FEB 2021 CCSS: Emerging Priorities in Women’s Health

FEB 2021 HS CCSS S01: Department of Veterans Affairs (VA)/Department of Defense (DoD) Collaboration in Women’s Mental Health: Available Resources for Female Service Members Transitioning from Active Service

Will the U.S Department of Veterans Affairs (VA) be setting up more stand-alone women health clinics like Philadelphia VA?The meet the needs of the growing number of women Veterans who are eligible for VA healthcare, VA is actively enhancing services and access for women Veterans. For example, this year VA will invest $75 million in hiring and new equipment to address women Veterans’ treatment needs. Women Veterans receive care in a variety of care settings, including comprehensive women’s clinics, such as the one in Philadelphia.  Decisions about the structure of these clinics and where they are located is determined locally and based on multiple factors.  Many facilities offer women’s clinics that are “stand alone” or have a private entrance.  Other facilities offer women’s comprehensive care in clinics that are co-located near mixed-gender care environments.  Across facilities, VA provides equitable, timely, high quality care to women (and all) Veterans.
Are you anticipating an increased need for mental health resources with the increase in work related trauma from active duty/VA COVID care providers working in critical care nursing/medicine? What resources are available/ what ways can care providers protect their own mental health to prevent burnout? 

Yes, there are a number of mental health resources available at pdhealth.mil including several blogs: 




Numerous resources to support Veterans and their providers have been developed by VA and can be accessed here: Coronavirus - Mental Health (va.gov)

Is training being planned for clinicians working with women who will be dealing with transgender SMs and Veterans accessing women’s services?The Department of Defense (DoD) is planning trainings for clinicians who will be providing care for Transgender Service Members (SMs). The Transgender policy is currently under revision, information about trainings will be determined shortly in an effort to align with the revised policy.  We plan to offer training on affirmative care for Transgender SMs.  VA has specialized treatment teams and numerous resources to support transgender Veterans.  A summary of these services can be found here: Veteran With an LGBT or Related Identity - Mental Health (va.gov).
Curious as to why there hasn't been a greater push/advocacy within the mental health care community for more male colleagues/clinicians to become more involved in the ongoing literature and training events pertaining to women mental health care needs given the prevalence of women issues.  How can we bring light to this issue without creating tension/sOur male colleagues are welcome to attend our training events. We are working to involve more of our male colleagues in a variety of roles including faculty. We are also seeking to provide leadership with the opportunity to welcome all providers within our community who are seeking to expand their skillset in gender-specific care.

FEB 2021 HS CCSS S02: Intimate Partner Violence: Effects to Women’s Health

Anecdotally it seems that we are seeing more Intimate Partner Violence (IPV) in clinic since COVID. Are the statistics demonstrating this as well?Yes, there are reports in the literature of increased IPV with the COVID pandemic.  We know that IPV increases during emergencies, and the social measures (self-isolation and lockdown) related to the pandemic may further be impacting this by increasing proximity to abusers, and removing freedom of movement and access to support.
How do you ask about IPV if partner is always present? Partner will not leave and patient states partner to stay.  I would only ask about IPV in private (this would be a red flag if the partner refused to leave).  In this case I would try to create a plausible reason to talk to the patient alone.  Perhaps when going to the restroom to collect a urine sample.
What do you do if the woman is the abuser?Good point.  Abuse may also be perpetrated by women.  I would handle the situation similarly, offering the male victim of abuse services and support and reporting the violence perpetrator in accordance with the victim’s wishes and state law.  Though my talk focuses on the impact in women’s health, this is also something that affects male health as well.
What does "were first made to penetrate” mean?  Referencing the statistic just posted on the slide for 1.5 million men.This refers to forced penetration for men (rape).
The abuse- does it need to have a physical component? What about "just" emotional and verbal abuse?

Abuse is defined as any of the following: Physical, Sexual, Emotional, and Stalking.  Though we often think about physical abuse, sexual, emotional and stalking are other forms of abuse that can significantly impact health!  Furthermore, these non-physical forms of abuse can be harder for victims to recognize as they may perceive jealous/controlling behavior as “protection” or “love”.

