Transgender Health
BASICS
- Definition: Transgender individuals have a gender identity or expression that differs from the sex assigned at birth. Not all transgender people pursue medical transition.
- Estimated Prevalence (2015):
- 0.6% of U.S. adults (~1.4 million)
- 0.7% of adolescents (13–17 years; ~150,000)
- Key Issues:
- Medically underserved
- Increased rates of mental health disorders, HIV, substance use
- Significant health care discrimination and systemic barriers
- Terminology:
- Ask patients their preferred terms for identity and anatomy.
- Distinguish gender identity from sexual orientation.
- Respect identities across the spectrum (e.g., nonbinary, gender diverse).
HEALTH CARE DISPARITIES
| Challenge | Impact |
|---|---|
| Stigma & discrimination | 24% report unequal treatment; 19% refused care |
| Avoidance of care | 33% skip preventive care; 23% delay needed care |
| Insurance discrimination | 55% denied surgery coverage; 25% denied hormones |
| Poverty | 29% live below poverty line (vs 14% general pop.) |
| Suicidality | 40% attempt suicide (vs 1.6% in general population) |
DIAGNOSIS
- Gender dysphoria (ICD: F64.1) may be used for insurance and clinical access to gender-affirming care.
- Defined as psychological distress due to incongruence between gender identity and assigned sex.
TRANSITION-RELATED MEDICAL CARE
Guidelines
- WPATH SOC v8
- Endocrine Society Guidelines (2017 update)
Hormone Therapy
Adolescents
- Puberty blockers (GnRH analogues):
- Reversible, used at Tanner stage 2–3
- Gender-affirming hormones:
- Typically started ≥16 years old with confirmed dysphoria and informed consent
Adults
| Feminizing Therapy | Masculinizing Therapy |
|---|---|
| Estradiol + anti-androgens (e.g., spironolactone) | Testosterone (IM, transdermal, SC formulations) |
| Goals: ↓ testosterone, develop breast tissue, soften skin, redistribute fat | Goals: ↑ muscle mass, deepen voice, facial/body hair, stop menses |
- Risks: VTE, liver dysfunction, gallstones, metabolic syndrome, ↓ fertility
- Monitoring: Hormone levels, CV risk, mental health
Gender-Affirming Surgery (GAS)
| Type | Notes |
|---|---|
| Chest/top surgery | Often first and does not require prior hormones |
| Genital surgery | Requires ≥6 months hormone therapy + psychiatric clearance |
| Examples | Vaginoplasty, phalloplasty, metoidioplasty, hysterectomy |
- GAS improves quality of life, self-esteem, and reduces dysphoria.
- 25% of transgender individuals have undergone some form of GAS.
PSYCHOSOCIAL CONSIDERATIONS
| Risk/Concern | Recommendation |
|---|---|
| Suicide risk | Screen regularly; provide mental health support |
| IPV, substance use | Annual psychosocial and behavioral assessments |
| Housing and job insecurity | Screen and refer for social support |
| Reluctance to disclose identity | Create welcoming, nonjudgmental environments |
PHYSICAL EXAM & SCREENING
- Always individualize based on current anatomy and transition stage.
- Explain each step, seek consent, and ensure comfort.
Routine Screenings
| Population | Screening Recommendations |
|---|---|
| Transmasculine | Chest wall exam (if any breast tissue), cervical cancer (if cervix present) |
| Transfeminine | Prostate cancer (if prostate intact), breast cancer (age >50 + ≥5 yrs estrogen) |
| All | STI/HIV testing per risk behavior; consider anal Pap (for receptive anal sex) |
- Consider bone mineral density if:
- Low hormone levels
- Age >50
- Long-term GnRH use
FERTILITY & CONTRACEPTION
| Group | Key Points |
|---|---|
| Transmasculine | Testosterone is not a contraceptive; ovulation may resume. |
| Discuss options before testosterone or hysterectomy. | |
| Pregnancy possible if uterus and ovaries retained. | |
| Transfeminine | Sperm banking before estrogen use is recommended. |
| Fertility may return after stopping hormones in some cases. |
- Always discuss fertility desires pre-transition.
- Provide barrier methods for STI prevention.
ONGOING CARE & MONITORING
| Component | Frequency |
|---|---|
| Hormone levels | Q3–6 months, then yearly |
| Labs (lipids, LFTs, CBC) | Per Endocrine Society |
| Mental health screening | Annually |
| CV risk factor monitoring | Annually or as indicated |
| BMD (if indicated) | Q1–5 years |
PROVIDER RESPONSIBILITIES
- Use inclusive language and correct pronouns.
- Ask for preferred name, gender, and anatomy terminology.
- Educate staff and ensure non-discriminatory clinic policies.
- Do not assume sexual orientation based on gender identity.
- Educate patients on:
- Hormone risks and benefits
- Surgical options
- Reproductive health
- Insurance rights and limitations
POLICY & LEGAL ISSUES
| Issue | Details |
|---|---|
| Insurance barriers | Many plans require gender dysphoria diagnosis |
| CMS policy (since 2014) | Covers transition-related care |
| VA coverage | Inconsistent; some gender-affirming surgeries not covered |
| Conversion therapy | Illegal in several states |
CLINICAL PEARLS
- Transgender identity ≠ mental illness; gender dysphoria is not required for identity.
- Suicide risk is drastically higher; proactive screening is life-saving.
- Hormone therapy and GAS are safe, effective, and within scope of primary care.
- Cultural competence and respectful language are cornerstones of care.
- Always individualize screening and treatment plans to match the patient’s anatomy and identity, not assumptions.
CODES
| ICD-10 Code | Description |
|---|---|
| F64.1 | Gender identity disorder in adolescence/adulthood |
| Z11.4 | Screening for HIV |
| Z72.52 | High-risk homosexual behavior |
REFERENCES
- Korpaisarn S, Safer JD. Rev Endocr Metab Disord. 2018;19(3):271-275.
- Nolan IT et al. J Craniofac Surg. 2019;30(5):1349-1351.
- ACOG Committee Opinion No. 823. Obstet Gynecol. 2021;137(3):e75-e88.
- Klein DA et al. Am Fam Physician. 2018;98(11):645-653.
- Safer JD, Tangpricha V. N Engl J Med. 2019;381(25):2451-2460.
- Coleman E et al. Int J Transgend Health. 2022;23(Suppl 1):S1-S259.
- Hembree WC et al. J Clin Endocrinol Metab. 2017;102(11):3869-3903.
- CMS Policy Updates for Transition-Related Care.