para>Transgender patients are at increased risk of suicidal ideation, suicide attempts, and suicide (1,4),(2)[A].
Improving access to care
General Measures
- Care of transgender people, including hormone therapy, is within the scope of primary care providers.
- Education of health care providers, for physicians, and those beginning in medical school, is crucial to providing optimal care to transgender patients (2).
Medication
First Line
- Hormone therapy (6)[A]
- Adolescents
- Suppress pubertal development using gonadotropin-releasing hormone (GnRH) analogues
- Progestin
- Cross-sex steroids at about age 16 years
- Surgical referral
- Adults
- Estrogens, antiandrogens, and/or GnRH agonists for male-to-female patients (6)[A]
- Ethinyl estradiol 100 ¼g/day or conjugated equine estrogen 2.5 mg/day
- Use transdermal ethinyl estradiol once in patient >40 years old; adjust dose to suppress total testosterone to <25 ng/dL; if estrogen doses reach twice above recommendations, add spironolactone, cyproterone acetate, or GnRH agonists to minimize estrogen requirement.
- At initial visit, do prostate-specific antigen (PSA), lipid panel, and liver function tests (LFTs); every 3 months, check testosterone levels until stable, monitor estradiol blood level for compliance, repeat lipid panel, and encourage breast exams.
- Every 6 months " 1 year, preoperatively, order visual fields to assess for prolactinoma, check serum prolactin, and repeat lipid panel; if patient is >50 years old, recheck PSA and consider mammogram.
- Every 6 months " 1 year, postoperatively, reduce estrogens to hormone replacement therapy (HRT) doses (conjugated equine estrogens 0.625 mg/day, transdermal ethinyl estradiol 0.05 " 0.1 mg/day, or ethinyl estradiol 0.02 " 0.05 mg/day) and do dual-energy x-ray absorptiometry (DEXA) scan to monitor for osteoporosis.
- Testosterone for female-to-male patients (6)[A]
- Testosterone esters 200 mg intramuscular (IM) every other week or transdermal testosterone 5 g/day with goal of serum testosterone in midmale range
- At initial visit, check weight, lipid panel, and glucose level.
- Every 3 " 6 months, repeat lipid panel and LFTs, do complete blood count to rule out polycythemia, and check testosterone levels.
- Every 6 months " 1 year, preoperatively, do pelvic exam and Papanicolaou (Pap) smear per current protocols.
- Every 2 years, do endometrial ultrasounds.
- Every 6 months " 1 year, postoperatively, titrate testosterone to maintain serum testosterone at 500 ¼g/dL (17.35 SI) and do DEXA scan.
Surgery/Other Procedures
- SRS (6)[A]
- Only after 1 year of hormone therapy
Ongoing Care
Interacting With the Health Care System
- Discrimination on the part of health care providers is a major barrier to care (4).
Patient Monitoring
- Routine medical screening:
- Pelvic exam (5)
- Cervical and anal Pap tests (5)
- Screening for STIs (5)
- Measurement of prolactin levels (6)
- Evaluation of cardiovascular (CV) risk factors (6)
- Bone mineral density tests, as indicated (6)
- Breast cancer screening per guidelines (6)
Patient Education
- Hormone therapy and potential health risks
- Counseling for gender-confirming surgery
- Legal issues
- Under the Affordable Care Act (ACA), denial of treatment of being transgender as a "pre-existing condition " is banned (2).
- Centers for Medicare and Medicaid Services (CMS) considers SRS experimental and denies coverage (2).
- The U.S. Department of Veterans Affairs (VA), while acknowledging the need to care for transgender veterans, denies coverage of SRS on the basis of a VA regulation that excludes gender alterations from the medical benefits package (2).
References
1.Roberts TK, Fantz CR. Barriers to quality health care for the transgender population. Clin Biochem. 2014;47(10 " 11):983 " 987.
[]
2.Stroumsa D. The state of transgender health care: policy, law, and medical frameworks. Am J Public Health. 2014;104:e31 " e38.3.Cruz TM. Assessing access to care for transgender and gender nonconforming people: a consideration of diversity in combating discrimination. Soc Sci Med. 2014;110:65 " 73.
[]
4.Lim FA, Brown DV Jr, Justin Kim SM. Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: a review of best practices. Am J Nurs. 2014;114(6):24 " 34.
[]
5.New York State Department of Health. Care of the HIV-Infected Transgender Patient. New York, NY:New York State Department of Health; 2011.6.Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132 " 3154.
[]
Additional Reading
- Agency for Healthcare Research and Quality. National Healthcare Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; 2011.
- Institute of Medicine of the National Academies. The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press; 2011.
Codes
ICD09
- 302.50 Trans-sexualism with unspecified sexual history
- V01.79 Contact with or exposure to other viral diseases
- V69.2 High-risk sexual behavior
ICD10
- F64.1 Gender identity disorder in adolescence and adulthood
- Z11.4 Encounter for screening for human immunodeficiency virus
- Z72.52 High risk homosexual behavior
- Z72.53 High risk bisexual behavior
- Z72.51 High risk heterosexual behavior
SNOMED
- 407375002 Surgically transgendered transsexual (finding)
- 171121004 Human immunodeficiency virus screening (procedure)
- 102947004 high risk sexual behavior (finding)
- 288291000119102 High risk bisexual behavior (finding)
- 288301000119101 High risk heterosexual behavior (finding)
- 288311000119103 High risk homosexual behavior (finding)
Clinical Pearls
- Health care providers must be sensitive to the unique needs of transgender patients, must be open to the care of such patients, and should, as with all patients, display an ethical, principled, and timely approach to care.
- Do use inclusive language in the care of transgender patients, assessing the individuals ' preferences, and respect differences among transgender patients.
- Always address health care needs particular to the transgender population.
- Avoid stigmatization of transgender patients, ensuring gender-blind clinical care.