If you could also address Talia's Law quickly, if you aren't going to already. Talia’s law was passed in 2016 (included in the 2016 National Defense Authorization Act), it requires that anyone employed by the Defense Department to report cases of suspected child abuse on military installations to state child protective services in addition to reporting such crimes to the Family Advocacy Program (FAP).  This includes cases where the employee has “credible information” or “reasonable belief” that there has been an incident of child abuse or neglect.
Although IPV is not a required report, domestic violence (DV) still is, correct?  I am addressing DV in a married relationship in which 1 member is active duty (AD).

DV is a broader term that encompasses IPV, child and elder abuse.  For IPV, an intimate partner is defined as married, cohabitating or having a child in common.  For cases of IPV, the restricted and unrestricted reports apply in the military + any civilian state laws.  For sexual assault of an intimate partner, there is a clause that allows these patients to avoid state mandatory reporting requirements (if they seek care at a federal facility).  However if there was both physical and sexual assault, and there was a state requirement for mandatory reporting of IPV (e.g. California), the clinician would be required to report the physical assault to the police in the county where the physical assault occurred.  The patient could still choose to submit a restricted report to FAP.

If there is any child abuse encompassed in the DV you are referring to, that is a mandatory report in all 50 states, and cannot be a restricted report in the military

How often do you follow patients with IPV?I would follow them based on clinical or social need, which may also depend on where they are in the process.  If in significant distress or needing support and treatment for depression, I may see them as frequently as every 1-2 weeks.  If there is concern for the safety of the patient or other family members, then I would contact local law enforcement and work with my Family Advocacy and social work team to ensure safety in the immediate period.
How would you approach a patient who describes being a victim of intimate partner violence but denies being a victim and believes that that behavior is normal?I would give examples of why I am concerned and reinforce that no one deserves to be treated badly.  If she was still in a space where she did not recognize this, I would acknowledge this and say something like – “I am concerned for your safety based on what you are telling me and the experiences of prior patients.  Please know this is always a safe place for you to come and get help.  I care about you and your health.”  I would also assess the patient’s safety and ensure that there is no child abuse that would need to be reported.
Any thoughts on navigating concern with husband who won’t leave the exam room when religious/cultural aspects are also at play?I would only ask about IPV in private (this would be a red flag if the partner refused to leave).  In this case I would try to create a plausible reason to talk to the patient alone.  Perhaps when going to the restroom to collect a urine sample.
Does the abuse need to include a physical component? The invisible part of emotional and verbal abuse can be just as detrimental.You are correct, we often think first about physical abuse, but abuse includes Physical, Sexual, Emotional, and Stalking.  These other forms of abuse that can also significantly impact health, and are sometimes harder to recognize!
Have you seen an increase in IPV within the lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) community? (especially since the requirements /restrictions in the military have changed)Yes, IPV is more common in LGBTQ patients and stressful situations such as changes in support in the military would further exacerbate this as well.
Can you talk a little bit more about the unrestricted reporting within states like California that require mandatory reporting? Is your experience that women feel like they have control over that experience? And if they don't want to process the assault through the local police they feel like that is easy to do? Or are they feeling pressured to continue processing through the local police?This is the “debate” over mandatory reporting: Are you helping abused women who cannot get help, or are you taking away their autonomy.  There is no clear answer.  For those of us practicing in a state that has mandatory reporting, licensed health care professionals (physicians, nurses, mental health professionals, emergency medical technicians [EMTs], paramedics, medical examiners and ALL employees in long term health facilities) are required to report IPV (physical, sexual, emotional and stalking) to the police in the county where the violence occurred.  The patient could still choose to submit a restricted report to FAP, and she does not have to cooperate with local authorities.  Because of this potential loss of autonomy, I tell the patients before I screen them of the mandatory reporting requirement before I ask about abuse so they can decide.
For sexual assault (only) of an intimate partner, there is a clause that allows them to avoid state mandatory reporting requirements if they seek care at a federal facility.  However if there was both physical and sexual assault, then the clinician would be required by state law to report to local law enforcement.
Would you advocate that a screening question be added to the Periodic Health Assessment (PHA) in the Mental Health Assessment (MHA) section? Currently it screens for gambling, thoughts of self-harm, harm to others, but not being a victim of IPV. Would screening for IPV be best in the Mental Health screenings or another part of the encounter?Yes I agree it would be a good idea to include IPV screening questions in the PHA.  I don’t know that it has to be in mental health specifically, I think it could be included in other general safety areas like wearing your seatbelt etc.

