HME

Transgender Person

Transgender Person, Transgender, Gender Identity, Gender Dysphoria, Gender Incongruence, Transsexualism, Cisgender, Gender-Affirming Surgery

Definitions

Assigned Gender at Birth
1. Assumed gender at birth based on physical characteristics
2. Assigned Female at Birth (AFAB)
3. Assigne Male at Birth (AMAB)
Transgender
1. Person's expressed gender differs from their gender assigned at birth
2. Distinct and separate from sexual orientation, Sexual Development, external gender expression
3. Female to Male (FTM, Transgender man, transman)
  1. Refers to assigned female at birth (AFAB) who identifies as a man
4. Male to Female (MTF, Transgender woman, transwoman)
  1. Refers to assigned male at birth (AMAB) who identifies as a woman
Gender Identity
1. Person's sense of being a man, woman, both or neither
Gender Dysphoria
1. Distress or functional problems in Transgender or gender diverse persons
Gender Incongruence
1. Discrepancy between experienced gender and assigned sex without mention of dysphoria or treatment
Transsexualism
1. Severe Gender Dysphoria, and persistent wish for physical characteristics and social roles of opposite sex
Cisgender (cis men, cis women)
1. Non-Transgender, in which patient's expressed gender aligns with their gender assigned at birth
Cross Dresser
1. Previously referred to as transvestite (now considered derogatory term)
2. Clothing, jewelry or makeup not typically associated with a person's anatomic gender
3. Not synonymous with Transgender
Sexual Orientation
1. Includes heterosexual, homosexual, bisexual, pansexual or asexual
2. Sexual orientation is independent of Gender Identity

Epidemiology

Prevalence: 140,000 teens, 1.4 Million overall or 0.6% (U.S., 2017)
Unequal treatment in healthcare reported by 24% of patients, and refusal of care in 19% of patients
Race and ethnicity
1. Non-Hispanic white: 35%
2. Latino or Hispanic: 21%
3. Black: 16%
Gender
1. Male to Female (MTF): 1 in 20,000
2. Female to Male (FTM): 1 in 50,000

Pathophysiology

Stria Terminalis changes have been associated with Transgender
1. Stria terminalis, a part of the Limbic System, is found on the ventricular surface of the Thalamus
  1. Increased in cis men, and decreased in cis-women
2. SomatostatinNeurons within the stria terminalis are also associated with Transgender identity
  1. Increased in cis men, and decreased in cis-women
3. Androgen exposure in early brain development impacts stria terminalis
  1. Stria Terminalis is sensitive to andriogens
  2. Lack of androgens in early development may predispose to transfemale
  3. Excess androhens in late development may presdispose to transmale
Male to Female (MTF) Transgender associated changes are similar to cis-women (non-Transgender women)
1. Stria terminalis is smaller in transwomen (similar to cis women) than cis men
2. Somatostatin Neurons are reduced in transwomen (similar to cis women) than cis men
Female to Male (FTM) Transgender associated changes are similar to cis-men (non-Transgender men)
1. Stria terminalis is larger in transmen (similar to cis men) than cis women
2. Somatostatin Neurons are increased in transmen (similar to cis men) than cis wo,men

Approach

Ask patients their preferred name, gender and pronoun (may differ from medical record)
1. Intake forms and medical record should reflect both chosen Gender Identity and assigned sex at birth
2. Consider re-writing patient intake forms to be gender neutral
Establish rapport and offer a welcoming and safe environment for Transgender patients
1. Clinicians and staff may benefit from additional training on culturally sensitive terminology and topics
2. Refer to body parts in gender neutral terms (e.g. chest, genitalia) when possible
Preventive health screening should be directed towards their birth gender
1. Billing for preventive services should be based on birth gender
2. Transgender men who have intact Breast tissue should have Breast Cancer Screening
3. Transgender men who have intact Uterus and Cervix should have Cervical Cancer Screening
4. Base medical calculations (e.g. GFR, Cardiac Risk) on birth gender

