We commend JAAPA for publishing its first feature article on preventive health and wellness for transgender and gender-diverse (TGD) adults.1 Subject-matter experts have long asserted that TGD health is primary care.2
Although Schmidt and Rizzolo's article reflects a statement from Reisner and colleagues' 2016 systematic review of the literature to the effect that little data exist to advise primary care providers, Reisner's summary and conclusion present a comprehensive perspective that bears repeating: “Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people.”3
Multiple guidelines for primary and gender-affirming care offer graded evidence for recommendations, and complement the subject-matter expert work of the World Professional Association for Transgender Health (WPATH), which has been publishing standards of care since 1979 (Figure 1).2,4,5
A cursory PubMed search identified six peer-reviewed journals with transgender in their title (International Journal of Transgenderism, Transgender Health, LGBT Health, Journal of LGBT Health Research, Journal of LGBT Youth, and Journal of LGBT Issues in Counseling), as well as 4,352 articles published between WPATH's first edition of standards of care in 1979 until 2016 (Figure 2).
With this in mind, we seek to enhance the conversation begun by Schmidt and Rizzolo with additional highlights from the literature, best practices, and clinical pearls.
COMMON, NORMAL VARIATIONS
Readers should keep in mind a number of important foundational concepts about regarding gender diversity. The first is recognizing that gender diversity is common across cultures, a normal variation (like left-handedness), and is not inherently pathologic or negative.6 The second is that the form taken by sex and gender is entirely dependent on whether the environment is permissive or restrictive—an observation that might have been credited to Charles Darwin if he had been a psychologist.7 We know a consistent personal narrative is necessary for psychologic well-being, yet TGD people across the lifespan who live in restrictive environments often find it necessary to go to great lengths to suppress or hide their gender identity to mitigate stigma, prejudice, discrimination, and violence ranging from subtle to life-threatening when accessing housing, healthcare, employment, education, public assistance, and other social services.8,9
The most challenging foundational concept for medical providers is that of nonbinary gender diversity. So vital is this concept to our care for TGD patients that attempts to frame healthcare in terms of a binary (transgender men and transgender women) often result in an oversimplification that undermines data quality, and risks going beyond the point of accuracy. Maintaining a binary paradigm does not support the breadth and depth of the scientific discourse involving gender. Many cultures outside the United States recognize more than two genders. Gender markers other than M or F can be found on official identity documents from Australia, Bangladesh, Canada, Germany, Denmark, India, Malta, Nepal, New Zealand, and Pakistan. In 2016, Oregon was the first state to allow nonbinary gender recognition; the District of Columbia and California recently followed suit.
The 2015 US Transgender Survey of 27,715 TGD people age 18 years and older from all US states, Puerto Rico, Guam, the US Virgin Islands, and US military bases overseas, reported that 31% of respondents identified as nonbinary and 12% identified as a gender not listed.9 Given the social and economic marginalization, pathologization, stigma, discrimination, and violence experienced by TGD people across the United States, this assertion of gender diversity highlights the power of resilience in these communities.8,9
Creating a welcoming and TGD-inclusive environment involves every person in the healthcare setting. Regardless of the gender marker or name on patients' identity and insurance documents, healthcare providers must be educated to not make assumptions about gender identity and to use gender-neutral forms of address until they can request the patient's self-identified name and pronoun. A patient's self-identified name should be included in electronic medical records, and, where feasible, printed along with legal data on patient safety identifiers such as wristbands.
TGD patients often face challenges when attempting to have their healthcare concerns addressed. Four critical opportunities to gather important gender information occur in the delivery of healthcare services: patient intake forms, the clinical interaction, the patient satisfaction questionnaire, and tracking of health outcomes.10
Patient intake should allow appropriate disclosures. The best practice for recognizing TGD individuals is a two-step system that asks about assigned sex at birth and gender identity.11 Ideally, patient registration should let TGD patients ensure their legal rights in visitation, advance directives, billing, self-identified name and pronouns, and so forth. The clinical interaction requires history-taking that is culturally sensitive and appropriate. Patient satisfaction evaluations and healthcare outcomes tracking should capture the experiences of TGD patients.10
When talking with patients about their anatomy, clinicians should ask about, and use the terms that patients themselves prefer to describe their body parts. For example, a transmasculine patient may use the term front opening instead of vagina. Understanding and mirroring terminology when talking with patients and maintaining open communication with respectful language, including use of self-identified names and pronouns, are strategies that will put patients at ease, build rapport, and obtain accurate information for sexually transmitted infection (STI), reproductive, cancer, interpersonal violence, and other health risk assessments.
