Introduction: Role of the Gynecologist
Obstetricians, gynecologists (OBGYNs), and other women’s health providers have a critical role in the care of transgender people. Transgender people, both transgender men and transgender women, have biophysiological and sociocultural needs, which can be addressed by the comprehensive and caring attention of the OBGYN provider.
For transgender men, the need for OBGYN care fits perfectly within an OBGYN’s scope of practice; while 80% of transmale patients use hormones as part of medical transition, only 20% undergo surgical transition and so many retain their pelvic organs. Providers should be aware that as transition progresses, attending a “women’s health” care–focused space or receiving “gynecological” care may be uncomfortable or may worsen baseline dysphoria in their trans male patients. Conversely, for transgender women, regardless of stage of transition, gynecologic care is often very affirming for them, and the experience may be very different.
Organizations that have historically been defined as “Womens’ health provider” organizations, including the American Congress of Obstetricians and Gynecologists (ACOG) and American College of Nurse-Midwives (ACNM) and associated educational institutions such as the Council on Resident Education in Obstetrics and Gynecology (CREOG) recognize the importance of providing care for transgender individuals. ACOG’s Committee Opinion on the topic states, “obstetrician-gynecologists should be prepared to assist or refer transgender individuals for routine treatment and screening as well as hormonal and surgical therapy. Basic preventative services, like sexually transmitted infection testing and cancer screening, can be provided without specific expertise in transgender care. Hormonal and surgical therapies for transgender patients may be requested, but should be managed in consultation with health care providers with expertise in specialized care and treatment of transgender patients.” The ACNM statement similarly recognizes that “the most important thing all midwives can do to improve the health care outcomes of gender variant individuals is to use their skills to create care that is welcoming and accessible.” The ACNM’s statement also recognizes that “most members of this community require the same primary, mental, and sexual health care that all individuals need. Musculoskeletal, cardiovascular, breast, and pelvic care for individuals who have undergone hormonal and/or surgical therapy is typically straightforward but in some cases requires additional training. Similarly, administration of hormone therapy for gender affirmation is appropriate for primary care providers, including certified nurse-midwives/certified midwives (CNMs/CMs) who have undergone appropriate training.” Both of these organizations recognize that transgender health care is within the scope of practice for women’s health care providers, but they also recognize that additional training might be necessary.
Education in this area is critically important as about half of transgender patient respondents in a large national survey reported having to educate their health providers about their health needs. The World Professional Association for Transgender Health (WPATH) “strongly encourages the increased training and involvement of primary care providers in the area of feminizing/masculinizing hormone therapy.” Similarly, ACOG calls for increased education in its Committee Opinion 512 entitled “Health Care for Transgender Patients.” Meeting these calls for education, training objectives have been incorporated into the CREOG curriculum in order to cover core competencies for obstetrics and gynecology residents. These guidelines are included in the “focused areas of gynecological care” under the larger theme of Primary and Preventative Ambulatory Health Care (Unit 2, Section 2.E). Concerns regarding the phrasing of these CREOG objectives exist as it is unclear whether the objectives as they stand actually recognize and guide the care of transgender men (individuals who identify as male but were assigned female at birth)—they are mistakenly referred to as “women” in the guidelines. The guidelines are currently limited, but they are well intentioned as they recognize the importance of OBGYN care for people of all genders. With time, they are likely to evolve and will become more accurate and comprehensive.
Currently, transgender health training for OBGYNs is not sufficient. Grimstad et al. surveyed OBGYN residency program directors and found that among the 39% of program directors that responded, 82% reported transgender health objectives were “very or somewhat important.” However, only 70% were aware of CREOG specific objectives, and fewer still used specific educational activities such as lectures (63%) and reading materials (52%) to train residents on these topics. Reassuringly, many more desired educational materials to be made available to their residents including enhanced reading materials, online modules, and patient exposure. Similar findings are presented by Unger who surveyed practicing OBGYNs in nine academic obstetrics and gynecology departments in the United States about provider experience with and knowledge about caring for transgender individuals. Among the 141 respondents, most of whom were generalists and many practicing in an academic environment, approximately 74% of whom had been in practice for more than 5 years, 80% did not receive training on caring for transgender individuals during training. She also reported that 11% of providers were unwilling to perform cervical cancer screening with Pap smear on transgender men, and 20% were unwilling to perform a routine breast examination on a transgender woman. As information became more specific in the survey, fewer individuals were knowledgeable or able to extend their knowledge base to transgender patients—with 66% not knowing the requirements transgender patients must meet for gender affirming surgeries and 62% not knowing routine health maintenance screening recommendations (prostate cancer, diabetes, and hyperlipidemia for transgender women). There is clearly a need to reassess how more current education objectives such as the CREOG guidelines influence the comfort level and preparedness of the practicing clinician. With time, this type of education should improve, and providers will hopefully be better equipped to care for this patient population.
