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Primary care of transgender individuals

Primary care of transgender individuals
Authors:
Jamie Feldman, MD, PhD
Madeline B Deutsch, MD, MPH
Section Editor:
Joann G Elmore, MD, MPH
Deputy Editor:
Kathryn A Martin, MD
Literature review current through: Dec 2022. | This topic last updated: Dec 01, 2021.

INTRODUCTION — In addition to gender-affirming medical care, transgender people have primary and preventive health care needs that are similar to the general population. Depending on an individual's history of gender-affirming care, primary and preventive care may require special considerations. Transgender patients often experience discrimination in the health care setting and lack of access to medical personnel competent in transgender medicine [1-3]. This results in lack of access to preventive health services and timely treatment of routine health problems [4-6].

This topic will provide an overview for providing primary care to transgender patients. The epidemiology, pathophysiology, and diagnosis as well as the hormonal and surgical treatment of transgender patients are discussed elsewhere. (See "Transgender women: Evaluation and management" and "Transgender men: Evaluation and management".)

TERMINOLOGY — The term "transgender" is generally used to describe a diverse group of individuals whose gender identity or expression differs from that assigned at birth (table 1) [7]. Primary care providers should be familiar with commonly used terms (table 1) and the diversity of identities within the transgender community. Natal sex refers to the sex the patient was assigned at birth. For example, transgender women (male to female, MTF) have a female gender identity and were assigned a male sex at birth and transgender men (female to male, FTM) have a male gender identity and were assigned a female sex at birth. Individuals who identify elsewhere along the spectrum of the masculine/feminine gender may use other terms. Gender-affirming care includes hormone therapy and gender-related surgeries, as well as other procedures, such as hair removal or speech therapy.

ROLE OF THE PRIMARY CARE PROVIDER — The role of the primary care provider for transgender patients includes the tasks typical for all patients (eg, primary and secondary prevention), in addition to the specific needs of transgender individuals [8-11]. For example, primary care clinicians may be involved in providing medical documentation of a patient's gender, navigating insurance coverage for gender-related interventions, and providing letters for change of gender on identification (eg, passport, driver's license). Referrals may also be sought for gender-affirming surgeries, voice therapy, hair removal through laser or electrolysis, or hair transplant [12].

Not every primary care clinician will be able to offer all elements of comprehensive transgender care; however, every clinician can become comfortable in working with transgender patients to meet their healthcare needs, including gender-affirming interventions. It is important that primary care providers be aware that patients may vary widely in terms of anatomy and hormonal status when they present, and these attributes may further change over time.

Hormone therapy may be managed by specialists or primary care providers [12]. Those that do not manage hormone therapy should be aware of common medications and doses used in hormone therapy, along with potential side effects. Finally, primary care providers should become knowledgeable regarding appropriate postsurgical self-care after genital surgeries. (See "Transgender women: Evaluation and management".)

CLINICAL MANAGEMENT — Providers should refer to transgender patients by their preferred name and pronouns, reassure them about confidentiality, and educate frontline and other clinical staff regarding these issues.

History — A comprehensive history may not be possible in one visit. History gathering should take place over time to build trust with the patient. In general, the history is similar to that of non-transgender patients. History that is specifically important for transgender patients includes:

Gender-related hormonal and surgical interventions – A thorough history of past and current gender-related hormonal use and surgical interventions is essential. Clinicians should also ask if the patient plans to pursue hormone therapy or surgeries in the future. Awareness of future plans is useful in coordinating referrals and planning relating to care for any coexisting medical, social, or psychologic concerns.

Past hormone use may have been medically supervised or unsupervised (often purchased on the internet or on the street). Medically unsupervised use is common among transgender patients with limited access to care, and patients may share needles in this setting [13]. Patients may use "herbal hormones" (eg, phytoestrogens or androgen-like compounds sold as dietary supplements such as red clover, black cohosh, and dehydroepiandrosterone). We also ask transgender women about the use of silicone injections (to their hips, buttocks, thighs, breasts, or face). These are often done without sterile technique and can increase risks for bloodborne infections [14].