History

Gender Dysphoria and Gender Incongruence history
1. Assess duration, severity and stability
2. Management to date (e.g. hormonal therapy, multispecialty care, surgical procedures)
Mental health
1. Anxiety Disorder
2. Uncontrolled Major Depression (esp. Suicidality)
3. Posttraumatic Stress Disorder
4. Intimate Partner Violence
5. Eating Disorder
6. Victim of Bullying
7. Substance Abuse
Social Situation
1. Homelessness
2. School Truancy
Sexual History
1. Are you sexually active?
2. What gender are your partners?
3. What type of sex do you have (e.g. oral sex, vaginal sex, anal sex, shared sex toys?)
4. What do you do to protect against Sexually Transmitted Infection (STI)?
5. Do you use Contraception?

Exam

Chaperoned exam specific to patient's current anatomy
Patient may limit the exam based on their level of comfort
Identify Sexual Development incongruent with assigned sex at birth that precedes hormonal or surgical treatment
1. Endocrinology and other specialty Consultation may be warranted

Associated Conditions

Overall mortality is 50% higher for MTF Transgender patients than the general population
Lower socioeconomic conditions
1. Poverty
  1. Four fold higher risk of household income <$10,000/year
2. Homelessness and evictions
3. Discrimination in hiring, firing and job promotions
Abuse
1. Sexual Assault
2. Physical Abuse
Mental Health
1. Suicidality (82%)
  1. Attempted Suicide (41%, esp. ages 18 to 44 years, and two thirds tried more than once)
2. Drug Abuse (29%)
3. Tobacco Abuse (30%)
HIV Infection
1. Prevalence - Male to Female (MTF): 28%
2. AIDS related mortality is 30 fold higher for Transgender than Cisgender HIV patients
3. Mechanisms
  1. Unprotected receptive anal intercourse (MTF)
  2. Needle sharing for Hormone injections
  3. Sex Work
Other Sexually Transmitted Infections are also very high risk in Transgender patients
Other Conditions
1. Cardiovascular Disease

Management
General

Consultation with Transgender specialists including mental health
1. Help guide patient in gender exploration (teen), as well as Gender Dysphoria and Gender Incongruence
2. Ensure safe environment and timing for patient's social affirmation
Do NOT recommend Gender conversion therapy
1. Gender conversion therapy is an effort to convert a person's Gender Identity to align with birth assigned sex
2. Gender conversion therapy is considered unethical and not consistent with guidelines including from AAFP
Health Maintenance
1. Follow general Health Maintenance guidelines
2. Standard screening and management for Hypertension, Hyperlipidemia, Diabetes Mellitus, Obesity
3. Tobacco Cessation and Substance Abuse management
4. Contraception (based on anatomical gender)
  1. Ensure reliable Contraception
  2. Testosterone is not a contraceptive Hormone
5. Pregnancy
  1. Pregnancy screening in Amenorrhea, Abnormal Uterine Bleeding or Pelvic Pain in transmasculine patients
  2. Observe for dysphoria related to body changes in pregnancy and postpartum
  3. Stop Testosterone if trying to conceive or if pregnancy is diagnosed
  4. Review patient's support system and multidisciplinary team (e.g. mental health, social work) as needed
  5. Dakkak (2022) Am Fam Physician 106(6): 608-11 [PubMed]
6. Sexually Transmitted Infection screening and management
  1. HPV Vaccine
  2. STD Screening including HIV Screening
  3. See HIV Preexposure Prophylaxis
  4. See HIV Post Exposure Prophylaxis
7. Cancer screening is based on patient's current anatomy
  1. Screening Mammography if Breast tissue present as per standard guidelines
  2. Cervical Cancer Screening
  3. Prostate Cancer Screening

