Current Obstetrics and Gynecology Reports

, Volume 6, Issue 2, pp 140–148 | Cite as

Gynecologic Care for Transgender Adults

  • Juno Obedin-MaliverEmail author
  • Gene de Haan
Care for the Transgender Patient (C Unger, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Care for the Transgender Patient


Purpose of the Review

Transgender people need both routine gynecological and reproductive health care and services specific to gender-affirming processes. However, there is little evidence to guide their routine gynecological and reproductive health care, and data suggests that 33% of transgender people avoid routine health care due to persistent discrimination and disrespect. Here we systematically approach the care of transmasculine and transfeminine people for practicing obstetrician-gynecologists (OBGYNs) with an eye towards enhancing knowledge and enhancing respectful care.

Recent Findings

Though hampered by a paucity of high-quality data specific to transgender people, topics covered in the review include routine health care maintenance; including cancer screening, assessment of sexually transmitted infections, and contraception; as well as issues specific to transgender individuals such as to use of gender-affirming hormones and care surrounding gender-affirming surgeries. Additionally, we incorporate perspectives to support cultural humility and provider preparedness towards promoting patient comfort in seeking and obtaining care.


We aim to demonstrate that though there are some clinical topics specific to transgender people and their health care that warrant enhanced training and resources, obstetrician-gynecologists (OBGYNs) are actually well-poised to support the care of this population. Bringing awareness of the needs of transgender people to OBGYNs will help decrease the well-documented care gap for this underserved population.


Transgender Transsexual Obstetrics Gynecology Reproductive health 


Compliance with Ethical Standards

Conflict of Interest

Juno Obedin-Maliver and Gene de Haan declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

