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AMSA Transgender Health Resources
Defining Terms |
Hate Crimes |
Hormone Therapy |
History & Physical |
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As a physician, the likelihood a transgender patient will present to you for
medical care is greater than you may think. During informal interviews with
doctors working in family practice, internal medicine and emergency medicine,
all stated they had treated at least two transgender patients during their
careers. While those in larger cities had more exposure to individuals in the
transgender community, physicians in rural areas around the country also had
experience with caring for the transgendered. If you're an endocrinologist or
psychiatrist, you can count on seeing transgender patients.
The above assumes you actually know, or the patient tells you they are
transgender. Many will avoid disclosing any history related to their gender.
The societal stigmatization and discrimination faced by a transgender person at
some point in their life, whether it's enduring or a only a matter of past
experience, creates understandable obstacles to disclosure. In some parts of
the country, incidences of violent assault and homicide perpetrated against
the transgendered are evident, including in communities well known for
their acceptance of gays and lesbians. Nondisclosure becomes a method of
self-defense, and it often remains as such in a physician's office or hospital.
Of course it would be in the patient's best interest to disclose their
medical history as requested or applicable. Or would it? In written and oral testimony given to the
American Medical Association in June of 2003, "13-39% of transgender
patients in SF, LA, and DC and 81% in Philadelphia report being denied
healthcare or experienced hostility by a healthcare provider." The history
of mistreatment and/or non-treatment of the transgendered by healthcare
professionals is infamous within the transgender community. It includes, among
many examples, Tyra Hunter, a transgender woman who died at the scene of a car
accident when paramedics refused to treat her. There is also Robert Eads, a
transgender man who died of ovarian cancer and was refused treatment by several
GYN's. The personal recollections of indifference and/or abuse at the hands of
professionals generally known for their compassion is as maddening as it is
sadly surprising.
Changing attitudes requires both exposure and education and now that you
have already been exposed, the next step is to educate. By exploring this
website, you have taken the first step towards learning about transgender
patients, so please continue on your journey taking a glance at the Journal of
the GLMA's special issue on Lesbian, Gay,
Bisexual and Transgender Health: Findings and Concerns, pgs 127-130.
This report raises numerous concerns and a few questions, one of which
involves pathology. Are the transgendered pathological? According to the
DSM-IV, the answer is "yes." Likewise, according to the previous
additions of the DSM up until 1986, homosexuals were either pathological or
potentially exhibited pathological behavior, although there is now general
consensus, intolerance withstanding, that homosexuality is not a pathological
disorder. Medicine has come a long way since the days of trephining, humors and
seizures symptomatic of demonic possession. Still, a century ago we were just
beginning to release inpatients in psychiatric institutions from the chains
tying them to the facility walls. A little more 50 years ago, we were just
beginning to realize pre-frontal lobotomies were not the best means of
relieving anxiety and depression. So it appears, as a matter of medical
evolution, that what we once thought was pathology often wasn't, or what
remains pathology was frequently treated with inhumanity I hope none of us
would espouse in the enlightenment of the 21st century.
Access to quality health care by the transgendered is an issue gaining
momentum around the world in the new millenium. Increased recognition of the
challenges encountered by transgender people and the healthcare providers who
see them have made apparent the shortcomings in basic knowledge of this
community. AMSA's Transgender Heath Initiative is designed to provide this
basic knowledge by introducing the transgender community to you. As with any
sensationalized topic and marginalized group of people, there is also
considerable misinformation. Here, we will define terms, give a requisite
overview and direct you to accurate and compelling health care and general
information resources. You'll learn, as succinctly as possible, what the
overwhelming majority of the public at large does not know about the
transgendered. As a result, we hope you'll take this information and apply it
to the equitable, quality and compassionate health care you would provide to
transgender patients seeking your care.
DEFINING TERMS
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Hormone Therapy |
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Perhaps the greatest barrier to understanding the transgender community is
the challenge in differentiating between terms that are often, and incorrectly,
used as synonymous by the public. Contrary to popular opinion, most
crossdressers are usually heterosexuals, most drag queens aren't transsexuals,
and the majority of the transgender individuals, while having the benefit of an
extraordinary experience, have lives similar to those in the general
population. So, in order to clarify those points and others, let's examine the
transgender community and the people of which it consists.
Transgender |
Intersex |
Transgenderist |
Transsexual
*Encyclopedia of Sex and Gender: Transgender Chapter*
Transgender
Transgender is a non-medical term, and encompasses a broad spectrum of
cross-gender behavior. The most prevalent transgender identifications are
crossdresser (a more sensitive term for transvestite), intersex,
transgenderist, and transsexual. "Transgender" as identification has
gained acceptance after years of controversy with regards to the inclusiveness
of gender non-conformist individuals, although some, especially the intersex
and transsexual people, may challenge "transgender" as a term
applicable to themselves for reasons that will follow under their own
definitions.
Before addressing the various transgender identifications, it's important to
differentiate between sexual orientation and gender identity.
Sexual Orientation, Gender Identity and Gender Role
Sexual orientation, in its simplest definition, is the sexual attraction
towards or interest in members of the same (homosexual), opposite
(heterosexual) or both (bisexual) biological sexes.
A transgender person may identify with a homosexual, heterosexual or
bisexual orientation depending upon how they define themselves. For example, a
post-operative (has had gender reassignment surgery) male-to-female transsexual
who maintains a sexual orientation towards males may identify as a heterosexual
female as a result of defining herself within the context of being physically,
albeit surgically, female. However, the same can be said of some pre-operative
(has not had gender reassignment surgery) male-to-female transsexuals,
considering many define themselves as female regardless of their anatomy. While
there is some professional contention, transgender people and therapists with
experience in transgender issues will likely tell you sexual orientations and
gender identities are not inclusive. There are many post-operative female
transsexuals who prefer intimate partnerships with natal women, despite being
aware and self-accepting of this orientation prior to surgery. In short, there
are no hard and fast rules to a transgender person's sexual orientation.
Gender roles and gender identity can also be delineated, in both the
transgender community and the general public. In reference to the transgender
community, intersex and transgenderist are probably the best examples of people
who blur the lines between traditional gender identity and gender role.
Regardless of how a person identifies in terms of gender identity (how they
subjectively feel about themselves in the context of maleness and femaleness),
the may behave in roles contrary to traditional ideas of how a man or woman
should behave. Gay and lesbian communities, the entertainment industry,
historical military campaigns and the average town in which you live are full
of examples of how people are stretching the boundaries of once traditional
gender roles without compromising how an individual feels about their own sense
of gender identity. Again, there are no firm rules to associate gender identity
with gender role, in the transgender community and many cultures including our
own.
Crossdressers - Transgender Diversity
Once known widely as "transvestite", and still classified as such in
psychiatric literature, a crossdresser is someone, usually a heterosexual male,
who derives erotic pleasure and/or some degree of emotional fulfillment by
wearing the traditional clothing of the opposite sex. Crossdressers,
differentiating from others in the transgender spectrum, do not pursue major
surgical intervention to permanently transition and live full time as the
opposite gender, although they may fantasize about doing so. Crossdressing, in
and of itself, is classified in the American Psychiatric Association's Diagnostic
and Statistical Manual (DSM-IV-TR) as
transvestic fetishism, a paraphilia and Axis I disorder.
There is a significant proportion of crossdressers for whom the above is not
entirely applicable. Drag queens are, for the most part, homosexual men who
crossdress and are involved in some sort of entertainment medium, from local
nightclubs to prime time television. They intentionally dress in eye-catching
fashion, and may very well be what the public considers representative of the
entire transgender community. In fact, the majority of the transgender
community will go to great lengths to blend in with society around them, even
if it's temporary or variable. Drag kings are the female version of drag
queens, but are much less sensational and prevalent. Female and male celebrity
impersonators can be similar to the drag queens and kings, but a significant
number crossdress only as paid entertainers.
Most physicians will usually encounter a crossdresser in only a few
professional settings and situations. One probable setting is in the ER (and
consulting departments) after a trauma or sudden illness has prevented them
from changing back into the traditional clothing of their natal gender before
being admitted. The other would likely be in a mental health setting for those
whose behavior, gender or otherwise, is a source of conflict. However, patients
with paraphilias are less likely to seek treatment, so crossdressers are more
likely to present, if ever, to a therapist specializing in gender issues.