Though education may be lacking, OBGYNs and other women’s health providers already have the skills necessary to provide care for transgender individuals. It is simply the context of that care that must change. In the book Trans Bodies Trans Selves, Simon Adriane Ellis, a genderqueer certified nurse midwife, provides important information about acquiring the skillset necessary to practice within this new context and describes, “Five Tips for ‘Women’s Health’ Providers Working with Gender-Variant Clients”: (1) Focus on your skills and biases—by recognizing already existent skills necessary to care for gender-variant people and acknowledging potential triggers about patient’s gender identity (GI) or expression that challenge comfort and professionalism; (2) Build trust and offer accommodations; (3) Keep your wording inclusive and honor patient preferences—by replacing terms like “women with the term people,” considering appropriate pronoun use, and incorporating these changes into forms and ensuring consistent staff usage; (4) Don’t let curiosity get the best of you—by maintaining “professional integrity” and “asking only what you need to know to provide excellent care”; (5) Don’t pass the buck—by resisting the “urge to refer patients to ‘someone who has more experience.’”
Creating a Trans Friendly Practice
Obtaining sexual orientation and gender identity information
It is important to incorporate a comprehensive assessment of both sexual orientation (SO) and gender identity (GI) into one’s practice. Sexual and gender minority individuals are underserved, understudied, and vulnerable to poor health and notable disparities exist for these patients, including: housing, employment, poverty, violence, trauma, and discrimination in the use of public accommodations. For example, transgender individuals experience double the rates of unemployment compared to the general population with 26% reporting that they have lost a job due to their transgender status. Additionally, 19% have reported experiencing homelessness in their lives because of being either transgender or gender nonconforming. Social and economic marginalization also results in poor access to quality health care and results in severe health disparities among this patient population. One finding from the National Transgender Health Discrimination Survey draws attention to the association between employment status and suicide attempts and reports that in 51% of unemployed transgender individuals, 56% of those who lost their job due to bias, and 60% who had worked in the underground economy (e.g., using transactional sex for survival) had attempted suicide at least once.
A critical foundational step in caring for these high-risk patients is identifying and assessing who is transgender and gender nonconforming and inquiring about patients’ sense of self and their identities. The importance of obtaining this SO/GI information in the clinical setting as part of basic demographics has been supported by the 2015 incorporation of the collection of SO/GI into the Centers for Medicare and Medicaid and the Office of the National Coordinator for Health Information Technology requirements for Meaningful Use certified electronic health record incentive programs for optional implementation in 2017 and mandatory implementation in 2018. Incorporation into Meaningful Use mandates that all eligible providers, eligible hospitals, and critical access hospitals receiving federal monies as part of their electronic health record incentive programs follow guidelines on collection and tracking of certain information. As a result, most large academic institutions, hospitals, and clinics now fall under this purview. For the solo or private practice practitioners, this is also important in that it enhances care.
Recommendations vary on how to ideally collect SO/GI information. In part this will depend on practice model and the point of data collection. The Williams Institute, The University of California San Francisco Center of Excellence for Transgender Health, and The Fenway Institute have created excellent models from which practitioners can work. These frameworks recommend utilizing three to five questions to obtain SO/GI data: one question for current GI, sex assigned at birth, SO, and then two additional questions to assess sexual behavior and sexual attraction ( Box 13.1 ). These questions can be modified depending on how they are used in practice (e.g., by in-person interview by a clinician or staff member or through data collection forms).
What is your current gender identity? (Check all that apply):
Trans male/Trans man
Trans female/Trans woman
Gender queer/Gender nonconforming
Additional Category (Please specify): ________
Decline to state
What sex were you assigned at birth, on your original birth certificate?
