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Feature: NCPD Connection

Nursing considerations for transgender men

Guelbert, Christopher DNP, MHSA, RN

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doi: 10.1097/01.NURSE.0000803428.47117.80

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NURSING PROFESSIONALS must be clinically and culturally competent to serve diverse patient populations, including the transgender population. However, a review of the literature reveals a lack of nursing articles on the process of gender transitioning. Many nursing professionals anecdotally express discomfort with and lack of knowledge and understanding about this patient population, which may result in issues in patient safety and communication, among others. To provide competent, clinically appropriate, and culturally sensitive care, nurses must have adequate knowledge about gender transitioning, including complications and postoperative care, as well as related concerns such as transgender patients' psychological health, privacy, and health promotion.

Operational definitions

Gender expression is manifested through behavior, mannerisms, speech patterns, clothing preferences, and hairstyles.1 Some people experience disassociation between the assigned gender at birth and their gender identity. Called gender dysphoria, this disassociation is a form of mental distress when an individual has an inner understanding at both the physical and psychological level of not matching gender expression with their external sexual anatomy at birth. Gender dysphoria is a diagnosis noted in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

A transgender man is an individual who was assigned female at birth and undergoes transition to become male through medical, surgical, or a combination of therapies following a diagnosis of gender dysphoria.1 In medical documentation, a transgender man is sometimes designated as female-to-male (FTM).

Statistical data

Limited statistical data exist on how many individuals identify as transgender in the US. Federal and state agencies collect data on assigned gender at birth but not on gender identity. Bureaus of vital statistics may only record assigned gender at birth. Individuals may have been assigned female at birth but psychologically and physically identify as male. Discrepancies between the assigned gender on a birth certificate and outward gender expression may lead to distress in an individual with gender dysphoria. Providing forms of identification for employment and legal purposes may lead to unnecessary and complicated explanations in public. Many transgender individuals choose to legally change their name and sex on birth certificates to reflect their gender identity.2

A 2020 report by the Williams Institute estimated that 1.4 million Americans (0.6% of the US population) identify as transgender.3 The Williams Institute, which is affiliated with the UCLA School of Law, conducts empirical research on lesbian, gay, bisexual, and transgender (LGBT) issues related to legal, policy, and cultural bias. The 2020 report also shows that younger adults (ages 18-24) are more likely to identify as transgender compared with older adults (age 65 and older).3

Psychological considerations

A major component of gender transitioning deals with the psychological aspects associated with this life-changing event. Counseling must be provided to individuals exploring their gender identity to support them in coming out as transgender, discuss issues related to living as a transgender person, and identify and treat underlying mental health issues such as depression or anxiety.1 An individual female who identifies as male will need to decide how far they wish to transition. Some individuals decide to undergo hormonal therapy only, whereas some decide upon a combination of hormonal therapy in association with surgical intervention. Individuals choosing to undergo hormonal therapy, mastectomy (top surgery), or genital (bottom surgery) require a letter of recommendation from a mental health provider.1

Financial considerations

Individuals who choose to transition face physical, psychological, financial, and legal challenges. Studies have shown that gender-affirming surgery improves patient self-esteem and functioning.4 In 2014, Medicare and Medicaid lifted an exclusion for transition-related care. Before this, insurance coverage for these procedures was extremely limited and patients had to self-pay. Since the lifting of this exclusion, many private insurance companies have increased coverage for gender affirmation surgery.4 Other financial costs include legal fees for name/gender changes with the Bureau of Vital Statistics, medical deductibles, copayments, counseling fees, and hormonal therapy costs.

