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Subject: Transgender Health
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Society’s growing acceptance of nontraditional lifestyles has, in recent years, made increased room for transgender individuals, as it has for lesbians, gays, and bisexuals, even as these populations continue to suffer unique health care disparities. Better education of physicians and other providers will improve the health of the transgender population. Such education begins with teaching acceptance of all human beings into health care and ensuring a safe office environment for transgendered individuals to speak openly with their clinicians. Once a “safe” space is created, it will be possible to provide appropriate and supportive health care to reduce disparities and the harms that result.
At least 1:11,900 males and 1:30,400 females in the United States define themselves as transgender (1).
Current conservative estimates indicate 0.3% of U.S. adults, or nearly 1 million people, identify themselves as transgender (2).
The terms “transgender” and “gender nonconforming” refer to those whose gender identity or presentation differs from the sex assigned at birth (3).
Gender identity, the sense of one’s self as male or female, and gender presentation, the outward expression of gender, may or may not reflect the self-identification of a transgender patient.
Transgender patients can no more be categorized or thought alike, than any other patients. Race, ethnicity, socioeconomic status, age, and other factors, all play a role in how transgender patients define themselves.
Moreover, a patient’s body may or may not match gender identity or presentation. Although a patient’s anatomy may determine treatment, that treatment must also be sensitive to, and respect, gender identity and/or presentation.
Transgender people may be sexually oriented toward men, women, other transgender people, or any combination of the above.
Transgender patients are further defined by those who have undergone surgical procedures and/or medical treatment to better align gender identity, by those who plan such procedures in the future, and by others who do not.
Accordingly, it is important to ask transgender patients how they would describe themselves and to honor terminology acceptable to each patient, specifically preferred name, preferred pronoun, and preferred gender identity, with those attributes ideally reflected within any electronic medical record (EMR).
Transgender people have a unique set of mental and physical needs (2).
Real or imagined stigma and discrimination are barriers to health care (3).
Transgender patients are less likely to have health insurance and more likely to encounter discrimination on the part of health care providers, thereby limiting access to health care services.
Over 50% of transgender patients delay needed care, compared to 20% in the general population (3,4).
Evidence-based medicine for transgender patients is lacking or limited to case reports and smaller studies aggravated, perhaps, by social stigma, marginalization, and discrimination (2).
Transgender patients may also suffer from gender dysphoria, recognized in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as the disconnection between gender expression and one’s assigned gender at birth (1).
Specific health concerns
Transition-related medical care, or gender-confirming therapy, including hormone therapy and surgical treatment, or sex reassignment surgery (SRS) help patients align primary and secondary sexual characteristics with gender identity (2).
The World Professional Association for Transgender Health (WPATH) has published standards of care (SOCs) that include hormone therapy and SRS (2)[C].
SOCs are endorsed by American College of Obstetricians and Gynecologists (ACOG), the Endocrine Society, the American Medical Association, and the American Psychological Association (2).
Hormone therapy and surgery not only treat symptoms of gender dysphoria but also help transgender patients achieve well-being (1).
Hormone therapy does convey a greater risk of thromboembolic disease, liver dysfunction, and cardiovascular (CV) disease (1).
Treatment is associated with a high degree of patient satisfaction, low prevalence of regrets, and significant relief of gender dysphoria (2)[C].
Rate of HIV infection among transgender people is 4 times that of general population (4).
Requires increased vigilance on the part of health care providers
Transgender people are at risk of victimization by others, of mental health issues, including depression and anxiety, and of suicide (4).
41% of transgender people have attempted suicide compared to 1.6% of the U.S. general population (1,2,4).
One 2012 survey found that 61% of transgender people had been victims of physical assault and abuse; 64% had been victims of sexual assault, mostly not reported (5).
Transgender people are at greater risk of societal discrimination, including housing and workforce discrimination, are more likely to be unemployed, homeless, and lacking in social support owing to federal and state laws that inadequately protect transgender people from discrimination (5).
Psychosocial assessment is recommended at baseline and at least annually (5)[C].
Mental health and substance abuse screening are also indicated (6)[C].
Transgender patients are at increased risk of suicidal ideation, suicide attempts, and suicide (1,2,4).
Improving access to care
Barriers to health care
Transgender patients are often reluctant to disclose gender identity or expression, owing to the risk of stigma or discrimination.
28% of transgender patients report being verbally harassed and 2% physically assaulted while seeking health care (1).
Providers’ lack of education and experience
Lack of health insurance
Unemployment among transgender people is twice the rate of general population (1).
Care of transgender people, including hormone therapy, is within the scope of primary care providers.
Education of health care providers, for physicians, and those beginning in medical school, is crucial to providing optimal care to transgender patients (2).
Hormone therapy (7)[A]
Suppress pubertal development using gonadotropin-releasing hormone (GnRH) analogues when girls and boys first exhibit pubertal physical changes (Tanner stage 2).
Cross-sex steroids at about age 16 years
Initiate treatment after persistent gender dysphoria/gender incongruence have been confirmed by a multidisciplinary team of medical and mental health providers and the patient has the mental capacity to provide informed consent, generally by age 16 years.