Decline to state
Self-identification: how one identifies one’s sexual orientation (gay, lesbian bisexual, or heterosexual)
Do you think of yourself as:
Lesbian, gay, or homosexual
Straight or heterosexual
Another (Please specify):______
Decline to state
Additional questions to refine sexual behavior and sexual attraction:
Sexual behavior: the gender(s) of sex partners (e.g., individuals of the same gender, different gender, or multiple genders). Note: additional information about specific sexual activities and body parts used for sex should also be assessed.
In the past (time period e.g., year) who have you had sex with?
Men only (cisgender men and/or transgender men)
Women only (cisgender women and/or transgender women)
People with various gender identities: please specify
I have not had sex
Sexual attraction: the gender(s) of individuals that someone feels attracted to
People are different in their sexual attraction to other people. Which best describes your feelings? Are you:
Only attracted to females?
Mostly attracted to females?
Equally attracted to females and males?
Mostly attracted to males?
Only attracted to males?
It is also important to consider in what order and what context these questions are asked. It is recommended that GI be assessed prior to sex assigned at birth to place emphasis on a person’s self-identity. It is also recommended that additional answer categories be allowed wherever possible in recognition of the changing and expanding lexicon, allowing for further self-definition. For questions regarding SO, we recommend assessing the three different domains (e.g., identity, behavior, and attraction) of SO separately from one another as well as distinctly from marital status and assessment of partnership or cohabitation.
Different practices use different methods of obtaining SO/GI depending on the methods used in a particular clinical setting for gathering other demographic measures. Information may be gathered prior to a clinical encounter through a web-based portal or paper questionnaire, on a paper form prior to seeing a clinician, or in an interview setting with a medical assistant prior to seeing the primary clinician. Finally, the clinician may ask or review these details in person. Data show that uniform clinical intake or registration forms help ensure quality and ubiquity of all data collected. and we recommend that practices incorporate SO/GI data collection into all patient assessments and intakes.
Despite concerns of stigma, discrimination, privacy, and confidentiality, there is high acceptability of SO/GI questions in clinical practice settings. Patients are able to recognize that there are benefits to disclosure in terms of enhanced quality of care and establishment of doctor-patient relationships. Clinicians may be concerned about asking patients to disclose their identities to them, but in general, patients desire to be asked about it. This is evidenced by the work of Cahill et al. who found that out of 301 randomly selected patients who were asked about their SO/GI information in four different clinical practice sites, only 1% declined to answer the GI question, only 2% declined to answer the sex assigned at birth question, and 1% had missing answers for SO questions. In that same cohort, 14% of respondents did not respond to the ethnicity question. Most questionnaires do not contain a question about preferred pronouns, which we believe is also an important part of the patient intake. Some individuals may use pronouns that differ from their legal gender or which may appear inconsistent with their gender expression. It remains critical to use the pronouns requested by that patient. There are many sets of pronouns available and asking which pronouns an individual uses will help establish rapport and communicate respect. Becoming competent in this area does take practice and there are clinical best practices that exist on assessing SO/GI in practice. Training opportunities are provided in Box 13.2 .
Association of American Medical Colleges. Diversity 3.0 Learning Series. Section: LGBT, Gender Nonconforming, and DSD Health. Includes over 20 videos on integrating LGBT health into medical education, interviewing techniques, strategies for teaching learners, development activities, curricular, and health promotion strategies. www.aamc.org/initiatives/diversity/learningseries/ .
Deutsch MB, ed. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People . 2nd ed. University of California, San Francisco—Center of Excellence for Transgender Health. transhealth.ucsf.edu/trans?page=guidelines-home . Accessed June 17, 2016.
Pronouns Matter. callen-lorde.org/transhealth . Callen Lorde. June 2016.
NYC Health and Hospitals (2011). LGBT Healthcare Training Video: To Treat Me, You Have to Know Who I Am. www.youtube.com/watch?v=NUhvJgxgAac&feature=kp . Accessed September 5, 2016.
University of California Center of Excellence for Transgender Health (2014). Online Learning: Acknowledging Gender and Sex. Transgender Health Learning Center. transhealth.ucsf.edu/video/story.html . Accessed September 7, 2015.