FEB 2021 HS CCSS S03: Human Papillomavirus: Opportunity to Eradicate Gynecologic Dysplasia and Cancer

Is there information on human papillomavirus (HPV) transmission? When HPV test is positive then is negative is it considered dominant because it can become active again? Is there testing for men yet?No true evidence of dormancy clinically, but can contract new infections and there are different “clinical threshold” cutoffs for the different HPV assays based on viral load which may cause a change in positive/negative from one test to another. No HPV testing for men is Food and Drug Administration (FDA) approved as of now.
What is the recommendation for the vaccine for women greater than age 26? Shared clinical decision making for those ages 27-45 based on risk factors (immunosuppression, new sexual partners, HPV workplace exposure etc.). I would encourage those not previously vaccinated to consider up to age 45.
Wondering why the women over 65 are not screened for HPV?U.S. Preventive Services Task Force (USPSTF) current guidelines are to cease cervical cancer screening with pap/HPV in average risk women with appropriate prior screening and no history of high grade cervical dysplasia in the past 25 years at age 65---not because you can’t develop cervical cancer over the age of 65 but because it is not cost effective from a public health perspective. 
If you have carcinoma in situ (CIS) and the Loop Electrosurgical Excision Procedure (LEEP) was done do you follow with paps for 20 years?After an excisional procedure like LEEP or cold knife cone for cervical squamous intraepithelial neoplasia (CIN) 2+, the American Society for Colposcopy and Cervical Pathology (ASCCP) recommendation is follow-up HPV-based testing at 6 and 12 months, then annually for 3 years, then q3 years for a total of 25 years as they remain at increased risk of recurrence. If there are any abnormalities on pap or remain HPV+, then they should undergo colposcopy with directed biopsies and endocervical curettage (ECC).
What does the data say about having to complete a pregnancy test showing they are not pregnant prior to giving the vaccine?

There are no recommendations to administer a pregnancy test prior to vaccination, however it is recommended that those who know they are pregnant should not receive the vaccine until they are postpartum. They state that there is likely little harm as it is just a virus like particle (VLP) vaccine with no active deoxyribonucleic acid (DNA) or ribonucleic acid (RNA), not a live virus, but as in most vaccines, they were not studied specifically in the pregnant population during the initial trials.

What is the thought to those that are actively pregnant with known HPV/cervical dysplasia to vaginal delivery versus cesarean section (C-section)?/Is there information on HPV transmission? When HPV test is positive then is negative is it considered dominant because it can become active again? Is there testing for men yet? Is there concern for transmission of HPV during a vaginal delivery? This is a great question and we don’t have a good answer. Those with known invasive cervical cancer, specifically those with residual tumor, are not recommended to have a vaginal delivery, but there has been documented vertical transmission of HPV regardless of route of delivery (no difference between C-section and vaginal delivery in one study). 
Given an abundance of literature on racial disparities in health care, as a military community how are we addressing the issue pertaining to the lack advocacy for preventative treatment and education at the provider level in the areas where women/men of color are at higher risk?

Great point. This should be a focus of care and training for our healthcare providers, starting with a task force to address racial disparities in military healthcare.

