CLINICAL ACTIONS:

ACOG has published an updated guidelines that addresses the provision of “inclusive and affirming care as well as clinical information on hormone therapy and preventive care” as well as “resources for those seeking information on the care of transgender adolescents.” Prior to initiating gender-affirming treatment, the diagnosis of gender dysphoria should be made by a mental health professional skilled in the area.  Individuals must be capable of understanding both benefits and risks of treatments as well as implications for future fertility.

Diagnosis

• The American Psychiatric Association DSM V provides criteria for gender dysphoria which is based on marked incongruence between assigned and expressed gender lasting at least six months manifested by ≥2 of the following
  • Discord between experienced/expressed gender and primary (or secondary) sex characteristics or anticipated sex characteristics
  • Strong desire to be rid of one’s primary and/or secondary sex characteristics
  • Strong desires for sex characteristics of alternative gender
  • Strong desire to be an alternative gender
  • Strong desire to be treated as an alternative gender
  • Strong conviction that one has feelings and reactions of an alternative gender

AND

• Clinically significant distress or impairment in social, occupational, or other important areas of functioning

SYNOPSIS:

Transgender individuals experience health care inequities and poorer health outcomes due to social and economic marginalization.  29% of transgender individuals living in poverty and had experienced homelessness at one point in their life.  Therefore, inclusive health care of the transgender patient requires a safe and sensitive clinical environment, including gender-neutral forms, brochures and information for sexual minorities, and use of open-ended questions about a patient’s gender identity, sexual orientation, transition and therapy.  Resources for evidence-based care include the World Professional Association for Transgender Health, the Endocrine Society, and the Pediatric Endocrine Society can be found in the ‘Learn More – Primary Sources’ section.

Background and Barriers to Care

• Barriers to care include
  • Health care inequities which are rampant in transgender individuals resulting in some e individuals avoiding resources due to stigma or mistreatment
  • Obstacles for insurance coverage
    • Denial of hormone therapy:25%
    • Coverage for transition-related surgery: 55%
• Overcoming barriers
  • Create an inclusive environment for transgender and gender non-conforming individuals
  • Train staff regarding appropriate ways to assess names and preferred pronouns
  • Include images and artwork representative of all individuals
  • Post the office’s non-discrimination policy
  • Use forms that include open-ended free response or include all gender and sexual orientation options
  • Create systems that easily displays preferred names, pronouns, and gender markers

Note: Example of welcoming language

 “Hello, I am Dr. X and I use she/her pronouns. Is the name on your chart what you would like me to call you? What pronouns do you use?”

Gender Transition

• Majority of medications for gender transition are common and can be safely prescribed
• Fertility preservation, parenting desires, and contraception should be discussed prior to initiation of transition
• Pregnancy may trigger unwelcome feelings or may prefer neutral language such as ‘parent’ instead of ‘mother’ and ‘chestfeed’ in lieu of breastfeeding
• Testosterone therapy is recommended to resume only after completion of chestfeeding due to suppression of milk production
• Transfeminine individuals should be encouraged to utilize sperm banking prior to hormone initiation due to concern for testicular damage after long-term estrogen exposure
• Methods are available that assist with lactation in those desiring to breastfeed
• Identify patient goals prior to hormone therapy

Medical Transition

Masculinizing Therapy

• Goals May include
  • Facial hair | Voice deepening | Increased body hair and muscle
• Other androgenic effects
  • Change in sweat and odor | Hairline recession | Male-pattern balding | Increased libido | Vaginal atrophy | Increased clitoral size
• Absolute contraindications
  • Current Pregnancy | Unstable coronary artery disease | Polycythemia vera (Hct >55%)
• Testosterone therapy monitoring
  • Check lipid profiles due to HDL decrease and triglyceride increase
• Testosterone preparations come in many varieties in the US including injectables (most commonly used) and gels, creams, patches or pellets
  • Testosterone level targets are normal physiologic male range (320 to 1,000 ng/dL)
  • Oral route is typically dosed 160 to 240 mg per day | Parenteral route is typically 50 to 200 mg per week or 100 to 200 mg every 10 to 14 days | Implant is dosed 75 mg | Transdermal gel is 2.5 to 10 g/day while the patch is 2.5 to 7.5 mg/day
• Side effects
  • Persistent spotting or bleeding can be treated with progesterone | Vaginal atrophy can be treated with lubricants, vaginal moisturizer, and topical estrogen

Note: Masculinizing testosterone therapy is not associated with increased risk for cardiovascular events

Feminizing Therapy

• Goals may include
  • Breast growth, decreased testicular size
• Other effects: Decreased erectile function | Increased body fat percentage
• No absolute contraindications
• Risks may include
  • VTE | Hypertriglyceridemia | Gallstone development | Liver dysfunction | Elevated liver enzymes
• Routine labwork for monitoring includes
  • Estradiol | Total testosterone levels | Sex hormone binding globulin | Albumin levels | Monitor every 3 months the first year
  • Goal: Estradiol <200 ng/mL and testosterone <55 ng/dL
• Preparations include oral, parenteral, transdermal, and anti-androgens | Transdermal preferred for those with risk factors | 17-beta estradiol preferred for oral formulations
  • Estradiol oral dosage is typically 2 to 4 mg daily | Parenteral is 5 to 30 mg every two weeks | Transdermal is 0.1 to 0.4mg twice weekly | Anti-androgens (progesterone, depo, GnRH agonist) are administered using the typical doses
  • Spironolactone 100 to 200mg daily is the most common anti-androgen | Requires monitoring for potassium and creatinine abnormalities every 3 months the first year