Intersex
The term "intersex" is a self identifying term chosen by a population
that had been previously named "ambiguous" or
"hermaphrodites" by medical and lay terms. Hermaphrodite is an
inaccurate term because it is defined as an organism that contains both sexual
reproductive organs, but most intersex individuals have either testes or
ovaries, not both simultaneously. Intersex was chosen to reflect this
population's belief that they lie along the natural spectrum of gender, between
the dichotomous extremes of male to female. Thus they are neither male, nor
female, but rather somewhere between the two - intersex.
People identifying as intersex are those who were born with
"ambiguous" or "conflicting" genitalia, malformed internal
reproductive organs and/or other anomalies leading to an undefined designation
of the child's natal sex. Most often, these individuals will be subject as
infants to "correction" of the anomalies and surgically assignment to
definite, recognizable and relatively functional male or female genitalia. As a
result, these individuals may find themselves at conflict during development
with the gender assigned to them and their subjective gender identity.
Although the physician or parent may be well-intentioned, surgical intervention
at an age when the child has yet to clearly display gender-relevant behavior
has caused considerable dysfunction in many intersexed people. A
recent study published in the New England Journal of Medicine supported
reexamining such practices.
It should be no surprise that intersex individuals might experience the same
symptoms of gender identity disorder as those suffered by transsexuals prior to
hormonal and surgical gender reassignment. The exception to this similarity, in
the case of the intersex, stems from the postnatal gender assignment, and the
suspicion that such surgery may have occurred; gender assignment and
reassignment have obvious limitations in duplicating a complete reproductive
anatomy. Eventual disclosure to the intersex person of their gender
reassignment as an infant may ameliorate some of the feelings of shame
associated with gender non-conformity, but the gender dysphoric symptoms can
still persist and there is the possibility of significant resentment regarding
the original intervention and secrecy surrounding it. It's common for people in
this situation to seek hormonal and surgical gender reassignment in order to
bring primary and secondary characteristics in line with the individual's
gender identity.
Far less common are those intersex individuals who did not have postnatal
gender assignment, although they may be increasing with frequency as parents
become more informed of their options with their intersex children. There is a
push by intersex advocacy groups to defer such surgeries until the child is old
enough (typically around puberty) to decide for his or herself. As suspected,
this creates its own developmental challenges, but intersex advocacy groups
often insist on postponing the option of surgical intervention until puberty or
later as the best of available alternatives. Medical concerns around
hypospadias, Klinefelter's syndrome, adrenal hyperplasia and other common
disorders often appearing in the intersexed have to be addressed, postnatal
gender assignment or not.
There is some controversy regarding the inclusion of the intersex people
under the transgender "umbrella," with more frequent calls as of late
by intersex advocacy groups to be considered a separate entity under the
informally accepted LGBT umbrella (i.e. LGBTI). Whether this actually takes
place remains to be seen, although such a move is receiving more support.
For more information on intersex issues, visit the Intersex Society of North
America at www.isna.org.
Transgenderist
A transgenderist lives as the gender opposite their
biological/anatomical sex, and may pursue various forms of hormonal and
surgical intervention to adopt secondary sex characteristics of that gender,
but does not seek gender reassignment surgery (vaginoplasty or
phalloplasty - PowerPoint 1.8MB).
Bi-genderists are most often considered transgenderists who live only part
time as the gender opposite their biological/anatomical sex. Hormonal and
surgical intervention are only as appropriate, if at all, as the degree the
bi-gender individual cares to present physical characteristics representative
of the opposite gender.
Androgynists (or androgyne) may or may not be transgenderists, but we will
include them here because, like the above, they usually chose to forgo gender
reassignment surgery. As the name implies, androgynists adopt an appearance
that is gender ambiguous. This is possible without hormonal or surgical
intervention in most cases.
Living as a transgenderist can be extremely challenging, especially from a
social perspective. In addition, transgenderists who forgo a gonadectomy
inevitably find themselves on relatively high and extended doses of
reproductive hormones obtained to counteract those produced in their natal sex.
The health implications of long-term hormone use are addressed in LGBT's TGHI Hormones Info and History and Physical.
Much of what transgenderists experience as a result of gender transition is
similar to that experienced by transsexuals, excluding GRS. See the
transsexuals section in LGBT's TGHI Defining Terms section below for more
information.
Transsexual
A transsexual is someone with persistent and intense cross-gender
identification, and who insists they are, or desire to be, the gender opposite
their phenotypic sex. Transsexualism was defined as a disorder in the DSM-III
but was replaced in DSM-IV with "gender identity disorder," or GID.
It is widely accepted that transsexuals are in some form of hormonal and/or
surgical gender transition as a result of addressing their GID. Having GID does
not necessarily make a person a transsexual, but transsexuals do report
experiencing the symptoms of GID. All the criteria for a diagnosis of GID can
be found in DSM-IV-TR.
Transsexuals often report cross-gender identification dating back to
childhood, some from their earliest memories at four and five years of age.
Histories may indicate cross-gender behavior displayed around that time, but
not always. Many times, a transsexual may recognize only in retrospect how
their cross-gender thoughts, feels and behavior materialized as they become
more socialized.
Gender identity disorder may develop in childhood and adolescence as well,
although the child and/or their parents may not seek treatment. Crossdressing
may appear around this time (more often in adolescence), although most of it is
in private or inconspicuous. The discovery/disclosure of crossdressing can be
one of the most frequent factors in facilitating treatment at that age.
However, depression, suicidal ideation, anxiety and poor social functioning may
be the factors leading to the disclosure of cross-gender identification, if not
already apparent. For more on this subject, download the Gender Identity Disorders in
Children and Adolescents Guide for Management.
The majority of children with gender identity disorder do not progress
towards gender reassignment, but develop a homosexual orientation instead. This
has led to the contentious categorization in some literature of homosexual
transsexualism (Blanchard, 1989), which is sometimes referred to primary
transsexualism. The contention stems from the implication that these
male-to-female transsexuals are actually homosexuals who, in denial, pursue
gender reassignment as a more appropriate alternative based on societal norms.
It remains to be seen if this categorization is applicable or appropriate, and
many transsexuals will argue that the course of gender transition actually
leads to more stigmatization than they would experience as a homosexual
remaining in their phenotypic sex.
Additionally, the category of autogynephilic transsexualism (Blanchard.
1989), sometimes referred to as secondary transsexualism, contends
male-to-female transsexuals without the homosexual orientation mentioned above
have a paraphilic disorder in which the image of themselves as the opposite sex
drives the gender identity disorder, and thus the desire for gender
reassignment. This type of transsexualism apparently manifests itself in late
adulthood, often around middle age, in comparison to homosexual transsexualism,
which usually leads to the beginning of gender transition in a person's 20's
and early 30's. If these terms are, in fact, appropriate, it would follow that
a marked decrease in homosexual transsexualism would be one result of the
growing social acceptance of homosexuality, but it's still too early to draw
that conclusion. Homosexual and autogynephilic transsexualism are not
psychiatric terms, but are prevalent in some therapeutic approaches. The
homosexual/autogynephilic distinction is not made in female-to-male transsexuals.
Therapists are finding, such as they did when homosexuality was treated as a
psychiatric disorder, that psychotherapeutic intervention is not efficacious in
ameliorating the symptoms of GID. For those whom hormonal and surgical
reassignment is not an option, the most that can be expected from psychotherapy
are methods for coping with GID.
Many transsexuals opt for gender reassignment, and such a decision is
subject, optimally, to extensive scrutiny. Professionals experienced with
treating transsexuals usually follow a set of guidelines called the World
Professional Association for Transgender Health's Standards, or SOC. The
standards detail, at length, the appropriate steps the patient, therapist and
other involved medical professionals must take in order to receive, recommend
and participate in the hormonal and surgical process of gender reassignment.
The most well known of the standards is a one year minimum period of living as
a transsexual's chosen gender (known as the real life test, or RLT) prior to
the recommendation for gender
reassignment surgery - PowerPoint 1.8MB (GRS, also called SRS). Three of
those months in that yearlong period must be completed prior to the
recommendation for cross-gender hormone therapy (CGHT). There also must be a
minimum three month period of follow-up with the therapist after the hormone
regimen has begun.
