Principles of transgender health care

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Transgender people have a gender identity that differs from the sex assigned at birth and sometimes choose to undergo hormone therapy and/or surgery to align their physical appearance and gender identity. Often, transgender individuals face social and institutional discrimination and stigmatization that affect their quality of life, including experiences with the health system and access to care. Clinicians should be aware of these issues and ensure a welcoming environment that allows for patients to provide the necessary information to address their health needs. Transgender patients present with the same spectrum of health problems and needs as cisgender patients, and the majority of presentations will be unrelated to gender identity. Hormone therapy and surgery are typically overseen by specialist centers; however, some patients may subsequently present to their primary care physician or local hospital with treatment side effects and complications, including long-term changes to physiology (e.g., secondary to gonadectomy and gender-affirming hormone therapy) that can increase the risk of certain diseases. Transgender people also face unique challenges in managing fertility, contraception, and pregnancy.

• Transgender: the identification with a gender that differs from the sex assigned at birth
• Gender-affirming care refers to:
  • Ensuring respectful and appropriate medical care for individuals of all gender identities
  • A set of interventions that individuals may choose to undergo with the objective of aligning external characteristics with gender identity, such as:
    • Gender-affirming hormone therapy (GAHT)
    • Gender-affirming surgery
    • Additional interventions: e.g., hair removal or transplantation, voice therapy, and chest binding.

^[2][3]

Systemic barriers and health risks disproportionately affecting transgender patients ^[2][3][4][5]

Transgender people often face structural barriers in society that can result in health inequities (including increased risks for specific medical conditions) and affect their quality of life and life expectancy. Consider screening for and addressing these barriers and conditions in at-risk patients if they are pertinent to the reason the patient is seeking care (see “Preventive health care”).

• Societal and structural factors (see also “Social determinants of health”)
  • Discrimination on the basis of gender identity or intersectional identities, e.g., gender and race.
  • Social exclusion
  • Increased risk of experiencing physical violence, sexual violence, and intimate partner violence
  • Barriers to accessing health care
  • Precarious and/or unsafe working conditions ^[5]
  • Increased risk of homelessness
• Specific medical conditions (May arise from structural and societal factors)
  • Trauma: e.g., sequelae of inflicted injuries or self-harm
  • Infections: e.g., sexually transmitted infections, skin and soft tissue infections, and bloodborne infectious diseases ^[6]
  • Mental health conditions: e.g., depression, anxiety, PTSD, suicidal ideation, substance use disorders, eating disorders

Avoid assuming a direct link between any medical or social risk and gender identity, as individual patient experiences vary. Unwarranted assumptions can damage the patient-provider relationship and decrease the likelihood that patients will feel comfortable divulging sensitive health information or returning to seek care. ^[7]

Factors affecting health care encounters ^[4][7][8]

Health care environments can be the source of stress, frustration, humiliation, and fear for transgender patients if systemic barriers and inappropriate health-provider behavior, biases, and incompetencies are left unaddressed. The following have been reported as factors that erode patients' trust in health care systems and personnel, and may prevent them from seeking care as a result:

• Systemic barriers
  • Lack of adequate health insurance
  • Risk of discrimination and harassment in healthcare institutions
  • Health care institutions lacking adequate resources to ensure privacy and confidentiality
  • Insufficient accommodation and facilities for gender-diverse patients
• Provider-related barriers: training gaps, biases, and unprofessional behavior
  • Insufficient knowledge surrounding transgender health and social issues
  • Inappropriate questioning
  • Use of culturally insensitive terminology
  • Accidental or intentional misgendering (i.e., failure and/or refusal to acknowledge transgender identity or use preferred pronouns) or outing the patient
  • Counseling that invalidates or devalues transgender experiences
  • Transphobic and disrespectful behavior of staff

Optimizing the patient experience

Best practices during health care visits

• Respecting patient preferences
  • Ask the patient what name and pronouns they prefer and adhere to using them.
  • When pertinent to the reason for the visit, ask directly and specifically about the following :
    • Sex assigned at birth
    • Gender identity
  • Familiarize yourself with preferred terminology regarding gender identity.
• Other recommendations ^[7]
  • Avoid gender-specific terminology.
  • Preferably, use last names when referring to patients in group settings.
  • Do not discuss sensitive information unless it is relevant to the reason for the visit.
  • Ensure privacy at all times (especially when discussing gender identity and other sensitive issues).

