II. Definitions

  1. Transgender
    1. Person's expressed gender differs from their gender assigned at birth
    2. Distinct and separate from sexual orientation, Sexual Development, external gender expression
  2. Gender Dysphoria
    1. Distress or functional problems in Transgender or gender diverse persons
  3. Gender Incongruence
    1. Discrepancy between experienced gender and assigned sex without mention of dysphoria or treatment
  4. Transsexualism
    1. Severe Gender Dysphoria, and persistent wish for physical characteristics and social roles of opposite sex
  5. Cisgender
    1. Non-Transgender, in which patient's expressed gender aligns with their gender assigned at birth

III. Epidemiology

  1. Prevalence: 140,000 teens, 1.4 Million overall or 0.6% (U.S., 2017)
  2. Unequal treatment in healthcare reported by 24% of patients, and refusal of care in 19% of patients

IV. Approach

  1. Ask patients their preferred name, gender and pronoun (may differ from medical record)
    1. Intake forms and medical record should reflect both chosen Gender Identity and assigned sex at birth
    2. Consider re-writing patient intake forms to be gender neutral
  2. Establish rapport and offer a welcoming and safe environment for Transgender patients
    1. Clinicians and staff may benefit from additional training on culturally sensitive terminology and topics
  3. Preventive health screening should be directed towards their birth gender
    1. Billing for preventive services should be based on birth gender
    2. Transgender men who have intact Breast tissue should have Breast Cancer Screening
    3. Transgender men who have intact Uterus and Cervix should have Cervical Cancer Screening
    4. Base medical calculations (e.g. GFR, Cardiac Risk) on birth gender

V. History

  1. Gender Dysphoria and Gender Incongruence history
    1. Assess duration, severity and stability
    2. Management to date (e.g. hormonal therapy, multispecialty care, surgical procedures)
  2. Mental health
    1. Anxiety Disorder
    2. Uncontrolled Major Depression (esp. Suicidality)
    3. Posttraumatic Stress Disorder
    4. Eating Disorder
    5. Victim of Bullying
    6. Substance Abuse
  3. Social Situation
    1. Homelessness
    2. School Truancy

VI. Exam

  1. Chaperoned exam specific to patient's current anatomy
  2. Patient may limit the exam based on their level of comfort
  3. Identify Sexual Development incongruent with assigned sex at birth that precedes hormonal or surgical treatment
    1. Endocrinology and other specialty Consultation may be warranted

VII. Management: General

  1. Consultation with Transgender specialists including mental health
    1. Help guide patient in gender exploration (teen), as well as Gender Dysphoria and Gender Incongruence
    2. Ensure safe environment and timing for patient's social affirmation
  2. Do NOT recommend Gender conversion therapy
    1. Gender conversion therapy is an effort to convert a person's Gender Identity to align with birth assigned sex
    2. Gender conversion therapy is considered unethical and not consistent with guidelines including from AAFP
  3. Health Maintenance
    1. Follow general Health Maintenance guidelines
    2. Standard screening and management for Hypertension, Hyperlipidemia, Diabetes Mellitus, Obesity
    3. Tobacco Cessation and Substance Abuse management
    4. Sexually Transmitted Infection screening and management
      1. HPV Vaccine
      2. STD Screening including HIV Screening
      3. See HIV Preexposure Prophylaxis
      4. See HIV Post Exposure Prophylaxis
    5. Cancer screening is based on patient's current anatomy
      1. Screening Mammography if Breast tissue present as per standard guidelines
      2. Cervical Cancer Screening
      3. Prostate Cancer Screening