Estrogens, antiandrogens, and/or GnRH agonists for male-to-female patients (7)[A]
Estradiol 2 to 6 mg/day, or estradiol transdermal patch 0.025 to 0.200 mg/day, or estradiol valerate or cypionate 5 to 30 mg IM every 2 weeks
Add spironolactone 100 to 300 mg/day, cyproterone acetate 25 to 50 mg/day, or GnRH agonists to minimize estrogen requirement.
At initial visit, do prostate-specific antigen (PSA), lipid panel, and liver function tests (LFTs); every 3 months, check testosterone levels until stable, monitor estradiol blood level for compliance, repeat lipid panel, and encourage breast exams (6)[A].
Every 6 months to 1 year, preoperatively, order visual fields to assess for prolactinoma, check serum prolactin, and repeat lipid panel; if patient is >50 years old, recheck PSA and consider mammogram (6)[A].
Every 6 months to 1 year, postoperatively, reduce estrogens to hormone replacement therapy (HRT) doses (conjugated equine estrogens 0.625 mg/day, transdermal ethinyl estradiol 0.05 to 0.10 mg/day, or ethinyl estradiol 0.02 to 0.05 mg/day) and do dual energy x-ray absorptiometry (DEXA) scan to monitor for osteoporosis (6)[A].
Testosterone for female-to-male patients (7)[A]
Testosterone esters 100 to 200 mg IM every other week or transdermal testosterone 2.5 to 7.5 mg/day or testosterone gel 1.6% 50 to 100 mg/day with goal of serum testosterone in midmale range
At initial visit, check weight, lipid panel, and glucose level (6)[A].
Every 3 to 6 months, repeat lipid panel and LFTs, do complete blood count to rule out polycythemia, and check testosterone levels.
Every 6 months to 1 year, preoperatively, do pelvic exam and Papanicolaou (Pap) smear per current protocols (6)[A].
Every 2 years, do endometrial ultrasounds.
Every 6 months to 1 year, postoperatively, titrate testosterone to maintain serum testosterone at 500 μg/dL (17.35 SI) and do DEXA scan (6)[A].
SRS (7)[A]: only after 1 year of hormone therapy
In adolescents, consider delaying gender-affirming genital surgery until the patient is at least 18 years old.
Discrimination on the part of health care providers is a major barrier to care (4).
Routine medical screening:
Pelvic exam (6)
Cervical and anal Pap tests (6)
Screening for STIs (6)
Measurement of prolactin levels (7)
Evaluation of CV risk factors (7)
Bone mineral density tests, as indicated (7)
Breast cancer screening per guidelines (7)
Screening, as indicated, for prostate cancer in transgender females treated with estrogens (7)
In adolescents, monitor clinical pubertal development every 3 to 6 months and check labs (LH, FSH, E2/T, 25[OH]D) every 6 to 12 months; do bone mineral density test every 1 to 2 years (7).
In adults, monitor physical changes and any adverse changes every 3 months during the 1st year of hormone therapy and then once or twice yearly (7).
Transgender males: Check serum testosterone every 3 months until levels are in the normal physiologic male range; check hematocrit and hemoglobin at baseline and every 3 months in year 1 and then once or twice a year; monitor lipids as indicated (7).
Transgender females: Check serum testosterone and estradiol every 3 months; if patient is on spironolactone, check serum electrolytes every 3 months in the 1st year of treatment and then annually.
Hormone therapy and potential health risks
Counseling for gender-confirming surgery
Under the Affordable Care Act (ACA), denial of treatment of being transgender as a “preexisting condition” is banned (2).
Centers for Medicare & Medicaid Services (CMS) considers SRS experimental and denies coverage (2).
The U.S. Department of Veterans Affairs (VA), although acknowledging the need to care for transgender veterans, denies coverage of SRS on the basis of a VA regulation that excludes gender alterations from the medical benefits package (2).
Agency for Healthcare Research and Quality. 2011 National Healthcare Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; 2011.
Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press; 2011.
F64.1 Gender identity disorder in adolescence and adulthood
Z11.4 Encounter for screening for human immunodeficiency virus
Z72.52 High risk homosexual behavior
Z72.53 High risk bisexual behavior
Z72.51 High risk heterosexual behavior
302.50 Trans-sexualism with unspecified sexual history
V01.79 Contact with or exposure to other viral diseases
V69.2 High-risk sexual behavior
407375002 Surgically transgendered transsexual (finding)
171121004 Human immunodeficiency virus screening (procedure)
102947004 high risk sexual behavior (finding)
288291000119102 High risk bisexual behavior (finding)
288301000119101 High risk heterosexual behavior (finding)
288311000119103 High risk homosexual behavior (finding)
Health care providers must be sensitive to the unique needs of transgender patients; must be open to the care of such patients; and should, as with all patients, display an ethical, principled, and timely approach to care.
Do use inclusive language in the care of transgender patients, assessing the individuals’ preferences, and respect differences among transgender patients.
Always address health care needs particular to the transgender population.
Avoid stigmatization of transgender patients, ensuring gender-blind clinical care.