Care of the Transgender Patient

Transgender and gender-incongruent persons have gender identities that differ from their sex recorded at birth (typically determined by examination of external genitalia). Studies estimate that 0.6% of U.S. adults, or 1.4 million persons, are transgender (1). This population faces disproportionate challenges in accessing health care services and may experience medical mistreatment (25). The largest barrier to care reported by transgender persons is a lack of knowledgeable providers (6). Barriers to accessing appropriate and culturally competent care play a significant role in health disparities among transgender persons, such as increased rates of certain types of cancer, substance abuse, mental health conditions, infections, and chronic diseases (3, 4, 713). Historically, care was largely limited to select facilities. Improving access to medically and culturally competent care requires involvement of primary care providers outside such specialized settings (14). Terminology and Initial Evaluation What does transgender mean? Gender identity refers to a person's sense of being male, female, neither, or a combination of both (Box). The terms transgender, transsexual, trans, gender nonbinary, gender incongruent, and genderqueer are used to describe persons whose gender identity does not align with the sex recorded at birth. Previously, the term transsexual indicated that the person had received medical and surgical treatment to align their appearance and gender identity. However, transgender has become the preferred term because it also includes those who have had no treatment. Cisgender refers to persons who are not transgenderthat is, those whose sex recorded at birth aligns with their gender identity. Common Terminology Gender/sex: Broad terms describing the entire category of relevant biological characteristics, self-identification, and stereotypical behaviors that might be considered male, female, or some variation. Gender identity: The internal sense of being male, female, or neither. Transgender, transsexual, trans, gender nonbinary, gender incongruent, genderqueer: Adjectives used to refer to persons whose gender identity does not align with their sex recorded at birth (the latter primarily based on visible physical anatomy). Cisgender, nontransgender: Adjectives used to refer to persons whose gender identity aligns with their sex recorded at birth. Gender expression: How a person communicates gender identity through appearance, dress, name, pronouns, mannerisms, and speech. Gender-affirming hormone treatment and surgeries: Broad categories of medical interventions that transgender persons might consider to align their appearance and their gender identity. Gender transition, gender affirmation, gender confirmation: An overall process of alignment of physical characteristics and/or gender expression with gender identity. Gender dysphoria: Discomfort felt by some persons due to lack of alignment between gender identity and the sex recorded at birth. Not all transgender persons have dysphoria, but many U.S. insurance companies require this diagnosis for payment for transgender medical and surgical interventions. Transgender men have a male gender identity but were identified as female at birth, and transgender women have a female gender identity but were identified as male at birth. Gender-nonbinary and genderqueer persons may identify with a gender that is neither male nor female or has features of both. Gender expression relates to how a person signals gender identity to others via clothing, hairstyle, actions, and mannerisms. Alignment of physical characteristics with gender identity is referred to as transition, gender affirmation, or gender confirmation. Gender dysphoria is a mental health diagnosis that describes the discomfort of misalignment of gender identity and the sex recorded at birth. Not all transgender persons have dysphoria, but many U.S. insurance companies require this diagnosis for reimbursement for transgender medical and surgical interventions (15). Although transgender identity does not equate with a mental health condition, the only codes for a transgender diagnosis in the International Classification of Diseases, 10th Revision (ICD-10), are in the mental health section. A tentative plan for ICD-11 is to add gender incongruence to the sexual health section and remove gender dysphoria entirely (16). What is known about the natural history of transgender identity development? Although the mechanisms are not known, data suggest a biological underpinning to gender identity that is present at birth (17, 18). Investigators report an inability to manipulate gender identity by external means (19, 20). Twin studies indicate that identical twins have greater concordance with regard to transgender identity than fraternal twins (21). Further, evidence shows increased rates of male gender identity among some persons with congenital adrenal hyperplasia who were exposed to excess androgen in utero (22), whereas those with complete androgen insensitivity syndrome have female gender identity (23). Children demonstrate an ability to articulate a gender identity as early as age 2 years and develop facility with gender labeling, including pronouns, by school age (24). High-quality epidemiologic studies and consistent definitions of gender identity among children are lacking. Depending on the ages included in the study and the definitions used, 0.6%2.7% of children may report some degree of gender incongruence (25). Not all such children seek medical intervention later in life (26). By adolescence, children are increasingly able to articulate gender identity. Puberty can be distressing for gender-incongruent children. The desire to avoid the wrong puberty may prompt some adolescents to report their gender incongruence to their parents, health care providers, and others (27). Most transgender persons present to clinicians in late adolescence or adulthood. Whether this represents delayed recognition of gender incongruence, inability to articulate gender identity, or outside pressure to conform is not known. Despite the late presentation, many transgender persons report becoming aware of their gender incongruence well before puberty. What is the initial approach for a patient who presents with gender incongruence? Transgender persons present in myriad ways (14). Some may be confident in their gender identity and have clear treatment goals. Others may be less able to articulate their gender identity and may benefit from greater support from mental health providers. Finally, some are clear about their gender identity but less clear about their desire for medical intervention to align their identity and appearance. This last group may benefit from guidance from both mental health providers and providers who can help set expectations about medical interventions. In the clinical setting, transgender identity can be established on the basis of history alone (Box). The patient should have persistent gender incongruence and the capacity to make treatment decisions (28). The clinician should also address mental health conditions that may confound the determination. The requirement for persistence does not have a specific time frame, but multiyear histories extending as far back as childhood are typical. Development of gender incongruence over shorter periods (for example, not measured in years) should prompt further exploration of underlying factors and individual goals. Transgender persons have higher rates of anxiety, depression, and suicidality (29), so clinicians should be alert to signs and symptoms of these conditions. Criteria for Establishing That a Patient Is Transgender or Gender Incongruent* Persistent gender identity that does not align with sex recorded at birth Capacity to make medical decisions Potential confounding mental health conditions are addressed *From reference 28. For assessment, relevant mental health conditions are those that would interfere with reliable history taking. For example, there have been reports of patients presenting as transgender who had obsessive compulsive disorder (30) or well-masked psychoses rather than true gender incongruence. Transgender persons can certainly experience obsessions, compulsions, and psychoses, and in such instances, a multidisciplinary approach to assessment and care that involves a mental health provider would be prudent. Although the Endocrine Society guidelines (31) state a preference for involvement of mental health providers in transgender determination for adults, they acknowledge that any sufficiently knowledgeable provider can make this determination. The provider should be knowledgeable enough to be able to identify mental health conditions that might confound the assessment or should refer the patient to a mental health provider who can help address this. Although the criteria for determining whether someone is transgender are the same for children and adolescents as for adults, children may articulate their gender identity in a more heterogeneous fashion. Thus, the Endocrine Society guidelines (31) recommend that assessment of children and adolescents involve a team of clinicians, including mental health professionals. Clinical Bottom Line: Terminology and Initial Evaluation Transgender describes persons whose gender identity does not align with their sex recorded at birth, which is usually based on visible anatomy at the time. In the clinical setting, determination of transgender identity is based entirely on history. In making this determination, the provider should establish that the patient has persistent gender incongruence. The patient should be competent to make an informed decision about transgender medical interventions. For children and adolescents, a qualified pediatric or adolescent mental health provider should be involved in the assessment. For adults, the determination may be made by any provider who is sufficiently knowledge