Even with the application of the SOC, permanent gender transition is a
traumatic, arduous process. The social, emotional, physiological and financial
implications are far reaching. Socially, it can lead to the total loss of
support from family and friends. Job loss, having to find another job, or
alienation by peers at the job in which one transitions are considerable risks.
The first years of transition, during which an individual should avoid
isolation per the SOC, are fraught stigma, discrimination and safety issues. Emotionally,
the consequences run the gambit, with reproductive hormones often exacerbating
mood swings. Aside from the limited development of some secondary sex
characteristics appropriate in the chosen gender, the postpubescent intake of
reproductive hormones has any number of effects on brain chemistry and, it is
believed, structure. Some self-reports include changes in the way transsexuals
perceive colors, stating they appear more or less vibrant. Others have compared
it to a mythic, spiritual experience. LGBT's TGHI Hormones Info goes
into greater detail on this topic.
Physiologically, the intake of reproductive hormones has definite
repercussions and possible complications beyond the development of secondary
sex characteristics. Estrogen tends to decrease sexual drive, while
testosterone seems to increase it. Impotence and eventual chemical castration
in natal males are relatively common, while clitoral enlargement and menses
cessation is possible. While these are not likely to be considered
"negative" by the transsexual, thrombosis, embolisms, hypertension,
liver toxicity, pituitary tumors, edema, and many other complications are
possible. Again, for more information on this issue, visit LGBT's TGHI Hormones Info.
Financially, gender transition is expensive and almost entirely out-of
pocket, with only very rare exceptions. The cost of GRS in a male-to-female
(MTF) transsexual can run from $10,000 to $25,000, including expenses for
travel, lodging, and so on. GRS for female-to-male transsexuals is much more
expensive and variable, with some estimates above $100,000. Psychotherapy can
cost thousands, even when a portion is covered under health insurance. CGHT,
when not covered by health insurance as is often the case, can cost over $1000
per year. Ancillary procedures like electrolysis (CGHT does very little to
diminish facial hair) sometimes surpasses $10,000 before it is complete. Facial
reconstruction to can top $35,000. There are also indirect costs from job loss,
legal fees (ex: name change and divorce), the expense of a new wardrobe, and
more. While unfortunate and representative of the minority, it is of little
surprise some transsexuals will turn to prostitution or other illegal means to
finance the cost of gender transition.
Of all transgender identities, transsexualism has received the most
attention. The overwhelming majority of research on transgender issues is
focused on transsexualism, in areas including the quality of life after GRS,
neuroanatomy, CGHT, HIV, social issues, surgical procedures and psychiatry.
There is some argument over the prevalence of transsexualism. The most
frequently referenced statistics place transsexualism at 1/30,000 natal males
and 1/100,000 natal females, based on the American Psychiatric Association's
data from Europe. Others place it at 1/12,000 natal males and 1/30,000 natal
females. There is also some thought the prevalence of MTF transsexuals in the
U.S. may reach 1:2500 post GRS and 1:500 pre-GRS (Conway, 2002). It is curious how the latter figures are
similar to those of children born intersex, which is estimated around 1:2000.
The challenge with presenting an accurate census revolves around those
transsexuals who have assimilated into society in their chosen gender and do
not report on various surveys. Some of the reported frequencies of gender reassignment
surgery suggest the incidence of transsexualism is closer to the latter
statistic, and may even be more frequent.
HATE CRIMES
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Hormone Therapy |
History & Physical |
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"A crime is a crime," but our society has found it necessary in
certain instances to define particular crimes as a crime motivated by hate in
order to bring perpetrators to justice in a court system that still reflects
the prejudices and discrimination that often motivated the crime itself. These
hate crimes are often more violent and more fatal than similar crimes occurring
between individuals of the same background. The victims of these hate crimes
are often part of a marginalized minority population that institutional justice
does not even care to keep record of. Hate crimes laws demonstrate two things:
that our society will no longer ignore the suffering of these victims and
individuals that motivate their crime with hate will be punished appropriate to
their actions to demonstrate to the public that hate crimes are no longer
acceptable.
'Disposable People' - Article on DC Trans Murders
A wave of violence engulfs transgender persons, whose murder rate may outpace
that of all other hate killings, according to this SPLC Intelligence Report.
HORMONE THERAPY
Defining Terms |
Hate Crimes |
History & Physical |
More Resources
Hormone therapy for the transgendered is most often termed cross-gender
hormone therapy or hormone replacement therapy (CGHT or HRT, respectively)
within the community and by health professionals experienced in this area.
Whatever you chose to call it, there is no question hormone therapy is the most
prevalent form of medical intervention for transgender people. Its purpose is
to aid in the development of the secondary sex characteristics of an
individual's chosen gender.
Physical Changes
CGHT in transgender women (transitioning male-to-female) adults does appear
to redistribute fat in proportions similar to that found in natal females. Body
hair may appear finer, and the skin may feel softer. Spontaneous erections
diminish or cease. Muscle mass tends to decrease over time, but bone structure
remains largely the same.
CGHT is subject to many false expectations from the transgender community
and general public. It usually takes only a short time for transgender people
on CGHT to realize the development of secondary sex characteristics in an
adult, especially a MTF adult, is limited. For example, in transgender women,
CGHT does not change the voice. It does not have a great impact on beard growth
in natal males, and hair removal methods (electrolysis, laser, etc.) are
necessary. Breast growth is minimal in most cases, with development rarely over
a B cup. For more information on expected results, see TransGenderCare's Medical Feminizing Program.
CGHT in transgender men (transitioning female-male) adults has more obvious
physiological changes. There is usually an increase growth and density of
facial and body hair, deepening of the voice, cessation of menstruation and an
increase in muscle mass. Many also report the enlargement of the clitoris and
increased libido. For more information on expected physical changes resulting
from the FTM hormone regimen, as well overall information on hormone therapy
and regimens in transgender individuals, see Dr. Anne Lawrence's concise 1 page
hand out Suggested Hormone
Regimens and the more extensive Tom Waddell Health Center Transgender
Team's Hormone Protocols Guide.
Many of CGHT's effects on secondary sex characteristics are permanent, especially
in transgender men. Activated hair follicles in natal male adults and
transgender men can not be deactivated, so hormonal facial hair (the thick,
prickly kind) has to be removed by other means such as those mentioned above.
While voice changes in natal males are not effected by CGHT, it has a permanent
effect on transgender men. Long term breast growth in transgender women, even
if minimal, is usually not effected the cessation of CGHT if necessary.
Clitoral enlargement in transgender men is permanent, but impotence in
transgender women is variable, depending on the duration and dose of
administered estrogens.
Emotional Changes
The most apparent, and more difficult to quantify, are emotional changes. On
a completely anecdotal note, having worked with dozens of transgender people in
the last decade, these affects are the most striking to me. In transgender
women (MTF adults), sexual libido decreases while, in transgender men, it
increases. Mood swings may be more obvious. There also seems to be an increase
in aggression in transgender men. There is some evidence HRT in menopausal women increases serotonin binding in the
prefrontal cortex, so it might be enlightening to investigate how CGHT
effects levels of serotonin in the transgendered as well.
Transgender Children
Unfortunately, there is not a wealth of information on CGHT for transgender
children. Physiological changes in secondary sex characteristics are usually
more dramatic due to the lesser degree of masculinization or feminization in
the individual's phenotypic sex. There is support where transgender children
are concerned regarding the delay of puberty through the use of LHRH,
progestins and antiandrogens. For more information, see WPATH's
SOC for the Assessment of and Treatment of Children and Adolescents.
Summary: A significant amount of information on CGHT can be found in the History and
Physical Section of this TGHI website. This History and Physical Section on
CGHT covers effects, risks, precautions, contraindications and much more.
Please see that page for more details on CGHT for transgender men and women.
HISTORY AND PHYSICAL
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Hormone Therapy |
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Taking a Sensitive History and Physical (H&P)
Transgender individuals have unique health care concerns stemming from
behaviors, practices, and environmental hazards that are more commonly faced by
transgender patients. These health concerns include hormone use, surgical
procedures, potential socioeconomic factors and mental health issues. In this
guide to taking a sensitive H&P, we are hoping to address common concerns
students may have when taking a history from and performing a physical exam on
transgender patients. By way of a detailed procedure, from a clinical
perspective courtesy of AMSA member and expert in transgender issues, Dr.