Surgeries may include both sex reassignment procedures and those to masculinize or feminize facial and body contours. (See "Transgender women: Evaluation and management", section on 'Gender confirmation surgery'.)

Reproductive history – A gynecologic and obstetric history is important in transgender men (female to male, FTM). Providers may delay taking this history until they have established a trusting relationship with the patient. Studies suggest that polycystic ovarian syndrome (PCOS) and hyperandrogenicity are commonly found in transgender men [15-18]. (See "Diagnosis of polycystic ovary syndrome in adults".)

Family history – The family history is similar to that of non-transgender patients. For patients taking or considering hormone therapy, particular attention to familial conditions that may be affected by the use of estrogen or testosterone may be warranted. (See "Transgender women: Evaluation and management", section on 'Adverse events' and "Transgender women: Evaluation and management" and "Transgender men: Evaluation and management", section on 'Adverse events'.)

As with natal females, transgender men with known or suspected genetic mutations for breast and ovarian cancer should be referred for genetic counseling for testing and prevention options. (See "Genetic testing and management of individuals at risk of hereditary breast and ovarian cancer syndromes".)

Sexual history – A sexual health history requires particular sensitivity for transgender patients. Discussion should be initiated gradually, and pacing should depend on patient comfort. A sexual history should cover sexual behaviors including assessing for any history of unprotected receptive anal intercourse, behaviors that increase risk for sexually transmitted infections (STIs; eg, sex work), unintended pregnancy, and sexual function (table 2). This history is important to determine what screening for STIs is appropriate. (See 'Sexually transmitted and bloodborne infections' below and "Screening for sexually transmitted infections", section on 'Assessing risk'.)

Sexual practices vary greatly, and assumptions should not be made about the gender of a patient's sexual partner(s) or sexual activities [19]. Transgender individuals may have male or female partners, including other transgender partners. They may use their natal sex organs during sexual activity. Surveys and focus-group studies suggest that social marginalization, stigma, and the need to affirm one's gender identity can drive high-risk sexual behaviors [20-23]. Transgender individuals (of any gender) who have sex with men are more likely to practice condomless sex [24].

Psychiatric history – Patients should be assessed for mood disorders (especially depression and anxiety), substance use, and posttraumatic stress disorder (including a history of physical, sexual, or emotional trauma or abuse). Compared with non-transgender patients, transgender individuals have more symptoms of depression and anxiety as well as higher rates of suicidal ideation [25]. These symptoms are often a result of longstanding experiences of oppression and denial of identity. One survey found that 41 percent of transgender and gender nonconforming respondents had attempted suicide at some point in their lifetime [4]. (See "Screening for depression in adults", section on 'Screening options' and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Assessment and Diagnosis' and "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis", section on 'Assessment' and "Clinical assessment of substance use disorders" and "Screening for unhealthy use of alcohol and other drugs in primary care".)

Social history – The social history should include a review of a transgender patient's family, economic, and larger social environments, which can be sources of support or stress. Social isolation, rejection by family or community of origin, harassment, and discrimination can significantly impact a transgender individual's health. Additionally, for a variety of reasons, including housing and employment discrimination, transgender individuals have a higher rate of homelessness compared with the general population [4].

Physical examination — Regardless of the gender identity of the patient, physical exams should be based on the organs present and the patient's presenting symptoms. Transgender patients may be uncomfortable with their bodies and find some elements of physical examination traumatic. Unless there is an immediate medical need, sensitive elements of the exam (particularly breast, pelvic, and rectal exams) should be delayed until strong clinician-patient rapport has developed. The physical exam provides an important opportunity to educate patients about their bodies and about the need for ongoing health maintenance.

In the absence of hormone therapy, findings suggestive of intersex conditions (eg, congenital adrenal hyperplasia, abnormal androgen synthesis, or Turner syndrome) should be further evaluated as appropriate. (See "Diagnosis and treatment of nonclassic (late-onset) congenital adrenal hyperplasia due to 21-hydroxylase deficiency" and "Adrenal hyperandrogenism", section on 'Clinical manifestations' and "Clinical manifestations and diagnosis of Turner syndrome", section on 'Clinical manifestations'.)

