  also there are some other resources. I do want to mention the Trans Lifeline out there, you know,  because as we talk about it, a lot of our transgender, gender non-binary people that have facing, can easily, with all the stress that they've been dealing with every day, there's  higher risk of suicide and other psychiatrists emergency as well. So the Lifeline, I think,  is also important resources for them. So I want to put it out there, and for everyone that's  interested to learn a little bit more. All right. I think that Howie, and I hope you agree  as co-moderator with me that we've had a great, great webinar. We're really excited to have our  attendees, and we're looking forward to more opportunities. We again appreciate AASLD giving  us a chance to present this. I want to thank our presenters and my co-moderator. Love working with  you all. Again, super fun. And unless I'm missing something, Howie, is there anything else you want  to add? No, I have not seen any more questions. But again, I know, you know, this is a topic that,  again, a lot of us probably not very super familiar with, but it's an emerging topic that,  you know, I think we all should start getting ourselves familiar with. So, you know, if you  have a question in the future, feel free to reach out to any of us, and, you know, we will try our  best to help. And I think this is going to be recorded on the, I'm putting on the liberal  learning website as well on AASLD. So if you have any friends or colleagues, or you just want to  refresh some of the points we talked about today, feel free to watch the recording on our website.  And I know I totally agree with Elisabeth, and, you know, this is the second time we did a similar  topic in DDW, and it's really our honor to share this with our hepatology society. And then,  and thanks to AASLD and AASLD LGBT Task Force to give us the opportunity to talk about this and share with everyone. So with that, I'm going to conclude our webinar today.  Thank you everyone again for joining us.

Video Summary

In this AASLD webinar, the presenters discussed the importance of providing gender affirming care for transgender and gender non-binary individuals in the hepatology field. They highlighted the disparities faced by the trans community and the need for healthcare providers to create an inclusive and affirming environment. The presenters emphasized that gender affirming care goes beyond hormones and surgeries, and can be provided by all healthcare professionals through respectful and inclusive practices. They also discussed the impact of gender affirming hormone therapy on liver health, including potential drug-induced liver injury and the effects on metabolic dysfunction and hepatic tumors. Best practices for providing gender affirming care were also shared, such as using inclusive language, collecting sexual orientation and gender identity data, and acknowledging and learning from mistakes. The presenters encouraged ongoing education and awareness to improve care for transgender and gender non-binary individuals.

Asset Caption

Recorded Webinar.
Live Date: Wednesday, June 28, 12:00 pm - 1:00 pm (EDT)
Moderator: Howard Lee, MD
Presenters: Elizabeth Goacher, PA-C, MHS, AF-AASLD | Sonali Paul, MD, MS | Laura Targownik, MD, MSHS, FRCPC
Hosted by AASLD LGBTQ Task Force

Sexual and gender minorities people often face discrimination and harassment due to their sexual orientation or gender identity, and this population has been identified as at risk for "healthy disparity" by the National Institute on Minority Health and Health Disparities. The hepatology care of transgender and gender non-binary people can be complicated, given the involvement of gender-affirming therapy, psychosocial stress and even legal challenges. In this session, we will discuss basic knowledge about transgender patients and how to provide best hepatology care for them.

Keywords

gender affirming care

transgender

gender non-binary

hepatology field

disparities

inclusive environment

hormones and surgeries

healthcare professionals

best practices