National LGBT Health Education Center (2015). Achieving Health Equity for Lesbian, Gay, Bisexual, and Transgender People. www.lgbthealtheducation.org/lgbt-education/continuing-education/?y=130 . Accessed September 5, 2016.
National LGBT Health Education Center (2012). Meeting the Health Care Needs of Transgender People. www.lgbthealtheducation.org/lgbt-education/online-courses/continuing-education/?y=13 . Accessed September 5, 2016.
National LGBT Health Education Center (2013). Providing Care and Support for Transgender Rural Latino/as and Migrant Farmworker. www.lgbthealtheducation.org/lgbt-education/continuing-education/?y=53 . Accessed September 5, 2016.
National LGBT Health Education Center (2015). Supporting LGBTQ Youth: Providing Affirmative and Inclusive Care Across the Spectrum of Gender and Sexual Identity. www.lgbthealtheducation.org/lgbt-education/continuing-education/?y=123 . Accessed September 5, 2016.
National Center for Transgender Equality (2016). An Introduction to Transgender People. www.facebook.com/TransEqualityNow/videos/vb.40078161989/10153582088701990/?type=2&theater . Accessed September 5, 2016.
National Center for Transgender Equality (2016). Supporting the Transgender People in Your Life: A Guide to Being a Good Ally. www.transequality.org/sites/default/files/docs/resources/Ally-Guide-July-2016_0.pdf . Accessed September 5, 2016.
National Center for Transgender Equality (2016). Understanding Non-Binary People: How to Be Respectful and Supportive. www.transequality.org/sites/default/files/docs/resources/Understanding-Non-Binary-July-2016_1.pdf . Accessed September 5, 2016.
The Lambda Legal 2010 report found that 21% of transgender and gender nonconforming individuals reported being subjected to hard or abusive language from a health care professional, and almost 8% reported experiencing physically rough or abusive treatment from a proivider. Therefore creating a safe environment conducive to disclosure and healing is paramount. Cultural competency training is necessary at every stage of the health care process; it is not enough for the provider alone to be competent in the care of transgender people. Individuals who work in registration, nursing, medical assisting, janitorial services, medical billing, medical records, radiology, etc. must all learn to create a positive experience for the patient. This will require training and attention. It may also require an assessment of systems of processing patient information, for example—how does your patient records and billing information track gender? Is it distinct from sex assigned at birth? How about legal name versus preferred name? Are patient’s pronouns noted? Importantly, many electronic medical records have challenges with certain “sex specific” services. For example, when working with a transgender man who has a gender marker of male, is it possible in your system to still document and bill for a Pap smear? Considering the challenges that patients may face prior to any encounters with transgender patients is critical to ensuring a safe and welcoming environment. Tools for the clinician aiming to evaluate and improve the clinical environment can be found in Box 13.3 .
National LGBT Health Education Center (2015). Ten Things: Providing an Inclusive and Affirmative Health Care Environment for LGBT People. www.lgbthealtheducation.org/lgbt-education/continuing-education/?y=114 . Accessed September 5, 2016.
The Joint Commission (2011). Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community. www.jointcommission.org/assets/1/18/LGBTFieldGuide_WEB_LINKED_VER.pdf . Accessed September 5, 2016.
National LGBT Cancer Network (2012). Best Practices in Creating and Delivery LGBTQ Cultural Competency Trainings for Health and Social Service Agencies. www.cancer-network.org/downloads/best_practices.pdf . Accessed September 2016.
Human Rights Campaign. All Children, All Families. hrc-assets.s3-website-us-east-1.amazonaws.com//files/assets/resources/HRC_All_Children_All_Families_Benchmarks_2016.pdf . Accessed September 5, 2016.
Obtaining a sexual history
Once a patient is in the clinical setting with a reproductive health provider, much can be done to enhance patient experience and the quality of information gathered from the patient, such as using language free of gendered assumptions about the patient and or any romantic or sexual relationships. Transgender individuals may have any of a variety of SOs and behavior patterns. One study by Bauer et al. addressed the sexual health of 227 female-to-male transgender individuals and found a diverse array of identities: bisexual/pansexual 24%; gay 10%; lesbian 4.1%; asexual 14.9%; queer 48.2%; straight/heterosexual 34.3%; Two-spirit 3%; Not sure/Questioning 11.9%; and other 5% which did not necessarily correspond with the past-year’s partners of whom 10% were trans men, 21.3% were cisgender men, 6.8% were transgender women, 43.6% were cisgender women, and 13.7% were genderqueer persons.