Focused history-taking ^[2][3]

This information should only be solicited if it is pertinent to the reason for seeking care and in a manner appropriate to the patient's gender identity.

• History of gender transition
  • Ask about any previous gender-affirming interventions and plans to undergo future ones.
  • Be aware of potential problems, changes, and mistakes in the patient's medical records and identification documents.
• Gynecological history: Ask about previous pregnancies, menstruation, and the most recent gynecological cancer screening.
• Sexual history: Obtain a detailed sexual history, including information on the number and gender(s) of sexual partners and any high-risk sexual behavior.
  • Assess the possibility of pregnancy and the need for birth control.
  • Counsel the patient on preventing sexually transmitted infections.
  • Identify sexual practices that may be affected by hormone therapy.
• Others: The rest of the clinical history should not differ from the one used for cisgender patients.
  • Family history: Ask especially about hormone-related cancers and cardiovascular disease.
  • Mental health: Screen for depression and suicidal ideation, and ask about any issues impacting quality of life.
  • Social support: Ask about the patient's financial and work situation and relationship with friends and family.

Only address aspects of gender identity that are clinically relevant. The focus should be on the reason for the patient's visit. Inappropriate questioning can erode the patient's trust in the health care system, contributing to poorer health outcomes in an already marginalized population.

Sensitive physical examination ^[2][3]

• Clinicians should be aware that secondary sex characteristics might be present, partially present, or not present at all, depending on whether the patient has had gender-affirming surgery and/or hormonal therapy.
• Ask the patient if they would like to have a chaperone in the examination room with them (this may be a person who came with the patient or a member of staff).
• Discuss all steps of the physical examination beforehand.
• Remind the patient to state if, at any time, they feel uncomfortable during the physical examination.

General principles

• Gender-affirming care may include treatment with hormone therapy and/or surgery.
• Most transgender people taking hormone therapy report an improved quality of life; however, medications can cause side effects that clinicians should be aware of. ^[9]
• Transgender people facing barriers to health care sometimes access hormone therapy without a formal prescription and these individuals may be at additional risk of side effects. ^[10]
• Nonbinary transgender patients may also elect to take hormone therapy for masculinization or feminization, or at partial doses to reflect their gender identity. ^[11]

Gender-affirming hormone therapy

Puberty suppression ^[14][15]

• Children and adolescents may be considered for therapy with puberty inhibitors to prevent the unwanted development of secondary sex characteristics of the sex assigned at birth.
  • First-line: GnRH agonists, e.g., leuprolide or histrelin ^[16]
  • Second-line: progestins
    • Male-to-female individuals: antiandrogenic progestins, e.g., cyproterone acetate and spironolactone
    • Female-to-male individuals: androgenic progestins, e.g., norethindrone and medroxyprogesterone acetate
• May be taken alongside masculinizing and feminizing hormone therapy

Procedures ^[17][18][19]

Gender-affirming surgery may include genital surgery, chest surgery, and additional procedures such as facial feminization or masculinization. Up to half of transgender individuals undergo a gender-affirming surgical procedure, and demand is increasing. Several procedures are often required to achieve the desired outcome. ^[18][20]

Transgender individuals may choose to undergo several or none of these procedures.

Surgical procedures for transgender women

• Genital surgery
  • Resection: orchidectomy and penectomy ^[21]
  • Reconstruction: vaginoplasty and vulvoplasty
    • Neovagina: often formed out of a tissue graft and/or penile skin (penile inversion vaginoplasty) but may also be constructed from a segment of the small or large intestine (intestinal vaginoplasty) ^[19]
    • Neoclitoris: typically formed out of the glans penis while preserving the neurovascular bundle
    • Labia majora and minora: typically constructed from the scrotum and penile skin ^[19]
• Chest surgery: breast augmentation, typically with silicone implants ^[16]

