Transgender Healthcare Demands Multispecialty Care

Bruce Jenner's Story Sparks Interest in Gender Issues

Wylie Hembree, MD; Christine Wiebe

Disclosures

May 08, 2015

In This Article

"A Little Estrogen," or Complete Transition?

Medscape: In your practice, do you make referrals if, for instance, a female wants to transition to male or the reverse? Do you then refer them to a urologist or a gynecologist or a plastic surgeon?

Dr Hembree: First, you need to see whether this individual falls into one of two categories. One category is the person who wants to do everything humanly possible to live their life in the gender that is opposite their natal sex. That would include surgery and all kinds of other things, as well as hormones. Then there are those individuals who know that these are options, but they choose not to take them.

I even get some people who come in and say, "You know, I'd just like to lower my testosterone a little bit." Or they say, "I'm not really quite sure where we're going to go with this, but I'd like to start hormone therapy." I've even had someone who said, "I can't do anything that my wife can ever know about...but can you give me a little bit of estrogen that would not be enough for her to notice?"

Medscape: And what would that do for them?

Dr Hembree: Although it might make them feel better and it might make them function better, I generally discourage that kind of thing, because I don't know what dose of estrogen you can give a male that I can reassure them would never be noticed by their wife. But it's an opportunity to talk about it, to ask, "Why do you want to do this? What do you expect as an outcome, and how is it going to help you in the long run?" I've had men say, "My life would be ruined if my wife found out about this," so do you think I'm going to give them a prescription for estrogen? No.

With those patients, I often suggest that we get a mental health professional involved. I tell them, "I want to help you do what's best for you, but it's not clear to me exactly what is the best, safest, most reasonable, and easiest thing to do."

On the other hand, some patients bring in their wives or their friends, and there are many indications that they have thought this through and they know what the consequence will be.

Issues of sex and sexuality are difficult for physicians.

You know, as good doctors, we take not only a medical history and a personal and social history, but we also take psychiatric histories from patients. As long as we have the freedom to be a good doctor, no matter how long it takes, then I think that we pursue all aspects of the patient history.

That's what's fun about being an endocrinologist, because things are often very complex. Rather than just saying, "Oh, okay, you're transgender and you want to be a transsexual; here's a prescription and I'll see you"—that's not the way we do it.

Medscape: Do most of your patients come by referral from a mental health professional or a primary care provider?

Dr Hembree In general, transgender individuals will go to a mental health professional to talk about this before they'll talk about it with their general practitioner, especially if the general practitioner has known them for years. Most people have been struggling for years with the "what gender am I?" issue, and I think they are more likely to seek mental health care for that.

Medscape: So, do you think it's even an issue for primary care doctors? Is it something that they should be looking out for?

Dr Hembree: I do think they need to be more aware of this. Of course, you're talking to someone who took an interest in testosterone and estrogen as a sophomore in medical school. I did a lot of evaluation and treatment of male infertility, which was something that most men didn't want to deal with and were embarrassed to discuss. They certainly wouldn't talk about it with their regular doctor.

Women may have discussed these issues more, because many women have better relationships with their gynecologists. Now still—and not inappropriately—gynecologists play a major role in being primary care physicians to natal women.

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