Addressing Needs of Transgender Patients: The Role of Family Physicians

Asa E. Radix, MD, PhD, MPH

Disclosures

J Am Board Fam Med. 2020;33(2):314-321. 

In This Article

Access to Gender-affirming Interventions

Transition refers to the period of time when a person starts to live in their true gender. It can include social transition (e.g., telling friends, family, and coworkers about one's gender identity and expressing one's gender identity in social contexts), legal transition (e.g., changing gender markers on legal documents) and medical transition (e.g., taking hormonal treatments and/or undergoing surgeries). Some transgender patients may request medical interventions to help align their gender presentation and/or sex characteristics with their gender identity. Family physicians can develop or improve their knowledge about medical and surgical interventions and gain expertise in hormonal therapy by following established clinical guidelines from the World Professional Association for Transgender Health,[20] the Endocrine Society,[2] and the University of California–San Francisco Center of Excellence for Transgender Health Primary Care Protocols[21] (Table 2).

It is important to recognize that transgender people may be at any stage of the medical gender affirmation process when seeking care. Some individuals may never plan to use hormones or undergo surgeries, while others may be seeking care specifically to access these interventions. Some may use hormonal therapy but have not had surgery, and still others may have undergone 1 or more gender-affirming procedures. Understanding which medical interventions a person has received and which interventions they are considering in the future is important to providing appropriate medical and preventive care services. For transfeminine people, hormonal therapy usually consists of estradiol and antiandrogens, such as spironolactone. This feminizing therapy results in breast growth, softening of the skin, and changes in fat distribution, resulting in a more feminine appearance.[22] Transfeminine individuals may undergo several gender-affirming surgeries, including breast augmentation, chondrolaryngoplasty (tracheal shave), facial feminization surgery, orchiectomy, and vaginoplasty.[20] In vaginoplasty procedures the neovagina is usually created using penile and scrotal skin but may use an intestinal or split skin graft.[23] For transmasculine individuals, hormone therapy usually consists of testosterone causing deepening of the voice, increase in muscle mass and facial hair.[24] Gender-affirming surgeries include bilateral mastectomy (top surgery), hysterectomy, oophorectomy, and creation of a neophallus using skin flaps from the forearm, chest wall, or thigh (phalloplasty), or a procedure that lengthens and frees the clitoris (metoidioplasty). These genital surgeries may also include scrotoplasty and testicular implants. The phalloplasty is performed in several stages, including placement of penile implants.[23,25] Although many transmasculine patients will undergo hysterectomy, oophorectomy, and vaginectomy (removal of the vagina) before undergoing genital reconstruction, some will opt to keep their organs, including the vagina. Understanding the types of surgeries that patients have undergone as well as the organs that remain will help the medical provider to ascertain the need for appropriate health screenings (Table 3).

Gender-affirming hormone therapy has many positive effects, including improved mental health, psychosocial outcomes, and quality of life.[26,27] These interventions, however, may also have untoward effects. Estrogen therapy in transgender women has been associated with elevated risks of thromboembolic disease[28] and dyslipidemia (elevated triglycerides).[29,30] Transgender women may also be at increased risk for osteoporosis, especially if there is inadequate estrogen treatment after gonadectomy.[22] Testosterone carries a risk of erythrocytosis, acne, vaginal atrophy, amenorrhea, and androgenetic hair loss.[15,24] Since testosterone does not provide adequate protection against pregnancy, transgender men may also need counseling about effective contraception.[15] Both estrogen and testosterone can negatively impact fertility in transgender people and current recommendations are to discuss fertility preservation options, such as semen, oocyte, or embryo cryopreservation before initiation of hormones, and again if patients opt to undergo gonadectomy procedures.[31]

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