Gender Affirming Care

Abstract

Gender is a concept that encompasses a complex relationship between a person’s body or physical sexual characteristics, their identity or a deeply held internal sense of self, and their gender expression or the way they present themselves to the world. Gender is distinct from sex, which describes the biological make-up of the individual. People are typically assigned a sex at birth based on the characteristic appearance of their genitalia as male or female, which is referred to as “natal sex.” Gender exists on a spectrum, and individuals who identify as transgender or gender non-conforming have unique healthcare needs. In this chapter, we discuss ways to improve the experience that transgender people have when interfacing with the healthcare system, preventative health topics, as well as specifics of gender affirming hormone therapy.

Review Questions

• 1. Jamie is a 45-year-old patient who presents to your office to establish care. Jamie was assigned a female sex at birth but does not identify as either female or male, but rather as both genders. Jamie prefers the pronouns they/them/their/themselves. Jamie dresses in whatever feels comfortable, which typically involves trousers, button down shirts or polos, and has long hair which they typically wear in a ponytail.

  Which of the following best describes Jamie’s gender identity?

  • A. Non-binary

  • B. Gender dysphoric

  • C. Transgender

  • D. Cisgender

  • E. Trans-masculine

  The correct answer is A. The best descriptor of Jamie’s gender identity is likely non-binary, which is a term to describe a person whose gender identity falls outside the traditional gender binary [1]. Jamie may be gender fluid, that is, someone who identifies with different genders; or agender, that is, someone who has a neutral gender identity; or non-binary, that is, someone who’s gender does not fit into the gender binary [1]. The best way to find out Jamie’s exact identity is to ask them. Jamie shows no evidence of gender dysphoria, which is a DSM diagnosis, that involves clinically significant distress due to a conflict between a person’s assigned gender and their gender identity [2]. In addition, Jamie is not cisgender, since they do not identify as the assigned female birth sex, or transgender, since they do not identify as male, which is the opposite of their birth sex [1].

• 2. A 52-year-old transgender female with a medical history significant for obesity, osteoarthritis, and gastroesophageal reflux disease presents for a routine visit. She has been on hormone therapy for 7 years; her regimen includes an estradiol patch, 0.1 mg/24 hours (changed twice weekly) and spironolactone 100 mg twice daily. She has not had gender reassignment surgery. She is currently sexually active with one female partner and engages in oral intercourse but does not use dental dams. Her vital signs and physical exam are entirely normal. Which of the following is the most appropriate next step in her management?

  • A. Perform a digital rectal exam for prostate cancer screening

  • B. Order a bone density test

  • C. Refer for mammography

  • D. Perform rectal screening for Chlamydia

  • E. Order a complete blood count (CBC)

  The correct answer is C. Cross-sex hormone therapy in transgender women may increase the risk for breast cancer. Guidelines from the Endocrine Society recommend that transgender women of average risk for breast cancer receive screening according to recommendations for natal women [11]. The USPSTF currently recommends biennial mammography for natal women aged 50–74 years; thus, it would be appropriate to offer mammography to this patient [11]. The University of California San Francisco Center of Excellence for Transgender Health offers slightly different recommendations and states that appropriate candidates for mammography include transgender women over the age of 50 who have received 5–10 years of feminizing hormone therapy [21]. Per those guidelines, the patient in this case should be offered screening mammography.

  All transgender women, regardless of whether they have had gender-affirming surgery, will have a prostate. According to the Endocrine Society Guidelines, providers should follow recommendations from the USPSTF, which recommends engaging in an informed consent discussion about the benefits and risks of prostate-specific antigen screening with individuals between the ages of 55 and 59. Based on this patient’s age, prostate cancer screening would not be currently recommended [11, 25].

  Rectal screening for Chlamydia is recommended in men who have sex with men and engage in receptive intercourse [10] so rectal screening is not appropriate for this patient.

  This patient is at low risk for osteoporosis and has been compliant with her hormone therapy. She should start screening for osteoporosis at the age of 60, which is consistent with the Endocrine Society guidelines for osteoporosis screening in transgender women [11].

  An increase in the hemoglobin and hematocrit is commonly seen with administration of testosterone therapy in transgender men but not in transgender women; therefore, routine CBC is not recommended.

• 3. A 62-year-old transgender female presents to establish care. She has a medical history significant for obesity, hypertension, hyperlipidemia, impaired glucose tolerance, and benign prostatic hypertrophy. She has been using hormonal therapy for 12 years, and her current regimen includes transdermal estradiol (0.1 mg/24 hours, change twice weekly) and spironolactone 100 mg twice daily. She is very satisfied with her hormonal therapy in terms of her emotional well-being as well as her physical appearance. She does not use tobacco, alcohol, or drugs, is not sexually active, and works as a truck driver. On exam, her blood pressure is 146/92 and her pulse is 62. Her physical exam is otherwise normal. On laboratory evaluation, her serum estradiol and testosterone levels are within goal range. Which of the following is the most appropriate next step in her management?

  • A. Discontinue estradiol because of the risk for cardiovascular complications

  • B. Continue the current hormonal regimen and maximize blood pressure control

  • C. Discontinue transdermal estradiol and start oral estradiol to minimize the risk for venous thromboembolism

  • D. Increase the dose of transdermal estradiol

  • E. Add a GnRH agonist to the hormonal regimen

  The correct answer is B. For many individuals, hormonal therapy may improve the emotional and mental well-being as well as quality of life. Conversely, abrupt discontinuation of hormone therapy can be associated with significant psychological consequences. Thus, hormone therapy should be continued in patients who are medically stable and are doing well on their regimen.

  Cardiovascular risk factors, such as hypertension and hyperlipidemia, are not absolute contraindications to hormonal therapy but should be managed according to published guidelines [11].

  Estradiol increases the risk for venous thromboembolism (VTE), and this should be discussed with the patient prior to initiating hormonal therapy. Transdermal estradiol is theoretically considered to be “safer” than oral estradiol with respect to VTE risk, as it avoids the “first-pass” effect and so is less likely to activate hepatic coagulation factors [14, 15].

  Changes in a patient’s hormonal regimen should be guided by their satisfaction with their appearance and well-being, as well as by serum hormone levels. Elevated blood levels of estrogen (exceeding guideline-recommended goal ranges) can increase the risk for VTE, liver dysfunction, and hypertension [4]. This patient is satisfied with her emotional health and physical appearance, and her serum levels are within goal range. Thus, it is not appropriate to increase the dose of transdermal estradiol.

  Several therapies can be used to decrease natal testosterone levels, including spironolactone and GnRH agonists [11]. Spironolactone is often used as first-line therapy due to ease of administration and cost. In this patient, spironolactone has effectively suppressed her testosterone levels to goal range, and thus a GnRH agonist is not indicated.