Masculinizing hormone therapy

Testosterone is the primary hormone utilized for FTM transition. Masculinization effects include clitoral enlargement; increased muscle mass and strength; deepening of voice; increase in skin oiliness/acne; androgenic male pattern hair loss; male body and pubic hair distribution; minimization of subcutaneous fat; and deposits of fat in the abdomal area.2 Testosterone is available as an injection, patch, gel, cream, or a troche, which is a small lozenge that dissolves in the buccal space for 30 minutes. One of the most common forms is given I.M. every 1 to 2 weeks. Testosterone can also be given the subcutaneous route. Injectables typically are the least expensive option for those without insurance. Creams, gels, and patches are typically used daily. An additional form of testosterone is implanted subcutaneously as pellets two to four times annually but usually is the most expensive form of treatment.2

Maintenance of steady testosterone levels will help prevent a dangerous increase in hematocrit levels, which can result in stroke.5 Testosterone has an erythrogenic effect that increases red blood cell production. Testosterone treatment is associated with a dose-dependent increase in hemoglobin and hematocrit levels. Hyperviscosity of blood may manifest as headache, fatigue, blurred vision, and paresthesias. A baseline hemoglobin and hematocrit should be obtained before initiation of testosterone therapy. Prevention of fluctuating levels can be accomplished through close monitoring of serum testosterone levels at 3, 6, and 12 months after initiation. Normal levels of testosterone are titrated between 400 and 800 ng/dL.6 Therapy should be discontinued if the patient shows signs of hyperviscosity and has a hematocrit greater than 54%.5,7

Testosterone can be given as a lifelong therapy unless complications occur. Adverse reactions include metabolic syndrome, obesity, impaired glucose tolerance, dyslipidemia, polycythemia, venous thromboembolism, mood disorders, and polycystic ovarian syndrome (PCOS).2

Transgender men will experience beard growth, clitoromegaly, acne, and male pattern baldness. Individuals who have bound their breasts for numerous years may have rashes or yeast infections in the skin under the breasts. Vaginal discharge or odor can be related to shifts in natural bacteria and yeast with hormonal changes. Testosterone can also cause atrophy of the uterus. Approximately 6 months after testosterone initiation, menstruation ceases. Any bleeding needs further investigation for endometrial hyperplasia and polyps, adenomyosis, leiomyoma, and malignancy. The possibility of pregnancy should also be considered if the transman is sexually active with someone who produces sperm.8 Missed or changed doses of testosterone can cause uterine bleeding. Testosterone-related cramping may be related to the inappropriate firing of pelvic wall muscles. Testosterone-related pelvic pain may be caused by decreased resilience in vaginal tissue and lubrication. Sexual intercourse can cause tissue tearing or microabrasions contributing to pelvic pain. If this is determined to be the cause, treatment with an estrogen cream may reduce symptoms.8 Ongoing pelvic pain or vaginal bleeding may indicate elevated estrogen levels. Trans men may develop fibroids and endometriosis. Testosterone can cause changes in ovaries similar to PCOS.7 (See Specific issues in screening trans men with past or current hormone use9)

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Trans men (FTM)
Breast cancer Intact breasts: Routine screening as for natal females
Postmastectomy: yearly chest wall and axillary exams
Cervical cancer Intact cervix: Routine screening as for natal females
Prostate cancer N/A
Cardiovascular disease Screen for risk factors
Diabetes mellitus Routine screening Δ
Dyslipidemia On testosterone: Annual lipid screening
Osteoporosis Screen all patients >65 years
Screen patients age 50 to 65 if off hormones for >5 years
Modified from www.uptodate.com, 20219
While there is no evidence to support clinical breast examinations in this population, we perform yearly chest wall and axillary exams and use this as an opportunity to examine scar tissue, examine any changes, and educate the patient about the small but possible risk of breast cancer.
ΔTrans men with polycystic ovary syndrome (PCOS) should be screened for diabetes as for natal females with PCOS. Refer to the UpToDate material on further evaluation after diagnosis of PCOS in adults.

Surgical interventions

Should individuals choose to undergo surgical intervention, a written recommendation from a healthcare provider must be obtained. Criteria used for adults include persistent, well-documented gender dysphoria, capacity to make informed decisions and consent for surgery, be of the age of majority, and any significant medical or mental concerns must be well controlled, such as diabetes, hypertension, obesity, anxiety, and depression.10 Additionally, the individual must have lived within a new gender identity role for at least 12 consecutive months.10

Simple mastectomy is one surgical intervention many choose to have performed. During the procedure, breast tissue is removed but the nipple-areolar tissue are preserved as a full-thickness graft. The nipple-areolar grafts are sutured back into place for cosmetic appearance after mastectomy.11

