Guidelines for Transgender Patients in Primary Care Released

Norra MacReady

July 02, 2019

Transgender individuals often cite a lack of knowledgeable providers as the biggest barrier to their finding care. A new guide published in the Annals of Internal Medicine aims to help clinicians better understand the needs of this population and covers issues such as medical and surgical treatment, practice improvement, and medicolegal and societal questions.

Care of transgender individuals is usually well within the skill set of primary care physicians, Joshua D. Safer, MD, told Medscape Medical News. "We really should be getting to a place where any transgender individual goes to any primary care provider and finds that that provider has a certain minimum knowledge of what they need to be doing with regards to transgender care."

Safer, who is executive director of the Center for Transgender Medicine and Surgery, New York City, cowrote the article with Vin Tangpricha, MD, PhD, of Emory University School of Medicine and the Atlanta VA Medical Center, Georgia.

Definitions and Important Information

The guide begins with a review of the terminology used regarding transgender patients. It includes a list of these terms, such as "transgender," "genderqueer," "cisgender," and "nontransgender," along with their definitions. The authors also discuss evolving medical and psychiatric views of the transgender population.

A patient's transgender or gender-incongruent status can be established with the help of any knowledgeable provider, the authors explain. Conclusions should be made on the basis of a patient's history of persistent gender incongruence and their capacity to make treatment decisions. The patient also should be evaluated for any coexisting mental health conditions that may confound the determination.

Endocrine and Surgical Treatment

Hormone therapy is an important part of care for many transgender patients, although not all such patients seek medical intervention. The guide includes a table that describes the hormone regimens most commonly used, with mechanisms of action, adverse effects to watch for, and notes on dosing and patient monitoring.

The authors also include a section on surgical options for transgender patients, important questions for clinicians to consider in helping patients make informed decisions, preoperative evaluations, and postsurgical follow-up. Of patients who undergo medical treatment, approximately half also seek transgender-specific surgery.

In general, said Safer, primary care physicians should understand the goals of hormonal regimens and how to follow patients, and they should know "what some of the typical surgical plans look like and what would need to be monitored for individuals who have those surgeries."

None of this is "far outside what primary care physicians already know — it's more a matter of reorienting some of their existing knowledge," he added.

Referral to a specialist such as an endocrinologist depends on the knowledge and comfort level of the primary care physician, Safer said. "Someone who sees a fair number of transgender patients might feel comfortable with the routine hormone-prescribing regimens, but then refer when there are reasons why those regimens might have to be adjusted, such as because of other medical conditions. Alternatively, someone with less experience might refer the patient to an endocrinologist to begin a hormone regimen and then simply follow that patient subsequently, as they would with some other hormone treatment."

Other Medical Considerations

It is important to address HIV-related problems, as well as questions of fertility, Safer and Tangpricha write. Hormone therapy may limit or suppress fertility, and patients who undergo genital reconstructive surgery that includes removal of the gonads "lose their reproductive potential altogether." Cryopreservation of sperm, oocytes, or embryos are among the possible options these individuals may wish to consider before proceeding with treatment.

Clinicians should remain aware of all of a patient's organs and tissues, "regardless of gender identity," the authors state. For example, a transgender woman who was assigned a male identity at birth will still have a prostate and should be monitored for prostate cancer. Similarly, a transgender man who was assigned a female identity at birth still has breasts, ovaries, and a uterus and should be monitored for cancers of those organs.

Practice Improvement

Patients or providers may encounter other types of obstacles. Many electronic medical records systems make it hard to change a patient's legal name or gender and sometimes require governmental approval for these adjustments, although processes vary widely among states, the authors write. Data collection procedures should be flexible enough to allow the recording of information such as the patient's preferred name and pronoun, as well as gender identity, be it male, female, or something else.

Staff training is also critical to creating an environment in which transgender patients feel safe in seeking and receiving care, Safer explained. "If people are going to trust their health to a team, including the provider and the staff, then a respectful environment, with staff that can demonstrate both respect and some understanding of what's really happening by using the appropriate pronouns and by being aware that there might be some question regarding the appropriate pronouns, is going to be an important part of creating that safe environment."

Transgender care "is not that complicated," he concluded. "Clinicians who take care of fewer transgender patients should feel free to seek assistance as they need it, but nonetheless, they should be creating welcoming environments for the transgender patients in their practices."

Safer has served on an advisory panel for Endo Pharmaceuticals and has given invited lectures for various academic institutions and professional organizations. His spouse is employed by Parexel. Tangpricha disclosed no relevant financial relationships.

Ann Intern Med. Published online July 1, 2019. Abstract

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