Transgender medicine involves the care of persons whose gender identity differs from their sexual assignment at birth. Gender incongruence is persistent incongruence between gender identity and external sexual anatomy at birth not arising from a confounding mental disorder; gender dysphoria is discomfort arising from incongruence between a person's gender identity and their external sexual anatomy at birth. A transgender man is someone with a male gender identity and a female birth-assigned sex; a transgender woman is someone with a female gender identity and a male birth-assigned sex.
Transgender people may avoid health care because of discriminatory or disrespectful interactions in prior health care encounters. Providing a safe environment is critical to ensure that transgender people establish and continue primary and gendering-affirming care. It is important for providers to understand basic terminology used by the trans community, which varies regionally.
Psychological and medical care must be provided in an environment that avoids preconceptions, and proper environmental signage, terminology, and staff training is essential (see WPATH Standards of Care). Accurate collection of gender identity information is also important; many organizations use a “two-step” method to collect these data: (1) gender identity and (2) sex listed on the original birth certificate, thus avoiding invisibility of transgender status.
Prior to a physical examination, history taking is necessary to understand an individual's anatomic changes associated with gender-affirming hormone therapy (GAHT) and surgical intervention. Secondary sex characteristics present on a wide spectrum of development in transgender patients. Providers should offer appropriate health maintenance and cancer screening based on an individual's anatomy.
GAHT is the most common medical intervention sought by transgender people and does not require subspecialty care. Primary care providers, gynecologists, and endocrinologists may prescribe this therapy. Treatment includes medications for hirsutism (spironolactone), contraception (estradiol/progestin), abnormal uterine bleeding (estradiol/progestins), menopause (estradiol/progestin), testosterone deficiency (testosterone), and benign prostatic hyperplasia (5-α reductase inhibitors).
GAHT must be patient-centered and individualized to the patient's goals. A discussion of the risks/benefits associated with treatment and informed consent are essential before beginning treatment. Criteria to consider before initiating GAHT include persistent, well-documented gender dysphoria, capacity to make a fully informed decision, age of majority in a given country, and if present, control of significant medical or psychological conditions. GAHT limits fertility, thus reproductive options should be discussed with patients prior to initiation of GAHT. Endocrine Society Clinical Practice Guidelines for GAHT are available. With GAHT, most physical changes occur over the course of 2 years, but the exact timeline of change is highly variable.
Feminizing hormone therapy is typically estradiol in combination with an androgen blocker. Goals are breast development; fat redistribution; and reductions in muscle mass, body hair, erectile function, sperm count, and testicular size. Estrogen therapy increases risk of deep venous thrombosis (DVT) and, to a lesser extent based on cohort study results, ischemic stroke and myocardial infarction; contraindications to estrogen therapy include a history of DVT, estrogen-sensitive neoplasm, and end-stage liver disease. Tobacco cessation should be encouraged prior to initiation of estrogen therapy due to increased risk of DVT. Anti-androgen therapy, such as spironolactone, diminishes secondary male sex characteristics and minimizes the estrogen dose needed, thus reducing risks associated with high-dose exogenous estrogen therapy. Monitoring testosterone and estradiol levels for adequate response to therapy is necessary for the first year.
Masculinizing hormone therapy is achieved using topical or injected testosterone with a goal of cessation of menses, facial hair growth, voice deepening, fat redistribution, increased muscle mass and body hair, and clitoral growth. Contraindications to testosterone therapy include pregnancy, unstable coronary artery disease, and polycythemia. Monitoring testosterone and estradiol levels for adequate response to therapy should occur for the first year. Hemoglobin also should be monitored.
Gender confirmation surgery is often the last intervention in transgender persons. Many transgender persons do not pursue surgery, but it is essential for alleviation of gender dysphoria in others. For transgender women, surgical procedures may include augmentation mammoplasty, genital surgery (penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty), and non-genital, non-breast surgery (facial feminization, voice surgery, thyroid cartilage reduction). For transgender men, surgical procedures may include mastectomy, hysterectomy with oophorectomy, phalloplasty, vaginectomy, scrotoplasty, and implantation of penile and/or testicular prostheses.
Stringent criteria must be met prior to undergoing irreversible gender reassignment surgery.