These type of data emphasize the importance of recognizing that that our patient’s partners are also multifaceted with respect to their gender, sex assigned at birth, and SO and it may important to also ask: “What are the genders of your sexual partners?” “What was the sex assigned at birth of your sexual partners?” And finally, “What specific sexual acts are you undertaking with examples: penis-in-vagina, vagina-to-vagina, penis-in-anus, mouth-to-anus, etc.” With training, providers can also become familiar using language that is more commonly used in the transgender community when describing genitalia and sex acts. For example, “Do you use your frontal opening/back opening for sexual activity?” As language is constantly changing and differs in time, geography, identity, and by individual, using the patient’s own language for their gender, sex, genitalia, sexual acts, and partners will help clarify the type of information clinicians are receiving while ensuring patients feel heard and understood. The importance of gathering both identity and specific sex behavior information will help in assessing risk for sexually transmitted infections and contraceptive needs for patients and their partners. Box 13.4 contains information on sexual history taking and suggested resources to help enhance the clinical interview.
Association of American Medical Colleges. Diversity 3.0 Learning Series. Section: LGBT, Gender Nonconforming, and DSD Health. Includes over 20 videos on integrating LGBT health into medical education, interviewing techniques, strategies for teaching learners, development activities, curricular, and health promotion strategies. www.aamc.org/initiatives/diversity/learningseries/ .
National LGBT Health Education Center (2016). Do Ask, Do Tell! Collecting Data on Sexual Orientation and Gender Identity in Health Centers” www.lgbthealtheducation.org/lgbt-education/online-courses/continuing-education/?y=142 . Accessed September 5, 2016.
National LGBT Health Education Center (2016). Training Frontline Staff to Collect Data on Sexual Orientation and Gender Identity. www.lgbthealtheducation.org/lgbt-education/online-courses/continuing-education/?y=149 . Accessed September 5, 2016.
National LGBT Health Education Center (2014). Taking a History of Sexual Health: Opening the Door to Effective HIV and STI Prevention. www.lgbthealtheducation.org/lgbt-education/continuing-education/?y=72 . Accessed September 5, 2016.
National LGBT Health Education Center (2014). Understanding and Assessing the Sexual Health of Transgender Patient. www.lgbthealtheducation.org/lgbt-education/webinars/ . Accessed September 5, 2016.
The Fenway Institute (2009). Knowing Your Patients: Taking a History and Providing Risk Reduction Counseling. www.lgbthealtheducation.org/wp-content/uploads/Module-2-Knowing-Your-Patients.-Taking-a-History-and-Providing-Risk-Reduction-Counseling.pdf . Accessed September 5, 2016.
The gynecologic exam
Another critical moment in the gynecological encounter is the physical exam. Many providers use gendered language during the exam, which can be uncomfortable for many and may worsen dysphoria in some transgender patients. Transgender men are significantly less likely to be up-to-date on Pap smears and often have longer latency between follow-up Pap smears when compared to cisgender women. One explanation for this finding may be poorer access to care, but another more likely reason is the physical and emotional discomfort patients may feel during gynecologic examinations. Potter et al. describe ways in which gendered language is often used during gynecologic exams and the authors offer alternatives that could be very useful in making transmasculine patients feel more comfortable. These terms are presented in Table 13.1 and were derived from narrative reviews of transgender men undergoing gynecologic services. We believe that incorporating this type of language into practice is important and will improve the care received not only by trans individuals but also by people of any gender in the gynecology office.
