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Research ArticleOriginal Research

Implementation of Transgender/Gender Nonbinary Care in a Family Medicine Teaching Practice

Irene Park Ulrich, Chase Harless, Gwen Seamon, Annie Kim, Lindsay Sullivan, Jenna Caldwell, Lisa Reed and Heidi Knoll
The Journal of the American Board of Family Medicine March 2022, 35 (2) 235-243; DOI: https://doi.org/10.3122/jabfm.2022.02.210182
Irene Park Ulrich
the Department of Family Medicine (IPU, LR), Department of Research and Library Sciences (CH), and Family Medicine Residency Program (HK), Mountain Area Health Education Center (MAHEC), Asheville, NC (IPU); UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU); Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU, LR, HK); MAHEC/UNC Eshelman School of Pharmacy, Asheville, NC (IPU); Mountain Community Health Partnership, Burnsville, NC (GS); UCSF Health, San Francisco, CA (AK); Mission Hospital, Asheville, NC (LS); and UNC Eshelman School of Pharmacy & Walgreen Co., Asheville, NC (JC).
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Chase Harless
the Department of Family Medicine (IPU, LR), Department of Research and Library Sciences (CH), and Family Medicine Residency Program (HK), Mountain Area Health Education Center (MAHEC), Asheville, NC (IPU); UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU); Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU, LR, HK); MAHEC/UNC Eshelman School of Pharmacy, Asheville, NC (IPU); Mountain Community Health Partnership, Burnsville, NC (GS); UCSF Health, San Francisco, CA (AK); Mission Hospital, Asheville, NC (LS); and UNC Eshelman School of Pharmacy & Walgreen Co., Asheville, NC (JC).
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Gwen Seamon
the Department of Family Medicine (IPU, LR), Department of Research and Library Sciences (CH), and Family Medicine Residency Program (HK), Mountain Area Health Education Center (MAHEC), Asheville, NC (IPU); UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU); Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU, LR, HK); MAHEC/UNC Eshelman School of Pharmacy, Asheville, NC (IPU); Mountain Community Health Partnership, Burnsville, NC (GS); UCSF Health, San Francisco, CA (AK); Mission Hospital, Asheville, NC (LS); and UNC Eshelman School of Pharmacy & Walgreen Co., Asheville, NC (JC).
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Annie Kim
the Department of Family Medicine (IPU, LR), Department of Research and Library Sciences (CH), and Family Medicine Residency Program (HK), Mountain Area Health Education Center (MAHEC), Asheville, NC (IPU); UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU); Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU, LR, HK); MAHEC/UNC Eshelman School of Pharmacy, Asheville, NC (IPU); Mountain Community Health Partnership, Burnsville, NC (GS); UCSF Health, San Francisco, CA (AK); Mission Hospital, Asheville, NC (LS); and UNC Eshelman School of Pharmacy & Walgreen Co., Asheville, NC (JC).
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Lindsay Sullivan
the Department of Family Medicine (IPU, LR), Department of Research and Library Sciences (CH), and Family Medicine Residency Program (HK), Mountain Area Health Education Center (MAHEC), Asheville, NC (IPU); UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU); Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU, LR, HK); MAHEC/UNC Eshelman School of Pharmacy, Asheville, NC (IPU); Mountain Community Health Partnership, Burnsville, NC (GS); UCSF Health, San Francisco, CA (AK); Mission Hospital, Asheville, NC (LS); and UNC Eshelman School of Pharmacy & Walgreen Co., Asheville, NC (JC).
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Jenna Caldwell
the Department of Family Medicine (IPU, LR), Department of Research and Library Sciences (CH), and Family Medicine Residency Program (HK), Mountain Area Health Education Center (MAHEC), Asheville, NC (IPU); UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU); Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU, LR, HK); MAHEC/UNC Eshelman School of Pharmacy, Asheville, NC (IPU); Mountain Community Health Partnership, Burnsville, NC (GS); UCSF Health, San Francisco, CA (AK); Mission Hospital, Asheville, NC (LS); and UNC Eshelman School of Pharmacy & Walgreen Co., Asheville, NC (JC).
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Lisa Reed
the Department of Family Medicine (IPU, LR), Department of Research and Library Sciences (CH), and Family Medicine Residency Program (HK), Mountain Area Health Education Center (MAHEC), Asheville, NC (IPU); UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU); Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU, LR, HK); MAHEC/UNC Eshelman School of Pharmacy, Asheville, NC (IPU); Mountain Community Health Partnership, Burnsville, NC (GS); UCSF Health, San Francisco, CA (AK); Mission Hospital, Asheville, NC (LS); and UNC Eshelman School of Pharmacy & Walgreen Co., Asheville, NC (JC).
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Heidi Knoll
the Department of Family Medicine (IPU, LR), Department of Research and Library Sciences (CH), and Family Medicine Residency Program (HK), Mountain Area Health Education Center (MAHEC), Asheville, NC (IPU); UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU); Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (IPU, LR, HK); MAHEC/UNC Eshelman School of Pharmacy, Asheville, NC (IPU); Mountain Community Health Partnership, Burnsville, NC (GS); UCSF Health, San Francisco, CA (AK); Mission Hospital, Asheville, NC (LS); and UNC Eshelman School of Pharmacy & Walgreen Co., Asheville, NC (JC).
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Article Figures & Data

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    Table 1.