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


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

  1. 1.
    Institute of Medicine (U.S.). Committee on Lesbian G, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. Washington, DC: National Academies Press; 2011.Google Scholar
  2. 2.
    Makadon HJ, Mayer KH, Potter J, Goldhammer H. Fenway guide to lesbian, gay, bisexual, and transgender health. 2nd ed. Philadelphia: American College of Physicians; 2015.Google Scholar
  3. 3.
    • Grant J.M., Mottet L.A., Tanis J., Harrison J., Herman J.L., Keisling M. Injustice at every turn: a report of the national transgender discrimination survey. In: National Center for Transgender Equality and National Gay and Lesbian Task Force, ed. Washington; 2011. A sentinal cross-sectional study on the experience of transgender individuals in American society; it includes reports on health and health care as well as education, housing, civic engagement, among others.Google Scholar
  4. 4.
    Erickson-Schroth L. Trans bodies, trans selves: a resource for the transgender community. 1st ed. New York: Oxford University Press; 2014.Google Scholar
  5. 5.
    American College of Obstetrics and Gynecology (ACOG). Committee opinion no. 512: health care for transgender individuals. Obstet Gynecol. 2011;118(6):1454–8.CrossRefGoogle Scholar
  6. 6.
    Obedin-Maliver J, Goldsmith ES, Stewart L, White W, Tran E, Brenman S, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306(9):971–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Educational Committee of the Council on Resident Education in Obstetrics and Gynecology. Educational objectives: core curriculum in obstetrics and gynecology. 10th ed. Washington, D.C.: American College of Obstetricians and Gynecologists; 2013.Google Scholar
  8. 8.
    Grimstad FW, Satterwhite CL, Wieneke CL. Assessing residency program approaches to the transgender health CREOG objective. Transgender Health. 2016;1(1):69–74.CrossRefGoogle Scholar
  9. 9.
    Unger CA. Care of the transgender patient: a survey of gynecologists’ current knowledge and practice. J Women’s Health (Larchmt). 2015;24(2):114–8.CrossRefGoogle Scholar
  10. 10.
    • Cahill S, Singal R, Grasso C, King D, Mayer K, Baker K, et al. Do ask, do tell: high levels of acceptability by patients of routine collection of sexual orientation and gender identity data in four diverse American community health centers. PLoS One. 2014;9(9):e107104. This study describes the response of patients to being asked diverse sexual orientation and gender identity questions at different clinical sites CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Sexual Minority Assessment Research Team (SMART). Best practices for asking questions about sexual orientation on surveys. In: Institute. TW, ed: The Williams Institute. 2009.Google Scholar
  12. 12.
    The Gender Identity in U.S. Surveillance (GenIUSS) Group. Best practices for asking questions to identify transgender and other gender minority respondents on population-based surveys. In: The Williams Institute, ed. Los Angeles; 2014.Google Scholar
  13. 13.
    Sausa LA, Sevelius J, Keatley J, Iñiquez JR, Reyes M. Policy recommendations for inclusive data collection of trans people in HIV prevention, care, & services. San Francisco: Center of Excellence for Transgender HIV Prevention, University of California, San Francisco; 2009.Google Scholar
  14. 14.
    The Joint Commission. The Joint Commission: advancing effective communication, cultural competence, and patient–and family-centered care for the lesbian, gay, bisexual and transgender (LGBT) community: a field guide. Oak Brook; 2011.Google Scholar
  15. 15.
    Peitzmeier SM, Khullar K, Reisner SL, Potter J. Pap test use is lower among female-to-male patients than non-transgender women. Am J Prev Med. 2014;47(6):808–12.CrossRefPubMedGoogle Scholar
  16. 16.