SEXUAL HEALTH: THE 6TH P
Clinicians can best serve our TGD patients by reframing how we think about the physiologic as well as psychosocial aspects of sexual health. The five Ps of sexual history-taking (partners, practices, protection from STIs, past history of STIs, prevention of pregnancy) should be further modified, reframing pregnancy prevention as family planning to allow for a more comprehensive conversation that covers fertility preservation and plans for parenting.12 Author Bruessow adds a sixth P representing pleasure, to describe sexual history-taking of preferential sexual interests, consent, and sexual function. This is where sexual history-taking explores differential diagnoses including hypoarousal disorders, erectile dysfunction, sexual trauma or violence, and paraphilias. Patients benefit when clinicians can take a sexual history that includes kink/BDSM and other sexually pleasurable activities beyond genital stimulation and coitus.
Gender identity differs from sexual orientation, and TGD patients may have sexual partners of any gender. The longstanding screening question, “Do you have sex with men, women, or both?” does not identify the anatomy or sexual behaviors of patients or their sexual partners. Open-ended invitations such as, “Tell me about the gender of your sex partners,” may be more likely to elicit an accurate and meaningful response. Closed-ended questions such as, “Are you sexually active?” further lack sensitivity, particularly among adolescents and sexual minorities, when patients perceive the question to be limited to penetrative vaginal sex.12
TGD patients vary in whether they modify their bodies to align with their gender. Some make no anatomical changes; others undergo hormone therapy, surgical interventions, or other procedures to affirm their gender. Gender-affirming genital surgery may affect the six Ps. Clinicians must be aware of available gender-affirming procedures and the resultant anatomical changes. This will help clinicians know which anatomic sites need to be evaluated, examined, or screened. Masculinizing procedures such as phalloplasty (creation of a phallus using skin from the forearm, chest wall, or thigh) or metoidioplasty (separation of the clitoris from the labia minora) may occur alone or in combination with vaginectomy or colpocleisis (removal of the vagina). Feminizing procedures may involve orchiectomy alone, or with a vaginoplasty—using either inverted penile skin (penile inversion), a loop of sigmoid colon (colovaginoplasty), or graftless vaginoplasty. None of these procedures involves removal of the prostate.
In general, prevention, screening, vaccination, counseling, diagnosis, and treatment of HIV and STIs among TGD patients should be undertaken based on an appropriately nuanced dialogue of partners and practices in the context of current anatomy. HIV-negative patients at ongoing risk for HIV should be offered preexposure prophylaxis; those living with HIV should be offered antiretroviral treatment.
CERVICAL CANCER SCREENING
To improve patients' low adherence to cervical cancer screening at the recommended frequency, the Patient-Centered Outcomes Research Institute funded research to compare self- with provider-collected swabs for high-risk HPV DNA testing as a primary cervical cancer screening technique. Preliminary findings suggest increased adherence to screening recommendations by eliminating the speculum examination, rendering cytologic inadequacy irrelevant, and removing fear of negative experiences during the pelvic examination.13-15
A recent systematic review by Streed and colleagues found that hormone therapy is associated with improved psychologic functioning in TGD adults.16 Reducing cardiovascular risk factors such as hypertension, diabetes, and tobacco use remains critical in preventing CVD in TGD patients. Hormone therapy, particularly with testosterone, is associated with worsening cardiovascular risk factors (such as increased BP, insulin resistance, and lipid derangements) but not with increases in cardiovascular morbidity or mortality. Hormone therapy with estrogen has potential thromboembolic risk, and lower-dose transdermal and oral bioidentical estrogen formulations are preferred to high-dose oral ethinyl estradiol formulations. Clinicians must closely follow older TGD adults who are on estrogen if they have higher cardiovascular risks, regardless of the age of initiation or duration of hormone therapy.16
In addition to affirming gender via hormones and surgical procedures, social affirmation improves patient psychologic well-being and may improve and/or prevent depression.
