Transgender patients: Providing sensitive care

,; ,; ,

Applied Evidence

Transgender patients: Providing sensitive care

J Fam Pract. 2016 July;65(7):450-452,457-461

PDF Download

References

1. Pew Research Center. A survey of LGBT Americans: attitudes, experiences and values in changing times. Available at: http://www.pewsocialtrends.org/2013/06/13/a-survey-of-lgbt-americans. Accessed June 24, 2015.

2. Gates GJ. How many people are lesbian, gay, bisexual and transgender? Available at: http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf. Accessed May 25, 2016.

3. van Kesteren PJ, Gooren LJ, Megens JA. An epidemiological and demographic study of transsexuals in The Netherlands. Arch Sex Behav. 1996;25:589-600.

4. Bhola S. An ally’s guide to terminology: talking about LGBT people & equality. Available at: http://www.glaad.org/2011/07/28/an-allys-guide-to-terminology-talking-about-lgbt-people-equality. Accessed June 24, 2015.

5. University of California, San Francisco. Transgender terminology. UCSF Center of Excellence for Transgender Health. Available at: http://transhealth.ucsf.edu/tcoe?page=protocol-terminology. Accessed June 24, 2015.

6. Istar A. How queer! the development of gender identity and sexual orientation in LGBTQ-headed families. Fam Process. 2010;49:268-290.

7. Goins ES, Pye D. Check the box that best describes you: reflexively managing theory and praxis in LGBTQ health communication research. Health Commun. 2013;28:397-407.

8. American Psychiatric Association. Gender dysphoria. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: American Psychiatric Association. 2013:451-459.

9. World Health Organization. The International Classification of Diseases, 10th rev. Classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. 1992; Geneva.

10. Coleman E, Bockting W, Botzer M, et al; World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgender. 2011;13:165–232.

11. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine Treatment of transsexual persons: an Endocrine Society Clinical Practice Guideline. J Clin Endo Metabol. 2009;94:3132–3154.

12. University of California, San Francisco. Assessing readiness for hormones. UCSF Center of Excellence for Transgender Health. Available at: http://transhealth.ucsf.edu/tcoe?page=protocol-hormone-ready. Accessed June 24, 2015.

13. Gooren L. Hormone treatment of the adult transsexual patient. Horm Res. 2005;64(suppl 2):S31-S614.

14. Hembree WC. Guidelines for pubertal suspension and gender reassignment for transgender adolescents. Child Adolesc Psychiatr Clin N Am. 2011;20:725-732.

15. Gay, Lesbian, and Straight Education Network (GLSEN). Harsh realities. The experiences of transgender youth in our nation’s schools. Available at: https://www.glsen.org/sites/default/files/Harsh%20Realities.pdf. Accessed May 29, 2016.

16. Berman M, Balingit M. Eleven states sue Obama administration over bathroom guidance for transgender students. May 25, 2016. Washington Post. Available at: https://www.washingtonpost.com/news/post-nation/wp/2016/05/25/texas-governor-says-state-will-sue-obama-administration-over-bathroom-directive/. Accessed May 31, 2016.

17. de Vries AL, Cohen-Kettenis PT, Delemarre-van de Waal H. Clinical management of gender dysphoria in adolescents. 2006. Vancouver Coastal Health - Transgender Health Program. Available at: http://www.amsa.org/wp-content/uploads/2015/04/CaringForTransgenderAdolescents.pdf. Accessed May 26, 2016.

18. TransYouth Family Allies. Empowering transgender youth & families. Available at: http://www.imatyfa.org/. Accessed May 26, 2016.

19. Human Rights Campaign. On our own: a survival guide for independent LGBTQ youth. Available at: https://www.hrc.org/resources/on-our-own-a-survival-guide-for-independent-lgbtq-youth. Accessed May 26, 2016.

20. Gay, Lesbian, Bisexual, and Transgender National Help Center. Available at: www.glbthotline.org. Accessed May 31, 2016.

21. University of California, San Francisco. Hormone administration. UCSF Center of Excellence for Transgender Health. Available at: http://transhealth.ucsf.edu/trans?page=protocol-hormones. Accessed December 12, 2015.

22. Gorin-Lazard A, Baumstarck K, Boyer L, et al. Hormonal therapy is associated with better self-esteem, mood, and quality of life in transsexuals. J Nerv Ment Dis. 2013;201:996-1000.

23. Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in adult men with androgen deficiency syndromes: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2006;91:1995-2010.

24. Boloña ER, Uraga MV, Haddad RM, et al. Testosterone use in men with sexual dysfunction: a systematic review and meta-analysis of randomized placebo-controlled trials. Mayo Clin Proc. 2007;82:20-28.

25. Gooren LJ, Giltay EJ. Review of studies of androgen treatment of female-to-male transsexuals: effects and risks of administration of androgens to females. J Sex Med. 2008;5:765-776.

26. Levy A, Crown A, Reid R. Endocrine intervention for transsexuals. Clin Endocrinol (Oxf). 2003;59:409-418.

27. Moore E, Wisniewski A, Dobs A. Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects. J Clin Endocrinol Metab. 2003;88:3467-3473.

