I TRANSGENDER INDIVIDUALS ^xv
“Transgender” is a broad term used for people whose gender identity or gender expression differs from their assigned sex at birth. However, there is no universally accepted definition of the word transgender because of the lack of agreement regarding what groups of people are considered transgender.
The spectrum of transgender identity includes transsexual, crossdresser, bi-gendered, intersex, female-to-male, and male-to-female (Box 3-29). Transgender individuals may live full-time or part-time in their chosen gender. Regardless, all transgender individuals should be referred to by their chosen pronoun.Estimates of the prevalence of transgender individuals are limited by the lack of centralized reporting and are not clearly established; however, studies suggest that transgender individuals constitute a small but substantial population. This low prevalence likely further contributes to their social marginalization and the scarcity of scientific data about their health care needs.
Barriers to Health Care
Transgender individuals are at increased risk of experiences with discrimination and violence and of poor health outcomes. A 2006 Internet survey of 446 female-to-male transgender individuals showed that they have diminished quality of life compared with other men and women in the United States. Fears about judgment or discrimination from health care providers may prevent transgender patients from revealing their chosen gender identity or from seeking health care at all. In 1999, the American Public Health Association passed a resolution that recognizes the unique health care needs of transgender individuals and urges researchers and health care providers to provide transgender individuals with sensitive and culturally competent health care. Insensitivity of health
Box 3-29. Transgender Definitions ^
Transsexual—an individual who strongly identifies with the other sex and seeks hormones, gender-affirmation surgery, or both to feminize or masculinize the body; may live full-time in the crossgender role.*
Crossdresser—an individual who dresses in the clothing of the opposite sex for reasons that include a need to express femininity or masculinity, artistic expression, performance, or erotic pleasure, but do not identify as that gender.
The term transvestite was previously used to describe a crossdresser, but it is now considered pejorative and should not be used.[XIII] [XIV]Bigendered—individuals who identify as both or alternatively male and female, as no gender, or as a gender outside the male or female binary.1
Intersex—individuals with a set of congenital variations of the reproductive system that are not considered typical for either male or female. This includes newborns with ambiguous genitalia, a condition that affects 1 in 2,000 newborns in the United States each year.1
Female-to-male—refers to someone who was identified as female at birth but who identifies and portrays his gender as male. This term often is used after the individual has taken some steps to express his gender as male, or after medically transitioning through hormones or surgery. Also known as FTM or transman.1 Male-to-female—refers to someone who was identified as male at birth but who identifies and portrays her gender as female. This term often is used after the individual has taken some steps to express her gender as female, or after medically transitioning through hormones or surgery. Also known as MTF or transwoman.1
care providers around transgender issues, such as not using appropriate pronouns or not acknowledging the chosen gender identity, has been reported and is frequently cited as a reason for avoiding health care services. Other factors that may inhibit individuals from seeking health care include low self-esteem from a negative body image and fear that their transgender status will be revealed. Maintaining privacy is critical when treating transgender patients, as concerns about breaches in confidentiality also are often reported as a barrier to care.
Caring for Transgender Individuals
The obstetrician-gynecologist should be prepared to provide or refer transgender patients for routine health maintenance and preventive care as well as hormonal and surgical therapies.
Basic preventive services, such as sexually transmitted infection (STI) testing and cancer screening can be provided without any specific training in transgender care. Physical examination and screening tests should be based on the organ systems present rather than the perceived gender of the patient.Female-to-Male Transgender Individuals
Discomfort with the female aspects of their physical body may make female-to-male transgender individuals less likely to seek gynecologic care. In one study of 122 female-to-male transgender individuals, 49% did not undergo annual pelvic examinations, with 40% citing “discomfort with the exam due to gender issues” as the reason. The presence of breasts is a source of significant gender identity conflict for female-to-male transgender patients, which may lead to avoidance of breast cancer screening. In addition, because of social marginalization, transgender individuals may be at increased risk of STIs and human immunodeficiency virus (HIV) and, therefore, require appropriate safe sex counseling and STI testing. Female- to-male transgender patients with male sexual partners may be at risk of pregnancy, and contraception should be discussed. Age-appropriate screening for breast and cervical cancer should be continued unless mastectomy has been performed or the cervix has been removed.
More than one half of female-to-male patients undergo testosterone therapy, which may put them at increased risk of hyperlipidemia, cardiovascular disease, liver disease, and breast cancer. Female-to-male transgender individuals who use androgens and have not had a hysterectomy may be at increased risk of endometrial cancer and ovarian cancer. The use of illicitly obtained testosterone is associated with an increase in needle sharing, which also puts these patients at increased risk of infection with HIV or hepatitis.
Supplemental calcium and vitamin D should be recommended according to current osteoporosis-prevention guidelines to help maintain bone density (see also the “Osteoporosis” section earlier in Part 3).
This is especially true for female-to-male patients who are taking testosterone (because of its unknown effect on bone density) or who have had, or are considering, oophorectomy.Male-to-Female Transgender Individuals
Age-appropriate screening for breast cancer (see also the “Cancer Screening and Prevention” section earlier in Part 3) and prostate cancer should be provided to male-to-female transgender patients. Opinions vary regarding the need for Pap testing in this population. In patients who have a neocervix created from the glans penis, routine cytologic examination of the neocervix may be indicated. It also is recommended that male-to-female transgender patients who receive estrogen therapy have an annual prolactin level assessment and visual field examination to screen for prolactinoma.
Creating a Welcoming Patient Care Environment
Most importantly, health care providers should treat transgender individuals with respect and dignity. Office and support staff should develop and maintain sensitive attitudes and practices for all patients, including transgender individuals, as well as for their families and significant others. Patient forms should be made inclusive and less discriminatory by including additional options for gender identification and relationship status. Questions should be framed in ways that do not make assumptions about gender identity, sexual orientation, or behavior. It is more appropriate for clinicians to ask their patients which terms they prefer. Language should be inclusive to allow the patient to decide when and what to disclose. Care of transgender individuals often requires special considerations that can be addressed best by physicians with expertise and experience in this area, although experts are mostly limited to large urban areas. Transgender individuals are entitled to compassionate and culturally appropriate care. Health care providers who are morally opposed to providing care to this population should refer them elsewhere.
Bibliography
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Resources
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