In 2016, two important publications enhanced our understanding of depression among TGD patients across the lifespan. One identified a lifetime suicidal ideation rate of 82% and a lifetime suicide attempt rate of 40% among TGD adults, nearly nine times as high as the prevalence in the US population (4.6%).8 The other explored a sample of transgender youth who were accepted and affirmed in their gender and were found to be psychologically indistinguishable from cisgender controls on depression measures, “suggesting that psychopathology is not inevitable in this group.”17 This supports previous research that has consistently identified family acceptance and support as notable protective factors. As the US Preventive Services Task Force declines to provide optimal timing or intervals for depression screening, and defers to clinical judgment with consideration of risk factors, comorbid conditions, and life events, we suggest that asking about family acceptance, support, and affirmation of gender identity when taking the psychosocial history of TGD adolescents and adults may be beneficial.
In closing, we hope to see many more JAAPA articles on transgender health, and recommend including TGD populations where relevant in articles addressing cardiovascular risk, cancer, healthcare disparities, obesity and eating disorders, mental health, geriatric medicine, substance abuse, adolescent medicine, STIs, smoking cessation, building a sexual history, building a medical history, ethics and professionalism, pediatrics, psychiatry/behavioral science, and obstetrics/gynecology.
1. Schmidt E, Rizzolo D. Disease screening and prevention for transgender and gender-diverse adults. JAAPA
2. World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version, 2011. www.wpath.org
. Accessed November 10, 2017.
3. Reisner SL, Poteat T, Keatley J, et al. Global health burden and needs of transgender populations: a review. Lancet
4. Deutsch MB, ed. Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People, 2nd ed. 2016. www.transhealth.ucsf.edu/guidelines
. Accessed November 10, 2017.
5. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders
. 5th ed.; 2013.
7. Nichols M. 21st century LGBTQ: clinical work with gender diversity, kink, and consensual non monogamy. Lecture presented at Greater New York Association of Imago Relationship Therapists, New York, NY, December 9, 2016.
8. Grant JM, Mottet LA, Tanis J, et al. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey
. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011.
9. James SE, Herman JL, Rankin S, et al. The Report of the 2015 US Transgender Survey
. Washington, DC: National Center for Transgender Equality; 2016.
10. Bruessow D. Keeping up with LGBT health: why it matters to your patients. JAAPA
11. Institute of Medicine. Collecting Sexual Orientation and Gender Identity Data in Electronic Health Records: Workshop Summary
. Washington, DC: National Academies Press; 2013.
12. Centers for Disease Control and Prevention. A Guide to Taking a Sexual History
. Accessed November 10, 2017.
13. Reisner SL, Deutsch MB, Peitzmeier SM, et al. Comparing self- and provider-collected swabbing for HPV DNA testing in female-to-male transgender adult patients: a mixed-methods biobehavioral study protocol. BMC Infect Dis
14. McDowell M, Pardee DJ, Peitzmeier S, et al. Cervical cancer screening preferences among trans-masculine individuals: patient-collected human papillomavirus vaginal swabs versus provider-administered pap tests. LGBT Health
15. Seay J, Ranck A, Weiss R, et al. Understanding transgender men's experiences with and preferences for cervical cancer screening: a rapid assessment survey. LGBT Health
16. Streed CG Jr, Harfouch O, Marvel F, et al. Cardiovascular disease among transgender adults receiving hormone therapy: a narrative review. Ann Intern Med
17. Olson KR, Durwood L, DeMeules M, McLaughlin KA. Mental health of transgender children who are supported in their identities. Pediatrics