    • 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(5):778–84. This single institution study compares the cervical cancer screening tests performed for female-to-male/transmasculine individuals to non-transgender females and describes the pathological outcomes including the relationship between testosterone use and test adequacy CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    •• Potter J, Peitzmeier SM, Bernstein I, Reisner SL, Alizaga NM, Agenor M, et al. Cervical cancer screening for patients on the female-to-male spectrum: a narrative review and guide for clinicians. J Gen Intern Med. 2015;30:1857–64. An important qualitative discussion based on clinical interactions with transmascuine individuals that will help gynecological and reproductive health providers provide gender neutral care with a sensitivity regarding transgender experiences CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Scheim AI, Bauer GR. Sex and gender diversity among transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. J Sex Res. 2014;52:1–14.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Obedin-Maliver J, de Haan G. Gynecologic care for transgender patients. In: Unger C, ed. Comprehensive care of the transgender patient. Philadelphia: Elsevier. 2017.Google Scholar
  20. 20.
    Movement Advancement Project (MAP) “Equality maps; identity document laws and policies” 2016;Pages on 30 Aug 2016.
  21. 21.
    Feldman J, Spencer K. Medical and surgical management of the transgender patient: what the primary care clinician needs to know. In: Makadon HMK, Potter J, Goldhammer H, editors. Fenway guide to lesbian, gay, bisexual and transgender health. 2nd ed. Philadelphia: American College of Physicians; 2015. p. 479–511.Google Scholar
  22. 22.
    Newfield E, Hart S, Dibble S, Kohler L. Female-to-male transgender quality of life. Qual Life Res. 2006;15(9):1447–57.CrossRefPubMedGoogle Scholar
  23. 23.
    White Hughto JM, Reisner SL. A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgender Health. 2016;1(1):31.CrossRefGoogle Scholar
  24. 24.
    • The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-nonconforming people. Int J Transgenderism. 2011;13(4):165–232. A critical resource for understanding international standards of clinical and professional care for transgender individuals as organized by transgender health professionals Google Scholar
  25. 25.
    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.CrossRefPubMedGoogle Scholar
  26. 26.
    •• Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. In: Deutsch MB, ed. 2nd ed. San Francisco: Center of Excellence for Transgender Health-University of California, San Francisco; 2016. An online, peer reviewed set of clinical guidelines to help support primary care for transgender individuals. Diverse topics related to both ensuring general care guidelines meet the needs of transgender individuals and exploring transgender specific health and healthcare needs.Google Scholar
  27. 27.
    Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer 3rd WJ, Spack NP, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132–54.CrossRefPubMedGoogle Scholar
  28. 28.
    Hembree WC. Guidelines for pubertal suspension and gender reassignment for transgender adolescents. Child Adolesc Psychiatr Clin N Am. 2011;20(4):725–32.CrossRefPubMedGoogle Scholar
  29. 29.
    Weiss E, Green J. Transgender patients care. Am J Obstet Gynecol. 2014;211(2):185–6.CrossRefPubMedGoogle Scholar
  30. 30.
    American College of Obstetricians and Gynecologists (ACOG). Practice bulletin no. 89: elective and risk-reducing salpingo-oophorectomy. Obstet Gynecol. 2008;111:231–41.CrossRefGoogle Scholar
  31. 31.
    Ergeneli MH, Duran EH, Ozcan G, Erdogan M. Vaginectomy and laparoscopically assisted vaginal hysterectomy as adjunctive surgery for female-to-male transsexual reassignment: preliminary report. Eur J Obstet Gynecol Reprod Biol. 1999;87(1):35–7.CrossRefPubMedGoogle Scholar
  32. 32.
    Gurjala AN, Nazerali RS, Salim A, Lee GK. World’s first baby born through natural insemination by father with total phalloplasty reconstruction. Ann Plast Surg. 2016;76(Suppl 3):S179–83.CrossRefPubMedGoogle Scholar
  33. 33.
    Nakamura A, Watanabe M, Sugimoto M, Sako T, Mahmood S, Kaku H, et al. Dose-response analysis of testosterone replacement therapy in patients with female to male gender identity disorder. Endocr J. 2013;60(3):275–81.CrossRefPubMedGoogle Scholar
  34. 34.
    Pelusi C, Costantino A, Martelli V, Lambertini M, Bazzocchi A, Ponti F, et al. Effects of three different testosterone formulations in female-to-male transsexual persons. J Sex Med. 2014;11(12):3002–11.CrossRefPubMedGoogle Scholar
  35. 35.
    Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120–7.CrossRefPubMedGoogle Scholar
  36. 36.