Melanie Spritz, we hope to bridge the gap between patients and health care
providers. At certain points, when the subject is one of particular emphasis
during the history or physical, there will be relevant information presented
for elaboration.
Note: for the sake of clarification, "transgender man" is the
same as "female-to-male transgender" and "FTM."
"Transgender woman" is the same as "male-to-female
transgender" and "MTF." "Transsexual," when applied in
the History and Physical, refers to those who have had, or are going to have,
SRS/GRS. SRS and GRS are synonymous. Masculine and feminine pronouns and
identifiers are used based on the individual's chosen gender rather than the
individual's gender as assigned at birth.
History (HPI)
We have gone through the subtypes of individuals, and we have related
problems in the current standards of care for treatment of individuals. We
shall now document the mechanisms by which a health care worker can do an
adequate history and physical of these individuals. We shall do this by telling
why certain questions should be asked. After that is completed, we shall then
go into the nuts and bolts that comprise the complete physical examination,
stating why certain procedures are necessary, and how a more complete
examination can be done on these individuals.
Name/Pronouns and General Informative History
The first part of our intake involves the name of the individual. This can pose
some difficulty to the practitioner, because the patient may desire to be
called a name other than what shows up on legal forms of identification. We,
however, choose to address the person in a manner congruent with their own
self-image and then to process any forms with the legal identification until
they have been altered as well. Thus, the primary health care provider is able
to gauge patient response, as well as the classification of the types of
transgender person that this individual may be, and over time how that image
will thusly change or be maintained. At this point, also ask about the marital
status of the individual, so that you can place and discuss the intimate
relationships that the individual has, and to relay the possibility of
partnership counseling as well, as the person undergoes the transition from one
gender to the other. Also ask about the religion of the individual, and if one
is active with it. This question can also lead to the individual relaying facts
of a spiritual nature, which are quite common in the transsexual subgroup of
individuals.
The next part of the history deals with the past ways in which the patient
has attempted to be transgender. It goes into when, if ever, the patient took
hormones, the name of the medication, how they were used and in what dose, and
the name of the physician (if there ever was a physician involved in the
patient's CGHT). This is the usual chief complaint form of the history, and
uses a patient's own words in defining themselves, as well as their problems of
living in this world. Use this portion of the history to get to know the
patient better. Think of it as the "history of present illness"
section, whereby one usually characterizes the symptoms, nature and course of
present state, as well as any precipitating events, frequency and severity.
This part plays a great role with crossdressers, and TS/TG individuals who
often go through several purges of clothing etc., before they come to terms
with their identity, also known as "coming out." During this time,
look for current manifestations in the individual, as well as quality, and go into
the last time the individual was treated for gender discordant behavior, by
whom that patient was treated, and the means and methods of the previous health
care practitioner.
Past Medical History (PMH)
General Overview of Common Health Issues
Now go into the patient's medical history. Like most conventional histories, we
go into life threatening illness, but particular attention is given to cardiovascular disorders, as well as the hyperlipidemias, since they can be altered with CGHT. We
also look for signs of metabolic and/or endocrinologic disease, like hypothyroidism and diabetes mellitus, since CGHT has also been found to alter
these disease patterns as well. In essence, we look upon anything that will
normally be altered by the sexual steroids, much like in post menopausal hormonal replacement therapy, or when
dispensing oral contraceptives. We also look into prior hospitalizations, with
particular emphasis placed on psychiatric hospitalizations for depression and/or suicide attempts, which are quite high in the transgender
community, much like in gay or lesbian communities. At this time, you can also
go into prior surgery, which may be useful to the transsexual who has already
undergone SRS. It can help with locating the surgeon and/or the year that
surgery took place, thus laying the foundation for learning the names of those
surgeons who perform SRS, awareness of their techniques, and any problems with
those techniques on the affected group of individuals. You can use this
knowledge to be aware of, as well as document, many postoperative complications
such as hemorrhage, fistula formation, and wound infection. You can also use
this time to document any trauma and/or injury, especially those that may be
self-inflicted or a consequence of an abusive relationship. At his point, you
can further the PMH by asking the usual questions about allergies. Anecdotal
evidence at this time suggest that this subgroup of individuals may have a
higher than average rate of allergies in comparison to the general population.
Remember the usual questions about blood transfusions, poisoning and childhood
immunizations while taking the medical history of the affected individual.
However, note of any travel may be significant, since it may play a role in the
surgical history of the patient. Further specific details about taking the
history of these individuals follows in the next paragraphs.
Web notes: Elaboration on issues such as cardiovascular disease and
endocrinologic disorders will follow below when they are emphasized in the
physical. Suicide, depression and self-inflicted injuries, especially mutilation
of natal genitalia, are major factors of consideration in the transgender
community. Violence inflicted against the transgender community is notorious,
and not covered under federal, and most state, hate crime legislation.
For more on transgender depression, suicide and self-inflicted injury, see:
For more information on violence against the transgender community, see:
Surgical History (SHx)
We investigate in terms of past surgeries with particular emphasis placed on
any plastic/reconstructive procedures, looking for SRS/GRS, rhinoplasties, chondrolaryngoplasties,
etc. At this point of time, it might also be useful to ask the patient, if she
is a transgender woman, whether she has had breast augmentation surgery and, if not, whether she
desires it. At this point, you can educate the patient about breast
augmentation, and give dissenting views if needed. We also use this time to ask
the patients about any procedures that may have been performed like orchiectomy, vasectomy, etc. This is important, as the person may have
undergone voluntary sterilization procedures, with the self-knowledge that in
undergoing SRS/SCS and CGHT that they may sterilize themselves. It is also
useful in that the practitioner can then assess what has been done in terms of
surgery via "the street," as well as through the techniques of the
various surgeons.
Web notes: Chondrolaryngoplasties and orchiectomies are generally thought
to have few complications. As emphasized in the TransgenderCare link below, an
orchiectomy is not recommended if GRS is expected in future, as some GRS
surgeons will refuse to operate on individuals who have had one. However, for
those who can not withstand typical preoperative transgender hormone regimens,
it may be a suitable alternative. Other feminizing surgeries and their
implications are discussed on/from the surgery page of this site. (Note to
designer: the surgery page will be sent later. In the mean time, we are going
to link to a ppt presentation. Ask David about particulars).
For more information on chondrolaryngoplasty, see:
For more information on orchiectomy, see:
Family History (FHx)
Next, we investigate the family history of the individual. It is important
to ask a transgender woman about the incidence of breast cancer, cervical cancer, testicular cancer, and prostate cancer in her family, since with the advent of
CGHT, she may be at risk for them as well. For the transgender man, it is also
important to ask the same questions as his risk may increase significantly as
well. It is important also to ask questions regarding metabolism because hyperthyroidism or hypothyroidism can be activated via CGHT, as can diabetes). Watch for psychiatric problems as well. This
should be asked in a patient's own medical history, as well as the family
history. Look for unipolar depression, bipolar states, personality disorders, and anxiety related states) like panic disorder. Also note if the patient is being treated,
or has been treated in the past, for any psychiatric disorder. Place emphasis
on any bleeding/thromboembolic history within the family, since CGHT may
alter the coagulation cascade of the affected patient. At this time, you may
ask whether there were any other individuals within the family tree that are
gay/lesbian/bisexual, or if there were any other family members who were
transgender. Particular emphasis in this portion of the history should be
placed on endocrine, liver, kidney, and heart diseases, as these are primarily affected by CGHT.
Web notes: The psychiatric disorders mentioned above should be addressed
from a patient history, as well as a family history. Many comorbidity studies
and professional examinations indicate two findings in particular: 1.) comorbid
psychiatric disorders frequently exist in the transgender people and 2.) there
is significant evidence these disorders exist in transgender people often as a
result of exposure to discriminatory behavior (see links below). It is also
important to recognize gender identity disorder left untreated, or gender
self-identity invalidated or unsupported in various social relationships, can
lead to symptoms of other psychiatric disorders (depression, anxiety, substance
abuse, etc.). Agreement on the above issues is leading towards a therapeutic
model demphasizing pathology and promoting support (Raj, 2002).
