Osteoporosis Care and Assessment Cues for Transgender People (Nursing)

00:01 The client in this picture is going through a DEXA scan.

00:05 Now you'll see at the bottom, we wrote out what that stands for.

00:07 See it.

00:08 Dual energy X-ray absorptiometry.

00:13 That's why we all call it a DEXA scan.

00:17 Now this is the most common bone density scan.

00:20 Now we'll go into detail of what this test is and how it works in other parts of our video series.

00:26 But just for a minute, pause and take a look.

00:28 Now they look very comfortable.

00:31 Right? Their feet are up on a kind of a block, but it's not uncomfortable.

00:36 They have a pillow underneath their head and they're having the scan.

00:41 So let's take a look at what are the recommendations for how often a client should receive a DEXA scan.

00:48 Let's look at the DEXA recommendations for a cisgender man.

00:52 Now the source for these recommendations is the US Preventive Service Task Force.

00:58 They do not recommend routine bone density testing for cisgender men.

01:03 You might ask, "Why not?" Well, cis men have a higher bone mass and lose bone mass more slowly than cis women which is why there is no recommendation for routine bone density testing for cisgender men.

01:19 Now if they have some unusual signs or something that would cause the healthcare provider to have concern.

01:25 Of course, they could have that scan.

01:28 In fact, 1 in 4 men over 50 will break a bone due to osteoporosis.

01:35 Now let's look at the DEXA recommendations for transgender people.

01:39 Now, if a client is a trans man.

01:42 They were assigned female at birth, they identify as male.

01:47 But let's look at some really special cases or instances.

01:50 So for this client who is a trans man, if they have not taken testosterone, their ovaries have not been removed, they should get tested after age 60 or sooner if they have some other risks.

02:03 So for this particular client, they did not take testosterone, their ovaries have not been removed, they should get tested after age 60 unless there's some other underlying cause or risk factor.

02:17 Let's look at a second kind of client.

02:20 If this client who is a trans man is taking testosterone for greater than five years, they should get tested after age 50.

02:28 And again sooner, if they have additional risk factors.

02:32 Now the third kind of gender affirming therapy client is if it's a trans man whose ovaries have been removed, they're not taking testosterone at all or only taking it occasionally, they should get tested no matter what their age.

02:48 Let's look at trans women.

02:50 If their DEXA scan is normal, repeat the scanning in two to three years is the recommendation.

02:57 So if I am a trans woman, that means I was identified as male at birth, I now identify as female or woman, you want to get a DEXA scan repeated every two to three years.

03:10 Now this is from the University of California, San Francisco Transgender Care.

03:15 This is the source of these recommendations.

03:18 They say and I would agree, there's insufficient evidence to guide recommendations for bone density testing in transgender women or men.

03:26 We need more research.

03:28 However, age 65 transgender people, regardless of birth assigned sex, should begin bone density screening at age 65.

03:38 Now wait a minute.

03:40 When we looked at the other task force recommendations, they said there's no routine screening recommended.

03:46 So you'll have to identify which type of policy or task force or recommendation your healthcare provider is following.

03:55 UCSF says everyone at 65 or older should have a DEXA scan ordered.

04:01 Now at age 50 to 64, we're going to look at screening.

04:06 So screen them for the risk factors of osteoporosis.

04:09 This is what should be considered for those with established risk factors for osteoporosis.

04:15 Now, remember, in this series, we've talked about seven medications that could increase a risk factor of having osteoporosis.

04:22 That's why you are the key to doing a thorough admission history and assessment when you're meeting your patients and you're helping them plan their care.

04:33 Now, here's one more unique or special case that I want to bring to your attention.

04:38 According to UCSF, they recommend transgender people, regardless of birth assigned sex.

04:46 Okay, so this is transgender, trans men or trans woman irregardless of what their birth assigned sex was who have undergone a gonadectomy.

04:57 Now do me a favor, encircle that word gonadectomy.

05:02 Ectomy means removal, and gonad has to do with your organs that are reproductive or sex hormones.

05:09 So in a male that would be testes.

05:12 In a female, that would be your ovaries.

05:15 Now, if you are a transgender person and you have undergone removal of your gonads, and have a history of at least five years without hormone replacement, you should be considered for bone density testing regardless of age.

05:31 Now I know that's a lot of words.

05:33 But go back after that word gonadectomy.

05:36 Hey, with removal of those gonads, we don't have adequate levels of those hormones, estrogen or testosterone that we know help with bone health.

05:47 And if you've chosen to not take hormone replacement therapy, that's why the bones are more at risk.

05:54 They've removed the organs that generally produce hormones, and they've not done any hormone replacement therapy.

06:00 So they are at a higher risk for osteoporosis.

06:03 So UCSF makes sense to us.

06:06 But remember, when you're looking at those results of studies, sometimes I really have to slow down, back it up, and make sure I understand what that recommendation is saying and why they're making it.

06:19 Then it's going to stick in my brain much better.

06:23 So we're talking about transgender people who are our clients.

06:27 There are pharmacologic and non-pharmacologic nursing care.

06:32 Now, on the non-pharmacologic side, we want to encourage them to have at least 1000 mg of calcium and 800 to 1000 units of vitamin D from their diet.

06:44 Remember, getting it nutrients from food is much better than a supplement, if you can.

06:49 We want them to engage in regular weight bearing activity even if it's just walking.

06:54 Weight bearing means I am holding my weight causing it to move.

06:59 Now, swimming is great, and it's really fun, but it is a non weight bearing activity.

07:05 So if we're talking about specific to bone health, your clients are going to need some weight bearing activity.

07:12 Don't drink too much.

07:13 Try not to smoke at all, but at least try to limit your smoking.

07:17 Maintain a normal BMI, and have unbiased access to gender affirming care.

07:23 These are the non-pharmacologic nursing care priorities for providing care for transgender clients.

07:31 Now let's look at the pharmacologic side.

07:33 We've gone to these in more detail.

07:35 But remember, you might want to consider calcium supplementation for bone health.

07:40 Think about hormone therapy, which one is appropriate whether you're a trans man or a trans woman.

07:48 Now if you've been with us through this video series on looking at osteoporosis in transgendered people, now let's talk about how you can put this all together.

07:57 This is the NCSBN nursing clinical judgement model.

08:01 Remember, NCSBN is the National Council of State Boards of Nursing.

08:06 Those are the folks that write your NCLEX exam.

08:09 They've written this model to help you understand how the next generation NCLEX questions will be written.

08:15 But honestly, it's what all good nurses should do.

08:19 Let's just look at those first steps where you're recognizing cues and analyzing cues.

08:26 So what are the types of cues you should look for in a geriatric client who is also a transgender client? The answer, they're the same that you would look for in any client.

08:38 But let's go over and review them just because.

08:40 So remember back pain, "Hey why is that a problem?" Because we know common fractures with osteoporosis can be the vertebral compression fractures, or it can be the hip fractures.

08:53 So you want to watch for back pain.

08:54 You also want to think about hip pain.

08:57 Look for loss of height over time.

08:59 Watch for a more stooped posture.

09:02 And remember, a bone that breaks more easily than we expected it to, that's an indication of osteoporosis.

09:10 Now think about the medications that they're on.

09:12 If you have a transgender client who's also on any one of these seven medications and they've been on them for a long period of time.

09:20 That could be problematic.

09:22 Put them at an increased risk for developing osteoporosis.