VIII. Management: Hormonal Therapy

  1. Precautions
    1. Hormonal therapy increases Venous Thromboembolism
      1. Avoid high Estrogen doses and Ethinyl Estradiol
      2. Tobacco Cessation
    2. Hormonal therapy (feminizing or masculinizing) are partially irreversible
    3. Monitor Bone Mineral Density (esp. in teens on GnRH agonists, until age 25-30 years old)
    4. Relative contraindications to hormonal therapy
      1. Hormone-sensitive active cancer (absolute contraindication)
      2. Older age
      3. Tobacco abuse
      4. Severe comorbidity
      5. VTE history or current
  2. Adolescents (Puberty to 16 years old)
    1. Consultation with Transgender specialists and mental health specialists
      1. Delayed treatment with "wait and see" may cause harm with psychosocial stress, Gender Dysphoria
    2. GnRH agonists (e.g. Lupron) are used to suppress Sexual Development of their birth gender (peds endo)
      1. Puberty suppression started once child reaches stage 2-3 of sexual maturity
      2. GnRH agonists have reversible effects and allow for stable Gender Identity
      3. Serum LH, Serum FSH, Vitamin D, Serum Estradiol (if ovaries), Serum Testosterone (if Testes) at 6-12 months
      4. Menstrual suppression with Oral Contraceptives and Breast binding may also be considered
  3. Adults (and adolescents over age 16 years old)
    1. Transgender women (transfeminine, male to female transition)
      1. Estrogens
        1. Goal Serum Estradiol >200 pg/ml
        2. Increases Breast development and redistributes fat
        3. Increases Breast Cancer risk, Prolactinoma, Cholelithiasis, Hypertriglyceridemia
      2. Antiandrogens (Spironolactone, Finasteride)
        1. Goal Serum Testosterone < 50 ng/dl
        2. Decreases muscle mass, libido and Terminal Hair growth
        3. Voice does not typically change
        4. Monitor for Hyperkalemia, Kidney injury, Hypotension on Spironolactone
    2. Transgender men (transmasculine, female to male transition)
      1. Non-estrogen Contraception (e.g. IUD, Implanon, depo-Provera)
      2. Testosterone
        1. Goal Serum Testosterone 320 to 1000 ng/dl
        2. Increases acne, scalp Hair Loss, body hair, deeper voice, clitoromegaly, weight gain, muscle mass
        3. Increased risk of erythrocytosis

IX. Management: Surgery

  1. Precautions
    1. Many Transgender patients will not require surgery
    2. Surgery is pursued when significant Gender Dysphoria persists despite hormonal management
  2. Contraindications of fertility limiting surgery (gonadectomy)
    1. Under legal age
    2. Coexisting conditions are not controlled
    3. Social affirmation and hormonal treatment <12 months
    4. Noncompliance or unwillingness to follow guidelines
      1. Continued hormonal therapy to prevent BMD loss
  3. Transgender women (transfeminine, male to female transition)
    1. Breast Augmentation
    2. Facial surgery
    3. Voice therapy
    4. Hair removal
    5. Gonadectomy
  4. Transgender men (transmasculine, female to male transition)
    1. Mastectomy
    2. Gonadectomy

X. Resources

XI. References

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Ontology: Gender Identity (C0017249)

Definition (NAN) The state of being a specific person in regard to sexuality and/or gender
Definition (MSH) A person's concept of self as being male and masculine or female and feminine, or ambivalent, based in part on physical characteristics, parental responses, and psychological and social pressures. It is the internal experience of gender role.
Definition (PSY) Inner conviction that one is male or female or inner sense of being masculine or feminine.
Definition (NOC) Acknowledgment and acceptance of own sexual identity
Concepts Mental Process (T041)
MSH D005783
English Gender Identities, Gender Identity, Identity, Gender, sex role identity, gender identity, sexual identity, identity sexual, Gender identity, Sexual Identity, Sexual Identity (Gender)
Swedish Könsidentitet
Czech pohlavní identita, ztotožňování pohlavní
Finnish Sukupuoli-identiteetti
Russian SEKSUAL'NAIA ROL', ANATOMICHESKAIA SEKSUAL'NAIA SAMOIDENTIFIKATSIIA CHELOVEKA, POLOVOI IDENTITET, АНАТОМИЧЕСКАЯ СЕКСУАЛЬНАЯ САМОИДЕНТИФИКАЦИЯ ЧЕЛОВЕКА, ОСОЗНАННАЯ ПОЛОВАЯ ПРИНАДЛЕЖНОСТЬ ИНДИВИДА, POLOVAIA IDENTICHNOST', ПОЛОВАЯ ИДЕНТИЧНОСТЬ, ОСОЗНАНИЕ ПОЛА, ПОЛОВОЙ ИДЕНТИТЕТ, GENDERNAIA IDENTICHNOST', OSOZNANIE POLA, ГЕНДЕРНАЯ ИДЕНТИЧНОСТЬ, OSOZNANNAIA POLOVAIA PRINADLEZHNOST' INDIVIDA, СЕКСУАЛЬНАЯ РОЛЬ
Japanese 性自認, 性の役割, 性的役割, ジェンダー, 性同一性, ジェンダー(性)
Croatian SPOL, IDENTITET
Polish Identyfikacja płciowa, Rola męska, Rola kobieca
Norwegian Kjønnsidentitet
French Identité sexuée, Identité sexuelle, Identité de genre
Spanish Género, Identidad de Género
Portuguese Gênero, Identidade de Gênero
German Geschlechtsidentität
Dutch Geslachtsidentiteit
Italian Identità sessuale