Management
Hormonal Therapy

Precautions
1. Hormonal therapy (esp. synthetic Estrogen) increases Venous Thromboembolism Risk
  1. Avoid high Estrogen and Ethinyl Estradiol doses
  2. Tobacco Cessation
2. Hormonal therapy (feminizing or masculinizing) is partially irreversible
3. Monitor Bone Mineral Density (esp. in teens on GnRH Agonists, until age 25-30 years old)
4. Relative contraindications to hormonal therapy
  1. Hormone-sensitive active cancer (absolute contraindication)
  2. Older age
  3. Tobacco Abuse
  4. Severe comorbidity
  5. VTE history or current
5. Indications (all must be met)
  1. Well documented Gender Dysphoria
  2. Medical decision making capacity to consent
  3. Age of Majority (State or region defined age at which a person considered an adult)
  4. Stable comorbid medical and psychiatric conditions
Adolescents (Puberty to 16 years old)
1. Consultation with Transgender specialists and mental health specialists
  1. Delayed treatment with "wait and see" may cause harm with psychosocial stress, Gender Dysphoria
2. GnRH Agonists (e.g. Leuprorelin or Lupron; Goserelin, Triptorelin)
  1. Used to suppress Sexual Development of their birth gender (peds endo)
  2. Puberty suppression started once child reaches stage 2-3 of sexual maturity
  3. GnRH Agonists have reversible effects and allow for stable Gender Identity
  4. Expensive medications that require Subcutaneous Injection every 4 to 12 weeks
  5. Hormonal suppression often achieved within first week of therapy
  6. Repeat labs at 6-12 months
    1. Serum LH and Serum FSH
    2. Vitamin D
    3. Serum Estradiol (if ovaries)
    4. Serum Testosterone (if Testes)
3. Other measures to be considered in FTM Transition
  1. Menstrual suppression with Oral Contraceptives
  2. Breast binding
Adults (and adolescents over age 16 years old)
1. Transgender women (transfeminine, male to female transition)
  1. Estrogens
    1. Dose: Estradiol 50 mcg/day
    2. Goal Serum Estradiol >200 pg/ml
    3. Effects may be present at 3-12 months, but full effect may take 2-3 years
    4. Increases Breast development, redistributes fat, softens skin
    5. Lowers Serum Testosterone, decreases Erections, atrophies Prostate and Testes
    6. Increases risk Venous Thromboembolism, Breast Cancer, Prolactinoma, Cholelithiasis, Hypertriglyceridemia
  2. Antiandrogens (Spironolactone, Finasteride)
    1. Goal Serum Testosterone < 50 ng/dl
    2. Decreases Muscle mass, libido and Terminal Hair growth
    3. Voice does not typically change
    4. Spironolactone
      1. Inhibits Testosterone secretion and androgen receptor binding
      2. Dose: 50 mg orally twice daily
      3. Monitor for Hyperkalemia, Kidney injury, Hypotension on Spironolactone
    5. Finasteride (off-label, second-line to Spironolactone)
      1. 5a-Reductase Inhibitor blocks Testosterone to dihydrotestosterone conversion
      2. Dose: 5 to10 mg orally daily
2. Transgender men (transmasculine, female to male transition)
  1. Non-estrogen Contraception (e.g. IUD, Implanon, depo-Provera)
  2. Testosterone
    1. See Testosterone Replacement
    2. Dose: 5 to 10 g gel topically (or 200 to 250 mg every 2 weeks IM)
    3. Goal Serum Testosterone 320 to 1000 ng/dl
    4. Effects may be present at 1-6 months, but full effect may take 4-5 years
    5. Amenorrhea by 3 to 5 months (but Ovulation may continue, use Contraception!)
    6. Clitoromegaly (enlarges to 3-5 cm) and may serve as microphallus
    7. Increases acne, scalp Hair Loss, body hair, deeper voice, weight gain, Muscle mass
    8. Increased risk of erythrocytosis
    9. Risk of Endometrial Cancer (Unopposed Estrogen from Testosterone conversion)
      1. Pelvic Ultrasound surveillance after 3 years of Testosterone and intact Uterus
    10. Testosterone is Teratogenic should Unintended Pregnancy occur
      1. Results in fetal abnormal genitalia
      2. Reliable Contraception is critical in those with intact Uterus and ovaries