28. Tangpricha V, Ducharme SH, Barber TW, et al. Endocrinologic treatment of gender identity disorders. Endocr Pract. 2003;9:12-21.

29. Dickersin K, Munro MG, Clark M, et al. Hysterectomy compared with endometrial ablation for dysfunctional uterine bleeding: a randomized control trial. Obstet Gynecol. 2007;110:1279-1289.

30. Prasad P, Powell MC. Prospective observational study of thermablate endometrial ablation system as an outpatient procedure. J Minim Invasive Gynecol. 2008;15:476-479.

31. University of California, San Francisco. General prevention and screening. UCSF Center of Excellence for Transgender Health. Available at: http://transhealth.ucsf.edu/trans?page=protocol-screening. Accessed June 24, 2015.

32. Ganly I, Taylor EW. Breast cancer in a trans-sexual man receiving hormone replacement therapy. Br J Surg. 1995;82:341.

33. Meriggiola MC, Gava G. Endocrine care of transpeople part II: a review of cross-sex hormonal treatments, outcomes and adverse effects in transwomen. Clin Endocrinol (Oxf). 2015;83:607-615.

34. University of California, San Francisco. Surgical options. UCSF Center of Excellence for Transgender Health. Available at: http://transhealth.ucsf.edu/trans?page=protocol-surgery. Accessed December 12, 2015.

Understanding and diagnosing gender dysphoria

Two classification systems are used for diagnoses related to GD: the Diagnostic and Statistical Manual of Mental Disorders, Fifth Ed. (DSM-5)⁸ and the International Classification of Diseases, 10th Rev. (ICD-10).⁹

The transitioning process is a complex and individualized journey that can include inward or outward change, or both.

ICD-10 criteria use the term “gender identity disorder;” DSM-5 refers to “gender dysphoria” instead. It is important to emphasize that these classification systems represent an attempt to categorize a group of signs and symptoms that lead to distress for the patient, and are not meant to suggest that being transgender is pathological. In fact, in DSM-5—released in 2013—the American Psychiatric Association revised the terminology to emphasize that such individuals are not “disordered” by the nature of their identity, but rather by the distress that being transgender causes.⁸

For a diagnosis of GD in children, DSM-5 criteria include characteristics perceived to be incongruent between the child’s sex at birth and the self-identified gender based on preferred activities or dislike of his or her own sexual anatomy. The child must meet 6 or more of the following for at least 6 months:

a repeatedly stated desire to be, or insistence that he or she is, of the other gender
in boys, a preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
strong and persistent preferences for cross-gender roles in make-believe play or fantasy
a strong rejection of toys/games typically associated with the child’s sex
intense desire to participate in stereotypical games and pastimes of the other gender
strong preference for playmates of the other gender
a strong dislike of one’s sexual anatomy
a strong desire for the primary (eg, penis or vagina) or secondary (eg, menstruation) sex characteristics of the other gender.⁸

Adolescents and adults must meet 2 or more of the following for at least 6 months:

a noticeable incongruence between the gender that the patient sees themselves as and their sex characteristics
an intense need to do away with (or prevent) his or her primary or secondary sex features
an intense desire to have the primary and/or secondary sex features of the other gender
a deep desire to transform into another gender
a profound need for society to treat them as someone of the other gender
a powerful assurance of having the characteristic feelings and responses of the other gender.⁸

For children as well as adolescents and adults, the condition should cause the patient significant distress or significantly affect him or her socially, at work or school, and in other important areas of life.⁸

Is the patient a candidate for hormone therapy?

Two primary sources—Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7, issued by the World Professional Association for Transgender Health (WPATH)¹⁰ and Endocrine Treatment of Transsexual Persons¹¹ by the Endocrine Society—offer clinical practice guidance based on evidence and expert opinion.

WPATH recommends that a mental health professional (MHP) experienced in transgender care diagnose GD to ensure that it is not mistaken for a psychiatric condition manifesting as altered gender identity. However, if no one with such experience is available or accessible in the region, it is reasonable for a primary care physician to make the diagnosis and consider initiating hormone therapy without a mental health referral,¹² as the expected benefits outweigh the risks of nontreatment.¹³

Whether or not a MHP confirms a diagnosis of GD, it is still up to the treating physician to confirm the patient’s eligibility and readiness for hormone therapy: He or she should meet DSM-5 or ICD-10 criteria for GD, have no psychiatric comorbidity (eg, schizophrenia, body dysmorphic disorder, or uncontrolled bipolar disorder) likely to interfere with treatment, understand the expected outcomes and the social benefits and risks, and have indicated a willingness to take the hormones responsibly.

Historically, patients were required to have a documented Real-Life Experience (RLE), defined as having fully adopted the new gender role in everyday life for at least 3 months.^10,11This model has fallen out of favor, however, as it is unsupported by evidence and may place transgender individuals at physical and emotional risk.^.Instead, readiness is confirmed by obtaining informed consent.¹²

Puberty may be suppressed with a gonadotropin-releasing hormone (GnRH) agonist in adolescents who have a GD diagnosis and are at Tanner stage 2 to 3 of puberty until age 16. At that point, hormone therapy consistent with their gender identification may be initiated.¹¹ (See “How to help transgender teens.”^11,14-20)