For patients on hormone therapy and/or who have had sex reassignment surgery, physical changes include:

Transgender women (male to female, MTF) Feminizing physical changes vary depending on the length of time on hormones (table 3). These patients may have feminine breast shape and size, often with relatively underdeveloped nipples; breasts may appear fibrocystic if there have been silicone injections. Galactorrhea is sometimes seen in patients with high prolactin levels, especially among those using breast pumps to stimulate development [26,27]. There may be minimal body hair and variable facial hair (depending on length of time on hormones and hair removal treatments). Testicles may become small and soft; defects or hernias at the external inguinal ring may be present due to the practice of "tucking" the testicles up near (or into) the inguinal canal. (See "Transgender women: Evaluation and management", section on 'Clinical outcomes'.)

Gender-affirming surgical procedures for transgender women include bilateral orchiectomy, penectomy, the creation of a clitoris and neovagina, and breast augmentation. (See "Transgender women: Evaluation and management".)

Transgender man (female to male, FTM) – Masculinizing physical changes vary depending on the length of time on hormones (table 4). These patients may have beard growth, clitoromegaly, acne, and androgenic alopecia; those who have bound their breasts for many years may have rash or yeast infection of the skin under the breasts. (See "Transgender men: Evaluation and management", section on 'Masculinizing effects'.)

Gender-affirming surgical procedures for transgender men include oophorectomy, hysterectomy, and vaginectomy. They may also undergo chest reconstruction (including mastectomy), metoidioplasty (creation of a microphallus), or phalloplasty (creation of a neophallus).

Laboratory studies — Normal values for transgender patients who are undergoing or have completed gender transition have not been established for any laboratory test [28]. In the absence of laboratory determined reference ranges, clinicians should interpret values based on the hormonal status of the patient, noting that this may differ from the lab-reported reference range. For example, in transgender women, creatinine may remain elevated above the female upper limit of normal due to preserved muscle mass, and the lower normal limit for hematocrit may be expected to be somewhere between the female and male ranges (due to reduced testosterone). Conversely, for transgender men on hormone therapy, hematocrit might be expected to be in the male range due to amenorrhea and the erythropoietic effects of testosterone supplementation [14].

SCREENING/PREVENTIVE CARE — The recommendations for screening and prevention for transgender patients who have not been on hormonal therapy and had no surgery are the same as those of the general population. (See "Geriatric health maintenance".)

Specific considerations in patients on hormones — For patients who have received hormones and/or undergone surgery, recommendations for screening and preventive care may depend on the patient's hormonal and surgical status. Specific issues, particularly screening for cancer (eg, breast, cervical, and prostate cancers) (table 5), are noted below. Unless noted, the screening and prevention recommendations are the same as the general population. (See "Geriatric health maintenance".)

Long-term prospective studies for most transgender health issues are lacking, resulting in variable preventive care recommendations based primarily on observational studies and expert opinion [5,29]. In many areas, case reports or series are the best data. The best available evidence for mortality comes from observational studies. One study of a Netherlands historical cohort involved 966 transgender women and 365 transgender men patients, with hormone use of at least one year and median follow-up of 18.5 years [30]. Mortality for transgender women (male to female, MTF) was noted to be 51 percent higher than the general male population, mainly due to increased rates of death from suicide, drugs, acquired immunodeficiency syndrome (AIDS), and, to a lesser extent, cardiovascular disease (CVD). The mortality for transgender men (female to male, FTM) was noted to be similar to women in the general population. Another retrospective study from the Veterans Health Administration including 5117 transgender patients found that the leading causes of death were related to diseases of the circulatory system and neoplasm [31]. The study also found that the crude suicide rate among transgender veterans was higher than the general population but similar to the suicide rate for veterans with serious mental illness (eg, depression or schizophrenia).

All transgender patients — Most screening and prevention for chronic diseases in transgender patients is the same as the general population. Specific issues for transgender patients include (table 5):

Cardiovascular disease — Assessing and treating risk factors for CVD is important in transgender patients as hormone therapy may increase cardiovascular risks, particularly in transgender women taking feminizing hormones. Management of cardiovascular risk factors may decrease the hazards associated with long-term hormone therapy. (See "Overview of established risk factors for cardiovascular disease".)

