Transgender Health

The World Health Organization (WHO) defines gender incongruence as “a marked and persistent incongruence between an individual’s experienced gender and the assigned sex, which often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual’s body align, as much as desired and to the extent possible, with the experienced gender.”

Although estimates are imprecise, survey-based studies estimate that 0.3%-0.5% of adults and 1.2%-2.7% of children and adolescents identify as transgender. The number of children and adolescents seeking gender-affirming medical care also appears to be increasing. For details on transgender care in pediatrics, please refer to the Pediatric Endocrinology rotation guide.

In this section, we review the following:

• Definitions

• Presentation and Assessment

• Endocrine Management

• Surgical Options

• Regular Health Maintenance

• Creating an Affirming Environment

Definitions

Presentation and Assessment

• Gender incongruence can be established based on history (patient report) alone. Many patients find it helpful to explore their gender identity with the help of a therapist with expertise in gender incongruence.

• Due to high rates of discrimination, marginalization, and stigmatization, transgender individuals are at higher risk of experiencing adverse social determinants of health as well as mental health concerns (e.g., depression, anxiety, and post-traumatic stress disorder). As a result, the medical history should include details of sexual history, social history, and mental health history.

• If a mental health disorder is suspected or identified, referral to a mental health provider for comanagement is appropriate.

• Because hormones and surgery can reduce fertility, patients should be assessed for their desire for fertility and interest in exploring fertility preservation.

Endocrine Management

• Children and adolescents:

  • Pharmacologic management has no role in prepubertal children.

  • In early puberty, a common approach is to postpone puberty with the use of a gonadotropin-releasing hormone (GnRH) agonist until the adolescent is older.

• Adults:

  • Not every patient with gender incongruence wants or needs hormones; when used, the goal of hormone therapy is to help the patient affirm their gender identity by promoting a physical appearance that is more congruent with their gender identity.

    • To feminize the body, estrogen is prescribed, usually with a second medication to block or lower testosterone.

    • To masculinize the body, the standard approach is to prescribe testosterone.

    • While on hormonal therapy, typical follow-up is every 3 months to ensure that the patient is doing well and progressing phenotypically, hormones levels are at target, and there is no laboratory evidence of side effects.

(Source: Care of Transgender Persons. N Engl J Med 2019.)

Surgical Options

Physical changes from hormones are slow, and the full effect can take upward of 3 years. Even when fully established, patients may be dissatisfied with their physical appearance. Some of these concerns can be addressed nonsurgically (e.g., laser hair removal). Other concerns require surgery, including facial feminization surgery, breast reduction or augmentation, and reconstructive genitourinary surgery. The following figure illustrates typical approaches to genital reconstruction surgery.

(Source: Care of Transgender Persons. N Engl J Med 2019.)

Regular Health Maintenance

For routine health care maintenance, refer to the table below. Of note, the approach is unclear for gender-specific risk calculators (e.g., atherosclerotic cardiovascular disease [ASCVD] risk calculators or fracture risk assessment tools [FRAX]). Clinicians often calculate the risk for both male and female sex and then use clinical judgment to decide how to interpret risk estimates. For lab reference ranges, the range that matches the hormonal environment is typically used. Spirometry or bone densitometry reference ranges that differ by gender are less certain.

Creating an Affirming Environment

Transgender patients experience disproportionately high rates of medical stigmatization, discrimination, and lack of access to care. The number of providers with expertise in transgender medicine is limited, and transgender treatment is not adequately taught in conventional medical curricula. According to the U.S. Transgender Survey, 63% of participants experienced serious acts of discrimination, including but not limited to job loss, eviction, physical assault, and sexual assault.

Due to this discrimination, even in health care settings, providers must make efforts to create a more inclusive and affirming environment for transgender patients. Practical considerations include:

• hiring more gender-diverse staff

• training all staff to use correct pronouns and names

• partnering with community programs

• advocating for insurance coverage of medical or surgical therapies

• modifying the electronic health system (EHR) to accommodate gender diversity

• practicing trauma-informed care

• ensuring forms include gender-diverse options

• adding images of gender-diverse people to marketing materials

• offering all-gender bathrooms

• highlighting nondiscrimination policies

• enforcing policies that prohibit disrespectful behavior based on gender identity

• displaying stickers, flags, and other signals that you ally with the patient