    Deutsch MB, Bhakri V, Kubicek K. Effects of cross-sex hormone treatment on transgender women and men. Obstet Gynecol. 2015;125(3):605–10.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Ferrero S, Gillott DJ, Venturini PL, Remorgida V. Use of aromatase inhibitors to treat endometriosis-related pain symptoms: a systematic review. Reprod Biol Endocrinol. 2011;9:89.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Amsterdam LL, Gentry W, Jobanputra S, Wolf M, Rubin SD, Bulun SE. Anastrazole and oral contraceptives: a novel treatment for endometriosis. Fertil Steril. 2005;84(2):300–4.CrossRefPubMedGoogle Scholar
  39. 39.
    Ailawadi RK, Jobanputra S, Kataria M, Gurates B, Bulun SE. Treatment of endometriosis and chronic pelvic pain with letrozole and norethindrone acetate: a pilot study. Fertil Steril. 2004;81(2):290–6.CrossRefPubMedGoogle Scholar
  40. 40.
    Jarrell JF, Vilos GA, Allaire C, Burgess S, Fortin C, Gerwin R, et al. Consensus guidelines for the management of chronic pelvic pain. J Obstet Gynaecol Can. 2005;27(9):869–910.CrossRefPubMedGoogle Scholar
  41. 41.
    Abercrombie PD, Learman LA. Providing holistic care for women with chronic pelvic pain. J Obstet Gynecol Neonatal Nurs. 2012;41(5):668–79.CrossRefPubMedGoogle Scholar
  42. 42.
    Miller-Matero LR, Saulino C, Clark S, Bugenski M, Eshelman A, Eisenstein D. When treating the pain is not enough: a multidisciplinary approach for chronic pelvic pain. Arch Womens Ment Health. 2015;Google Scholar
  43. 43.
    Obedin-Maliver J, Light A, de Haan G, Jackson RA. Feasibility of vaginal hysterectomy for female-to-male transgender men. Obstet Gynecol. 2017;129(3):457–63.CrossRefPubMedGoogle Scholar
  44. 44.
    Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013;20(9):888–902; quiz 3–4.Google Scholar
  45. 45.
    Grynberg M, Fanchin R, Dubost G, Colau JC, Bremont-Weil C, Frydman R, 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(4):553–8.CrossRefPubMedGoogle Scholar
  46. 46.
    Miller N, Bedard YC, Cooter NB, Shaul DL. Histological changes in the genital tract in transsexual women following androgen therapy. Histopathology. 1986;10(7):661–9.CrossRefPubMedGoogle Scholar
  47. 47.
    Perrone AMCS, Maria Salfi NC, Ceccarelli C, De Giorgi LB, Formelli G, Casadio P, Ghi T, Pelusi G, Pelusi C, Meriggiola MC. Effect of long-term testosterone administration on the endometrium of female-to-male (FtM) transsexuals. J Sex Med. 2009;6(11):3193–200.CrossRefPubMedGoogle Scholar
  48. 48.
    Kao A, Binik YM, Kapuscinski A, Khalife S. Dyspareunia in postmenopausal women: a critical review. Pain Res Manag. 2008;13(3):243–54.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Obedin-Maliver J. Pelvic pain and persistent menses in transgender men. In: Deutsch MB, editor. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. 2nd ed. San Francisco: Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco; 2016.Google Scholar
  50. 50.
    Weber MA, Kleijn MH, Langendam M, Limpens J, Heineman MJ, Roovers JP. Local oestrogen for pelvic floor disorders: a systematic review. PLoS One. 2015;10(9):e0136265.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Dorr MB, Nelson AL, Mayer PR, Ranganath RP, Norris PM, Helzner EC, et al. Plasma estrogen concentrations after oral and vaginal estrogen administration in women with atrophic vaginitis. Fertil Steril. 2010;94(6):2365–8.CrossRefPubMedGoogle Scholar
  52. 52.
    Santen RJ. Vaginal administration of estradiol: effects of dose, preparation and timing on plasma estradiol levels. Climacteric. 2015;18(2):121–34.CrossRefPubMedGoogle Scholar
  53. 53.
    Gooren LJ. Clinical practice. Care of transsexual persons. N Engl J Med. 2011;364(13):1251–7.CrossRefPubMedGoogle Scholar
  54. 54.
    Gorton N, Buth J, Spade D. Medical therapy and health maintenance for transgender men: a guide for health care providers. In: Lyon-Martin Women’s Health Services, ed. San Francisco; 2005:89.Google Scholar
  55. 55.
    Nikolic DV, Djordjevic ML, Granic M, Nikolic AT, Stanimirovic VV, Zdravkovic D, et al. Importance of revealing a rare case of breast cancer in a female to male transsexual after bilateral mastectomy. World J Surg Oncol. 2012;10:280.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Gooren L, Bowers M, Lips P, Konings IR. Five new cases of breast cancer in transsexual persons. Andrologia. 2015.Google Scholar
