Transgender women: Evaluation and management
- Vin Tangpricha, MD, PhD
Vin Tangpricha, MD, PhD
- Associate Professor
- Emory University School of Medicine
- Joshua D Safer, MD, FACP
Joshua D Safer, MD, FACP
- Associate Professor of Medicine and Molecular Medicine
- Boston University School of Medicine
- Section Editors
- Peter J Snyder, MD
Peter J Snyder, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Pituitary Disease; Male Reproductive Endocrinology
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Alvin M Matsumoto, MD
Alvin M Matsumoto, MD
- Section Editor — Male Reproductive Endocrinology
- Professor of Medicine
- University of Washington School of Medicine
The terms transgender and gender incongruence describe a situation where an individual's gender identity differs from external sexual anatomy at birth. Health care providers should be familiar with commonly used terms (table 1). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries as well as other procedures such as hair removal or speech therapy .
This topic will use the term transgender in the broadest sense to include any person with incongruence between gender identity and external sexual anatomy at birth. The evaluation and management of transgender women are discussed here. The evaluation and management of transgender men, the primary care of the transgender adult, and gender nonconformity in children and adolescents are reviewed separately. (See "Transgender men: Evaluation and management" and "Primary care of transgender individuals" and "Overview of gender development and clinical presentation of gender nonconformity in children and adolescents" and "Overview of the management of gender nonconformity in children and adolescents".)
STANDARDS OF CARE
Several large medical professional organizations have issued guidelines to assist providers in the care of transgender individuals (the World Professional Association for Transgender Health [WPATH] , the Endocrine Society , the American Congress of Obstetricians and Gynecologists [ACOG] ).
Prevalence — Previous research had suggested that 0.3 to 0.5 percent of the adult population was transgender [4,5]. The prevalence of transgender depends upon the definition used to classify a person as transgender. In studies that included only individuals who had undergone hormone therapy, gender-affirming surgery, or had diagnostic codes documenting transgender, the reported prevalence of transgender was 7 to 9 per 100,000 people . However, studies that include transgender status based upon self-report indicate a prevalence of transgender of approximately 871 per 100,000 people .
Although the mechanisms remain unclear, there is evidence for a biologic basis of gender identity .
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- STANDARDS OF CARE
- INITIAL PRESENTATION
- Psychiatric comorbidity
- OVERVIEW OF APPROACH
- Initial assessment
- Counseling before treatment
- Individualized approach
- Hormone therapy goals
- Criteria for starting treatments
- EVALUATION AND DIAGNOSIS
- Diagnostic criteria
- Gender dysphoria
- HORMONAL THERAPY
- Transgender women (male-to-female, MTF)
- - Suppression of androgen secretion or action
- GnRH agonists
- - Estrogen
- - Clinical outcomes
- - Monitoring
- - Long-term maintenance therapy
- - Major adverse events
- Cautions when using estrogen therapy
- Fertility considerations
- GENDER CONFIRMATION SURGERY
- Sexual function after gender confirmation surgery
- Regrets after gender confirmation surgery
- PSYCHOSOCIAL OUTCOMES OF TREATMENT
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS