Skip to main content
SpringerLink
Log in

The Medical Management of Gender Dysphoric, Gender Fluid, Gender Nonconforming, Gender Queer, Nonbinary, and Transgender Patients: One Clinic’s Approach

  • Sexual Orientation and Identity (J Vencill and M Coleman, Section Editors)
  • Published:
Current Sexual Health Reports Aims and scope Submit manuscript

Abstract

Purpose of the Review

To present a practical guide to the care and treatment of gender diverse patients with and without gender dysphoria.

Recent Findings

Gender diverse patients experience considerable discrimination in the healthcare system and often cannot obtain basic medical care or specialized hormonal management. There is scant evidence to guide the clinician in making the care decisions of gender diverse patients. Although some guidelines exist, these often lack the rationale and practical considerations that are necessary for the respectful care of this oppressed community.

Summary

Providing healthcare to gender diverse patients, with and without gender dysphoria, and their partners can be challenging. The current article provides practical guidance and a review of the literature to support that guidance.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Schuster MA, Reisner SL, Onorato SE (2016). Beyond bathrooms--meeting the health needs of transgender people. N Engl J Med;375(2):101-103. doi: https://doi.org/10.1056/NEJMp1605912.

  2. Reisner SL, Poteat T, Keatley JA, Cabral M, Tampose M, Dunham E, et al. Global health burden and needs of transgender populations: a review. Lancet. 2016;388(10042):412–36. https://doi.org/10.1016/S0140-6736(16)00684-X.

    Article  PubMed  Google Scholar 

  3. •• Winter S, Diamond M, Green J, Karasic D, Reed T, Whittle S, et al. Transgender people: health at the margins of society. Lancet. 2016;388(10042):390–400. https://doi.org/10.1016/S0140-6736(16)00683-8Excellent presentation of the problems gender diverse patients face interacting with the healthcare system.

    Article  PubMed  Google Scholar 

  4. de Haan G, Santos GM, Arayasirikul S, Raymond HF. Non-prescribed hormone use and barriers to care for transgender women in San Francisco. LGBT Health. 2015;2(4):313–23. https://doi.org/10.1089/lgbt.2014.0128.

    Article  PubMed  Google Scholar 

  5. Snelgrove JW, Jasudavisius AM, Rowe BW, Head EM, Bauer GR. “Completely out-at-sea” with “two-gender medicine”: a qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Serv Res. 2012;12:110. https://doi.org/10.1186/1472-6963-12-110.

    Article  PubMed  PubMed Central  Google Scholar 

  6. The World Professional Association for Transgender Health (WPATH). Standards of care for the health of transsexual, transgender, and gender nonconforming people, Vol. 7. https://www.wpath.org/media/cms/Documents/Web%20Transfer/SOC/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf. Downloaded August 12, 2018.

  7. Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869–903. https://doi.org/10.1210/jc.2017-01658.

    Article  PubMed  Google Scholar 

  8. Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people; 2nd edition. Deutsch MB, ed. June 2016. Available at http://www.transhealth.ucsf.edu/trans?page=guidelines-home Downloaded 8/12/18.

  9. Lindroth M. ‘Competent persons who can treat you with competence, as simple as that’ - an interview study with transgender people on their experiences of meeting health care professionals. J Clin Nurs. 2016;25(23-24):3511–21. https://doi.org/10.1111/jocn.13384.

    Article  PubMed  Google Scholar 

  10. https://en.wikipedia.org/wiki/Transgender. Downloaded August 12. 2018.

  11. McCann E, Brown M. Discrimination and resilience and the needs of people who identify as transgender: a narrative review of quantitative research studies. J Clin Nurs. 2017;26(23-24):4080–93. https://doi.org/10.1111/jocn.13913.

    Article  PubMed  Google Scholar 

  12. • Goldstein Z, Corneil TA, Greene DN. When gender identity doesn’t equal sex recorded at birth: the role of the laboratory in providing effective healthcare to the transgender community. Clin Chem. 2017;63(8):1342–52. https://doi.org/10.1373/clinchem.2016.258780Explains the inherent bias that gender diverse patients face by omitting and ignoring evidence-based changes in clinical laboratory values associated with gender transition.