The long-term effects of feminizing hormone therapy on CVD are not clear. There is some evidence to suggest that it leads to an overall deleterious effect on CVD risk factors (eg, lipids and insulin sensitivity) [32,33]. Studies also suggest that feminizing hormone therapy may be associated with an increase in CVD morbidity and mortality [30,33-35]. However, these studies may not have controlled for other CVD risk factors (eg, older age, smoking).

The effect of testosterone on CVD risk in transgender men is unclear. Studies have not shown an increase in cardiovascular events [30,34,36]. Masculinizing hormone therapy increases lipid parameters associated with increased cardiovascular risk, but studies have not shown negative effects on other risk factors, such as blood pressure and insulin sensitivity [29,33,35,37]. Specific considerations for transgender patients include:

Smoking – Smoking prevalence is higher among transgender patients compared with the general population [4]. Similar to non-transgender patients, we encourage smoking cessation. (See "Overview of smoking cessation management in adults".)

Diabetes mellitus – Transgender men with polycystic ovarian syndrome (PCOS) should have diabetes screening. In other patients, we follow screening guidelines for non-transgender patients, keeping in mind that transgender women on estrogen therapy may be at higher risk for diabetes because of increased insulin resistance, weight gain, and an increase in body fat [35,38-41]. Testosterone therapy may increase visceral fat and decrease fasting glucose, with little effect on insulin resistance [32,35,38]. A Dutch observational study noted an increased prevalence of type 2 diabetes mellitus among transgender men and women in comparison with both age-matched, non-transgender male and female groups [34]. (See "Screening for type 2 diabetes mellitus" and "Diagnosis of polycystic ovary syndrome in adults", section on 'Cardiometabolic risk assessment'.)

Lipids – While we typically follow lipid levels yearly in patients taking hormones, the utility of routine lipid monitoring in all patients regardless of risk is unknown. Oral estrogen therapy, both in postmenopausal women and transgender women, is known to increase triglycerides and has precipitated pancreatitis in a trans woman and postmenopausal women on hormone replacement therapy [42-44]. However, lipids are not routinely monitored yearly in women on hormonal contraception or hormone replacement therapy. Studies of testosterone therapy among transgender men tend to show a decrease in high-density lipoprotein (HDL) cholesterol, with no changes or, more commonly, increases in low-density lipoprotein (LDL) cholesterol [33,37,45]. Supraphysiologic doses may increase the risk of lipid abnormalities. (See "Menopausal hormone therapy and cardiovascular risk", section on 'Lipids' and "Hypertriglyceridemia-induced acute pancreatitis", section on 'Secondary hypertriglyceridemia' and "Use of androgens and other hormones by athletes", section on 'Cardiovascular'.)

Risk calculators may be used to determine when to start treatment for hyperlipidemia. However, they do not account for transgender patients on current or past hormone therapy. It may be reasonable to use natal sex-based calculators in transgender people who have transitioned later in life. Using a patient's affirmed gender may be more appropriate for those who have been on hormone therapy since adolescence or young adulthood [14]. Depending on the age at which hormones are begun, the intensity of hormone therapy (for patients who do not seek a binary transition), and total length of exposure, providers may also choose to use an average of the calculators. (See "Low-density lipoprotein cholesterol-lowering therapy in the primary prevention of cardiovascular disease".)

Osteoporosis — There are no long-term studies of fracture risk, especially in an older adult transgender population. Loss of bone density is most likely after gonadectomy in those patients with other risk factors (eg, White or Asian race, smoking, family history, high alcohol use, hyperthyroidism) and in those who are not fully adherent to hormone therapy.

Screening In the absence of accepted guidelines, we screen the following patient groups for osteoporosis [14,37,46]:

Transgender patients who have undergone gonadectomy and have a history of at least five years without hormone replacement should be screened, regardless of age.

Between ages 50 and 64 years, we screen patients with established risk factors for osteoporosis (table 6), including patients on androgen suppression only, or with evidence of prolonged hypogonadal state.

Starting at age 65 years, we screen all transgender patients.