For more on psychiatric comorbidity in transgender people, see:
Social History (SHx)
In terms of social history, it is important to see if the patient smokes due
to the increased risk of thrombophlebitis and other conditions associated with
CGHT/HRT and oral contraceptives. It is also important to know the alcohol/drug related history, as they may alter concomitant liver function and play a role in activating microsomal
enzyme systems. These are also important to note for the purpose of seeing
various coping mechanisms. Note if the patient has undergone or is receiving
treatment for their substance abuse, its location and/or length of time, and if
the patient feels that they have been successful. It is also important to ask
questions about caffeine intake, as they can tip off the knowledgeable
practitioner about various anxiety-related states. At this time, if appropriate, you
can ask about the ability to obtain hormones on the street as well.
It is sometimes best to combine the psychiatric history within the social
history. However, if questions on identity yield answers in any of the same
categories, then follow the patient's own flow and obtain or repeat the same
answers during the course of the history as a matter of clarification. During
this time, you can ask about the education and occupation of the individual,
because both may play a role in the gender identity formation of the patient,
as well as for stratification by type for the health care practitioner.
Furthermore, questions involving military service are of particular
significance for transgender women, as has been documented as a "flight
into hypermasculinity" frequently seen in subtypes of these individuals.
Military service is also quite significant for transgender men, as they may
find military service as way of escape from their previously assigned female
gender role. Military service may also be a marker for crossdressing males, as
they seem to gravitate to many of the "more masculine" of occupations
in a cognitive dissonance with their feminine identity that coexists with the
male identity. As in any other social history, note what a typical day for the
patient is like, their overall satisfaction or frustration, as well as
hygenical habits, lifestyle, dietary habits, and extent of sports and exercise.
The social history of the patient will often provide the practitioner with most
of the context and texture of the patient's life.
Web notes: smoking, in combination with CGHT/HRT in particular, increases
the risk thrombophlebitis, which can lead to serious complications that may be
fatal (pulmonary embolus, stroke). Smoking and hormone use also increases the risk of hypertension, which increases the risk of stroke, heart disease and kidney disease, all of which can lead to death. The risks
from combining smoking and CGHT/HRT are so great that some physicians will not
prescribe hormones unless the individual quits smoking, or is at least involved
in a smoking cessation program. Substance abuse, as was already mentioned as a
major concern in the transgender community, further increases the risks to an
individual's health. Alcohol abuse, in particular, can cause hypertension and
certain types of heart disease, exacerbating the risks mentioned earlier, and
can lead to its own set of health problems (liver disease, neuropathy), and more). Estrogen may facilitate weight
gain, so another risk factor is added. It is essential that smoking, substance
abuse and obesity be addressed before CGHT/HRT is prescribed, and monitored
afterwards. A good, specific motivational tool you can share with a transgender
patient is by informing them that, among all the other reasons to quit smoking,
it increases the efficacy of estrogens.
Even without smoking and substance abuse to complicate matters, CGHT/HRT has
its own set of risks. Thrombophlebitis is still a major consideration. An
elevation in blood pressure may or may not be seen with the initiation of
CGHT/HRT, so it should to be monitored during routine exams. Migraine headaches
are a possibility, as well as nausea seen especially with oral estrogens.
CGHT/HRT can also elevate liver enzymes, although this is usually temporary
with the initiation of CGHT. Consistently elevated liver enzymes (they should
be checked every couple of months after the initiation of CGHT and then about
every six months) may indicate an intolerance to the estrogen, its dose or mode
of delivery, as well as any number of factors known to do the same. Elevated
LFT's in a transgender person are a red flag for alcohol and other substance
abuse.
Venous Thrombo-Embolism and (Oral) Estrogen Use
Mortality and morbidity in transsexual subjects treated with
cross-sex hormones
The WHI study on women between the ages of 50-75, using a combination of
estrogen and progestin, was stopped in 2002 because of an unexpected increase
in breast cancer seen in participants. There were also slight increases other
components such as heart disease and stroke. (WHI, 2003). However, the addition
of progesterone may have been a facilitating factor, although further studies
have yet to determine if that was indeed the case.
At one time, physicians might prescribe progesterone with estrogen for CGHT
as it demonstrated small increases in breast growth. However, the practice was
going out of favor prior to the WHI study, and now most physicians chose to
avoid it as part of a CGHT regimen. Its efficacy in increasing breast growth is
minimal, in comparison to the potential risk of adding it to a CGHT regimen. Of
course, WHI participants were natal females so all the results may not apply to
male-to-female transgender people. However, considering the absence of this
data relevant to the transgender community, appropriate cautions should be taken
across the board. Cases of breast cancer after CGHT in transgender women have
been reported, so regular breast exams, including mammography, should be
followed as they would in a natal female.
Women's Health Initiative
Hormone Treatment in Transsexuals
Prolactinomas, or non-cancerous pituitary tumors, in transgender women may result as
estrogen levels rise and testosterone levels fall. It is thought the appearance
of high prolactin levels are a sign of estrogen abuse, and it could
be, but prolactin levels sometimes rise and fall, so regular prolactin testing
is necessary. There is not much research indicating an increased cancer risk in
transgender women, although evidence found in the WHI study did indicate an
increase in breast cancer during HRT (WHI, 2003). Evidence of an increased risk
of prostate cancer is scarce or anecdotal, although there are
reports of prostate cancer being found in transgender women. Most of what we
currently have shows either no link with CGHT, or a decrease in risk with CGHT
(Gooren, et al.). Since the prostate is not removed during GRS, typical
guidelines for prostate checks should be followed because the patient is still
susceptible regardless of CGHT and GRS. However, some new information has been
relayed indicating there may be other considerations and will be posted when
received.
Prostate cancer in male to female transsexual
There is also a risk of developing Type II diabetes, which may result from a undetermined
combination of risk factors that exist for diabetes mellitus (obesity, age,
hypertension, race/ethnicity, etc.), hypertriglyceridema and some evidence that estrogens reduce
glucose tolerance and increase insulin resistance (Feldman, 2002).
New
Onset of Type 2 Diabetes Mellitus with Feminizing Hormone Therapy
Since there are various means of delivery for estrogens, there is a bit of contention about which is
best: oral, IM or transdermal. There are many variables for consideration. Oral
estrogens show variable hepatic toxicity, with Estradiol lower than some
conjugated estrogens like Premarin, and potency varies along the same lines.
Estradiol is less expensive than Premarin. Oral estrogens typically cause more
nausea than the other delivery modes, but Estradiol is a small tablet that can
be dissolved under the tongue (sublingual), which may have an advantage with
regard to hepatic toxicity. Estradiol levels are easier to check than those
from conjugated estrogens. Estinyl was widely available for a time, and was
popular because of its potency, but it was also thought to carry an increased
thrombophelbitis risk.
IM estrogens (estradiol valerate, a.k.a. Delestrogen) is a popular
alternative because of its lower hepatic toxicity and risk of thrombophleitis
than oral estrogens (especially conjugated), fewer GI problems, and ability to
be screened for estradiol levels. However, it is sometimes more difficult to
obtain and has the distinct disadvantage of being injectable. This is a
particular, and perhaps justified, argument for not prescribing IM estrogens to
transgender people on the "street," considering the risks that come
with sharing needles. There is also the possibility of adhesions at the
injection site, although this can be avoided to a large extent by using
multiple, bilateral sites. IM estrogens can also increase prolactin levels more
than other estrogens, which, as discussed earlier, is a potential risk in
developing prolactinomas. Some complain IM delivery causes a "rush"
of HRT related symptoms, so physicians sometimes prescribe a low dose, daily
oral estrogen like Estradiol as a stabilizing agent. The cost of IM estrogens
also appear more variable for the same medication, from $60 - $100 typically
for a 10mg/5ml vial.
Transdermal estrogens are becoming popular for their relatively (to oral)
low thrombophlebitis and hepatic toxicity risk. They are also more expensive
than oral preparations, may cause skin reactions, and, for some, a challenge
when getting them to adhere to the application site.
Anti-androgens are also usually used with the estrogen regimen. By and
large, spironolactone, a diuretic anti-hypertensive, is the
medication of choice for an anti-androgen. It has very few side effects, is
generally inexpensive and can help reduce hypertensive effects of estrogens if
they appear. Typical CGHT doses range between 100 - 200mg per day, although
some use higher doses without issue. However, as mentioned, it is a diuretic,
which means increased urination for a time. Spironolactone is potassium sparing, so additional potassium through diet or
supplements should be avoided. If possible, spironolactone should be used
instead of progesterone.