We have some providers who want a negative pregnancy test prior to providing.  Is there data to show whether this is necessary?It is not mandated prior to administration per the FDA approval or Centers for Disease Control and Prevention (CDC) recommendations.
Are you aware of, or do you have an opinion on use of AHCC to eliminate/cure HPV infection?  This is research out of University of Texas.I have not seen any results from this trial although they have concluded enrollment. One pilot study showed 5 of 10 patients testing HPV negative with at least 3 months of treatment. It is encouraging that we could use a supplement with little to no side effects as a curative approach to HPV.
Just want to make sure I heard correctly.  Is there a recommendation to have health care personnel (HCP) vaccinated if we perform colposcopies?I would consider colposcopies likely lower risk in terms of contracting HPV in a workplace setting, but specifically those exposed to HPV that is aerosolized through a LEEP or cold knife cone (CKC) procedure with the thermal energy involved.
Recommendation for HPV vaccination after COVID vaccination, is there a time after vaccination needed?  Both vaccines are very immunogenic.You are correct, we often think first about physical abuse, but abuse includes Physical, Sexual, Emotional, and Stalking.  These other forms of abuse that can also significantly impact health, and are sometimes harder to recognize!
Have you seen an increase in IPV within the lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) community? (especially since the requirements /restrictions in the military have changed)I believe the recommendation is to wait at least a month after a COVID vaccine to receive any other vaccination. That is our current policy here in our department.
The MTF I work in recognizes that the HPV vaccine can now be given to women up to age 45. Does any research or professional opinion agree with that and suggest giving vaccines past age 26?Yes, American College of Obstetricians and Gynecologists (ACOG), ASCCP etc. all advocate for shared clinical decision making in this scenario with their healthcare provider.
Do you recommend that health care providers get the latest vaccine even if they had the early version?There is no clear recommendation for this and, from a public health perspective, they say that we should not routinely offer if already vaccinated with quadrivalent.
How can we join the working group?Send an email to me at Erica.r.hope.mil@mail.mil.
Do you highly recommend the vaccine for men?Absolutely. They are part of the 80% who have it and can transmit it! In addition, oropharyngeal cancer predominately affects older men and it is the most prevalent and fastest growing HPV related cancer in the US.

FEB 2021 HS CCSS S05: Management of COVID-19 in Pregnancy

Has there been any notable effects of the treatment for the virus on the fetus? What are they?  None of the currently accepted treatments for COVID-19 are known to have deleterious effects on the fetus.
What are your thoughts on early intervention with quercetin and zinc for low risk patients, quercetin being a zinc ionophore?

There are no well designed studies which show a clinical benefit to zinc supplementation.  Available studies have either shown no benefit or had significant methodological flaws (i.e. unrandomized retrospective studies in which the groups were significantly unbalanced). Currently the Centers for Disease Control and Prevention (CDC) guidelines state that there is insufficient evidence of benefit to recommend for or against zinc, however, due to the known side effects (copper deficiency), the panel recommends against use of zinc above the RDA. 

Quercetin is naturally occurring flavonoid commonly used in Chinese Medicine.  It has been purported to have effects on downregulation of the angiotensin-converting enzyme-2 (ACE2) receptors that CO-V-2 uses to gain entry to the host cells, however, there are no known studies which show a clinical benefit in patient populations.  The U.S. Food and Drug Administration (FDA) registry of randomized-controlled trials (RCT) contains one study on use of quercetin for COVID-19. This study conducted out of Turkey completed in August 2020 and results have not yet been published, so the outcomes are unknown.  

I know this is a bit out of the scope of the lecture, but do you have any recommendations on counseling pregnant patients on getting the COVID vaccine?

BLUF: There is no evidence of COVID vaccines being harmful to a woman or her fetus during pregnancy. Conversely, there is good evidence of COVID disease being more severe in pregnancy, though the absolute risk is low in either case. According to American College of Obstetricians and Gynecologists (ACOG) and Society of Maternal-Fetal Medicine (SMFM), the decision for or against vaccination should be an individualized decision after discussion of the risks and benefits between the woman and her obstetric provider.  
There is no good justification to deny eligible women who are pregnant the opportunity to be vaccinated, solely based on her pregnancy status.  

Observational data has repeatedly shown that pregnant women with COVID-19 are at increased risk of severe illness.  Although the absolute risk for severe disease remains low, the rate of admission to the intensive care unit (ICU), need for mechanical ventilation or extracorporeal membrane oxygenation (ECMO) and risk of death are all significantly increased in pregnancy. 

