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

  • Charles Moser
  • Maura Devereux
Sexual Orientation and Identity (J Vencill and M Coleman, Section Editors)
  • 19 Downloads
Part of the following topical collections:
  1. Topical Collection on Sexual Orientation and Identity

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.

Keywords

Transgender Gender dysphoria Gender diverse Stigma in healthcare Nonbinary 

Notes

Compliance with Ethical Standards

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.

References

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

  1. 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.CrossRefGoogle Scholar
  2. 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.CrossRefPubMedGoogle Scholar
  3. 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)00683-8 Excellent presentation of the problems gender diverse patients face interacting with the healthcare system. CrossRefPubMedGoogle Scholar
  4. 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.CrossRefPubMedGoogle Scholar
  5. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 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. 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.CrossRefPubMedGoogle Scholar
  8. 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. 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.CrossRefPubMedGoogle Scholar
  10. 10.
    https://en.wikipedia.org/wiki/Transgender. Downloaded August 12. 2018.
  11. 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.CrossRefPubMedGoogle Scholar
  12. 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.2016.258780 Explains the inherent bias that gender diverse patients face by omitting and ignoring evidence-based changes in clinical laboratory values associated with gender transition. CrossRefPubMedGoogle Scholar
  13. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 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.CrossRefPubMedGoogle Scholar
  15. 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.CrossRefGoogle Scholar
  16. 16.
    Moser C. Defining sexual orientation. Arch Sex Behav. 2016;45(3):505–8.CrossRefGoogle Scholar
  17. 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.CrossRefGoogle Scholar
  18. 18.
    Lawrence AA. Sexuality before and after male-to-female sex reassignment surgery. Arch Sex Behav. 2005;34(2):147–66.CrossRefGoogle Scholar
  19. 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. 20.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.Google Scholar
  21. 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.CrossRefPubMedGoogle Scholar
  22. 22.
    Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003;32(4):299–315.CrossRefGoogle Scholar
  23. 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.CrossRefPubMedGoogle Scholar
  24. 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.CrossRefGoogle Scholar
  25. 25.
    Dimitrakakis C, Bondy C. Androgens and the breast. Breast Cancer Res. 2009;11(5):212.  https://doi.org/10.1186/bcr2413.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    • Gooren LJ, T’Sjoen G. Endocrine treatment of aging transgender people. Rev Endocr Metab Disord. 2018.  https://doi.org/10.1007/s11154-018-9449-0 Highlighting another aspect of our lack of knowledge about the medical care of gender diverse people. CrossRefGoogle Scholar
  27. 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.CrossRefPubMedGoogle Scholar
  28. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 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.CrossRefGoogle Scholar
  30. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 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.CrossRefPubMedGoogle Scholar
  32. 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.CrossRefPubMedGoogle Scholar
  33. 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. 34.
    Stoner E. The clinical development of a 5α-reductase inhibitor, finasteride. J Steroid Biochem Mol Biol. 1990;37(3):375–8.CrossRefGoogle Scholar
  35. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 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.CrossRefGoogle Scholar
  37. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 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.CrossRefGoogle Scholar
  39. 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.CrossRefPubMedGoogle Scholar
  40. 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.CrossRefGoogle Scholar
  41. 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.CrossRefPubMedGoogle Scholar
  42. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 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. 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.CrossRefGoogle Scholar
  45. 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.CrossRefGoogle Scholar
  46. 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.CrossRefPubMedGoogle Scholar
  47. 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.CrossRefPubMedGoogle Scholar
  48. 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.CrossRefPubMedGoogle Scholar
  49. 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.CrossRefPubMedGoogle Scholar
  50. 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.CrossRefPubMedGoogle Scholar
  51. 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.CrossRefPubMedGoogle Scholar
  52. 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.CrossRefPubMedGoogle Scholar
  53. 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.CrossRefPubMedGoogle Scholar
  54. 54.
    Diamond LM. Sexual fluidity: understanding women’s love and desire. Harvard University Press: Cambridge, MA, 2008 333 pp., ISBN: 978-0674032262.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Charles Moser
    • 1
  • Maura Devereux
    • 2
  1. 1.Diverse Sexualities Research and Education InstituteSan FranciscoUSA
  2. 2.Sutter Pacific Medical FoundationSan FranciscoUSA

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