COMMENTARY

Treating Transgender Patients: A Primer

Ranit Mishori, MD, MHS

Disclosures

September 17, 2015

Editorial Collaboration

Medscape &

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My name is Ranit Mishori and I am a professor of family medicine at the Georgetown University School of Medicine.

Approximately 700,000 Americans are transgender, according to some studies.[1] The actual number may be higher.

Transgender patients come from all races, sexual orientations, socioeconomic levels, and educational backgrounds. They may have bodies that don't necessarily match their gender identity or presentation, or they may have had (or want to have) medical or surgical treatments to modify their bodies to affirm their gender.

Few of us have been trained in the care of transgender individuals. As a result, many of us may feel a certain level of discomfort addressing transgender health, needs or even a degree of confusion when meeting patients whose gender identity or presentation does not correspond with their physiology.

Today I will address a few topics for consideration. This is not a comprehensive review; I would urge you to look up some of the excellent and comprehensive resources that are accessible online. [See Suggested Reading and Web Resources sections below.]

Using Patient-Preferred Identification Terminology

Language is important when it comes to addressing and describing transgender patients. One commonly used descriptor is "male to female" (MTF) or "female to male" (FTM).

Some transgender people may prefer the terms "transgender man" (same as FTM) or "transgender woman" (same as MTF) because these terms affirm the chosen identity. Others still might prefer the term "affirmed male" or "affirmed female."

One of the key concepts when caring for transgender people is honoring the patient's preferred gender identity and using the pronouns and terminology that the patient prefers.

Transgender Identity Is Not Defined by Anatomy

A transgender patient's body may have elements, traits, or characteristics that do not conform to the patient's gender identity. It is important to realize that for transgender people, their anatomy does not define them. While some transgender people opt to have surgery so that their bodies more fully match their identities, others do not desire or cannot afford surgery.

If you think you might see transgender patients in your office, consider updating the office intake form, specifically the questions about gender. The ideal patient intake form has both a "gender question" and an "assigned-sex-at-birth question." Some may have an optional "preferred pronoun" question. Asking both a gender and a sex question instead of just one (either sex or gender), and offering many choices, allows for specific disclosure of a person's history and also validates their current gender identity.

It is also a good idea—once the patient is in the exam room—to ask the patient's preferred name and pronoun, and whether the patient feels comfortable sharing their experiences concerning gender.

Another key issue to remember is that most medical problems that arise in the transgender patient are not necessarily related to cross-sex hormone use. However, hormone therapy and surgical interventions are important when considering preventive health. And, of course, hormone replacement itself, with or without gonadectomy, may contribute to endocrine issues.

Patients may come to their primary care physician while considering hormone therapy, after initiation of hormone therapy, or years after initiation of hormone therapy. While some will look up to their primary care physicians to assist with hormone initiations, others may see an endocrinologist or go to comprehensive centers for transgender health.

This is beyond the scope of this video, but excellent resources are available to help with dosing questions.

Remember the following when treating transgender MTF patients:

  • Feminizing cross-sex hormone therapy usually requires the use of estrogen and antiandrogen medication.

  • Treatment aims to decrease the testosterone level to the female range and maintain an estradiol level similar to that of premenopausal women.

  • Within the first 3 months, patients will start to experience fat redistribution, breast growth, and voice and skin changes, as well as decreased muscle mass, erections, libido, and sperm production.

  • Risks associated with hormone use include thromboembolic disease, prolactinoma, hypertension, liver disease, osteoporosis, permanent infertility, and breast cancer.

  • Androgen blockers may cause hyperkalemia and hypotension.

And remember the following when treating transgender FTM patients:

  • Masculinizing hormone therapy is meant to increase the serum testosterone level to the male range.

  • Physiologic changes include fat redistribution, acne, clitoromegaly, vaginal atrophy, voice deepening, amenorrhea, facial and body hair growth, and increased muscle mass.

  • Risks associated with hormone use include polycythemia, hyperlipidemia, and osteoporosis.

When it comes to prevention and screening, provide care for the anatomy that is present, regardless of the patient's self-description or identification. For example, an affirmed male may still have a cervix, in which case he should be followed with Pap smears. An affirmed female most likely still has a prostate, so a discussion about prostate cancer screening may be warranted.

Assess Social Adjustment

A discussion of social adjustment, libido, sexual behavior, and quality of life should be attempted at every visit. In general, transgender persons experience more mental health issues than the general population, so it is important to have a general discussion on mental well-being at every visit.

Violence should also enter the conversation. Transgender people are believed to be victims of violence more frequently than others—from verbal and physical abuse to murder—directly related to their gender identity. Ask about a history of verbal, emotional, or physical abuse. Ask about violence, and screen for depression, suicidal thoughts, and substance abuse.

I hope this brief introduction was helpful. For additional information, please refer to the resources listed at the end of this transcript. Thank you.

Suggested Reading

American College of Obstetricians and Gynecologists. Health care for transgender individuals. Committee Opinion No. 512. Obstet Gynecol. 2011;118:1454-1458.

Feldman JL. Updated recommendations from the World Professional Association for Transgender Health Standards of Care. Am Fam Physician. 2013;87:89-93.

Olson J. Care of a transgender adolescent. Am Fam Physician. 2015;92:142-148.

Web Resources

Center of Excellence for Transgender Health UCSF: Primary care protocol for transgender patient care; 2011

American Academy of Family Physicians: Transgender health resources

American Medical Student Association: Transgender health: introduction to language

Vancouver Coastal Health: Transgender health information program

The World Professional Association for Transgender Health: Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People; 2012

First live course leading to transgender health provider certification: Transgender Health: Best Practices in Medical and Mental Health Care; November 5-7, 2015 (Chicago, Illinois)

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