In addition, data on the safety of COVID-19 vaccines in pregnancy is limited as all of the major studies have excluded pregnant women from their trials.  However, there is no biologically plausible mechanism which has been suggested for fetal risk.  The messenger ribonucleic acid (mRNA) vaccines (Pfizer and Moderna) act locally at the site of infection and the mRNA which induces the immune response is rapidly broken down by the body’s mechanisms.  The adenovirus vector vaccines (Johnson & Johnson) is a well known vector platform 
which has been used in treating other viral outbreaks and has not shown adverse effects on pregnancy or on fetal or infant development. 

Currently both Moderna and Pfizer have started clinical trials of their vaccines in pregnancy and results may be available later this year.  Vaccine companies are also following the outcomes of women in the Phase 3 studies who received the vaccine and then were incidentally found to be pregnant. Currently, there is no data to suggest adverse maternal or fetal outcomes from vaccination.  

The CDC is also following the outcomes of women who were vaccinated through the CDC V-safe after vaccine health monitoring study.  As of Feb 2021, 30,000 women have received vaccination and are enrolled in the V-safe study. There have been 275 completed pregnancies and 232 live births.  Results thus far have not shown adverse outcomes above the 
expected baseline population rate.  Women who chose to be vaccinated during pregnancy, should be encouraged to join the CDC V-safe study. 

The side effects associated with COVID vaccination are similar to those experienced by non-pregnant patients. Side effects are a normal part of the body’s reaction to the vaccine and do not indicate that the vaccine recipient has “gotten COVID from the vaccine.”  As mentioned, it is not possible for any of the vaccines to cause COVID disease.  Most recipients reported mild side effects similar to influenza-like illness. These includes injection site reactions (84.1%), fatigue (62.9%), chills (31.9%), muscle pain (38.3%), joint pain (23.6%), and headaches (55.1%). In the study subgroup of persons age 18-55 years fever greater than 38C occurred in 3.7% after the first dose and 15.8% after the second dose. Most of these symptoms resolved by day 3 after vaccination.   Pregnant women who experience fever following vaccination should take acetaminophen, as fever has been associated with adverse pregnancy outcomes. Routine prophylaxis with acetaminophen (such as Tylenol) is not recommended at this time due to lack of information on impact of use on vaccine-induced antibody responses. Acetaminophen can be offered as an option for pregnant people experiencing fever (which has been associated with adverse pregnancy outcomes) or other post-vaccination symptoms.

Does the virus transfer to the newborn? / Is there any evidence of vertical transmission?

BLUF: Vertical transmission is rare, but appears to be possible. Most of the available evidence is from women who were infected in the third trimester.  From other congenital infections, we know that risk of transmission is highest with infection in the third trimester, however, the risk of serious fetal outcomes is highest with infection in the first trimester. Currently, there is very little information on the pregnancy or fetal outcomes of women infected in the first or second trimester.     

A recent meta-analysis of case reports and case series included approximately 1000 pregnancies with laboratory confirmed COVID-19 during pregnancy. Overall, the authors found that the risk of maternal-fetal transmission was approximately 3% for women who were infected in the 3rd trimester.  The best direct evidence of vertical transmission may be a case report from France which demonstrated SARS-CoV-2 RNA in the placenta, amniotic fluid and fetal serum of a newborn born to a woman with COVID-19 during the third trimester.  

FEB 2021 HS CCSS S07: Updates on Select DHA Women and Infants Clinical Community Initiatives


Is it possible for us to maybe get copies of those templates?

Please contact the presenter(s), contact information can be found at the end of the presentation.

Are only 41 MTFs participating in NPIC because that is all that provide maternal care?

Yes, all inpatient obstetrical care at military medical treatment facilities are part of National Perinatal Center (NPIC).

Not a question, but a request for additional collaboration process. Family Advocacy has a prevention program, New Parent Support Program (NPSP). Works with families at high risk for maltreatment. Given recent numbers of DV among women, it would be wonderful to have an integrated electronic way to provide the NPSP screening format during pregnancy intake. NPSP can be considered family readiness = mission readiness.