    Article  CAS  PubMed  Google Scholar 

  13. Gupta S, Imborek KL, Krasowski MD. Challenges in transgender healthcare: the pathology perspective. Lab Med. 2016;47(3):180–8. https://doi.org/10.1093/labmed/lmw020.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Newman-Valentine D1, Duma S. Injustice to transsexual women in a hetero-normative healthcare system. Afr J Prim Health Care Fam Med. 2014;6(1):E1–5. https://doi.org/10.4102/phcfm.v6i1.574.

    Article  PubMed  Google Scholar 

  15. Moser C, Devereux, M. Gender neutral pronouns: a modest proposal [Letter to the editor]. International Journal of Transgenderism. Published online 09 Sep 2016. DOI: 10.1080/15532739.2016.1217446.

  16. Moser C. Defining sexual orientation. Arch Sex Behav. 2016;45(3):505–8.

    Article  Google Scholar 

  17. Galupo MP, Lomash E, Mitchell RC. “All of my lovers fit into this scale": sexual minority individuals’ responses to two novel measures of sexual orientation. J Homosex 2017;64(2):145-165.

  18. Lawrence AA. Sexuality before and after male-to-female sex reassignment surgery. Arch Sex Behav. 2005;34(2):147–66.

    Article  Google Scholar 

  19. Moser C. (2008), The DSM-V and the gender diagnoses. Society for Sex Therapy and Research Newsletter, 25(2), 4-5. [WWW document] URL http://www.sstarnet.org/download/News2008Jul.pdf

  20. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.

  21. Gooren LJG, Assies J, Asscheman J, De Slegte R, Van Kessel H. Estrogen-induced prolactinoma in a man. J Clin Endocrinol Metab. 1988;66(2):444–6. https://doi.org/10.1210/jcem-66-2-444.

    Article  CAS  PubMed  Google Scholar 

  22. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003;32(4):299–315.

    Article  Google Scholar 

  23. Murphy TF. Should mental health screening and psychotherapy be required prior to body modification for gender expression? AMA J Ethics. 2016;18(11):1079–85. https://doi.org/10.1001/journalofethics.2016.18.11.ecas2-1611.

    Article  PubMed  Google Scholar 

  24. Klaver M, de Blok CJM, Wiepjes CM, Nota NM, Dekker MJHJ, de Mutsert R, et al. Changes in regional body fat, lean body mass and body shape in trans persons using cross-sex hormonal therapy: results from a multicenter prospective study. Eur J Endocrinol. 2018;178(2):165–73. https://doi.org/10.1530/EJE-17-0496.

    Article  Google Scholar 

  25. Dimitrakakis C, Bondy C. Androgens and the breast. Breast Cancer Res. 2009;11(5):212. https://doi.org/10.1186/bcr2413.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. • Gooren LJ, T’Sjoen G. Endocrine treatment of aging transgender people. Rev Endocr Metab Disord. 2018. https://doi.org/10.1007/s11154-018-9449-0Highlighting another aspect of our lack of knowledge about the medical care of gender diverse people.

  27. Bergendal A, Kieler H, Sundström A, Hirschberg AL, Kocoska-Maras L. Risk of venous thromboembolism associated with local and systemic use of hormone therapy in peri- and postmenopausal women and in relation to type and route of administration. Menopause. 2016;23(6):593–9. https://doi.org/10.1097/GME.0000000000000611.

    Article  PubMed  Google Scholar 

  28. Leinung MC, Feustel PJ, Joseph J. Hormonal treatment of transgender women with oral estradiol. Transgend Health. 2018;3(1):74–81. https://doi.org/10.1089/trgh.2017.0035.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288(3):321–33. https://doi.org/10.1001/jama.288.3.321.

