HME

Transgender Person

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Transgender Person, Transgender, Gender Identity, Gender Dysphoria, Gender Incongruence, Transsexualism, Cisgender

  • 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
  • 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
  • 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
  • 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. Intimate Partner Violence
    5. Eating Disorder
    6. Victim of Bullying
    7. Substance Abuse
  3. Social Situation
    1. Homelessness
    2. School Truancy
  4. Sexual History
    1. Are you sexually active?
    2. What gender are your partners?
    3. What type of sex do you have (e.g. oral sex, vaginal sex, anal sex, shared sex toys?)
    4. What do you do to protect against Sexually Transmitted Infection (STI)?
    5. Do you use Contraception?
  • 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
  • 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
  • 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
  • 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
  • Resources
  • References