Ontology: Transsexualism (C0040765)

Definition (MSH) Severe gender dysphoria, coupled with a persistent desire for the physical characteristics and social roles that connote the opposite biological sex. (APA, DSM-IV, 1994)
Definition (PSY) The urge to belong to the opposite sex that may include surgical procedures to modify the sex organs in order to appear as the opposite sex.
Concepts Mental or Behavioral Dysfunction (T048)
MSH D014189
ICD9 302.5
ICD10 F64.0 , F64.1
SnomedCT 4296008, 191786005, 192508005
English Transsexualism, Transsexualisms, Trans-sexualism, Transexualism, transsexualism (diagnosis), transsexualism, Transsexualism NOS, Transsexualism [Disease/Finding], transexualism, trans-sexualism, Transsexualism NOS (disorder), Transsexualism (disorder), Transsexualism, NOS
Dutch transseksualiteit, Transseksualiteit, transseksualisme, Transseksualisme
Italian Transessualità, Transessualismo
Portuguese Transexual, Transexualismo
Japanese 性転換願望, セイテンカンガンボウ
Swedish Transsexualism
Czech transsexualismus, Transsexualita
Finnish Transseksuaalisuus
Russian TRANSSEKSUALIZM, ТРАНССЕКСУАЛИЗМ
German Transsexualismus, Transsexualitaet, Transsexualität
Korean 성전환증
French Transidentité, Transsexualité, Transsexualisme
Polish Transseksualizm
Hungarian Transzszexualitás, Transz-szexualitás
Spanish transexualismo, SAI, transexualismo, transexualismo (trastorno), transexualismo, SAI (trastorno), Transexualismo
Norwegian Transseksualitet

Ontology: Gender dysphoria (C0686346)

Concepts Mental or Behavioral Dysfunction (T048)
SnomedCT 93461009
English dysphoria gender, gender dysphoria, gender dysphoria (diagnosis), Gender dysphoria (disorder), Gender dysphoria, Gender dysphoria, NOS
Spanish disforia sexual (trastorno), disforia sexual

Ontology: Transgendered Persons (C3266856)

Definition (MSH) Persons having a sense of persistent identification with, and expression of, gender-coded behaviors not typically associated with one's anatomical sex at birth, and with or without a desire to undergo SEX REASSIGNMENT PROCEDURES.
Concepts Population Group (T098)
MSH D063106
SnomedCT 407374003
English Transgender, transgenderal, transgender, transgendered, transgenders, Person, Transgender, Person, Transgendered, Transgender Person, Persons, Transgendered, Persons, Transgender, Transgendered Person, Transgender Persons, Transgenders, Transgendered Persons, transgender (history), Transgendered
Czech transgender
French Transgenres, Personnes transgenres
German Transgender
Italian Transgender, Persone transgender
Spanish Personas Transgénero
Polish Transseksualiści
Russian ТРАНССЕКСУАЛЫ, TRANSSEKSUALY, ТРАНСГЕНДЕРЫ, TRANSGENDERY, ТРАНСГЕНДЕРНЫЕ ЛИЦА, TRANSGENDERNYE LITSA
Portuguese Pessoas Transgênero
Norwegian Transkjønnede personer