Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know

 

Persons whose experienced or expressed gender differs from their sex assigned at birth may identify as transgender. Transgender and gender-diverse persons may have gender dysphoria (i.e., distress related to this incongruence) and often face substantial health care disparities and barriers to care. Gender identity is distinct from sexual orientation, sex development, and external gender expression. Each construct is culturally variable and exists along continuums rather than as dichotomous entities. Training staff in culturally sensitive terminology and transgender topics (e.g., use of chosen name and pronouns), creating welcoming and affirming clinical environments, and assessing personal biases may facilitate improved patient interactions. Depending on their comfort level and the availability of local subspecialty support, primary care clinicians may evaluate gender dysphoria and manage applicable hormone therapy, or monitor well-being and provide primary care and referrals. The history and physical examination should be sensitive and tailored to the reason for each visit. Clinicians should identify and treat mental health conditions but avoid the assumption that such conditions are related to gender identity. Preventive services should be based on the patient's current anatomy, medication use, and behaviors. Gender-affirming hormone therapy, which involves the use of an estrogen and antiandrogen, or of testosterone, is generally safe but partially irreversible. Specialized referral-based surgical services may improve outcomes in select patients. Adolescents experiencing puberty should be evaluated for reversible puberty suppression, which may make future affirmation easier and safer. Aspects of affirming care should not be delayed until gender stability is ensured. Multidisciplinary care may be optimal but is not universally available.

In the United States, approximately 150,000 youth and 1.4 million adults identify as transgender.1,2 As sociocultural acceptance patterns evolve, clinicians will likely care for an increasing number of transgender persons.3 However, data from a large observational study suggests that 24% of transgender persons report unequal treatment in health care environments, 19% report refusal of care altogether, and 33% do not seek preventive services.4 Approximately one-half report that they have taught basic tenets of transgender care to their health care professional.4

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Training clinicians and staff in culturally sensitive terminology and transgender topics, as well as cultural humility and assessment of personal internal biases, may facilitate improved patient interactions.

C

5, 12, 14, 15, 21, 24

Clinicians should consider routine screening for depression, anxiety, posttraumatic stress disorder, eating disorders, substance use, intimate partner violence, self-injury, bullying, truancy, homelessness, high-risk sexual behaviors, and suicidality. However, it is important to avoid assumptions that any concerns are secondary to being transgender.

C

5, 11, 12, 14, 15, 19, 21, 2629

Efforts to convert a person's gender identity to align with their sex assigned at birth are unethical and incompatible with current guidelines and evidence.

C

6, 8, 11, 12, 14, 15, 17, 21, 31

Not all transgender or gender-diverse persons require or seek hormone therapy. However, those who receive treatment generally report improved quality of life, self-esteem, and anxiety.

B

5, 6, 3944

Clinicians should consider initiation of or timely referral for a gonadotropin-releasing hormone analogue to suppress puberty when the patient has reached stage 2 or 3 of sexual maturity. No hormonal intervention is warranted before the onset of puberty.

C

5, 6, 8, 17, 21, 40, 44


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Training clinicians and staff in culturally sensitive terminology and transgender topics, as well as cultural humility and assessment of personal internal biases, may facilitate improved patient interactions.

C

5, 12, 14, 15, 21, 24

Clinicians should consider routine screening for depression, anxiety, posttraumatic stress disorder, eating disorders, substance use, intimate partner violence, self-injury, bullying, truancy, homelessness, high-risk sexual behaviors, and suicidality. However, it is important to avoid assumptions that any concerns are secondary to being transgender.

C

5, 11, 12, 14, 15, 19, 21, 2629

Efforts to convert a person's gender identity to align with their sex assigned at birth

The Authors

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DAVID A. KLEIN, MD, MPH, is associate program director of the National Capital Consortium Family Medicine Residency at Fort Belvoir (Va.) Community Hospital and an assistant professor in the Departments of Family Medicine and Pediatrics at the Uniformed Services University of the Health Sciences, Bethesda, Md....

SCOTT L. PARADISE, MD, is a third-year resident at the National Capital Consortium Family Medicine Residency at Fort Belvoir Community Hospital.

EMILY T. GOODWIN, MD, is a second-year resident at the National Capital Consortium Family Medicine Residency at Fort Belvoir Community Hospital.

Address correspondence to David A. Klein, MD, MPH, Fort Belvoir Community Hospital, 9300 DeWitt Loop, Fort Belvoir, VA 22060 (e-mail: david.a.klein26.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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