Transgender patients: Providing sensitive care

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Applied Evidence

Transgender patients: Providing sensitive care

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

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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.

Male-to-female transition

CASE 2 ›

Before heading into your office to talk to a new patient named Carl S, you glance at his chart and see that he is a healthy 21-year-old who has come in for a routine physical. When you enter the room, you find Carl wearing a dress, heels, and make-up. After confirming that you have the right patient, you ask, “What is your current gender identity?” “Female,” says Carl, who indicates that she now goes by Carol. The patient has no medical problems, surgical history, or significant family history, but reports that she has been taking spironolactone and estrogen for the past 3 years. Carol also says she has a new female partner and is having unprotected sexual activity.

Feminizing hormone treatment

The desired effects of feminizing hormones include voice change, decreased hair growth, breast growth, body fat redistribution, decreased muscle mass, skin softening, decreased oiliness of skin and hair, and a decrease in spontaneous erections, testicular volume, and sperm production.^10,11 The onset of feminizing effects ranges from one month to one year and the expected maximum effect occurs anywhere between 3 months and 5 years.^10,11 Regimens usually include anti-androgen agents and estrogen.^13,26-28

The medications that have been most studied with anti-androgenic effects include spironolactone and 5-alpha reductase inhibitors (5-ARIs) such as finasteride. Spironolactone inhibits testosterone secretion and inhibits androgen binding to androgen receptors; 5-ARIs block the conversion of testosterone to 5-alpha-dihydrotestosterone, the more active form.

Males transitioning to females should undergo breast cancer screening beginning at 40 to 50 years of age if they remain on hormone therapy.

Estrogen can be administered via oral, sublingual, transdermal, or intramuscular route, but parenteral formulations are preferred to avoid first-pass metabolism. The serum estradiol target is similar to the mean daily level of premenopausal women (<200 pg/mL) and the level of testosterone should be in the normal female range (<55 ng/dL).^13,26-28

The selection of medications should be individualized for each patient. Comorbidities must be considered, as well as the risk of adverse effects, which include venous thromboembolism, elevated liver enzymes, breast cancer, cardiovascular disease, diabetes, hyperprolactinemia, weight gain, gallstones, cerebrovascular disease, and severe migraine headaches.^10,11 Estrogen therapy is not reported to induce hypertrophy or premalignant changes in the prostate.³³ As is the case for masculinizing hormones, feminizing hormone therapy should be continued indefinitely for long-term effects.

Frequent monitoring is recommended. Patients on feminizing hormones (transwomen) should be seen every 2 to 3 months in the first year and monitored once or twice a year thereafter. Serum testosterone and estradiol levels should initially be monitored every 3 months; serum electrolytes, specifically potassium, should be monitored every 2 to 3 months in the first year until stable.

CASE 2 ›

You recommend that Carol S be screened annually for sexually transmitted diseases, as you would for any 21-year-old patient. You point out, too, that while estrogen and androgen-suppressing therapy decrease sperm production, there is a possibility that the patient could impregnate a female partner and recommend that contraception be used if the couple is not trying to conceive.

You also discuss the risks and benefits of hormone therapy and reasonable expectations of continued treatment. You ask Carol to schedule a follow-up visit in 6 months, as her hormone regimen is stable. Finally, if the patient remains on hormone therapy, you mention that the only screening unique to men transitioning to women is for breast cancer, which should begin at 40 to 50 years of age (as it is for all women).

Gender-affirming surgical options

Nearly 9 in 10 transgender youth report being verbally harassed at school because of their gender expression. More than half report being physically harassed.

Surgical management of transgender patients is not within the scope of family medicine. But it is essential to know what procedures are available as you may have occasion to advocate for patients during the surgical referral process and possibly to provide postoperative care.

For transmen, surgical options include chest reconstruction, hysterectomy/oophorectomy, metoidioplasty (using the clitoris to surgically approximate a penis), phalloplasty, scrotoplasty, urethroplasty, and vaginectomy.^10,34The surgeries available for transwomen are orchiectomy, vaginoplasty, penectomy, breast augmentation, thyroid chondroplasty and voice surgery, and facial feminization.^10,34 Keep in mind that not all transgender individuals desire surgery as part of the transitioning process.

CORRESPONDENCE
Abbas Hyderi, MD, MPH, 1919 West Taylor Street, M/C 663, Chicago, IL 60612; ahyder2@uic.edu.

The authors would like to acknowledge the assistance of Michelle Forcier, MD, MPH, and Karen S. Bernstein, MD, MPH, in the preparation of this manuscript.