Many of the risks discussed above also apply to CGHT in female to male
transgender people, also known as transgender men, although quite a bit is
hypothetical. Hypertension may be seen as a result of FTM CGHT, which opens the
door to heart and renal complications, as well as CVA. Quite a few transgender
men have reported migraines after the initiation of CGHT. Elevated liver
enzymes may be a concern, although they are usually temporary and/or minimal
considering IM and transdermal modes of testosterone delivery are the most
common, in comparison to potent oral testosterone. Levels of estrogen and
testosterone during FTM CGHT, much like MTF CGHT but in the opposite direction,
can fluctuate, especially in those who have not been castrated or had a
hysterectomy. So, just as estrogens in a transgender woman increase the risk of
thrombophlebitis, consideration should likewise be given to transgender men,
who still have high levels of estrogen but now in combination with higher
levels of testosterone. Lipid levels, LDL's in particular, may rise with
testosterone (Goh, et. al, 1995), so complications from hyperlipidemia, which
includes types of cardiovascular disease, are possible. Weight gain is a
concern. FTM CGHT tends to increased appetite, so certain adjustments to diet
may be necessary.
Osteoporosis may be a concern if, after a hysterectomy, hormone use is
discontinued or not maintained on a regular basis. This also applies to
transgender women after castration (chemical or otherwise). Testosterone and
estrogen play a factor in maintaining bone density, so the combination of the decrease
in those hormones that would occur post-surgically plus the cessation/decrease
of those obtained by CGHT would have a negative impact and put these
individuals at risk
A frequently mentioned effect of testosterone CGHT is an increase in libido.
In and of itself, an increase in sex drive is not necessarily a problem.
However, the initial stages of changing gender have often been compared to a
"second puberty," and leave transgender men and women very vulnerable
to the emotional changes that occur. It is essential these emotional changes
and the risks they pose, especially sexually indiscriminate behavior and unsafe
sex practices, be monitored and addressed if necessary.
Effects
of Cross-Sex Hormone Treatment on Emotionality in Transsexuals
There are remarkably few published studies on the risks posed to transgender
men via an intact reproductive system. By way of what is known, endometriosis
is a particular concern, and there are reports of uterine fibroids. Some
symptoms associated with polycystic ovaries are similar to those that occur
with androgen CGHT, and a possible secondary complication of polycystic ovaries
is endometrial cancer and hyperplasia. Further complicating matters, polycystic
ovaries are difficult to differentiate from ovaries exposed to CGHT levels of
androgens (Gooren, 1999). Likewise, some of the effects of androgen CGHT are
similar to occurring with ovarian cancer, such as weight gain, abnormal menstrual
cycles and some non-specific symptoms. Fortunately, ovarian cancer is rare but,
when it does occur, the chances of survival are poor. Hysterectomy obviously
reduces some of these risks, but some residual complications from conditions
like endometriosis may reappear even after a hysterectomy.
Typical modes of delivery for testosterone or a bit different than mentioned
above. In the case of female-to-male transgender people, injections or
transdermal patches are preferred because oral preparations are often far too
potent and increase the risk of liver damage, thrombophlebitis, heart disease
and other associated adverse effects. Until more research is done in this area,
and as long as a transgender man maintains an intact reproductive system,
regular gynecological exams are essential. Unfortunately, this is easier said
than done, as such exams are especially unpleasant for these people. To
exacerbate the situation, gynecologists have a legendary reputation in the FTM
community as indifferent to their health care. A great deal of sensitivity
needs to be applied during transgender health care to overcome this perception,
as well as effectively treat these patients.
For more detailed information on CGHT, regimens, effects, risks and tests,
see:
Gynecological History (GYN)
In transgender men and women, remember the most important part of the
history prior to the physical examination: the OB/Gyn section. However, this
section, given the diversity of the transgender population, should be applied
to all individuals and be properly labeled as genital history. In those
individuals born female, ask questions relating to last menstrual period, age
of menarche, and menstrual character such as frequency, duration, regularity
and flow. The transgender man may be obviously uncomfortable with such
questions, considering their reproductive status as women is a particularly
sensitive issue, especially in the course of a medical examination. However, as
mentioned above, this portion of the history is important. Likewise, ask
post-GRS transgender women about vaginal infections and whether they are
dilating their neovagina, which is especially significant in all types of
male-to-female SRS surgery. Also ask about whether this individual has ever had
a Papanicolaou smear, because these women could be in a
precancerous state just like any other woman since homologous tissues are used
in SRS. Ask both transgender men and transgender women about lactation, as well as prior use of contraceptives for
transgender men, and the onset of perimenopausal symptoms in transgender women.
Sexual History/HIV Screening (SHx)
Furthermore, as you ask for the sexual history of the individual, it must be
emphasized that many interpretations can exist for gay, lesbian, and
heterosexual relationships, and that the organs of the individual play no role
in how a relationship is labeled. As a result, the practitioner must be aware
of safe sexual techniques, not only for heterosexual partners, but those that
apply to gay, and lesbian relationships as well. Furthermore, you can use this
part of history taking to bring up to the patient, dependent upon where in the
typology the individual fits, the basics of doing breast self-examinations and testicular self examination. Furthermore, at this point the
practitioner may be asked to explain many methods of self-stimulation to provide
sexual satisfaction to the patient population. This is also an opportunity to
make the individual aware of various rewards, and/or limitations of their new
anatomy. Avoid asking the patient whether contraception is involved or whether
the patient had any type of births involved, as they may be offensive to the
individual. Those questions may be appropriate if they were discovered in the
HPI section of the history, or the practitioner determines they are relevant.
Be very careful in this portion of this history, and to use the utmost tact and
sensitivity to the individuals treated.
Web Notes: Thanks to some fine work by various organizations such as
UCSF's Center for AIDS Prevention Studies, there is mounting research on
transgender people and their risk of HIV. Health care can be a challenge for
any marginalized group but the disparities in transgender communities are
becoming more evident.
What Are
the HIV Prevention Needs of Male-to-Female Transgender Persons?
Transgender
and HIV: Risks, Prevention and Care
This piece of the International Journal of Transgenderism is bigger than it
looks. Go to the main page and scroll down after reading the preface page.
There are 12 HIV and transgender articles there.
New
Mexico AIDS InfoNet
Healthy
Oakland Teens Program
Review of History
Like any other history, do a review of the symptoms section (hereafter known as
ROS). At this point, note all of the other conventional portions of the
history, but should also look for any detail involving gastrointestinal
symptomology, commonly found in high dose CGHT prior to the surgery,
cardiopulmonary symptomology significant for PE, or CAD/CHF/MI, and urinary for opportunistic infections. Also remember
the endocrine, because it may show the signs and symptoms of Cushing's syndrome, prominent in transgender women who take
high doses of sexual steroids. The urinary history should check for UTI's in the newly postoperative transsexual woman, as she
may be ignorant of her new anatomy, the increasing frequency of UTI's in the
female population, and how to treat them. Pay attention to the rheumatological portion, since connective tissue disorders
may predominate in the "she-male " group of individuals who often
inject industrial strength silicon in order to further their feminine
appearance, and are thus apt to suffer many illnesses that affect connective
tissues as a consequence. Also look into the neurologic, as the incidence of
strokes in these individuals is 35-45% higher than the given population. One
should never neglect the genitals, as this portion of the history taking will
serve as a guide to the individual's mechanisms of sexual satisfaction, as a measure
of the progress of CGHT over time, and the effects of SRS surgery. Psychiatric
portions of the ROS should be emphasized for both Axis I and Axis II disorders,
other psychiatric problems that the patient has, or has a tendency to develop
in the future.
Physical Exam (PE)
The physical examination of transgender individuals should be structured
like any other physical examination. Particular attention should be paid to the
facies, voice, body build, and to the general appearance of the individual.
