New Guidance on Care of Transgender Persons for Non-Experts

Becky McCall

December 23, 2019

'Care of Transgender Persons', a new review from two experts in the field, offers valuable guidance to physicians who treat transgender patients, including those who provide hormonal therapies, mental health care and surgery.

The review aims to help overcome one of the biggest barriers to care for transgender individuals: a lack of knowledgeable providers, say its authors. It largely refers to the care of adults in the US, but briefly touches on how to approach children too.

In authoring the work, Joshua Safer, MD, executive director of the Mount Sinai Center for Transgender Medicine in New York City, and Vin Tangpricha MD, PhD, of Emory University in Atlanta, Georgia, provide a review of available evidence supporting various care strategies, detail any existing formal guidelines, and then go on to provide clinical recommendations.

Safer is a firm believer in the power of education in overcoming barriers to good care for transgender persons.

"The most influential vehicle to effect long-lasting, meaningful change across current and future generations of clinicians in all specialties caring for transgender individuals is education," he asserts in a press release from Mount Sinai accompanying the new publication.

He and Tangpricha note that the advice in their article, published in the December 19 edition of The New England Journal of Medicine, is generally consistent with the latest Endocrine Society guidelines on transgender medical care, issued in 2017, with some distinctions.

Driven by a need for better healthcare for transgender persons, Safer points out that improved access for these individuals will require the participation of more general providers outside specialized settings. For this reason, the new review is aimed at helping all physicians to separate the known from the unknown within transgender medicine.

Addressing Knowledge Gap: Make Sure to Assess Mental Health Too

"The intention of the review is to provide straightforward guidance to address the gap that transgender individuals may face in their care," explains Safer, who is also a spokesperson on transgender medicine for the Endocrine Society.

He highlights the fact that many transgender persons still experience barriers to healthcare access, as well as medical mistreatment.

Data suggest that approximately 25% of transgender people report denial of medical services, and 30% report avoidance of care owing to fear of discrimination.

Regarding presentation and assessment, Safer and Tangpricha draw attention to the need for clinician evaluation of transgender patients, including mental health with thorough assessment of anxiety, depression, and suicidality — all of which are reported to be more common among transgender than cisgender persons.

In addition, healthcare providers should obtain a social and sexual history and establish persistence of gender incongruence. 

They also highlight the need for specialist mental health care providers to "participate in the assessment of adults if a mental health condition is suspected or identified."

Safer and Tangpricha note that discussion around transgender youth is not within the scope of this review, but they briefly touch upon certain issues. 

Regarding mental health, they make the point that children and adolescents who present for evaluation of transgender identity should be routinely assessed by a mental health care provider because they "articulate gender identity more heterogeneously." And they should also be assessed for coexisting mood disorders and other psychiatric conditions; plus, the risk of suicide is higher in these children than in their cisgender peers.

No medical intervention is indicated before puberty, they stress. But once puberty has begun, reversible therapy with a gonadotropin-releasing hormone agonist ('puberty blockers') can delay development until a long-term treatment plan can be established.

Medical and Surgical Interventions for Adults

In terms of hormone treatment for transgender men, testosterone can be administered to achieve levels in the male range; for transgender women, estrogens lower testosterone levels through central suppression of the reproductive axis while having feminizing effects and protecting bone health.

However, the authors caution that in transgender women, estrogen therapy is associated with an increased risk of venous thromboembolism, but that concomitant treatment with androgen-lowering agents, for example spironolactone, allows for administration of lower doses of exogenous estrogen.

Safer and Tangpricha point out that a rise in prolactin levels (and the potential for development of a prolactinoma) has been a reported concern in transgender women. They recommend prolactin monitoring but add that reports of elevated prolactin levels are limited to clinics that use estrogen/cyproterone regimens rather than estrogen/spironolactone.

Fertility is addressed, noting that transgender-specific hormone therapy may reduce fertility, and genital reconstruction surgery that includes the removal of gonads can destroy reproductive potential entirely.

The authors assert that before individuals start any treatment, they should be encouraged to consider fertility preservation (egg harvesting and cryopreservation of oocytes or embryos in transgender men; cryopreservation of sperm in transgender women).

Uncertainty with regard to hormone therapy is recognized.

"The long-term consequences of hormone therapy in transgender persons and the best strategy for surveillance remain unclear," the authors acknowledge. 

They also highlight a research gap in the comparison of different medical regimens and strategies for monitoring patients.

Gender reassignment surgery is undertaken by roughly half of those transgender individuals who undergo medical therapy, according to surveys, the authors note.

Choice of surgery should be customized to patient goals, say Safer and Tangpricha, with consideration of associated risks and the patient's interest in fertility.

Surgical options are outlined, and detailed explanatory diagrams are featured in the article to aid understanding of the physical changes involved.

Psych Assessment for Gender Incongruence in Adults Not Obligatory

Safer and Tangpricha note that their advice largely reflects that of the latest Endocrine Society and World Professional Association for Transgender Health (WPATH) guidelines for the medical care of transgender persons.

However, they point out that although the Endocrine Society no longer mandates that providers of mental health determine gender identity in adults, the Endocrine Society guideline "still expresses preference for participation by these providers when making that assessment."

But Safer and Tangpricha believe that "absent further data, we express no such preference for adults unless there is evidence of mental health issues."

Bullet point recommendations include:

  • Determining readiness for treatment for those who seek it by establishing that the patient has persistent gender incongruence and is competent to make medical decisions.

  • Screening by the clinician or mental health consultant for mental health conditions that may confound the assessment of gender identity or complicate management of care.

  • Prescribing and managing hormone therapy based on expected impact and awareness of the potential adverse effects of the treatment.

  • Understanding the various surgical options for transgender individuals with consideration of the challenges associated with each.

No Need to Monitor Prolactin, Recommend Hysterectomy

Safer and Tangpricha also add that the Endocrine Society guideline recommends monitoring prolactin levels in transgender women and considering hysterectomy in transgender men as prophylaxis for cancer.

"We refer to new data that suggest these procedures may not be necessary," the authors write.

NEJM. Published December 19, 2019. Clinical Practice

Safer reports receiving fees for serving on an advisory board from Endo Pharmaceuticals. Tangpricha has disclosed no relevant financial relationships.

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