
Am Fam Physician. 2023;108(6):626-629
Author disclosure: No relevant financial relationships.
Key Points for Practice
• TGD people use terms to refer to themselves that can be personally and culturally important. Mirroring the patient’s language helps physicians provide more effective care.
• TGD people have higher rates of cardiovascular disease, partly due to undertreatment of risk factors.
• Gender-affirming treatment improves mental health and functioning and reduces suicidality.
• Social transitioning is important for mental health and can occur before, concurrent with, or after medical transitioning depending on patient preference and age-specific treatment recommendations.
From the AFP Editors
Although less than 0.1% of people are identifiied as transgender and gender-diverse (TGD) in medical records, 0.5% of adults consider themselves transgender and up to 4.6% of adults assigned male at birth and 3.2% of adults assigned female at birth report gender incongruence or ambivalence. Up to 2.7% of children and adolescents consider themselves transgender. The World Professional Association for Transgender Health (WPATH) conducted systematic reviews to publish guidelines for care of TGD people.
TGD people often use names, pronouns, and terms for gender self-identity and body parts that vary based on personal preferences, cultural relevance, and shifting community standards. Mirroring this language and being aware of the stigma and discrimination they may experience can help physicians provide more affirmative and effective care.
Primary Care for TGD Patients
Most primary care needs for TGD patients are indistinguishable from other care for similarly aged individuals.
TGD people have higher rates of cardiovascular disease, partly due to lower treatment of risk factors. Although TGD women have higher rates of myocardial infarction and stroke than cisgender women, their risks may not be higher than cisgender men. Standard cardiovascular risk-factor management is recommended. Smoking cessation is important and should be addressed, especially before referral for gender-affirming surgery.
TGD patients receiving estrogen therapy should receive the same breast cancer screening as cisgender women. TGD people with breasts from natal puberty that have not been surgically removed should also receive screening. Cervical cancer screening should be offered to all people who have a cervix. Oophorectomy and hysterectomy are not recommended solely to reduce cancer risk.
Although TGD adults appear to have lower bone mineral density, this finding is present before and during hormone treatment and is thought to be related to lower physical activity. Physical activity should be encouraged, and individualized bone density screening and supplementation with calcium and vitamin D should be considered.
Mental Health Care
Although there is evidence of increased rates of depression and anxiety in TGD patients, psychiatric symptoms—including suicidality—decrease when gender-affirming care is provided. Gender dysphoria and social stigma contribute to these symptoms. TGD youth who have their identity supported show similar psychosocial and functional outcomes as their cisgender peers.
TGD people are more likely to have neurodiverse diagnoses, including autism and attention-deficit/hyperactivity disorder, than their cisgender peers.
Mental health symptoms that might interfere with the ability to consent to gender-affirming care or participate in ongoing or perioperative care should be addressed. Because mental health symptoms usually improve with gender-affirming care, withholding that care because of mental health concerns may be counterproductive.
Reproductive Health
Infertility can be a consequence of gender-affirming hormone and surgical treatments. Fertility preservation through sperm, egg, or embryo banking can be offered to interested patients. Many are willing to delay or interrupt hormone therapy to preserve fertility or conceive. Although hormone therapy decreases fertility, it is not sufficient to act as contraception because pregnancies have been reported.
Gonadotropin-releasing hormone (GnRH) agonist therapy in adolescents can inhibit spermatogenesis and ovulation. Spermatogenesis generally starts three months or longer after discontinuation. Oocyte maturation should also restart, although evidence is lacking.
Pregnancy care for TGD patients requires an individualized approach to minimize gender dysphoria. Body changes, desire for pregnancy care, and infant feeding should be discussed. Discussing chest feeding instead of breastfeeding can be helpful. Before a planned pregnancy, testosterone should be discontinued until after delivery and any chest-feeding. Breast growth and lactation can increase gender dysphoria.
Sexual Health
On average, TGD patients report lower sexual pleasure than cisgender people, some of which may be due to stigma, discrimination, and violence, including sexual violence. Hormone medications may affect mood, libido, erectile function, ejaculation, and genital tissue health. Gender-affirming surgery can affect erogenous sensation, sexual desire, and sexual arousal and pleasure. Although most TGD patients report improved sexual functioning with gender-affirming care, realistic expectations and counseling around risks are important.
TGD people who wish to have penetrative intercourse can benefit from erectile dysfunction medication and vaginal estrogen, depending on their anatomy.
TGD people have a higher risk of sexually transmitted infections, including HIV. For people with high risk, regular sexually transmitted infection screening is recommended. People at high risk may also benefit from HIV preexposure prophylaxis, which can safely be combined with gender-affirming hormone therapies.
Assessment and Treatment in TGD Adults
Gender-affirming treatments show positive mental and physical health impacts in patients with persistent gender incongruence who meet the diagnostic criteria for gender dysphoria Estimating the influence of gender-affirming care on existing mental health may require an experienced specialist.
For assessments pertaining to gender-affirming hormone or surgical treatments, the role of social transition should be discussed with the patient. Not all patients can or will want to socially transition. Some may want to do that before or during gender-affirming treatment, and others may want to transition after treatment is complete. Some patients may want to undergo facial and chest surgeries before social transition. A comprehensive multidisciplinary assessment involving experienced transgender health experts can be helpful before interventions for transitioning or detransitioning, with careful consideration of social-transitioning elements. Common regimens for gender-affirming hormone treatments in adults are listed in Appendix C—Table 4 of the original guideline.
Setting expectations for the effects of hormone treatment can be important. Only 1 in 5 patients will obtain a result consistent with Tanner stage 4 or 5 in their affirmed gender with hormone therapy alone.
