Primary care of transgender individuals
- Jamie Feldman, MD, PhD
Jamie Feldman, MD, PhD
- Associate Professor, Family Medicine and Community Health
- University of Minnesota
- Madeline B Deutsch, MD, MPH
Madeline B Deutsch, MD, MPH
- Associate Professor of Clinical Family and Community Medicine
- University of California - San Francisco
In addition to gender-affirming medical care, transgender people have primary and preventive health care needs that are similar to the general population. Depending on an individual's history of gender-affirming care, primary and preventive care may require special considerations. Transgender patients often experience discrimination in the health care setting and lack of access to medical personnel competent in transgender medicine [1-3]. This results in lack of access to preventive health services and timely treatment of routine health problems [4-6].
This topic will provide an overview for providing primary care to transgender patients. The epidemiology, pathophysiology, and diagnosis as well as the hormonal and surgical treatment of transgender patients are discussed elsewhere. (See "Transgender women: Evaluation and management" and "Transgender men: Evaluation and management".)
The term "transgender" is generally used to describe a diverse group of individuals whose gender identity or expression differs from that assigned at birth (table 1) . Primary care providers should be familiar with commonly used terms (table 1) and the diversity of identities within the transgender community. Natal sex refers to the sex the patient was assigned at birth. For example, transgender women (male to female, MTF) have a female gender identity and were assigned a male sex at birth and transgender men (female to male, FTM) have a male gender identity and were assigned a female sex at birth. Individuals who identify elsewhere along the spectrum of the masculine/feminine gender may use other terms. Gender-affirming care includes hormone therapy and gender-related surgeries, as well as other procedures, such as hair removal or speech therapy.
ROLE OF THE PRIMARY CARE PROVIDER
The role of the primary care provider for transgender patients includes the tasks typical for all patients (eg, primary and secondary prevention), in addition to the specific needs of transgendered individuals . For example, primary care clinicians may be involved in providing medical documentation of a patient's gender, navigating insurance coverage for gender-related interventions, and providing letters for change of gender on identification (eg, passport, driver's license). Referrals may also be sought for gender-affirming surgeries, voice therapy, hair removal through laser or electrolysis, or hair transplant .
Not every primary care clinician will be able to offer all elements of comprehensive transgender care; however, every clinician can become comfortable in working with transgender patients to meet their healthcare needs, including gender-affirming interventions. It is important that primary care providers be aware that patients may vary widely in terms of anatomy and hormonal status when they present, and these attributes may further change over time.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Daniel H, Butkus R, Health and Public Policy Committee of American College of Physicians. Lesbian, Gay, Bisexual, and Transgender Health Disparities: Executive Summary of a Policy Position Paper From the American College of Physicians. Ann Intern Med 2015; 163:135.
- Schuster MA, Reisner SL, Onorato SE. Beyond Bathrooms--Meeting the Health Needs of Transgender People. N Engl J Med 2016; 375:101.
- Safer JD, Coleman E, Feldman J, et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes 2016; 23:168.
- Grant JM, Mottet LA, Tanis J, et al. Injustice at every turn: A report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Task Force; Washington, DC 2011.
- Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. Washington DC: National Academies Press; 2011 www.iom.edu (Accessed on November 19, 2014).
- Vogel L. Screening programs overlook transgender people. CMAJ 2014; 186:823.
- Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet 2016; 388:390.
- Wylie K, Knudson G, Khan SI, et al. Serving transgender people: clinical care considerations and service delivery models in transgender health. Lancet 2016; 388:401.
- Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend 2012; 13:165.
- Rotondi NK, Bauer GR, Scanlon K, et al. Nonprescribed hormone use and self-performed surgeries: "do-it-yourself" transitions in transgender communities in Ontario, Canada. Am J Public Health 2013; 103:1830.
- Center of Excellence for Transgender Health. Primary care protocol for transgender patient care, 2nd ed, Deutsch MB (Ed), University of California, San Francisco 2016.
