Chapter 26: Transgender Health Care

LEARNING OBJECTIVES

1. Identify the health needs of transgender individuals at various stages of life.

2. Explain the diagnostic criteria and issues associated with the diagnosis of gender dysphoria.

3. Describe appropriate use and monitoring of medications used for medical gender transition.

4. Select pharmacologic therapy for transgender individuals taking into consideration associated risks and the patient’s unique needs and goals.

5. Utilize published guidelines and emerging research to develop health monitoring and patient education strategies for transgender individuals.

INTRODUCTION

As described in Chapter 2, providing culturally sensitive care involves being prepared to care for patients with a variety of gender identities as well as staying up to date with this rapidly evolving area of health care. This chapter refers to individuals who seek, have sought, or may receive medications or procedures to masculinize or feminize their bodies. Transgender men or transmasculine individuals are people who were assigned a female sex at birth but who identify with more masculine identities.¹ Transgender women or transfeminine individuals are people who were assigned a male sex at birth but who identify with more feminine identities. These terms should be interpreted to also include individuals who select masculinizing or feminizing procedures or treatments but align with no particular gender, those who consider themselves agender, identify with both genders (bigender), or have a fluid gender.² These individuals, and others who may not fit societal norms for gender expression, may refer to themselves as gender-nonconforming, gender nonbinary, and/or genderqueer.¹ Although some individuals use the word transgender as part of their identity, other transgender men and women will simply select male or female when asked to identify their gender or sex. The term cisgender, meaning “same side,” will be used to refer to those whose sex assigned at birth aligns with their affirmed gender when drawing a distinction with transgender individuals. Affirmed gender is how people feel internally and this term is preferable to other terms like chosen gender, which implies that transgender individuals choose to be transgender.

The health care provider should consider transgender individuals to represent a diverse spectrum of people, which represent approximately 0.6% of the US adult population.³ Some individuals will recall desires to undergo a gender transition in early childhood and others will have experienced similar needs much later in life. A variety of factors influence these trajectories. Individuals who are transgender are marginalized by society, which impacts the degree to which they disclose, accept, and/or are willing to address their gender-related needs. External societal influences also play a significant role, such as access to gender affirming and experienced providers, fear of discrimination in health care settings, ability to pay for transition-related care through financial means or health insurance, access to stable employment, and/or the needs and desires of their loved ones (eg, their partners, spouses, children, or parents). These issues can have a significant impact on health outcomes, for example, up to ...