Working with transgender in primary care

[djmatte, ADN, MSN, RN, NP]

At the practice in which I work, there is a patient who is transgender (female to male). The patient had gone to a regional health system in the past for testosterone, but is unable to travel that far now. The patient has since been getting therapy through our clinic. Most of the providers have been continuing the therapy for now, but many are growing uncomfortable with prescribing testosterone without training or any parameters to work within. These include an older primary care md and 3 fnps. It was a PA and an ANP who really set up this persons plan and they don't work much at the clinic anymore. With other comorbidities including obesity, diabetes, and hyperlipidemia that the patient isn't working to control, I had to decline to continue this treatment and told the patient I'd refer to endocrine. Patient was pretty upset but this is pretty risky stuff imo. Any thoughts on this situation? Anyone actively managing these patients and maybe have good resources?

[Sindoriel, ASN, BSN, RN]

There's a pretty useful website with guidelines for treatment, which also provides references on pretty much every page. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People: Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People

[AnnieNP, MSN, NP]

I have no experience with this, but can you contact the regional health system the patient had been going to for care? Do you have Urology at your clinic?

[djmatte, ADN, MSN, RN, NP]

There's a pretty useful website with guidelines for treatment, which also provides references on pretty much every page. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People: Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People

Found that after I posted here. Looked legit, but didn't want to blindly take information from a Google search. Still interested in others experiences though. :)

[celtic harper]

I think the main key is that the patient isn't working to control his diabetes and obesity. Testosterone on its own isn't a mystery, and there are plenty of resources out there, BUT I do think you're right to demur with a complex, non-compliant patient. The records from wherever he was getting care in the past are essential, however, as there was -I hope- a reasonably full workup done. Many endocrinologists aren't doing blood testing for T levels any more, though, they just go on the development of secondary sex characteristics.

If you manage to get the records from his former providers, I would strongly recommend you also get either his informed consent for hormone therapy, or the authorization letter from his psychiatrist/psychologist (if he has one) or both. There is currently a much higher reliance on self-reporting than psychological evaluation, and there has been a corresponding increase in those who regret their transition, and are looking for someone to blame. Oh, and yes, I'm a transgender woman, and transitioned many years ago- when I was a school nurse.

BTW- if you're looking for up-to-date resources, contact Dr. Jack Turco and/or Dr. Ben Boh, both in Endocrinology at Dartmouth-Hitchcock Medical Center in New Hampshire.

[offlabel]

There's a pretty useful website with guidelines for treatment, which also provides references on pretty much every page. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People: Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People

Where, in this website, do guidelines for the complexity of the OP's patient exist? This is more of a "start-up" overview that provides general guidelines for a generic population, not one complicated by non-compliance and co-morbidities. This patient needs an endocrinology consult.

[djmatte, ADN, MSN, RN, NP]

The problem we've run into is that no endocrinologist in the region will take the case because they are all Muslim and don't agree with it (all referrals have done this route sadly) University of Michigan is the closest and the patient can't get there because it's over an hour away. In hindsight and doing my own research, I'm less problematic about the care. But the PA in our clinic took over care and I agreed to help her out when she's gone. The patient does have some problems ongoing that we are working to correct including severely elevated liver enzymes and as noted an out of control a1c. So just taking it one problem at a time.