  57. 57.
    National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology-genetic/familial high-risk assessment: breast and ovarian. Fort Washington: National Comprehensive Cancer Network; 2016. p. 1–105.Google Scholar
  58. 58.
    Massad LS, Einstein MH, Huh WK, Katki HA, Kinney WK, Schiffman M, et al. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2013;17(5 Suppl 1):S1–s27.CrossRefPubMedGoogle Scholar
  59. 59.
    Dizon DS, Tejada-Berges T, Koelliker S, Steinhoff M, Granai CO. Ovarian cancer associated with testosterone supplementation in a female-to-male transsexual patient. Gynecol Obstet Investig. 2006;62(4):226–8.CrossRefGoogle Scholar
  60. 60.
    Hage JJ, Dekker JJ, Karim RB, Verheijen RH, Bloemena E. Ovarian cancer in female-to-male transsexuals: report of two cases. Gynecol Oncol. 2000;76(3):413–5.CrossRefPubMedGoogle Scholar
  61. 61.
    Urban RR, Teng NN, Kapp DS. Gynecologic malignancies in female-to-male transgender patients: the need of original gender surveillance. Am J Obstet Gynecol. 2011;204(5):e9–e12.CrossRefPubMedGoogle Scholar
  62. 62.
    Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(Rr-03):1–137.PubMedGoogle Scholar
  63. 63.
    Ellis SA, Wojnar DM, Pettinato M. Conception, pregnancy, and birth experiences of male and gender variant gestational parents: it’s how we could have a family. J Midwifery Womens Health. 2014;60:62–9.CrossRefPubMedGoogle Scholar
  64. 64.
    Cipres D, Seidman D, Cloniger 3rd C, Nova C, O’Shea A, Obedin-Maliver J. Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco. Contraception. 2016;95:186–9.CrossRefPubMedGoogle Scholar
  65. 65.
    Bauer GR, Redman N, Bradley K, Scheim AI. Sexual health of trans men who are gay, bisexual, or who have sex with men: results from Ontario, Canada. Int J Transgend. 2013;14(2):66–74.CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    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.CrossRefPubMedGoogle Scholar
  67. 67.
    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.CrossRefPubMedGoogle Scholar
  68. 68.
    Carter HB, Albertsen PC, Barry MJ, Etzoni R, Freedland SJ, Greene KL, et al. Early Detection of Prostate Cancer: American Urological Association (AUA) Guideline. American Urological Association; 2013:1–28.Google Scholar
  69. 69.
    Trum HW, Hoebeke P, Gooren LJ. Sex reassignment of transsexual people from a gynecologist’s and urologist’s perspective. Acta Obstet Gynecol Scand. 2015;94:563–7.CrossRefPubMedGoogle Scholar
  70. 70.
    Loverro G, Di Naro E, Caringella AM, De Robertis AL, Loconsole D, Chironna M. Prevalence of human papillomavirus infection in a clinic sample of transsexuals in Italy. Sex Transm Infect. 2016;92(1):67–9.CrossRefPubMedGoogle Scholar
  71. 71.
    Unger CA. Care of the transgender patient: the role of the gynecologist. Am J Obstet Gynecol. 2014;210(1):16–26.CrossRefPubMedGoogle Scholar
  72. 72.
    Weyers S, De Sutter P, Hoebeke S, Monstrey G, t Sjoen G, Verstraelen H, et al. Gynaecological aspects of the treatment and follow-up of transsexual men and women. Facts Views Vis Obgyn. 2010;2(1):35–54.PubMedPubMedCentralGoogle Scholar
  73. 73.
    Green N, Hoenigl M, Morris S, Little SJ. Risk behavior and sexually transmitted infections among transgender women and men undergoing community-based screening for acute and early HIV infection in San Diego. Medicine (Baltimore). 2015;94(41):e1830.CrossRefGoogle Scholar
  74. 74.
    Stephens SC, Bernstein KT, Philip SS. Male to female and female to male transgender persons have different sexual risk behaviors yet similar rates of STDs and HIV. AIDS Behav. 2011;15(3):683–6.CrossRefPubMedGoogle Scholar
  75. 75.
    Horbach SE, Bouman MB, Smit JM, Ozer M, Buncamper ME, Mullender MG. Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques. J Sex Med. 2015;12(6):1499–512.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York (outside the USA) 2017

Authors and Affiliations

  1. 1.Department of Obstetrics, Gynecology & Reproductive SciencesUniversity of California, San FranciscoSan FranciscoUSA
  2. 2.Department of General Internal MedicineSan Francisco Veterans Affairs Medical CenterSan FranciscoUSA
  3. 3.Department of Obstetrics and GynecologyOregon Health & Science UniversityPortlandUSA

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