    Article  Google Scholar 

  30. Unger CA. Hormone therapy for transgender patients. Transl Androl Urol. 2016;5(6):877–84. https://doi.org/10.21037/tau.2016.09.04.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Ogston-Tuck S. Intramuscular injection technique: an evidence-based approach. Nurs Stand. 2014;29(4):52–9. https://doi.org/10.7748/ns.29.4.52.e9183.

    Article  PubMed  Google Scholar 

  32. Spratt DI, Stewart II, Savage C, Craig W, Spack NP, Chandler DW, et al. Subcutaneous injection of testosterone is an effective and preferred alternative to intramuscular injection: demonstration in female-to-male transgender patients. J Clin Endocrinol Metab. 2017;102(7):2349–55. https://doi.org/10.1210/jc.2017-00359.

    Article  PubMed  Google Scholar 

  33. Handelsman, DJ. Androgen physiology, pharmacology and abuse. In Endotext [Internet] De Groot LJ, Chrousos G, Dungan K, et al., editors. https://www.ncbi.nlm.nih.gov/books/NBK279000/

  34. Stoner E. The clinical development of a 5α-reductase inhibitor, finasteride. J Steroid Biochem Mol Biol. 1990;37(3):375–8.

    Article  CAS  Google Scholar 

  35. Kim JH, Baek MJ, Sun HY, Lee B, Li S, Khandwala Y, et al. Chung BI Efficacy and safety of 5 alpha-reductase inhibitor monotherapy in patients with benign prostatic hyperplasia: a meta-analysis. PLoS One. 2018;13(10):e0203479. https://doi.org/10.1371/journal.pone.0203479 eCollection 2018.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Traish AM, Hassani J, Guay AT, Zitzmann M, Hansen ML. Adverse side effects of 5α-reductase inhibitors therapy: persistent diminished libido and erectile dysfunction and depression in a subset of patients. Sex Med. 2011;8(3):872–84. https://doi.org/10.1111/j.1743-6109.2010.02157.x.

    Article  CAS  Google Scholar 

  37. Stevenson MO, Wixon N, Safer JD. Scalp hair regrowth in hormone-treated transgender woman. Transgend Health. 2016;1(1):202–4. https://doi.org/10.1089/trgh.2016.0022.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Glynn TR, Gamarel KE, Kahler CW, Iwamoto M, Operario D, Nemoto T. The role of gender affirmation in psychological well-being among transgender women. Psychol Sex Orientat Gend Divers. 2016;3(3):336–44.

    Article  Google Scholar 

  39. Defreyne J, Motmans J, T’sjoen G. Healthcare costs and quality of life outcomes following gender affirming surgery in trans men: a review. Expert Rev Pharmacoecon Outcomes Res. 2017;17(6):543–56. https://doi.org/10.1080/14737167.2017.1388164.

    Article  PubMed  Google Scholar 

  40. Frohard-Dourlent H, Dobson S, Clark BA, Doull M, Saewyc EM. “I would have preferred more options”: accounting for non-binary youth in health research. Nurs Inq. 2017;24(1). https://doi.org/10.1111/nin.12150.

  41. Katz-Wise SL, Reisner SL, Hughto JW, Keo-Meier CL. Differences in sexual orientation diversity and sexual fluidity in attractions among gender minority adults in Massachusetts. J Sex Res. 2016;53(1):74–84. https://doi.org/10.1080/00224499.2014.1003028.

    Article  PubMed  Google Scholar 

  42. Anderson PL, Reirden D, Castillo-Mancilla J. Pharmacologic considerations for preexposure prophylaxis in transgender women. J Acquir Immune Defic Syndr. 2016;72(Suppl 3):S230–4. https://doi.org/10.1097/QAI.0000000000001105.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Mayer KH, Krakower D. Administration of pre-exposure prophylaxis against HIV infection. Uptodate https://www.uptodate.com/contents/administration-of-pre-exposure-prophylaxis-against-hiv-infection. Downloaded 8/25/18.45a

  44. Streed CG Jr, Harfouch O, Marvel F, Blumenthal RS, Martin SS. Mukherjee Mann Cardiovascular disease among transgender adults receiving hormone therapy: a narrative review. Intern Med. 2017;167(4):256–67. https://doi.org/10.7326/M17-0577.