NPSP is a process that is part of all Obstetrics clinics and inpatient units. A Point of Contact (POC) for further discussion would be appreciated.

How is the walk in contraception clinic utilizing virtual health? Any thoughts to doing something like the civilian option of “simple health” for contraception?

Virtual Health capacities continue to evolve. Offering a virtual health option for those requesting simple refills or oral contraceptives is a great idea and we will send this forward. 

Clinical Communities Speaker Series: Review of Current Trends and Best Practices in Primary Care 28-MAY-2020

May 2020 CCSS S04: Hepatitis C for Primary Care: From Diagnosis to Cure and Beyond

What is the difference between hepatitis C virus (HCV) vs A&B?Dr. Rife: In addition to the response I gave during the Q&A, I would additionally refer to the Centers for Disease Control and Prevention (CDC) website for additional details on hepatitis A & B. These are 3 distinct viruses that just have the common nomenclature of causing inflammation of the liver.
If your patient has antibodies to hepatitis C and no viral load, is there a time period you should obtain a follow-up viral load? If both viral loads are non-detectable, are they considered hepatitis C free or cured? Or do they always have a risk of relapse? I have had patient state they cannot donate organs because once diagnosed with the infection they were considered always infected.If your patient has antibodies to hepatitis C and no viral load, is there a time period you should obtain a follow-up viral load? If both viral loads are non-detectable, are they considered hepatitis C free or cured? Or do they always have a risk of relapse? I have had patient state they cannot donate organs because once diagnosed with the infection they were considered always infected.
Dr. Rife: If a patient has a positive hepatitis C virus (HCV) antibody and negative viral load in the absence of treatment, it is presumed that the patient spontaneously cleared. It takes 2-3 weeks after exposure for the viral load to become detected, but it takes 4-10 weeks for the antibody to become positive.
A patient is considered “cured” if their viral load remains undetectable 12-weeks post-treatment, or what is referred to as having achieved a sustained virologic response-12 (SVR12). Some providers may also choose to additionally recheck the viral load 24-weeks post-treatment or what is referred to as SVR24. If a patient achieves SVR, no additional monitoring of their HCV viral load or risk of relapse is warranted unless a suspicion arises due to a rising aspartate aminotransferase (AST) & alanine transaminase (ALT) and/or new risk factor exposure. Patients who achieve SVR from treatment are not protected from reinfection. However, patients without risk factors for reinfection have a very rare/low risk of relapse and should not be routinely monitored for unless the patient has a rise in their AST and ALT.
This is in contrast to hepatitis B virus (HBV). Patients ever exposed to HBV indicated by a positive HBV core antibody-total may indefinitely carry a risk of reactivation. The American Gastroenterological Association (AGA) has HBV reactivation prophylaxis guidelines that outline who is at risk of HBV reactivation and when prophylaxis is warranted or should be considered.
Patients ever exposed to (HCV) will indefinitely have a positive HCV antibody and are at this time indefinitely disqualified from donating blood. However, it is becoming more common to allow HCV patients to donate organs and to just have the recipient undergo HCV treatment after organ donation.
Any ideas on the physiologic basis between HCV and diabetes mellitus (DM)?Dr. Rife: Please see our attached manuscript that discusses some of the proposed physiologic bases for HCV increasing rates of DM. It is likely multifactorial, with a key role being the effects of the increased inflammatory cytokines of patients with HCV.
Is there a specific threshold for viral load to withheld HCV treatment?Dr. Rife: No, there is not a viral load threshold for withholding HCV treatment. Per the American Association for the Study of Liver Disease (AASLD) guidelines, all patients with chronic HCV should be evaluated for HCV treatment.