- Baba T, Endo T, Honnma H, et al. Association between polycystic ovary syndrome and female-to-male transsexuality. Hum Reprod 2007; 22:1011.
- Mueller A, Gooren LJ, Naton-Schötz S, et al. Prevalence of polycystic ovary syndrome and hyperandrogenemia in female-to-male transsexuals. J Clin Endocrinol Metab 2008; 93:1408.
- Calvar C, Fernandez M, Duran Y, et al. Polycystic ovary syndrome (Pcos) in female-to-male (Ftm) transsexual persons. Endocrine Abstracts 2016.
- Becerra-Fernández A, Pérez-López G, Román MM, et al. Prevalence of hyperandrogenism and polycystic ovary syndrome in female to male transsexuals. Endocrinol Nutr 2014; 61:351.
- Bauer GR, Travers R, Scanlon K, Coleman TA. High heterogeneity of HIV-related sexual risk among transgender people in Ontario, Canada: a province-wide respondent-driven sampling survey. BMC Public Health 2012; 12:292.
- Nuttbrock L, Hwahng S, Bockting W, et al. Lifetime risk factors for HIV/sexually transmitted infections among male-to-female transgender persons. J Acquir Immune Defic Syndr 2009; 52:417.
- Brennan J, Kuhns LM, Johnson AK, et al. Syndemic theory and HIV-related risk among young transgender women: the role of multiple, co-occurring health problems and social marginalization. Am J Public Health 2012; 102:1751.
- Sevelius JM. Gender Affirmation: A Framework for Conceptualizing Risk Behavior among Transgender Women of Color. Sex Roles 2013; 68:675.
- Sevelius J. "There's no pamphlet for the kind of sex I have": HIV-related risk factors and protective behaviors among transgender men who have sex with nontransgender men. J Assoc Nurses AIDS Care 2009; 20:398.
- Feldman J, Romine RS, Bockting WO. HIV risk behaviors in the U.S. transgender population: prevalence and predictors in a large internet sample. J Homosex 2014; 61:1558.
- Nuttbrock L, Rosenblum A, Blumenstein R. Transgender identity affirmation and mental health. Int J Transgend 2002; 6:1.
- Schlatterer K, Yassouridis A, von Werder K, et al. A follow-up study for estimating the effectiveness of a cross-gender hormone substitution therapy on transsexual patients. Arch Sex Behav 1998; 27:475.
- Tangpricha V, Ducharme SH, Barber TW, Chipkin SR. Endocrinologic treatment of gender identity disorders. Endocr Pract 2003; 9:12.
- Roberts TK, Kraft CS, French D, et al. Interpreting laboratory results in transgender patients on hormone therapy. Am J Med 2014; 127:159.
- 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 Endocrinol Metab 2009; 94:3132.
- Asscheman H, Giltay EJ, Megens JA, et al. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol 2011; 164:635.
- Blosnich JR, Brown GR, Wojcio S, et al. Mortality Among Veterans with Transgender-Related Diagnoses in the Veterans Health Administration, FY2000-2009. LGBT Health 2014; 1:269.
- Gooren LJ, Giltay EJ, Bunck MC. Long-term treatment of transsexuals with cross-sex hormones: extensive personal experience. J Clin Endocrinol Metab 2008; 93:19.
- Elamin MB, Garcia MZ, Murad MH, et al. Effect of sex steroid use on cardiovascular risk in transsexual individuals: a systematic review and meta-analyses. Clin Endocrinol (Oxf) 2010; 72:1.
- Wierckx K, Elaut E, Declercq E, et al. Prevalence of cardiovascular disease and cancer during cross-sex hormone therapy in a large cohort of trans persons: a case-control study. Eur J Endocrinol 2013; 169:471.
- Gooren LJ, Wierckx K, Giltay EJ. Cardiovascular disease in transsexual persons treated with cross-sex hormones: reversal of the traditional sex difference in cardiovascular disease pattern. Eur J Endocrinol 2014; 170:809.