Note: Because feminizing hormones do not affect vocal pitch, referral to a speech language pathologist with specific training in this area may be of benefit to those individuals who find this a concern | Ethinyl estradiol increases risk of VTE and is not indicated (cycle control not required in transgender women)

Surgical Transition

• Many insurance companies require mental health assessment letter
• University of San Francisco’s Center of Excellence for Transgender Health has excellent resources for gender-affirming surgery care (see ‘Learn More – Primary Sources’ section)

Masculinizing Surgery

• Transmasculine surgery includes chest reconstruction, hysterectomy, metoidioplasty, or phalloplasty
• If a patient desires a hysterectomy, the procedure is considered medically necessary, with or without salpingo-oophorectomy
  • Shared decision-making should be employed when discussing oopherectomy | Include discussion regarding fertility desires and long-term hormonal usage
  • Testosterone therapy sufficient to prevent bone demineralization without increased risk for cardiovascular events | However, lack of access to continuous testosterone prescription may hinder continuity

Feminizing Surgery

• Feminizing surgery includes breast augmentation, orchiectomy, vaginoplasty, and facial feminization surgeries
  • Majority of respondents desired, or had undergone vaginoplasty (87%) and majority (74%) desired, or had undergone, breast augmentation
  • Hormone therapy should be initiated at least 6 months, if not 2 to 3 years, prior to breast augmentation to allow maximum effects
• Post-op care after vaginoplasty with a local ObGyn is common, given the limited number of centers providing vaginoplasty procedures
  • After vaginoplasty, the vagina will not self-lubricate as it is covered by skin as opposed to mucosa | Recommend vaginal dilators and lubrication
  • Pelvic floor physical therapy can be considered for persistent pain
  • Retained lubricant or semen, or dead skin and sebum from skin lining the vagina can cause significant vaginal discharge and can clean or douche with soap | Consider cleansing solution with vinegar if exceptionally strong odor
  • Granulation tissue can be treated with silver nitrate

Contraception

• Contraception is required even with hormone therapy
  • Patients should be counseled the cessation of menses, or hormone therapy, does not provide adequate protection against pregnancy
  • Transmasculine individuals that cease testosterone may safely achieve pregnancy after discontinuation of medications
• Barrier methods for STI prevention should be discussed
• Hormonal contraception, including estrogen-containing compounds, for transmasculine individuals are acceptable even with concurrent testosterone use
  • Little data to show that estrogen-containing compounds change the masculinization effects seen with testosterone

Cancer Screening and Preventative Care

• Transmasculine individuals
  • Include routine recommendations for all organs present, including breast cancer screening (if residual breast tissue) and cervical cancer screening
  • Cervical cancer screening more likely to have unsatisfactory Pap tests compared to cisgender patients with many patients preferring self-collected vaginal HPV swab
  • Increased screening for endometrial cancer is not required

• Transfeminine individuals
  • Routine cytologic screening not required
  • Continue routine prostate cancer screening
  • Breast cancer screening requires discussion on benefits versus risks | Transfeminine individuals have dense breasts with potential for false-negative results
  • Breast cancer screening should begin after (a) prolonged hormone use of 5 years or more and (b) 50 years of age

Preventative Care Considerations

• Mental health screening should be standard with 40% lifetime risk of attempting suicide for transgender patients
• Screening for HIV is extremely important | Rates of HIV are five times higher in transgender population compared to general population

KEY POINTS:

• Offering an inclusive health care environment, from the front desk to the office signage, is extremely important to being to mitigate the gap in health equity for transgender patients
• Informed consent process is more appropriate for treatment of gender dysphoria then the previous document-heavy historical requirements of a referral letter from a mental health professional
• The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People, published by the World Professional Association for Transgender Health, is an excellent resource on transgender care (see ‘Learn More – Primary Care’, below)
• Hormone therapy is medically necessary treatment for gender dysphoria and uses common medications, like testosterone and estrogen, that can be safely prescribed by a wide range of primary care and specialist clinicians
• Hormone therapy does not prevent pregnancy, therefore discussion of initiation of hormone therapy should include topics of fertility, parenting desires, and contraception
• Masculinizing therapy requires monitoring of lipid levels | Only contraindications include: current pregnancy, unstable coronary artery disease, and polycythemia vera (Hct >55%)
• Feminizing therapy requires evaluation every 3 months of estradiol and total testosterone levels, sex hormone binding globulin, and albumin levels and should avoid ethinyl estradiol due to increased risk of VTE compared to other formulations
• Preventative care should continue routinely for any organs still presents: breast, cervix, prostate
• Preventative care should also include screening for mental health, and STI screening, including HIV given higher risk in the transgender population

Professional Organizations

ACOG

• ACOG addresses issues regarding discrimination and states

The American College of Obstetricians and Gynecologists opposes discrimination on the basis of gender identity, urges public and private health insurance plans to cover necessary services for individuals with gender dysphoria, and advocates for inclusive, thoughtful, and affirming care for transgender individuals.

World Professional Association for Transgender Health

• Although the American Psychiatric Association’s DSM V includes the diagnosis “gender dysphoria”, allowing for insurance coverage for medically necessary procedures such as hysterectomy, The World Professional Association for Transgender Health notes that

the expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally diverse human phenomenon [that] should not be judged as inherently pathological or negative

Learn More — Primary Sources:

ACOG Committee Opinion 823. Health Care for Transgender and Gender Diverse Individuals

The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People, published by the World Professional Association for Transgender Health

American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders

Center of Excellence for Transgender Health | Division of Prevention Science (ucsf.edu)

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