May 2020 CCSS S06: Cardiovascular Health and Transgender Patients: Considerations for Primary Care Practitioners

This is more than about gender. What about the ambiguously sexed persons?Dr. Hashemi: Yes, this presentation is about gender identity. The main goal here was to be able to differentiate between “sex” and “gender”. In everyday living, even in medical practice, we use these two words interchangeably but they are not the same thing. Institute of Medicine defines sex as “the classification of living things, generally as male and female according to their reproductive organs and function assigned by chromosomal complement,” while gender is defined as “ a person’s self-identification as male or female”. While sex differences are caused by biological factors as consequences of genetic, molecular, cellular interaction, gender difference is due to environmental factors like social and cultural role of an individual. Sexual ambiguity is due to faulty pathways when reproductive organs are made. This was not the topic of interest today.
Could you please repeat where to find the paper you composed?Dr. Hashemi: In the list of references at the end of the talk, there is a paper written by myself and my colleagues about the “Transgender Care in Primary Care Setting: A Review of Guidelines and Literatures.”
What are the possible outcomes if a patient abruptly or repeatedly stops the hormone treatments?Dr. Hashemi: The main concern is mood problem. Transgender individuals usually take hormone replacement to decrease their anxiety due to gender dysphoria, which could be problematic. Some of the desired changes like hair pattern, etc. that have been achieved by taking hormone could go away if not going back on hormone.
Are there policy determinations as to the age of a person (child) when treatments can proceed? Especially in light of cardiovascular issues?Dr. Hashemi: Yes, they are. WPATH has a section about the care of transgender kids. I am not aware of any data about cardiovascular health and gender-affirming hormone treatment in kids, but that doesn’t mean data does not exist. It means I do not know.
What additional resources are you aware of that will assist health care providers with adopting a more respectful treatment approach and environment for transgender patients?Dr. Hashemi: There are national and international conferences. Also University of California- San Francisco (UCSF) has a website that people can do consult and ask questions. (https://transcare.ucsf.edu/guidelines). I love USCF transgender guidelines. Very well organized and easy to follow.
In light of the legislation that has passed, are there ongoing initiatives from the Veterans Affairs (VA) that address the discrimination and health care disparities experienced by individuals within the transgender community?Dr. Hashemi: Yes, the transgender health research is an HSR&D priority research. VA also has a national LGBTQ center. They work very hard to establish guidelines. Drs. Jillian Shipherd and Michael Kauth are in charge of the program. They can be reached out at VALGBTProgram@va.gov, website: Transgender SharePoint: http://go.va.gov/Transgender
Treatment options for transgender patients are still very new. Do you know of any evidence-based training opportunities for health care teams supporting a transgender patient that can be attended by health care providers, either sponsored by the VA, DoD or some other reputable source?Dr. Hashemi: Unfortunately I do not know of any program at VA but there is E-consult available nationally that any questions the providers have regarding Transgender care are answered.
Do you have any recommendations to the primary health care providers working with Active Duty transgender patients to prepare them for VA health care prior to discharge?Dr. Hashemi: They can enroll at VA upon discharge like any other veteran. Non-discriminatory care is the VA’s goal. They also can reach out to the national LGBTQ center for more information.
Has the spread of COVID-19 impacted the care for transgender patients in any way?Dr. Hashemi: I am sure they are as affected as others. I am not aware of any hard evidence or data about how affected they are. VA Greater Los Angeles continues to offer virtual care during the COVID pandemic in non-urgent cases and face to face visits for urgent cases. I am not an expert in COVID-19 and not able to comment further.
As a primary care physician, how often do you recommend meeting with an endocrinologist or other care providers associated with the transgender patients that you care for?Dr. Hashemi: It really depends on how comfortable one is with providing care, even if the patients are not able to meet with endocrine specialist in person, E-consult is available to the primary care physicians at VA. The primary care practitioner (PCP) is able to get recommendations via E-consult.
As a primary care provider working for the VA, can you discuss any recommendations within your health care system that you believe will improve the provision of care for a transgender patient?Dr. Hashemi: I wish VA would change the face-sheet to include sex at birth and gender.
How long does a transgender person need to take hormone therapy?Dr. Hashemi: It depends on the patient really, the reason for taking hormone is gender dysphoria. The hormone replacement treatment decreases the person’s anxiety, improves the quality of life. Some patients do not experience gender dysphoria, so they do not need hormone treatment. While some have severe dysphoria and need to take the hormone to the full extent to have secondary sex characteristics of the opposite sex and in addition to that have surgical interventions. Gender dysphoria has a wide spectrum.