Surgical procedures for transgender men

• Genital surgery
  • Resection
    • Hysterectomy and oophorectomy ^[16]
    • Vaginectomy via thermal ablation or mucosectomy
  • Reconstruction
    • Metoidioplasty: creation of a microphallus from the clitoris
    • Phalloplasty: creation of a neophallus and neourethra, commonly out of a tissue flap
    • Scrotoplasty: creation of a neoscrotum from the labia majora; may include a testicular implant
• Chest surgery: bilateral subcutaneous mastectomy and construction of masculinized features ^[22]

Additional procedures ^[18]

• Facial feminization or masculinization, e.g., rhinoplasty or lip augmentation
• Body contouring, e.g., liposuction or gluteal augmentation
• Voice modification surgery

Complications ^[17][19][21]

General complications

• Increased risk of perioperative VTE and pulmonary embolism in transgender women receiving estrogen ^[19][23]
• Necrosis of the nipples in patients who have had chest surgery
• Urinary tract infections following any genital surgery

Complications of male-to-female genital surgery

• Wound dehiscence ^[24][25]
• Necrosis of vagina and labiae
• Rectovaginal and urethrovaginal fistulae
• Urethral stenosis and urinary retention ^[21]
• Constricted introitus and insufficient vaginal depth
• Additional complications due to the use of a bowel segment in intestinal vaginoplasty

Complications of female-to-male genital surgery

• Urethral stenosis and fistulae ^[21]
• Necrosis of neophallus
• Persistent discharge, fistulae, and abscesses in patients with incomplete vaginectomy ^[21]

Urinary retention is a common complication following gender-affirming surgery. ^[21]

Gender-affirming treatments such as hormone medication or surgery may have a permanent impact on patients' fertility, and counseling on future family planning should be offered prior to starting treatment. Because fertility may still be possible despite treatment, clinicians should ensure that patients are fully aware of their contraceptive options.

Fertility

Fertility preservation rates in transgender individuals are low despite a high expressed desire for children; possible explanations are insufficient knowledge on the part of health care providers, high cost, and individual concerns about the invasiveness of the treatment. ^[26][27]

Contraception ^[29][30]

Patients who retain their gonads may still become pregnant or impregnate a sexual partner and should, therefore, be offered counseling on contraception. Counseling is particularly important for transgender men, as testosterone therapy is teratogenic.

• Transgender women: condoms or vasectomy
• Transgender men
  • Hormonal contraception
    • Oral: e.g., a progestin-only pill such as desogestrel or levonorgestrel
    • Progestin IUD or subdermal progestin implant
  • Nonhormonal contraception: e.g., copper IUD or bilateral tubal ligation

Contraceptive counseling is mandatory for transgender individuals and they should be advised that testosterone therapy is teratogenic. ^[28]

Pregnancy and lactation in transgender patients ^[27][28]

Transgender men may become pregnant. Data and clinical guidance on pregnancy (planned or unplanned) in transgender men are limited.

Considerations during pregnancy

• Testosterone should be stopped because of its teratogenic effects.
• Preferred anatomical terminology should be established with the patient.
• When possible, transabdominal ultrasound should be offered rather than transvaginal ultrasound.
• Gender dysphoria may worsen during pregnancy and delivery.

Considerations during lactation

• Chestfeeding may be possible following pregnancy, or it may be induced in both transgender men and women without prior gestation via hormone administration. ^[31]
• The decision to continue GAHT during lactation should be made in collaboration with the patient.
  • Hormones such as testosterone may suppress lactation.
  • There is a paucity of evidence on the safety of using GAHT during lactation.
• Infant latch may be difficult if chest surgery has been performed.

Most principles of preventive health care are the same for transgender and cisgender patients. Patients should be offered appropriate age-based screening and general preventive health advice (e.g., healthy eating, exercise, smoking cessation).

Disease risk

Risks for certain diseases can vary between transgender and cisgender persons. Risks can be influenced by whether or not individuals have undergone gender-affirming surgery or are taking hormones and at which age gender-affirming treatment was performed or started.

Cancer screening for transgender individuals

• Do not make assumptions about what reproductive body parts patients may have or what screening should be offered.
• Clarify the person's gender identity, sex assigned at birth, and previous gender-affirming procedures, and offer screening that is appropriate to their bodies (see also “Approach to the clinical evaluation”).
• Bear in mind that patients may be uncomfortable with the screening of body parts that are incongruent with their gender identity.