Introduction to Language
“Transgender” is an umbrella term used by people in a number of different groups, including but not limited to cross-dressers (those who wear clothing of the other sex some of the time) to genderqueer people (those who feel that they belong to either both genders or neither gender) and transsexuals (an older term for people who take hormones and have sex-reassignment surgery (SRS) in order to transition to a different sex.
Today the term transgender is most often used by those who feel comfortable in a gender to which they were not assigned at birth. Many use the shorthand “trans.” Some trans people take hormones or go through surgeries to feel more comfortable with their bodies; others do not. Whether someone has had these treatments or not, and whether they desire to, does not affect their identity as trans.
The descriptors male to female (MTF) and female to male (FTM) are often used to describe trans people. Many trans people prefer the terms “transgender man” (same as FTM) or “transgender woman” (same as MTF) because these terms affirm the chosen identity. Some prefer the terms “affirmed male” and “affirmed female.” When giving comparisons (often for medical reasons) between trans and non-trans people, the terms “bio-male” or “bio-female” or “natal male” or “natal female” refer to non-transgender people. Always allow your patients to define to you the way they see their identity, without making assumptions.
Inclusive Office Practices
There are a number of relatively simple things that can be done in an office to make transgender patients more comfortable. Gender neutral bathrooms are an easy step that can really have a positive effect. On intake forms, leaving a blank space after the question on gender or offering a “transgender” option indicates to patients that their physician is conscious of their existence. Using gender neutral language (such as “partner”) when asking about a patient’s sexual or relationship history allows individuals to be more open about their lives.
Like any other definable group, transgender people have particular health disparities as compared to the overall population. It is important to understand these disparities, but not to assume that all transgender people have the same risks. For example, it is true that MTFs have an increased risk of HIV infection. However, as with any other population, it is the individual’s activities that confer risk, so not every MTF is at high risk for HIV, and some may have no risk at all. Talk to your patients and ask them about their health histories and activities that would lead them to develop particular problems.
Transgender people are believed to be victims of violence more often than others. One study showed that 27% of participants were victims of violence. Murders of transgender people have been reported in 20 states and 89 cities across the United States.
Suicidal ideation is increased in transgender people, and may be up to 64%. In studies, suicide attempt rates range from 16-37%. Suicidality and attempts are believed to be mostly due to the difficulty encountered by transgender people when attempting to be themselves in an unfriendly world. Significant substance abuse is also noted in transgender people, and current treatment programs are thought to lack the needed cultural sensitivity to effectively help this population.
Lack of health insurance or health care coverage is a problem for many transgender people. There are high rates of unemployment and poverty in this population, partly because of the difficulty navigating the working world as a gender-nonconforming person.
HIV infection rates are increased in MTFs as compared to the general population. MTF sex workers are at especially high risk for HIV infection.
For an easy pocket guide to Transgender Health, check out AMSA’s Transgender Health White Coat Cards.
General healthcare for transgender patients is much the same as it is for others. However, there are certain guidelines that may be helpful to physicians as they approach primary care for transgender patients. One important rule is to remember that medical care should focus on the body parts a person has, whether those are congruent with the gender identity or not. For example, an affirmed male may still have a cervix, in which case he should be followed with PAP smears. An affirmed female most likely still has a prostate, in which case she should be screened for prostate cancer at the appropriate age. Vancouver Coastal Health provides guidelines for Transgender Primary Medical Care, as well as Caring for Transgender Adolescents.
Many transgender people choose to take hormones so that their bodies more fully match their gender identities. This hormone treatment is often under the care of a primary care physician, and sometimes an endocrinologist. The World Professional Association for Transgender Health (WPATH), in its Standards of Care suggests that a person live full-time in the chosen gender for a year before beginning hormone treatment. Some physicians follow the WPATH standards directly, and others use them as a rough guideline, but do not require their patients to follow the WPATH standards directly. Newer models, such as that proposed by Dr. Maddie Deutsch at the 2008 Gay and Lesbian Medical Association Conference, give patients more autonomy and use “ informed consent” to begin hormone treatment in adults who desire it. Also see Suggested Hormone Regimens from Dr. Anne Lawrence.
