The Clinician's Guide to Transgender Care
Key strategies necessary to provide comprehensive, sensitively delivered care

Common Clinical Concerns in Ongoing Transgender Care

Chapter 4: Overview of typical medical issues that may arise after initiating transgender hormone therapy or surgery as well as general and ongoing medical follow-up.

Even after a person begins transgender medical care, other medical concerns will undoubtedly arise, encompassing both those related to the transgender therapy treatment and more so, with regard to general, ongoing health needs and concerns.

In a survey conducted by the Scottish Transgender Alliance,1 researchers found that 84% of trans individuals had considered ending their lives, and the estimate of actual suicide attempts was 48%. The respondents cited abusive practices and attitudes from healthcare providers as the main reasons for their dispair.1

Societal and family responses to family who trans* necessitate mental health support.A multidisciplinary team can both anticipate and address clinical and mental health concerns of transgender patients..

Therefore, practitioners who are enlightened about the clinical needs of and treatment concerns faced by transgender patients will be able to ease any anxiety, improve their mental health outlook, and lessen any worries by acknowledging the patient’s feelings.  

Generally, Transgender Treatment Produces No Regrets

In a study appearing in the Archives of Sexual Behavior, researchers reported examining a 50-year period, from 1960 through 2010, to determine how many of 767 people applying for legal gender marker change and transgender surgery in Sweden had changed their mind or regretted the decision. The authors found that 15, or just 2.2%, filed regret applications.2

While the number of medically or surgically treated transgender individuals feeling remorse is very small, when regret does arise, it can be tragic. One well-publicized example in the US concerned a Los Angeles Times sportswriter, Christine Daniels. She bravely wrote about her experience in a column in 2007.  The need for sufficient mental health support is crucial before, during, and after medical and/or surgical treatment for both the transgender individual and for the family members whose ability to be supportive may be impacted by their own inability to cope with the emotional stressors that are likely to arise.

Create a Welcoming, Sensitive Clinical Setting

If quality clinical care is to be provided, the initial introduction to the physician's office must be positive. To ease anticipated sensitivities that may occur during transgender medical treatment, there are steps that endocrinologists and primary care physicians may take to lessen any potential for patient distress:4

Five simple but essential clinical practices to employ with each patient:

  • Always inquire about their gender identity.
  •  Ask which pronoun is used by the patient, then note it clearly on the chart and ensure that all office personnel are sensitized to check the chart before addressing patient.
  • Use the patient's preferred name—in person, on all correspondence, in medical records, and when placing prescription orders—even if a separate “insurance” name must be maintained.
  • Do not respond to every health concern as if it is directly related to the patient’s trans status because most medical matters will be general or routine problems.
  • Provide gender-neutral bathroom facilities.

Addressing Other Health Considerations

Expanding the Multidisciplinary Team

Exactly how best to meet the medical and mental health needs of trans patients is evolving, but the World Professional Association for Transgender Health (WPATH) issues a clinical guidance that articulate Standards of Care for the health of transsexual, transgender, and gender nonconforming people (7th ed).5 These clinical care recommendations are evidence-based and informed by practitioners with expertise to form consensus opinions. The expert panel is currently in the process of preparing an updated guidance—8thedition.

Just as in other areas of current clinical care, a patient-centric approach to healthcare delivery is best provided with at least a virtual multidisciplinary team reflecting an endocrinologist, primary care provider (adult or pediatric), a mental health specialist, a surgeon when appropriate, and other specialists as needed or as other medical concerns arise.

Offices should establish a protocol to provide cultural sensitivity training to ensure that all office personnel receive sufficient information about possible barriers to care. Initial hiring and orientation processes should include training on common health concerns for trans patients.

All office staff, both clinical and administration, should be familiar with (and fluent in) basic terminology used by the trans community. (See chapter 1.) At present, suggestions for addressing common and routine medical needs of persons who have received transgender medical and/or surgical treatment are as follows:5-7

Mental health—Primary care providers will want to have a referral list of mental health providers and services with experience in trans health.5

Reproductive health—Many trans people may wish to have children. Hormone therapy limits fertility, so patients should be counseled to consider this issue even in the abstract and to make at least some fertility decisions before hormone therapy is initiated or they proceed with surgery. Younger patients may seem uninterested in giving consideration to the prospect of having a family, but the discussion should be presented, and options such as sperm banking, and egg or embryo freezing, at least should be introduced.

Younger people who are pre-pubertal or pubertal when they begin treatment may never develop reproductive functioning.

Cancer and other Screenings—Cancer screenings should be based on organ-specific care. While recommended screening guidelines for the general population should be followed for trans patients, for some clinical concerns, the usual guidelines may either over- or under-state the cost-effectiveness of screening for those who are receiving hormone therapy. No different than any other patient, transgender individuals should be monitored for all reproductive cancers (eg, breast, cervical, ovarian, uterine, prostate).

While there is no consensus with regard to recommendations for breast cancer screening in the trans community, trans women appear at lower risk for breast cancer since their lifetime exposure to estrogen is lower and progesterone is extremely limited. While data are mixed, trans women typically have dense breasts, setting them up for greater cancer  for non-trans women of the same age.is

It is strongly advised that endocrinologists rely on established protocols and best practices, such as those issued by the Endocrine Society (2017) with support from the American Association of Clinical Endocrinologists and the World Professional Association for Transgender Health.6

Cardiovascular disease (CVD)—The risk may shift following transgender hormone treatment. While important, a lack of research characterizing any differences in or changes to risk of CVD remains inconclusive. However, both baseline risks and age of the patient at the onset of hormone administration ought to be considered for each individual in assessing risk of cardiovascular disease. There is some indication that CVD risk (ie, hypertension, insulin resistance, and dyslipidemia) may rise following transgender hormone therapy more so for trans women but the data has been gathered in younger individuals so not generalizable to older trans patients.8,9

Factors that appear more relevant to CVD risk include diabetes, tobacco use, and obesity.10

Osteoporosis— There is an increased risk for fracture when there are prolonged hypogonadal states. And, while we know that both estrogen and testosterone have key roles in bone metabolism, there is little research on the prevalence of osteoporosis within the trans community. Since research of non-trans individuals has indicated that the risk for osteoporosis increases in women with low estrogen and men with low testosterone, the best clinical course is to monitor bone density based in trans patients based on the overall risk for each patient.

Urogenital problems—Transgender people who have genital surgery, may need special instructions for genital issues that arise. Transgender women may need to be informed of the need for regular vaginal dilation or penetrative intercourse to maintain vaginal depth and width. Transgender men who have some genital surgeries may need to be informed about the risk of lower urinary tract infections. In addition, some transgender men report symptoms consistent with atrophic changes of the vaginal lining due to masculinizing hormones.

Voice Training—Some trans individuals may choose to have voice and communication therapy.11 Voice specialists may assist individuals with pitch, intonation, resonance, speech rate, and phrasing patterns aligned with gender identity.  Specialists can also help with non-verbal patterns, such as gestures and facial expressions with the s

 

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Putting Transgender Medical Care Into Context for Practitioners
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