|Gendered||Less Gendered||Least Gendered|
|Vulva||External pelvic area|
|Vagina||Genital opening, frontal pelvic opening, internal canal|
|Uterus, ovaries||Reproductive organs||Internal organs|
|Pap smear||Pap test||Cancer screening|
|Cervical cancer||Cancer, HPV-related cancer|
|Pads/tampons||Any absorbent product that works for the patient|
Gynecologic Care for Transmasculine People
Basics of transition
The concept of “transition”—also known as gender affirmation—will mean different things to different patients. One definition includes “a person’s adoption of characteristics that they feel match their gender identity.” Though often discussed as a journey that starts with one’s sex assigned at birth and a gender congruent with that assigned sex and transitioning to the “other sex” and “other gender,” this understanding is limited. Many transgender individuals feel as though their affirmed gender has always been a part of their lives, and so the process is more of a revealing or affirmation than a transition. Additionally, the idea of moving from “one sex to another sex” is predicated on the notion of a gender binary wherein there are only two options: male or female. In one study, the minority of people reported a linear transition from one sex to another and the authors discovered a diversity of paths and definitions of transition. As part of this diversity, gender is increasingly seen as existing on a spectrum. Thus there is no such thing as “complete transition” as this process can often be very dynamic with each individual having different goals and milestones. Throughout this section of the chapter, the term “transmasculine” will be used to describe people who are assigned female at birth but identify somewhere along the masculine gender spectrum. Conversely the term “transfeminine” will be used for those assigned male at birth but who identify along the feminine gender spectrum. Though imperfect, we believe that these terms allow for a more inclusive discussion of the social/medical/and surgical components of transition and are more inclusive of a myriad of different identities including but not limited to: female-to-male (FTM), trans man, genderqueer/non-binary, gender non-conforming, and masculine of center for those on the masculine spectrum. For those who identify along the feminine spectrum other notable identities include but are not limited to: male-to-female (MTF), trans woman, genderqueer/non-binary, gender non-conforming, and feminine of center (see separate section below). The term “trans” will be used when referring to all communities that fall somewhere within a transgender framework and who are gender nonconforming, inclusive of transmasculine, transfeminine, and genderqueer identities.
It is important to remember that not everyone will identify with or engage in a transition process. For those who do, this may include social transition, or physical transition, which can include medical and or surgical components. Social transition is generally considered disclosing one’s GI within social circles. The degree of disclosure will be unique to every individual. This often involves dressing openly in a manner concordant with GI (e.g., modifications of one’s gender expression). Some people may change names (casually or legally) and/or pronouns. Transitioning into using gender-segregated spaces (e.g., bathrooms and locker rooms) that align most with one’s sense of self may also be a component of social transition. Social transition may not always be possible without medical or surgical components however: 28% of the lesbian, gay, bisexual, and transgender (LGBT) population lives in states that require proof of sex reassignment surgery, court order, and/or amended birth certificate in order to change gender marker.
Social transition may occur at different times with different groups of people, as many trans people may not feel comfortable disclosing their identity to their family, employers, or certain friends or acquaintance groups due to the risk of rejection, loss of employment, being ostracized from communities, or violence. For example, 52% of LGBT people in the United States live in a state that does not prohibit employment discrimination based on GI or SO. In 2011, a large survey of trans people found that 35% of those who expressed their GI between the age of 5 and 18 experienced physical violence. This violence continues throughout life as trans people are murdered at an alarming rate. Recent international research documented 2115 murders of trans people between 2008 and 2016, which is likely a gross underestimation given the underreporting and misidentification of trans people.
Even in the United States, which seems to have a comparative lower rate of murder of trans people than other countries, other policies make social transition dangerous and daunting. In 2016, North Carolina joined many other states in a recent spate of newly emergent restrictive transgender laws, but was the first state in the country mandating that people use the bathroom consistent with the sex designated on their birth certificate by passing House Bill 2 (HB2—Session Law 2016-3). Beyond simple policy that protects majority citizens, the felt effects of these bills are threatening the safety, well-being, and access to public accommodation for trans people—especially those who don’t “pass” in their affirmed gender. Beyond mere inconvenience, there are data from over 2300 transgender people suggesting that those who are denied access to bathrooms consistent with their affirmed gender have a significantly higher rate of suicide than those with safe and available bathroom access. Internationally, obtaining legal documentation of affirmed gender may require a statement of mental illness, divorce, and or sterilization. These daunting realities faced by many trans people may profoundly affect someone’s ability to disclose their identity and pursue medical or surgical transition. Others may not engage in any form of transition by choice, as they do not feel it a necessary element of their GI or expression.