We use Dual Energy X-ray Absorptiometry (DXA) scans for osteoporosis screening. Bone density measurements for transgender men should be compared with male standards (and transgender women with female standards). Osteoporosis screening is discussed in detail separately. (See "Screening for osteoporosis in postmenopausal women and men".)

Prevention – In general, for patients who have had gonadectomy, estrogen, or testosterone therapy should be continued to reduce the risk of osteoporosis. If there are contraindications to hormone therapy, we advise patients to participate in weightbearing exercise and have adequate calcium and vitamin D intake to limit bone loss, as have been recommended for postmenopausal women. (See "Prevention of osteoporosis", section on 'Lifestyle measures' and "Transgender women: Evaluation and management", section on 'Long-term maintenance therapy' and "Transgender men: Evaluation and management", section on 'Routine monitoring'.)

Trans women, even prior to feminizing hormone therapy, may have lower bone mineral density compared with age-matched male controls, likely due to decreased physical activity as well as lower Vitamin D levels [47,48]. Bone mineral density in response with hormone therapy appears to vary with regimen, duration, and dose as well as any interruptions in hormone use after gonadectomy [14,49].

Trans men begin with an average of 10 to 12 percent less bone density than natal males, prior to any hormonal or surgical intervention [50]. Studies have suggested that uninterrupted testosterone therapy maintains or increases bone density among trans men [37].However, studies of transgender men after oophorectomy indicate that bone mineral density may decrease even with testosterone supplementation, particularly if testosterone use is interrupted or the dose is inadequate to suppress luteinizing hormone [51-54].

Transgender women (MTF) — Specific considerations for screening and prevention in transgender women include (table 5):

Breast cancer — There are no studies evaluating routine screening mammography for transgender women receiving hormonal therapy [37]. However, breast cancer risk may increase with a longer length of feminizing hormone exposure and use of progestins [37]. Based on this possible increased risk, it is reasonable to discuss mammography screening with transgender women ≥50 years with additional risk factors for breast cancer (eg, estrogen and/or progestin use >5 years, positive family history, body mass index [BMI] >35). It is important to also discuss the higher likelihood of a false-positive screen, as the risk of breast cancer in this population is likely significantly less than natal females. When the decision is made to screen, screening should be based on the recommendations for natal females. Breast augmentation is common among transgender women and screening in women with breast implants is discussed elsewhere. (See "Factors that modify breast cancer risk in women", section on 'Factors associated with greater breast cancer risk'.)

There are no long-term studies evaluating the risk of feminizing hormones on the risk of breast cancer. One prospective observational study found no difference in breast (or any other cancer) between transgender men and women compared with control men and women [34]. Transgender patients were on hormone therapy for an average of 7.4 years, and the average age of trans women at start of study was 43.7 years. Two large retrospective studies indicate a relatively low breast cancer rate, similar to those found in cisgender male populations [55,56]. The majority of patients in the latter study were <40 years and had ≤20 years of estrogen exposure. There are case reports of breast cancer among trans women using feminizing hormone therapy [56,57].

Cervical cancer — Cervical cancer screening is not necessary in transgender women with a neovagina since it is typically lined with keratinized penile skin. There is only one published case report of vaginal dysplasia in this population, and evidence suggests that the risk of neoplasia is extremely small [58-60].

Prostate cancer — Similar to non-transgender men, we discuss the risks and benefits of prostate cancer screening with transgender women. The prostate is not removed in feminizing genital surgery. Feminizing hormone therapy appears to decrease the risk of prostate cancer, but the degree of reduction is unknown [61]. Cases of prostate cancer have been reported among patients on feminizing therapy, both before and after sex reassignment surgery [49,61]. If prostate specific antigen is checked, it is important to recognize that it may be falsely low in an androgen-deficient setting, even in the presence of prostate cancer [62,63]. (See "Screening for prostate cancer", section on 'Approach to screening'.)

Venous thromboembolism — Transgender women taking estrogen may be at higher risk for venous thromboembolism. Primary care providers should be aware of the relative risks of various forms of estrogen. This is discussed elsewhere. (See "Transgender women: Evaluation and management", section on 'Adverse events'.)