Performed generally as an outpatient procedure, clients will have an elastic compression wrap in place for 4 to 5 days postoperatively. Closed suction drains will typically be placed bilaterally. Patients will be discharged home with an oral analgesia, antibiotic, stool softener, and antiemetic. The individual should not get the incision or drain sites wet until the surgeon gives approval to do so. Heavy lifting is discouraged and limited to only 10-15 lb for several weeks.2

Postoperative complications may include poor cosmetic outcome, residual breast tissue, hematoma or seroma, or loss of the nipple graft. Additional surgery may be required, as in the case of pectoplasty or insertion of chest implants, done primarily to enhance pectoral musculature.2

The FTM may consider more extensive lower body surgery. However, the incidence of this type of surgery in the US is estimated to be less than 10% of individuals. Obstacles for this type of surgery include extensive costs and risks associated with the procedure.

Many of these surgeries are multistage in nature. Primary goals of this type of surgery include the construction of a male phallus and the ability to stand while urinating.2 One surgical option is known as a simple metoidioplasty. In this surgical procedure, a neophallus is created from the clitoris. Individuals choosing this surgery have been on testosterone therapy prior to the procedure, which creates an enlarged clitoris. During simple metoidioplasty, the surgical team releases the tethered-down clitoris from the labia minora. Labial skin is then surgically drawn around to the front and sutured closed.2 The reconstructed neophallus can achieve an erection when aroused. However, this procedure may not allow for urination while standing, as the native urethral opening remains intact without modification. Penetration during sexual intercourse may be impossible due to a smaller phallic size. Sometimes, this procedure is performed in conjunction with a hysterectomy and bilateral salpingo-oophorectomy (BSO), and vaginectomy. Many transgender men undergo BSO to eliminate the risks of cervical, uterine, and ovarian cancer. If BSO is not performed, as testosterone levels rise, estradiol levels decrease significantly, canceling the effects of endogenous sex hormones.2

Vaginectomy is complicated and involves either resection of the full-thickness epithelium of the vagina or de-epithelialization followed by obliteration of the vaginal canal. Most surgeons perform a version of colpocleisis which is the obliteration and surgical closure of the vagina. Risks of vaginectomy include retention of vaginal lining tissue and internal mucus buildup or discharge.2

During a ring metoidioplasty procedure, a urethral tube is created by sewing the labial skin around a urinary tube. Urination while standing is an advantage of this procedure. A patch of mucosa from the vagina completes the urinary tube. Complications can exceed 10% in this procedure. Complications may include urethral fistulas and strictures.2 Anticholinergic drugs may be prescribed to prevent bladder spasms while a suprapubic catheter is in place. Postoperative use of a vacuum pump is recommended to prevent retraction of the neophallus. A vacuum pump consists of a plastic tube that fits over the neophallus. A hand or battery-powered pump is attached to the tube creating suction. Such a device causes erection and lengthening of the neophallus. Also, phosphodiesterase type-5 inhibitors may be prescribed, such as sildenafil, vardenafil, tadalafil, and avanafil.2

An additional complicated procedure the FTM individual may choose is the phalloplasty. The procedure involves the creation of a neophallus from extragenital tissue. It is considered the most challenging and complex procedure in reconstructive surgery. Different techniques employ the use of an abdominal, groin, anterolateral thigh, or latissimus dorsi flap to create a phallus. Typically, all female reproductive organs are removed, followed by the creation of the neophallus. Urethral lengthening must also be performed using vaginal tissues. Use of a penile prosthesis may also be inserted during this surgical procedure. Postoperative care includes keeping the neophallus in an elevated position to prevent graft kinking. Kinking of the neophallus can interrupt blood flow leading to failure of the graft. Complications include graft flap necrosis, infection, urinary stricture, or fistula.2 After each stage of urethral reconstruction, a suprapubic catheter will be in place. Anticholinergics may be given for spasms and cramping while the suprapubic catheter remains in place. Patients must be informed of the adverse reactions of anticholinergics, such as dry mouth, blurred vision, constipation, and sedation.12