Appearances can both fortify as well as distract the practitioner. They can
"fool" even the most aware medical practitioner, and they are no
indication of sexual orientation or intersex status. Facies are considered to
be important because it may show early signs of Cushing's syndrome associated with sexual steroid usage
and/or overdosage. The voice may or may not give away the gender of birth of
the patient. Body build and/or habitus may also show effects of sexual steroid usage, or
of how much work may be necessary for a patient to "pass" as a member
of their new gender. Also use posture and gait for clues for
"passability" in the new gender as well.
Naturally, vital signs are important as in all patients. However, different
fever patterns may play a role in the treatment of the immunocompromised patient, and hyperthermia may be one of the first symptoms of an adrenal
crisis, along with tachycardia. Adrenal crisis is significant for those patients who had
previously obtained their "hormones off the street," as well as for
intersex patients who may have several salt-wasting syndromes.
Head
Beginning the examination, we shall start at the head. Significant signs to
look for are facial edema, a sign of Cushing's syndrome and several adrenocortical insufficencies. Myxedema, as seen in hyperthyroid conditions, should also be checked. Perform an auscultation to look for bruits indicative of arteriovenous fistulas or aneurysms. Look for signs of hirsutism, as polycystic ovarian disease incidence is found to be high in
intersex individuals, and is possible in transgender men. Also do Chovstek's
sign to look for evidence of hypocalcemia, and palpate the sinuses for any person
predisposed to any allergic condition. In looking at the eyes, look for alopecia in the eyebrows commonly found in hypothyroid states. Additionally, examine the optic fundi
for signs of diabetic retinopathy, hypertensive retinopathy, and arteriolosclerosis. Check for signs of icteric sclerae common in hepatitis. Look for injected conjunctivae, commonly found
in those people who use both recreational drugs and alcohol. Also look for
changes in the macula densa in terms of color or contours indicative of
hepatoxicity, as well as for any signs of adrenocortical deficency, or excess
by changes in the pigmentation of the macula densa. When you look at the ears
of the patient, pay attention to the pinna for gouty tophi or for some of the first signs of Marfan syndrome, common in homocystinuria that has been found in transsexual
individuals. When looking at the mouth, be aware of white areas in the mucosa indicative of candida and leucoplakia, as well as for brownish pigmentation
indicative of Addison's disease. Examine the teeth for signs of caries and abrasion that may show some of the early signs
of wasting in immunocompromised patients. Look at the tongue for any abnormal
papillae, as well as check for the macroglossia present in hypothyroidism. Routinely test the
gag reflex, and look for tongue and/or uvula deviation as part of the
neurological examination.
Neck
At the neck, look for the webbing indicative of Turner's syndrome, as well as for any signs of edema, for adrenal syndromes, and for goiter indicative of various thyroid states. Looks for
tracheal deviation of any sort, either as a consequence of the previously
mentioned syndromes, or as an indication of any pulmonary problems. In
evaluating for goiter, palpate for multi-, diffuse or single nodules, and
should also do Pemberton's sign for signs of compression if a goiter is
noticed. Check for lymph nodes of any sort, since they can be signs of an upper
respiratory infection or signs of immunocompromised hosts. Be aware of the
cricoid cartilage of the transgender woman; she may desire a
chondrolaryngoplasty to remove her Adam's Apple if it is prominent.
Thorax
When checking the thorax of the transgender patient, look for any signs of
assymetry, pectus excavatum, and pectus carinitum, or barrel chest. Also look for any lymph
nodes, as they may be indicative of breast cancer in its early stages for any transgender
individual. Check for chest wall expansion and fremitus much like any other
patient. However, palpate the chest of those individuals who had previously
used any form of silicon for crepitation, seen in subcutaneous emphysema common in these patients. Otherwise,
use the scratch sign, looking for any signs of pneumothorax common in those patients affected with autoimmune diseases associated with the use of silicon.
Heart
In doing the examination of the heart, look for heart sound indicative of mitral stenosis and/or regurgitation associated with endocarditis and intravenous drug use, which might be
common in certain segments of the transgender population. This is also an
opportunity to continue checking for any of the congenital abnormalities
associated with either Turner's or Marfan syndrome.
Chest
When beginning the chest exam, instruct those both transgender men and women in
the art of breast self-examination. Look for signs of edema, dimpling, pigmentation changes indicative of a
cancerous process, and any signs of discharge which could indicate excessive
hormonal use. Also look for any masses, particular in those individuals, by
virtue of their history prone to fibrocystic disease and breast cancer.
Abdomen
Examination of the abdomen begins with inspection looking for scars indicative
of surgeries, as SRS often leaves many such scars. Also check for masses and
hernias, as they may play a role in the eventual surgery of the patient. Looks
for striae, spider nevi, and changes in hair and pigmentation that
coexist with many endocrine abnormalities. Looks for caput medusae prevalent in hepatic pathology as a result of IVDA of hormones "on
the street." On auscultation of the abdomen, check for bowel sounds
associated with peptic and abdominal ulcer, as well as gastric reflux as a result of the hyperistalsis of the
sexual steroids. Also check for hepatic abscess, as a consequence of street drugs. The
medical practitioner should also try to elicit tenderness when palpating the
abdomen for signs of GERD and PUD. Look for any hernias or periumbilical lymph nodes that
may be indicative of STD's.
In examining the abdomen there are several organ systems that merit
particular attention. These include the liver, gallbladder, spleen, and urinary
bladder. So, we shall go into more detail with these organs. When examining the
liver, palpate for size, surface and edge, and try to estimate the size and
character of the organ, because it may be affected as a consequence of CGHT or
other drug used by the patient. Always use Iceberg's sign if there are any
signs of ascites and/or hepatomegaly in the patient. When examining the
gallbladder, particular attention must be paid to Murphy's and Couoisier's
sign, as they may aid the practitioner in finding cholestasis, cholecystitis, and choledocholithiasis. When checking the urinary bladder,
look for any abnormal signs of distension, which may result from overuse of
some anti-androgens found "on the street."
Genitalia
The examination of the genitalia of the transgender patient must be performed
with utmost tact and professionalism on the part of the health care practitioner.
These patients must be approached as if they have undergone some sort of
"rape trauma," since this part of the examination focuses on a part
of the body for which the patient feels distaste or revulsion. You must respect
the patient's mindset and emotions. This may be the longest portion of the
physical examination as a consequence, so the practitioner must be aware of any
time constraints as well. These examinations must be performed on every patient
initially, then at 3-6 month intervals thereafter, to note the effects of CGHT
and any subsequent SRS. In this portion of the examination, the examiner notes
changes in the escutcheon by using the Tanner stages of the gender of choice.
Look for any signs of hypertrophy or atrophy of the affected organs as a consequence of CGHT. At
this point of the examination, also probe further with the sexual history, as
well as teach the individual ways of self-stimulation if the patient is
postsurgical. It should also be noted in the postsurgical patient that there
might be some loss of sensation in the perianal area as a consequence of SRS,
The practitioner, at the patient's request, may also do a sensory examination
of that area. You can also show the recently postoperative female on the
correct usage for vaginal dilatation and/or stent use.
At this point of the examination it would be helpful to detail salient
points in examining the neovagina and the neophallus. First, let's consider the
neophallus. Unlike the regular phallus, the neophallus can be of one of two
types based on the type of surgery the patient has undergone. If it is a
phalloplasty, then approach the examination by looking at superficial tissues
for signs of STD's. Examine the neoscrotum to see if the testes are in place
and there are no masses just like in the ordinary testicular examination. Also
examine the patient for signs of herniation. Transilluminate the testes as well. Examine the glans
penis, scrotum etc. for signs of STD's. If the patient has had a phalloplasty,
then the viability of the pump (like one after TURP surgery) needs to be considered. Examine the pump in
much the same way as a patient who has had prostate surgery is examined.
Furthermore, since superficial perineal nerve fibers are often excised or repositioned in the course of SRS, a
superficial sensory examination must be performed to determine to both the
patient and to the practitioner the extent of viability of orgasm in the new
gender. Also examine the bladder and urethra, as they are stretched during
surgery, which may result in hematuria, asymptomatic bacteruria,
and urinary tract infections. Look for fungal infections, since
this part of the anatomy is homologous to that of a natal female, and thus may
harbor some fungi in the course of their normal flora.