Management
Gender-Affirming Surgery - General

Background
1. Prevalence: 11,000 gender confirmation surgeries per year (U.S., 2019)
2. Male to Female (MTF) gender confirmation surgery outnumber FTM by 3:1 ratio
Precautions
1. Many Transgender patients will not require surgery
2. Surgery is pursued when significant Gender Dysphoria persists despite hormonal management
Indications (all must be met)
1. Persistent, well-documented Gender Dysphoria
2. Referral from mental health provider
  1. Two mental health providers if genital surgery
3. Medical decision making capacity to consent
4. Age of Majority (State or region defined age at which a person considered an adult)
5. Stable comorbid medical and psychiatric conditions
6. Twelve months of continuous Hormone therapy (if not contraindicated)
7. Twelve months of continuous living in Gender Identity role
Contraindications of fertility limiting surgery (gonadectomy)
1. Under legal age
2. Coexisting conditions are not controlled
3. Social affirmation and hormonal treatment <12 months
4. Noncompliance or unwillingness to follow guidelines
  1. Continued hormonal therapy to prevent BMD loss
Perioperative recommendations
1. Avoid Tobacco for 1 month before and 6 months after surgery
2. Avoid Estrogen for 2-4 weeks before surgery to reduce Venous Thromboembolism Risk
Sexual Dysfunction after Gender Affirming surgery
1. Libido often decreases after Gender-Affirming Surgery
2. Patients can consider sex therapy, self-stimulation and modifications of their hormonal therapy

Management
Gender-Affirming Surgery -Transgender women (transfeminine, male to female transition)

Breast Augmentation or augmentation mammoplasty (performed in 60-70% of MTF)
Hair removal
Head and Neck procedures (otolaryngology)
1. Facial feminization surgery
2. Voice therapy
3. Tracheal shave (Laryngeal or Adam's Apple Reduction)
Orchiectomy
1. Longterm hormonal therapy is recommended after orchiectomy to prevent Osteoporosis
  1. Before gonadectomy, perform at least 6 month trial of Estradiol
  2. Monitor Bone Mineral Density after orchiectomy
2. Orchiectomy is well tolerated, with few surgical complications
3. If future vaginoplasty is desired, Scrotum is left intact for reconstruction
4. Scrotal Hematoma may require drainage
External genitalia construction
1. Labia Minora is constructed from penile skin
2. Labia Majora are constructed from scrotal skin
3. Neoclitoris constructed from glans penis (with intact dorsal nerve and vessels)
Prostate
1. Prostate remains after genital surgery
2. Prostate will be anterior to constructed vagina
  1. Perform Prostate exam through the constructed vagina (not Rectum)
Vaginoplasty
1. Functional, self lubricating, deep vagina-like structure is created
  1. Penile inversion vaginoplasty is most common procedure
  2. Alternative methods use rectosigmoid colon segments
2. Prosthesis is initially placed inside the neovagina for first 5 days
  1. Regular lifelong vaginoplasty dilation is required (home use of vaginal dilators)
  2. Without regular vaginal dilation, permanent vaginal stenosis may occur
3. Avoid sexual intercourse for 8-12 weeks after surgery
4. Follow-up
  1. Patient should have surgical follow-up regularly in first year
  2. Repeat speculum exam for new vaginal symptoms and routinely every 1-2 years
    1. Evaluate for complications (see below)
    2. Use a small speculum or Anoscope
5. Complications
  1. General
    1. Intravaginal scarring or granulation tissue
    2. Persistent pain
    3. Wound dehiscence
    4. Hair Growth within the vaginal canal
    5. Skin graft or flap necrosis
  2. Hypergranulation (may present with bleeding or discharge)
    1. May respond to Silver Nitrate, topical intravaginal Estrogen
    2. Depending on graft source, bleeding may also be due to Colon Cancer or inflammatory bowel
  3. Rectovaginal fistula (1 in 400 surgeries)
    1. Vaginal tampon will discolor from food coloring dyed rectal water enema
    2. Small fistulas may heal on liquid or low residue diet
    3. Larger or refractory fistulas may require skin grafts
  4. Vaginal Stenosis
    1. Often results from non-compliance with regular vaginal dilation regimen
    2. Gradual dilation with topical lubricant (Lidocaine 2% jelly or Lidocaine/Prilocaine cream)
    3. Consider Estradiol Vaginal Tablets
    4. Consider pelvic floor physical therapist referral
  5. Vaginal Discharge or odor
    1. Constructed vagina is colonized by both skin flora and vaginal Bacteria
    2. Discharge and odor may be due to sebum, dead skin or retained lubricant
    3. Periodic use of douche with warm soapy water (or dilute vinegar/Betadine solution)
    4. Vaginal Metronidazole for 5 days may be used for persistent odor
    5. Evaluate for Sexually Transmitted Infections and Vaginitis as for Cisgender patients
  6. Urinary tract complications
    1. Urethral Stricture or stenosis
    2. Urinary Tract Infections
      1. More common after vaginoplasty due to shortened Urethra
    3. Urinary Incontinence
      1. Rare after vaginoplasty and should prompt surgical referral