Transgender men (FTM) — Specific considerations for screening and prevention in transgender men include (table 5):

Breast cancer — Regardless of testosterone use, the recommendations for screening transgender men with intact breasts for breast cancer are the same as for natal females. (See "Screening for breast cancer: Strategies and recommendations", section on 'Summary and recommendations'.)

For transgender men who have undergone mastectomy, the risk of breast cancer is greatly reduced with chest surgery, and testosterone does not appear to increase the risk of breast cancer in transgender men [34,56]. While there is no evidence to support clinical breast examinations in this population, we perform yearly chest wall and axillary exams. We use this as an opportunity to examine scar tissue and any changes and educate the patient about the small but possible risk of breast cancer. Transgender men who undergo breast reduction or mastectomy retain some degree of underlying breast tissue for good cosmetic result. There are case reports of breast cancer among transgender men on hormone therapy, even after chest surgery [64-66]. The best evidence comes from a retrospective Dutch study of 795 transgender men treated with testosterone and mastectomy for a mean of 20.1 years [56]. There was one confirmed case of breast cancer. Also, the majority of patients in this study were <40 years and had ≤20 years of testosterone exposure.

Cervical cancer

Cervix intact – When possible, patients with an intact cervix should have cervical cancer screening as recommended for the general population. There is no evidence that testosterone increases or reduces the risk of cervical cancer [37]. However, testosterone may affect the yield of Pap smear testing. One study in 233 transgender men found a higher rate of unsatisfactory or inadequate Pap smears compared with non-transgender women at the same clinic, associated with length of time on testosterone therapy [67]. As testosterone therapy can result in atrophic dysplasia-like changes to the cervical epithelium, the pathologist should be informed of the patient's hormonal status [68]. (See "Screening for cervical cancer in resource-rich settings".)

Pap smears may be traumatic for many transgender patients. For patients without any history of sexual activity involving vaginal penetration, it is reasonable to have an informed discussion with patients regarding the risks of deferring cervical cancer screening, which may vary depending on sexual behaviors. There is some evidence to suggest that the risk of human papillomavirus infection (and thus cervical cancer) in this population may be lower than the general population [69]. However, bisexual and lifetime lesbians have a higher rate of cervical cancer compared with heterosexual women, and this correlates with a lower rate of cervical cancer screening [70]. (See "Sexual and gender minority women (lesbian, gay, bisexual, transgender, plus): Medical and reproductive care", section on 'Cancer risk, screening, access, and conduct of care'.)

Patients with abnormalities found on cervical cancer screening may find it difficult to adhere to adequate cervical cancer screening on a long-term basis. Options for treatment and improving comfort with procedures should be discussed with the patient. In patients with findings that have a higher risk for cervical cancer, total hysterectomy can be discussed as an option for treatment, unless the patient wishes to preserve the option for pregnancy or health would be adversely affected by surgery. (See "Cervical intraepithelial neoplasia: Management", section on 'Overview'.)

Total hysterectomy (no cervix) – Screening recommendations are identical to those in non-transgender women who are status post-total hysterectomy. (See "Screening for cervical cancer in resource-rich settings".)

Polycystic ovarian syndrome — Similar to natal females, transgender men who present with PCOS are at increased risk for insulin resistance and hyperlipidemia [34]. The evaluation of transgender men with PCOS is similar to non-transgender women and discussed elsewhere, though patient concerns relating to virilization and oligo-ovulation may differ from those of women. (See "Clinical manifestations of polycystic ovary syndrome in adults" and "Diagnosis of polycystic ovary syndrome in adults", section on 'Further evaluation after diagnosis'.)

There is no evidence to support screening transgender men with PCOS for ovarian or endometrial cancer. The evidence regarding the effects of testosterone on the endometrium in transgender men is mixed, with evidence of both atrophic and proliferative changes [71]. However, providers should evaluate unexplained uterine bleeding with appropriate modalities. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis".)

Sexually transmitted and bloodborne infections

Screening The recommendations for screening for sexually transmitted infections (STIs) are the same as those for the general population. It is particularly important to take a good sexual history, as screening should be based on behaviors and number of sexual partners. Screening should also take into account the anatomy of the patient. (See 'History' above and "Screening for sexually transmitted infections".)