- Wierckx K, Mueller S, Weyers S, et al. Long-term evaluation of cross-sex hormone treatment in transsexual persons. J Sex Med 2012; 9:2641.
- Feldman J. Preventive care of the transgender patient. In: Principles of Transgender Medicine and Surgery, Ettner R, Monstrey S, Coleman E (Eds), Routledge, 2016.
- Elbers JM, Giltay EJ, Teerlink T, et al. Effects of sex steroids on components of the insulin resistance syndrome in transsexual subjects. Clin Endocrinol (Oxf) 2003; 58:562.
- Elbers JM, Asscheman H, Seidell JC, Gooren LJ. Effects of sex steroid hormones on regional fat depots as assessed by magnetic resonance imaging in transsexuals. Am J Physiol 1999; 276:E317.
- Koh-Banerjee P, Wang Y, Hu FB, et al. Changes in body weight and body fat distribution as risk factors for clinical diabetes in US men. Am J Epidemiol 2004; 159:1150.
- Resnick HE, Valsania P, Halter JB, Lin X. Relation of weight gain and weight loss on subsequent diabetes risk in overweight adults. J Epidemiol Community Health 2000; 54:596.
- Glueck CJ, Lang J, Hamer T, Tracy T. Severe hypertriglyceridemia and pancreatitis when estrogen replacement therapy is given to hypertriglyceridemic women. J Lab Clin Med 1994; 123:59.
- Goldenberg NM, Wang P, Glueck CJ. An observational study of severe hypertriglyceridemia, hypertriglyceridemic acute pancreatitis, and failure of triglyceride-lowering therapy when estrogens are given to women with and without familial hypertriglyceridemia. Clin Chim Acta 2003; 332:11.
- Perego E, Scaini A, Romano F, et al. Estrogen-induced severe acute pancreatitis in a male. JOP 2004; 5:353.
- Ott J, Aust S, Promberger R, et al. Cross-sex hormone therapy alters the serum lipid profile: a retrospective cohort study in 169 transsexuals. J Sex Med 2011; 8:2361.
- Feldman J. Medical and surgical management of the transgender patient: What the primary care clinician needs to know. Fenway guide to lesbian, gay, bisexual, and transgender health 2008; :372.
- Van Caenegem E, Wierckx K, Taes Y, et al. Body composition, bone turnover, and bone mass in trans men during testosterone treatment: 1-year follow-up data from a prospective case-controlled study (ENIGI). Eur J Endocrinol 2015; 172:163.
- Van Caenegem E, Taes Y, Wierckx K, et al. Low bone mass is prevalent in male-to-female transsexual persons before the start of cross-sex hormonal therapy and gonadectomy. Bone 2013; 54:92.
- Feldman J, Brown GR, Deutsch MB, et al. Priorities for transgender medical and healthcare research. Curr Opin Endocrinol Diabetes Obes 2016; 23:180.
- Campion JM, Maricic MJ. Osteoporosis in men. Am Fam Physician 2003; 67:1521.
- Van Caenegem E, Wierckx K, Taes Y, et al. Bone mass, bone geometry, and body composition in female-to-male transsexual persons after long-term cross-sex hormonal therapy. J Clin Endocrinol Metab 2012; 97:2503.
- Turner A, Chen TC, Barber TW, et al. Testosterone increases bone mineral density in female-to-male transsexuals: a case series of 15 subjects. Clin Endocrinol (Oxf) 2004; 61:560.
- van Kesteren P, Lips P, Gooren LJ, et al. Long-term follow-up of bone mineral density and bone metabolism in transsexuals treated with cross-sex hormones. Clin Endocrinol (Oxf) 1998; 48:347.
- Goh HH, Ratnam SS. Effects of hormone deficiency, androgen therapy and calcium supplementation on bone mineral density in female transsexuals. Maturitas 1997; 26:45.