A final procedure known as scrotoplasty involves the creation of a male scrotum from the labia majora. Testicular implants of silicone or saline of various sizes may be used. Risks include infection and implant expulsion. The larger the implant, the higher the risk of expulsion. An FTM individual must consider many factors when choosing lower body surgery. Simple metoidioplasty is preferred by those who want a male-like appearance of the genitals but do not wish to undergo complex and multistaged surgeries seen with phalloplasty.2

A major disadvantage of this surgery is the inadequate phallus length required for penetrative intercourse. Alternatively, phalloplasty allows for voiding in a standing position and provides good sexual function. A major disadvantage of phalloplasty is the complicated nature of the reconstruction process, multiple surgeries, and a higher rate of complications. Urologic complications are common, such as urinary retention, strictures, meatal stenosis, fistulas, and voiding dysfunction.2 A major nursing consideration when caring for a patient who underwent lower body surgery is obtaining a urology consult in cases of urinary retention. Placing a standard urinary catheter may be contraindicated, especially when urethral lengthening was done.2

Health promotion among FTMs

Healthcare professionals must promote health measures among patients undergoing FTM surgery. Topics to be discussed include diet and exercise, regular screening for hypertension, dyslipidemia, and hyperglycemia, immunizations, as well as cancer screening. Breast self-exams and breast cancer screening must be encouraged for those who did not undergo mastectomy, and regular gynecologic exams with Pap smears for those who did not undergo hysterectomy. Substance abuse, depression, and anxiety screenings are of utmost importance in this population with a higher incidence seen than the general community.7

Caring for transgender men does not need to be mysterious and uncharted territory. Nurses must have adequate knowledge about mental health concerns, hormonal therapy, and surgical procedures related to gender transitioning, including complications and postoperative care. They should also promote health measures, protect patients' privacy, and communicate using an individual's preferred gender pronouns such as she, her, he, him, to provide culturally sensitive care.

REFERENCES:

1. Keatley J, Deutsch M, Sevelius J, Guitierrez-Mock L. Creating a foundation for improving trans health: understanding trans identities and health care needs. In: Makadon H, Mayer K, Potter J, Goldhammer H, eds. Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. 2nd ed. Philadelphia, PA: American College of Physicians; 2015:459–475.
2. Ferrando C. Comprehensive Care of the Transgender Patient. Philadelphia, PA: Elsevier; 2020.
3. Williams Institute at the UCLA School of Law. (2020). How many adults in the United States identify as transgender? Los Angeles: Williams Institute.
4. Cohen WA, Sangalang AM, Dalena MM, Ayyala HS, Keith JD. Navigating insurance policies in the United States for gender-affirming surgery. Plast Reconstr Surg Glob Open. 2019;7(12):2564.
5. Cervi A, Balitsky AK. Testosterone use causing erythrocytosis. CMAJ. 2017;189(41):1286–1288.
6. Deutsch M. Overview of masculinizing hormone therapy. 2016. https://transcare.ucsf.edu/guidelines/masculinizing-therapy.
7. Deutsch M, Bowers M, Radix A, Carmel T. Transgender medical care in the United States: a historical perspective. In: Schneider J, Silenzio V, Erickson-Schroth L, eds. The GLMA Handbook on LGBT Health. Vol. 1. Santa Barbara, CA: Praeger; 2019:99.
8. Obedin-Maliver J. Pelvic pain and persistent menses in transgender men. 2016. https://transcare.ucsf.edu/guidelines/pain-transmen.
9. Specific issues in screening for transwomen and transmen with past or current hormone use. UptoDate. 2021.
10. Wylie K., Knudson G., Khan S. (2016). Serving transgender people: clinical care considerations and service delivery models in transgender health. The Lancet, 388, 401–411.
11. Etemad SA, Furuyama WM, Winocour JS. Double incision mastectomy with free nipple graft for masculinizing chest wall surgery. Plast Reconstr Surg Glob Open. 2020;8(11):3184.
12. Vallerand A., Sanoski C. (2020). Davis's drug guide for nurses. Philadelphia: F.A. Davis.
Keywords:

hormone therapy; gender affirmation; transgender

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