For STIs that require a vaginal swab, when possible, testing with a self- or clinician-collected vaginal swab is the recommended sample type. A first-catch urine specimen is acceptable but might detect up to 10 percent fewer infections when compared with vaginal and endocervical swab samples [72]. However, this test can be used regardless of anatomy, providing an acceptable alternative testing method when a vaginal, endocervical, or urethral swab is not appropriate or distressing to the patient.

Prevention STI prevention strategies should be appropriately targeted to each individual patient's anatomy and specific sexual practices. To prevent condom breakage for vaginal penetrative intercourse, transgender women with a neovagina and transgender men on testosterone (who may have vaginal atrophy and dryness from decreased estrogen) should use supplemental lubrication. Water-based lubricants only should be used with latex barriers as oil-based products degrade latex. (See "Prevention of sexually transmitted infections".)

Because needle sharing with injectable hormones (or silicone) is a trans-specific potential risk factor for bloodborne infections, patients need to be educated regarding the risks and safe handling practices of needles and syringes.

MENTAL HEALTH — Transgender patients seek mental health services for a variety of reasons. These include assessments or referrals for medical or surgical interventions, exploration of identity, and assistance in coping with stressors and dealing with stigma, as well as general mental health concerns. Compared with non-transgender patients, transgender patients have more anxiety, depression, and suicidal ideation. (See 'Physical examination' above.)

Transgender patients can feel at times disempowered in accessing adequate health care and may be reticent to bring up issues surrounding mental health, substance use, or higher-risk behaviors. While more medical providers have moved to a model of providing hormone therapy based on informed consent, a mental health assessment is still required for most surgical procedures; behavioral health providers have historically been the "gatekeepers" for medical and surgical interventions for transgender patients. This historical context of the relationship has resulted in many transgender patients being uncomfortable about the role of behavioral health providers in medical care, which may act as a barrier to care [73]. Primary care providers are in a position to be able to use the rapport built with transgender patients to support accessing behavioral health care services when needed [46].

SEXUAL FUNCTION — Among transgender men, testosterone therapy may increase libido [74]. Among transgender women, feminizing hormone therapy may reduce libido, reduce erectile function, and decrease ejaculation. Sexual function (libido, arousal, pain with sex, and orgasm) varies following sex reassignment surgery. (See "Transgender women: Evaluation and management", section on 'Outcomes'.)

FERTILITY — Fertility in the setting of hormone therapy is discussed separately. (See "Transgender women: Evaluation and management", section on 'Fertility considerations' and "Transgender men: Evaluation and management", section on 'Fertility considerations'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Transgender health".)

SUMMARY AND RECOMMENDATIONS

The term "transgender" is generally used to describe a diverse group of individuals whose gender identity or expression differs from that assigned at birth (table 1). Primary care providers should be familiar with commonly used terms (table 1) and the diversity of identities within the transgender community. (See 'Terminology' above.)

In general, the history is similar to that of non-transgender patients. History that is specifically important in transgender patients includes history of past and current gender-related hormone use and surgical interventions, sexual history (table 2), and psychiatric history. (See 'History' above.)

Regardless of the gender identity of the patient, physical exams should be based on the organs present. (See 'Physical examination' above.)

The recommendations for screening and prevention for transgender patients who have not been on hormonal therapy and have had no gender-related surgeries are the same as those of the general population. (See "Geriatric health maintenance".)

For patients who have received hormones and/or surgery, risk assessment and recommendations for screening and preventive care may depend on the patient's hormonal and surgical status, particularly for cancer screening (eg, breast, cervical, and prostate cancer) (table 5). Assessing and treating risk factors for cardiovascular disease is particularly important in transgender patients as hormone therapy may increase cardiovascular risks, particularly in transgender women (male to female, MTF) taking feminizing hormones. (See 'Specific considerations in patients on hormones' above and 'Transgender women (MTF)' above and 'Transgender men (FTM)' above.)

Sexually transmitted infection screening and prevention strategies should be appropriately targeted to each individual patient's anatomy and specific sexual practices. (See 'Sexually transmitted and bloodborne infections' above.)

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Topic 82964 Version 20.0

References