Like the phalloplasty , the patient who has undergone metediaplasty requires
the same sort of examination on the neoscrotum, as well as the bladder/urethra
as above. However, they differ in the fact that in the metediaplasty, the
clitoris has hypertrophied and is used as the primary organ for sexual
stimulation. Naturally, a sensory examination has to be performed
postsurgically, and periodically afterwards as above. However, since the
clitoris now acts as a micropenis, with the hood acting as a glans penis, it
has secretions similar to fluid from the seminal vesicles. However, unlike the
phalloplasty, skin is not grafted, and the labia majora and minora form the
basis of the neoscrotum as above. However, there is no pump that has to be
checked. In all other respects, the examination differs little from the
previous genital exam.
When examining the neovagina, first determine whether a neoclitoris was
formed as a consequence of surgery. If it has, then do the conventional pap smear on the individual patient in addition to the pap
smear detailed in the succeeding paragraph. Also examine whether penile
inversion surgery has taken place, or whether the small intestine is attached
to the neovaginal wall. If the penile inversion surgery has been performed, and
a neoclitoris created, you should, like any other genital exam, look at the
external structures and examine them for any signs of disease. Then examine the
patient in the following manner:
- Wipe away excess mucus, or
leukorrhea with a cotton pledgette. This is especially important in those
people who have had the surgery with the small intestine, as it may cause
excess mucus, in contrast to the penile inversion surgery, where
participants have to lubricate themselves.
- Obtain a thorough
endocervical smear with a brush, a cotton swabbed applicator or an
aspirator.
- Repeat the same steps above
with the sides of the neovagina wall; use on another slide for Pap smear.
- Immediately fix both
specimens with fresh fixative.
- Use the wooden Ayre spatula
to collect a thorough endocervical, and neovaginal wall specimen, and be
certain the cells are obtained from beyond the borders of glans penis
(neovaginal wall).
Once the following examination is performed, it is still essential to
perform a bimanual examination, despite the fact that the woman involved is
essentially a postmenopausal female who has had a total
abdominal hysterectomy and bilateral salpingo-oophorectomy. It is performed
to locate any masses formed as a consequence of surgery. This is not an
entirely uncommon problem, but it is often unrecognized by all but the surgeons
who perform SRS/SCS. So the practitioner is asked to examine the vaginal walls
for cystoceles, urethroceles, rectoceles,
and enteroceles. Furthermore, examine the genitialia for varicosities and fistula formation. Prior to this examination, the exterior
of the neovagina is examined for edema and Bartholin's
cyst formation in the labia majora. Remember to look for secretions in the
urethral meatus. If the transsexual woman has a neoclitoris, examine the corpus
cavernosa and the glans, as they shall still be present, albeit in different
places. Also examine the introitus for any signs of prolapse. This is especially important in the newly
operated transsexual woman, as the neovagina is prone to collapse in these
areas, as well as fistula formation. Also examine the perineum for any signs of
sexually transmitted diseases, or any other signs of infection.
Genitalia: Intersex
In the intersex patient, you should ask if the patient is aware of their
particular differences, and/or diagnosis. From here, examine the intersex
patient in either a conventional manner or in a manner similar to the
postoperative transsexual above, considering there may have been significant
SRS/SCS done in early childhood. Allow flexibility of techniques, as well as
melding and/or creativity, given the intersex patients' gender of choice and
presence of existing surgical techniques to aid the person in becoming the
gender of ease in childhood. Also ask the patient if (s)he is sensitive about
the examination. If (s)he feels that they are damaged by the SRS/SCS at such a
tender age, then proceed accordingly. Be aware of the extent that a condition
is clinically medical hermaphroditism or pseudo-hermaphroditism, and then proceed
accordingly. In other cases, you can use conventional medical examining
techniques, but may hurt or damage the patient in the process as a result of
the practitioner's ignorance. It is important to note that any health care
practitioner involved in the care of the transgendered will see a higher than
average number of intersex patients. So it will pay to read up or be aware of
many conditions found in medical textbooks listed as 'Disorders of Sexual
Differentiation,' and in pediatric endocrinology textbooks. The clientele is
predominantly adult, but it's important to be aware of what can be expected for
a particular diagnosis and alter the PE accordingly. The scope of such a
discussion is beyond the breadth of this detailed process, except for the
advice about combining the transgender examination with that of the
conventional patient.
Rectum
Next, examine the rectum, performing an initial inspection for erythema, fissures, fistulas, ulcers, hemorrhoids, abscesses, and polyps. Then examine the sphincter for tone and the anal
canal for stenosis, and then checks for any masses or polyps in the
walls, as done with any other patient. However, in the transsexual woman, also
examine the prostate, as that organ is retained regardless of which type of
surgery is performed. Examine for all the conventional things found in the
usual prostate examination of the male. Look for site, shape, consistency,
mobility and masses. Usually, the organ is atrophied as a result of CGHT, so
expect a noticeably smoother consistency than found in male patients. Be
especially vigilant in looking for tumors or nodules, as the patient has been
exposed to extraordinarily high cross gender sexual steroids for a prolonged
length of time presurgically. It is not known what the long term effects of
CGHT are on the prostate, although one can hypothesize that since the
medications used to treat prostate cancer are similar to those used as part of
the chemical castration of the patient involved, the risk is minimized.
However, since there is no data at the present time it is advisable not to
speculate. So note your findings on a patient, and then proceed to note
differences on this patient and others in a longitudinal fashion. Remember the
rectal examination of the intersex patient, and handle it in relationship to
the patient' history and medical diagnosis, as well as with modification of
the above examination accordingly.
Extremities
The physical examination of the transgender patient is not finished. In
examining the extremities, inspect both upper and lower portions for signs of edema, masses, crepitation or lymph nodes consistent with adrenocortical syndromes,
overuse of steroids, immunocompromised activity, and migration of silicon and
connective tissue diseases as a consequence. Check the hands for palmar creases, hyperpigmentation indicative of Addison's disease, as well as for the palmar erythema
significant for liver disease. Also look for thenar and hypothenar hypertrophy indicative of
hepatoxicity, and for signs of Dupytren's
contracture as well. Don't neglect looking for Osler's
nodules, as a certain segment of the transgender population may indulge in
IVDA of all types including sexual steroids.
Also remember looking for Janeway's
spots for the same reason -- endocarditis. Also look at the nail beds for onycholysis secondary to the hypocalcemia of CGHT in transgender women. If that
individual has a history of IVDA, then the splinter hemorrhages indicative of
endocarditis are again significant. Pay attention to the nail beds because they
may show signs of metabolic abnormalities. It should be remembered that Plummer's
nail beds show hypothyroidism show signs of cirrhosis. The white transverse lines of Muehrcke's
nails show signs of hypoalbuminaemia.
When the proximal portion of the nail is white, and the distal portion is red,
it is indicative of ARF secondary to spironolactone abuse or overdosage within
the population. As a result of the increased rate of thromboembolic disease in transgender patients, Homan's sign should be performed routinely, especially in
the lower extremities.
The dermatological examination should look for all sings of metabolic
disease, as well as ARF and chronic renal failure and signs of hepatitis. Remember to check for the lesions found in the
immunocompromised patient, which are indicative of herpes, KS, or a number of dermatological manifestations found in AIDS patients. In doing so, look at the size, shape,
arrangement, and distribution of said lesions.
Musculoskeletal
You should also do a thorough musculoskeletal examination on the transgender
patient. Thoroughly check the muscles for strength and tone, as they may be
altered as a result as CGHT. Also note any signs of hypertrophism or atrophy as
a result of CGHT, and for the presence or absence of any deformities, paresis, or paralysis as a result of injections of silicon.
Furthermore, check the bones for any tenderness, masses or deformities, as well
as ligaments especially for alterations in laxity or stability. In both
transgender men and women, it is especially important to test the knee, as CGHT
can alter many ligaments' laxity in that particular area.
Neurological
The neurological examination is especially important, especially the mental
status examination of the individual. This can be done better by many
psychiatrists, however the general health care practitioner must be aware of
the general level of consciousness of the patient, behavior, thought content,
affect and mood, intellectual functioning, memory, judgement, and insight.
Grading of the reflexes is especially important, particularly in the
transgender man, and the sensory examination must be duplicated and performed
not just on the general areas of the body, but on the genitalia of the patient
both presurgical and postsurgical. Perform the traditional examination of the
cranial nerves, checking for |