Management
Gender-Affirming Surgery - Transgender men (transmasculine, female to male transition)

Mastectomy and chest reconstruction (performed in 93% of FTM)
1. Double incision Mastectomy with free nipple graft is most common
2. Residual Breast tissue remains in all procedures, and Breast Cancer may still occur
  1. Routine Breast Cancer Screening is not recommended by ACR
  2. Diagnostic imaging for symptoms (e.g. chest mass, axillary nodes, nipple retraction, skin changes)
    1. Breast Ultrasound or Breast MRI are preferred imaging after Mastectomy
    2. Avoid Mammography (inadequate Breast tissue for imaging)
Gonadectomy (often performed in FTM)
1. Hysterectomy
  1. Vaginal Hysterectomy is difficult procedure after Testosterone Replacement (Vaginal Atrophy)
  2. Cervical Cancer Screening after Hysterectomy follows the same protocols as for Cisgender patients
2. Bilateral salpingo-oopherectomy
  1. Avoid in premenopausal patients if they are not willing to take Hormone Replacement (Testosterone)
3. Vaginectomy
Reconstructive Surgery (less commonly performed)
1. Phalloplasty
  1. Seven inch penis construction
  2. Functional for Erection and penetration (with Penile Prosthesis implant)
  3. Constructed from non-dominant radial Forearm free flap transplant (skin, fat, nerves, vessels)
  4. Urethral lengthening allows for standing urination
    1. Requires Hysterectomy and vaginectomy
  5. Risk of Urethral fistula, Urethral Stricture and Urinary Retention
    1. Longterm urology follow-up is recommended
  6. Risk of flap necrosis
    1. Postoperative hourly monitoring of color, Temperature, color, pulse, Capillary Refill for 2 days
2. Metoidioplasty
  1. One to 6 inch penis construction from enlarged clitoris
  2. Does not allow for penetration
  3. Urethral lengthening may be performed to allow for standing urination
    1. Labial tissue is used for the construction
    2. Requires Suprapubic Catheter for 2 to 4 weeks
  4. Risk of Hematoma, Urethral Stricture, Urinary Incontinence, flap necrosis
  5. Patients with intact vagina who have receptive intercourse should be screened for STD
    1. Use patient collected vaginal swabs (dirty urine is inadequate after genital surgery)
    2. Speculum exam is typically difficult after Metoidioplasty
3. Scrotoplasty (Scrotum construction)
  1. Constructed from hollowed-out labia majora and testicular implants
  2. Risk of implant rejection, implant migration, neoscrotum rupture

Resources

UCSF Transgender
1. http://transhealth.ucsf.edu/
UCSF Primary Care Guidelines
1. http://transhealth.ucsf.edu/trans?page=guidelines-home
World Professional Association for Transgender Health (WPATH)
1. https://www.wpath.org/
2. Standard of Care guidelines including hormonal therapy, surgery and postoperative care

References

(2016) Presc Lett 23(11)
Allen (2021) Crit Dec Emerg Med 35(10): 17-28
Klein (2018) Am Fam Physician 98(11): 645-53 [PubMed]
Jackson (2024) Am Fam Physician 109(6): 560-5 [PubMed]