    Chart Review Elements for Adherence to Recommendations for Care and Criteria to Meet Recommendations

    Element ReviewedCriteria to Satisfy RecommendationAction Taken If Criteria Not Met
    Name/gender markersAccurate gender identity, name, and/or pronouns documentedPatient identifiers updated in chart
    Appropriate prescription for PrEPDocumentation of PrEP prescription for anyone who met the following criteria:
    AMAB who have sex with AMAB are sexually active and have 1 of the following: an HIV-infected partner; recent syphilis, gonorrhea, or chlamydia infection; or inconsistent condom use during anal sex
    Sexually active people who have 1 of the following: a serodiscordant sex partner, inconsistent condom use during sex with a high-risk partner of unknown HIV status, or recent syphilis or gonorrhea infection
    IVDU with sharing of injection paraphernalia or engagement in risky sexual activity
    Message sent to provider notifying them of the action needed
    Contraception/family planningDocumentation of discussion regarding need for contraception/family planning
    Mental healthDocumentation of depression screening (PHQ-2 and PHQ-9) within the past year and/or discussion regarding therapy or counseling
    Health maintenancePapanicolaou smear per USPSTF recommendations, if the patient has a cervix
    Mammograms starting at age 50, per USPSTF recommendations, if patient has breast tissue
    Osteoporosis screening for transmasculine transgender patients at age 50 on testosterone for >10 years; otherwise starting at age 60
    Follow-upAppointment scheduled with primary care provider
    Gender-affirming hormone therapy
        TestosteroneAbsence of absolute contraindications (ESRD, acute hepatitis, pregnancy, unstable CAD, hematocrit > 55%, and active sex hormone–sensitive cancer)
    Relative contraindications documented and addressed (HTN, T2DM, chronic liver disease, personal or family history of CAD, PCOS, VTE, and history of sex hormone–sensitive cancer)
    Documentation of laboratory tests at appropriate intervals (total testosterone at 3, 6, and 12 months in year 1, then annually if stable; H/H at baseline and at 3, 6, and 12 months in year 1, then annually if stable)
    Message sent to provider notifying them of the action needed
        SpironolactoneAbsence of contraindications (hyperkalemia, renal insufficiency)Documentation of laboratory tests at appropriate intervals (BMP at baseline, 2 to 4 weeks, 3 months, 6 months, and 12 months, then annually)
        EstrogenAbsence of absolute contraindications (ESRD, acute hepatitis, personal history of estrogen-sensitive cancer, and history of VTE with ongoing smoking)
    Relative contraindication documented and addressed (HTN, T2DM, chronic liver disease, smoking, migraine with aura, age > 40, obesity, CAD, personal history of VTE, and prolactinoma)
    Documentation of laboratory tests at appropriate intervals (estradiol at 3 and 6 months, then as needed; total testosterone at 3, 6, and 12 months, then as needed)
    • Abbreviations: AMAB, assigned male at birth; BMP, basic metabolic panel; CAD, coronary artery disease; ESRD, end-stage renal disease; H/H, hemoglobin/hematocrit; HTN, hypertension; IVDU, intravenous drug user; PCOS, polycystic ovary syndrome; PHQ, patient health questionnaire; PrEP, pre-exposure prophylaxis; T2DM, type 2 diabetes mellitus; USPSTF, United States Preventive Services Task Force; VTE, venous thromboembolism.

    • View popup
    Table 2.

    Adherence to Recommendations Chart Review: Baseline Demographic Characteristics (n = 65)

    CharacteristicValue
    Mean age, y27.1
    Race, No. (%)
        White53 (81.5)
        Unknown9 (13.8)
        Asian/American Indian3 (4.5)
    Gender identity* (n = 65), No. (%)
        Female-to-male33 (50.7)
        Male-to-female19 (29.2)
        Neutral10 (15.4)
        Unknown3 (4.5)
    • ↵* Terminology defined by the practice electronic medical record.

    • View popup
    Table 3.

    Discrepancies in Care Identified in Chart Review for Adherence to Recommendations

    DiscrepancyProportion (%)
    Corrected gender marker/name11/65 (16.9)
    Recommended PrEP1/65 (1.3)
    Contraception/family planning recommended3/65 (4.6)
    Needed updated mental health screen27 (41.5)
    Health maintenance: Papanicolaou smear needed9/16 (56.3)
    Health maintenance: mammogram needed2/3 (66.7)
    Health maintenance: DEXA needed1/2 (50.0)
    Needed to be scheduled for follow-up40 (61.5)
    Gender-affirming hormone therapy
        Testosterone: CI identified0/22 (0)
        Testosterone: laboratory tests needed15/22 (68.2)
        Estradiol: CI identified1/15 (6.7)
        Estradiol: laboratory tests needed4/15 (26.7)
        Androgen blocker: CI identified0/14 (0)
        Androgen blocker: laboratory tests needed8/14 (57.1)
    • Abbreviations: CI, contraindication; DEXA, dual-energy radiograph absorptiometry; PrEP, pre-exposure prophylaxis.

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The Journal of the American Board of Family     Medicine: 35 (2)
The Journal of the American Board of Family Medicine
Vol. 35, Issue 2
March/April 2022
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Implementation of Transgender/Gender Nonbinary Care in a Family Medicine Teaching Practice
Irene Park Ulrich, Chase Harless, Gwen Seamon, Annie Kim, Lindsay Sullivan, Jenna Caldwell, Lisa Reed, Heidi Knoll
The Journal of the American Board of Family Medicine Mar 2022, 35 (2) 235-243; DOI: 10.3122/jabfm.2022.02.210182

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Implementation of Transgender/Gender Nonbinary Care in a Family Medicine Teaching Practice
Irene Park Ulrich, Chase Harless, Gwen Seamon, Annie Kim, Lindsay Sullivan, Jenna Caldwell, Lisa Reed, Heidi Knoll
The Journal of the American Board of Family Medicine Mar 2022, 35 (2) 235-243; DOI: 10.3122/jabfm.2022.02.210182
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