Continuing therapy within medical and detention facilities can be important because discontinuing these medications affects mental health and social functioning.
When TGD patients are transitioning, voice changes may be an important element to consider. Although minor changes in voice and communication can occur with hormone therapy, many patients will need referrals to voice and communication professionals.
Gender-Affirming Interventions
Gender-affirming surgeries have similar complication rates to similar procedures for non-TGD diagnoses. Gender-affirming surgery tends to increase quality of life and satisfaction with body appearance, while decreasing gender dysphoria. Rates of regret after gender-affirming surgery are less than 4%, and the decision to detransition is rare.
WPATH recommends patients have at least six months of hormone therapy before most surgical interventions, with the exception of chest surgery.
Children and Adolescents
In surveys, 7% to 9% of adolescents self-report concern about gender identity. The timing of declaring gender identity and its permanence are highly variable. Age of TGD self-identification does not correlate to TGD identity permanence. Importantly, children and adolescents who change TGD identities or who detransition over time do not regret having socially transitioned or medically transitioned using hormone-blocking medications (e.g., GnRH agonists). Children and adolescents whose decisions are supported have improved psychosocial and educational well-being. Supported adolescents have rates of mental health disorders similar to age-matched cisgender adolescents.
WPATH emphasizes recognizing that children and adolescents need to feel safe and nurtured in each setting they frequent. For physician assessments, environmental safety screening results in better understanding of well-being, strengths, opportunities, and risks. Because neuro-divergence is more likely in TGD children and adolescents, neuropsychiatric and mental health assessments should be considered.
Family support of TGD youth is a primary predictor of well-being and mental health outcomes. Social transitioning involves informing families, friends, and social institutions about the transition, including changes in name, pronouns, and clothing. Children and families may choose to transition gradually, identifying the safer places in which to transition first. Social transitioning is important for mental health and educational goals. This transitioning can occur before, concurrent with, or after medical transitioning, depending on patient preference and age-specific treatment recommendations.
Transitioning techniques can include chest binding, chest padding, genital tucking, and genital packing. In masculine TGD patients, chest binding can increase comfort, reduce misgendering, and improve safety. Binders specifically designed for TGD patients have fewer adverse effects than duct tape, elastic wraps, and plastic wraps. For feminine TGD patients, genital tucking is positioning the penis and testes to reduce the outward genital bulge, often with an undergarment to hold the position. The major risk is decreased sperm concentration and mobility.
Conversion therapy, or reparative therapy, has been shown to worsen multiple outcomes, including mental health, suicidality, achieving educational goals, and health care avoidance. Although detransitioning is rare after binary social transition, supporting the patient’s decision to detransition is essential.
Intersex children, including those with congenital adrenal hyperplasia and androgen insensitivity, need inclusive multidisciplinary care tailored to gender identity and the specific condition. Families need education about having an intersex child and the lifelong implications. In addition to mental health and psychosocial support, self-determination should be supported by puberty suppression, hormone treatment, and gender-affirming surgery, as determined by the patient and family. Treatment discussions should cover impacts on fertility and available preservation options, as well as alternative paths to parenthood.
Treatment in Adolescents
For TGD adolescents, hormone therapy involves initiating hormone suppression in eligible patients at Tanner stage 2, using GnRH agonists for puberty blocking or progestins if GnRH agonists are unavailable. Discussion with patients about the risks of taking GnRH agonists should include decreased bone density, which is reversible, and infertility, which increasing evidence shows is reversible but is still a risk because it is not completely known.
Physically developed adolescents can undergo hormone suppression without replacement using GnRH agonists. Gender-affirming treatment with sex hormones requires parental involvement in nonemancipated individuals. Monitoring hormone levels according to Tanner stage, especially in uterus-bearing patients, is important, and collaboration with transgender health experts is essential for comprehensive care.
When starting sex steroid therapy, reaching adult levels of hormones typically takes two years. At least 12 months of hormone therapy is recommended before considering gender-affirming interventions. Recommendations for initiating gender-affirming care in TGD adolescents include ensuring that the patient has reached Tanner stage 2, has documented marked and sustained identity under the TGD umbrella, and has received the following:
Counseling about fertility preservation and potential and unknown reproductive concerns in the long term
Counseling about the levels of reversibility of medical therapies
Assessment for cognitive maturity to provide consent/assent for treatment
Comprehensive assessment that includes mental health, medical health, and safety in school, home, and other environments
At least 12 months of hormone therapy before gender-affirming interventions
- Parental/guardian involvement, unless it is determined to be harmful to the adolescent
- Common regimens for gender-affirming hormone treatments in adolescents are listed in Appendix C—Table 3 of the original guideline.
Training in TGD Care
WPATH recommends multidisciplinary training across age groups for any health care centers that may encounter TGD patients, including outpatient, inpatient, and other residential institutions (e.g., long-term care, palliative care). WPATH also recommends TGD training for professionals working in educational or detention systems. Ongoing education is important because standards continue to evolve.

Score | Criteria |
---|---|
Yes | Focus on patient-oriented outcomes |
Yes | Clear and actionable recommendations |
Yes | Relevant patient populations and conditions |
Yes | Based on systematic review |
No | Evidence graded by quality |
Yes | Separate evidence review or analyst in guideline team |
Yes | Chair and majority free of conflicts of interest |
Yes | Development group includes most relevant |
specialties, patients, and payers | |
Overall – useful |
Guideline source: World Professional Association for Transgender Health
Published source: Coleman E, et al. Standards of care for the health of transgender and gender diverse people, v. 8. Int J Transgend Health. 2022;23(suppl 1):S1–S259.