Some patients realize that they are transgender before or when they are first entering puberty. Under the guidance of a therapist and an endocrinologist, these patients may be treated with Gonadotropin Releasing Hormone (GnRH) analogues, such as Lupron, that delay puberty until the patient and parents are ready to make a decision about cross-sex hormones, usually at age 16.
There is much controversy surrounding transgender identity and the field of mental health. At the moment, transgender people often receive medical care under the diagnosis of Gender Identity Disorder in the Diagnostic and Statistical Manual of Mental Disorders IV-TR. Many people believe that transgender identity is not a mental disorder and should be a medical, rather than psychiatric, diagnosis. Most people recognize that even if transgender identity is a medical issue, the social stigma associated with the identity can create a difficult situation for those with transgender feelings. Vancouver Coastal Health provides guidelines on Counseling and Mental Health of Transgender Adults and Loved Ones.
Some transgender people opt to have surgery so that their bodies more fully match their identities, while others do not desire or cannot afford surgery. Vancouver Coastal Health has produced a guide for Care of the Patient Undergoing SRS.
Surgeries for affirmed males include “top” surgery, (conversion of the chest from a female appearance to a male appearance), hysterectomy (removal of the uterus), metoidioplasty (release of the suspensory ligament of the clitoris to create a small phallus without standing urination), ring metoidioplasty (rearrangement of the urethra so that standing urination is possible through a small phallus), testicular implants, and phalloplasty (creation of a penis from skin on another part of the body, such as the forearm).
Surgeries for affirmed females include breast augmentation, genital surgery (creation of a vagina, labia and clitoris), and tracheal shave (reduction of the thyroid cartilage to minimize the “adam’s apple”).
Historical Notes and Depictions on Male to Female Sex Reassignment Surgery are available through the University of Michigan.
Intersex Society of North America
The Intersex Society of North America (ISNA) is devoted to systemic change to end shame, secrecy, and unwanted genital surgeries for people born with an anatomy that someone decided is not standard for male or female.
National Center for Transgender Equality
The National Center for Transgender Equality (NCTE) is a 501(c)3 social justice organization dedicated to advancing the equality of transgender people through advocacy, collaboration and empowerment.
Survivor Project is a non-profit organization dedicated to addressing the needs of intersex and trans survivors of domestic and sexual violence through caring action, education and expanding access to resources and to opportunities for action. Since 1997, we have provided presentations, workshops, consultation, materials, information and referrals to many anti-violence organizations and universities across the country, as well as gathered information about issues faced by intersex and trans survivors of domestic and sexual violence.
Sylvia Rivera Law Project
The Sylvia Rivera Law Project (SRLP) works to guarantee that all people are free to self-determine their gender identity and expression, regardless of income or race, and without facing harassment, discrimination, or violence. SRLP is a collective organization founded on the understanding that gender self-determination is inextricably intertwined with racial, social and economic justice. Therefore, we seek to increase the political voice and visibility of low-income people of color who are transgender, intersex, or gender non-conforming. SRLP works to improve access to respectful and affirming social, health, and legal services for our communities. We believe that in order to create meaningful political participation and leadership, we must have access to basic means of survival and safety from violence.
TransGenderCare contains a large archive of compiled health information on medical, psychological, electrology, and general health services for the transgender community.
The Transgender Roadmap is a resource for patients that provides a guide to the journey of transitioning.
Vancouver Coastal Health Transgender Health Program
A very good resource for students and physicians. Includes clinical guidelines for practicing with transgender patients. Also has lots of good patient handouts.
World Professional Association for Transgender Health
The World Professional Association for Transgender Health (WPATH, formerly known as the Harry Benjamin International Gender Dysphoria Association, Inc. (HBIGDA) is a professional organization devoted to the understanding and treatment of gender identity disorders.