    Article  Google Scholar 

  45. Layton JB, Li D, Meier CR, Sharpless JL, Stürmer T, Brookhart MA. Injection testosterone and adverse cardiovascular events: a case-crossover analysis. Clin Endocrinol. 2018;88(5):719–27. https://doi.org/10.1111/cen.13574.

    Article  CAS  Google Scholar 

  46. Beek TF, Kreukels BP, Cohen-Kettenis PT, Steensma TD. Partial treatment requests and underlying motives of applicants for gender affirming interventions. J Sex Med. 2015;12(11):2201–5. https://doi.org/10.1111/jsm.13033.

    Article  PubMed  Google Scholar 

  47. Wiepjes CM, Vlot MC, Klaver M, Nota NM, de Blok CJ, de Jongh RT, et al. Bone mineral density increases in trans persons after 1 year of hormonal treatment: A Multicenter Prospective Observational Study. J Bone Miner Res. 2017;32(6):1252–60. https://doi.org/10.1002/jbmr.3102.

    Article  CAS  PubMed  Google Scholar 

  48. Gooren L, Lips P. Conjectures concerning cross-sex hormone treatment of aging transsexual persons. J Sex Med. 2014;11(8):2012–9. https://doi.org/10.1111/jsm.12563.

    Article  PubMed  Google Scholar 

  49. Deebel NA, Morin JP, Autorino R, Vince R, Grob B, Hampton LJ. Prostate cancer in transgender women: incidence, etiopathogenesis, and management challenges. Urology. 2017;110:166–71. https://doi.org/10.1016/j.urology.2017.08.032.

    Article  PubMed  Google Scholar 

  50. Adkins BD, Barlow AB, Jack A, Schultenover SJ, Desouki MM, Coogan AC, et al. Characteristic findings of cervical Papanicolaou tests from transgender patients on androgen therapy: challenges in detecting dysplasia. Cytopathology. 2018;29(3):281–7. https://doi.org/10.1111/cyt.12525.

    Article  CAS  PubMed  Google Scholar 

  51. Brown GR, Jones KT. Incidence of breast cancer in a cohort of 5,135 transgender veterans. Breast Cancer Res Treat. 2015;149(1):191–8. https://doi.org/10.1007/s10549-014-3213-2.

    Article  PubMed  Google Scholar 

  52. 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(12):3129–34. https://doi.org/10.1111/jsm.12319.

    Article  PubMed  Google Scholar 

  53. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2935–59. https://doi.org/10.1016/j.jacc.2013.11.005.

    Article  PubMed  Google Scholar 

  54. Diamond LM. Sexual fluidity: understanding women’s love and desire. Harvard University Press: Cambridge, MA, 2008 333 pp., ISBN: 978-0674032262.

Download references

Author information

Authors and Affiliations

  1. Diverse Sexualities Research and Education Institute, 1199 Bush Street, Suite 400, San Francisco, CA, 94109, USA

    Charles Moser

  2. Sutter Pacific Medical Foundation, San Francisco, CA, 94114, USA

    Maura Devereux

Authors
  1. Charles Moser
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Maura Devereux
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Charles Moser.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Research Involving Human Participants and/or Animals

This article does not contain any studies with human or animal subjects performed by the author.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Sexual Orientation and Identity

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Moser, C., Devereux, M. The Medical Management of Gender Dysphoric, Gender Fluid, Gender Nonconforming, Gender Queer, Nonbinary, and Transgender Patients: One Clinic’s Approach. Curr Sex Health Rep 11, 421–429 (2019). https://doi.org/10.1007/s11930-019-00221-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11930-019-00221-y

Keywords

Search

Navigation