- Brown GR, Jones KT. Incidence of breast cancer in a cohort of 5,135 transgender veterans. Breast Cancer Res Treat 2015; 149:191.
- Gooren LJ, van Trotsenburg MA, Giltay EJ, van Diest PJ. Breast cancer development in transsexual subjects receiving cross-sex hormone treatment. J Sex Med 2013; 10:3129.
- Sattari M. Breast cancer in male-to-female transgender patients: a case for caution. Clin Breast Cancer 2015; 15:e67.
- Lawrence AA. Vaginal neoplasia in a male-to-female transsexual: Case report, review of the literature, and recommendations for cytological screening. Int J Transgend 2001; 5.
- van Trotsenburg MA. Gynecological aspects of transgender healthcare. Int J Transgend 2009; 11:238.
- Moyer VA, U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012; 156:880.
- Gooren L, Morgentaler A. Prostate cancer incidence in orchidectomised male-to-female transsexual persons treated with oestrogens. Andrologia 2014; 46:1156.
- Morgentaler A, Bruning CO 3rd, DeWolf WC. Occult prostate cancer in men with low serum testosterone levels. JAMA 1996; 276:1904.
- Morgentaler A, Rhoden EL. Prevalence of prostate cancer among hypogonadal men with prostate-specific antigen levels of 4.0 ng/mL or less. Urology 2006; 68:1263.
- Gooren L, Bowers M, Lips P, Konings IR. Five new cases of breast cancer in transsexual persons. Andrologia 2015; 47:1202.
- Katayama Y, Motoki T, Watanabe S, et al. A very rare case of breast cancer in a female-to-male transsexual. Breast Cancer 2016; 23:939.
- Brown GR. Breast Cancer in Transgender Veterans: A Ten-Case Series. LGBT Health 2015; 2:77.
- Peitzmeier SM, Reisner SL, Harigopal P, Potter J. Female-to-male patients have high prevalence of unsatisfactory Paps compared to non-transgender females: implications for cervical cancer screening. J Gen Intern Med 2014; 29:778.
- Miller N, Bédard YC, Cooter NB, Shaul DL. Histological changes in the genital tract in transsexual women following androgen therapy. Histopathology 1986; 10:661.
- Marrazzo JM, Koutsky LA, Kiviat NB, et al. Papanicolaou test screening and prevalence of genital human papillomavirus among women who have sex with women. Am J Public Health 2001; 91:947.
- Valanis BG, Bowen DJ, Bassford T, et al. Sexual orientation and health: comparisons in the women's health initiative sample. Arch Fam Med 2000; 9:843.
- Grynberg M, Fanchin R, Dubost G, et al. Histology of genital tract and breast tissue after long-term testosterone administration in a female-to-male transsexual population. Reprod Biomed Online 2010; 20:553.
- Centers for Disease Control and Prevention. Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae--2014. MMWR Recomm Rep 2014; 63:1.
- Corneil TA, Eisfeld JH, Botzer M. Proposed changes to diagnoses related to gender identity in the DSM: A World Professional Association for Transgender Health consensus paper regarding the potential impact on access to health care for transgender persons. Int J Transgend 2010; 12:107.
- Feldman J, Safer J. Hormone therapy in adults: suggested revisions to the sixth version of the standards of care. Int J Transgend 2009; 11:146.
- ROLE OF THE PRIMARY CARE PROVIDER
- CLINICAL MANAGEMENT
- Physical examination
- Laboratory studies
- SCREENING/PREVENTIVE CARE
- Specific considerations in patients on hormones
- - All transgender patients
- Cardiovascular disease
- - Transgender women (MTF)
- Breast cancer
- Cervical cancer
- Prostate cancer
- Venous thromboembolism
- - Transgender men (FTM)
- Breast cancer
- Cervical cancer
- Polycystic ovarian syndrome
- Sexually transmitted and bloodborne infections
- MENTAL HEALTH
- SEXUAL FUNCTION
- SUMMARY AND RECOMMENDATIONS