There are elements of physical transition that do not include hormones or surgery. For transmasculine people, this may include wearing masculine or “men’s” clothing in public and/or getting a more traditionally masculine haircut. Some might engage in chest binding to achieve a flatter contour. This can be done with specific binders designed for these purposes. Others might use a tightly fitting sports bra or, more rarely, an ace bandage or duct tape. The latter is far more uncomfortable and may restrict blood flow or breathing. If a patient is using uncomfortable or unsafe methods of binding, this could be due to financial resources or lack of awareness for different options. There are many cities that have community organizations that help connect people with used binders and many online stores that sell more comfortable and durable products. Binding does not have any known health effects on breast tissue, though we are unaware of any studies in this area. However, it is important to consider the potential for skin breakdown and subsequent infection depending on the method of binding used.
Medical Transition: Hormones
Hormone therapy should be considered a medically necessary intervention. For those transmasculine people who are interested in medical transition, this is done primarily with the administration of testosterone, whereas for transfeminine people this is primarily achieved with estrogen with or without other androgen blockers. As mentioned in prior chapters, the WPATH publishes Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People in 14 languages. In version 7, the most recent version published in 2011, there is a clinical tool to assess “readiness” for hormones. The WPATH provides general guidelines to be used as a framework by providers and individual clinical assessment of the patient is necessary prior to beginning treatment. Determining a contraindication to hormone treatment should be done with great care. Given that the risk of severe depression and suicide attempt in trans people is estimated to be approximately 41%, denying hormone treatment due to concern for clinical side effects must account for the risk of untreated gender dysphoria. Additionally, hormone therapy improves mental health, psychological adjustment, and quality of life. One study demonstrated that once estrogen therapy was initiated for transgender women they had decreased anxiety and depression. Therefore as long as the patient has decision-making capacity, they should be provided with hormonal treatment and concurrent treatment for support of mental health concerns or conditions. Furthermore, given the significant barriers to health care commonly experienced by trans people, many patients will present to providers already taking hormones they have procured through their communities, dealers, or online, in which case the assessment of readiness becomes obsolete.
There are a number of different masculinizing hormone regimens used by patients and providers. There have been no controlled clinical trials comparing different hormone regimens in terms of efficacy, safety, or patient satisfaction. For this reason, WPATH does not endorse any specific regimen. Geographic and regional variation of available medications, insurance access and coverage, socioeconomic situation, and patient preference should be considered when choosing between regimens. Protocols for masculinizing hormone therapy and management have been reviewed in Chapter 5 , Hormone Therapy for Adults .
If a transmasculine patient is not interested in the virilizing effects of testosterone, but would like to achieve amenorrhea, this can be accomplished through a number of hormonal methods. If they do not have any contraindications to combined oral contraceptives, they can be placed on a continuous low-dose regimen for the purpose of suppressing menses. Alternatively, a levonorgestrel intrauterine device (IUD) can be offered for those patients who have contraindications to combined oral contraceptives, do not want to take systemic hormones, or who have breakthrough bleeding with oral regimens. Oral (daily) or injectable (every 3 months) medroxyprogesterone acetate is another alternative that may be preferable for some patients or if menses prove difficult to suppress with combined oral contraceptives or the levonorgestrel IUD. Combined oral contraceptives, the levonorgestrel IUD, and injectable medroxyprogesterone acetate are also effective contraceptive methods if the patient is having penis-in-vagina sex and not desiring to conceive (see section on “contraception”).
With virilizing hormone therapy, hair growth tends to occur in a similar distribution experienced by cisgender males during puberty. Darkening and thickening of chest and extremity hair generally develops first. Facial hair growth may begin slowly and take 1 to 4 years to reach full thickness. Overall, hair distribution tends to follow maternal inheritance, as does male pattern baldness. Hair growth is a permanent change, though body hair may thin following cessation of testosterone similar to that of older cisgender men. Hair loss can occur shortly after initiating therapy and occurs as either frontal/temporal recession or more classic male pattern baldness. If troublesome, thinning or balding hair is treated similarly in transmasculine and cisgender men and involves treatment with minoxidil, a 5-alpha-reductase inhibitor, or surgery.
Vocal pitch deepening usually occurs between 6 to 10 weeks after initiation and is a permanent change. It may take up to 1 year for the voice to drop to its permanent pitch. After initiation of testosterone, body fat distribution will change (generally with more abdominal distribution and less subcutaneous) and muscle mass tends to increase. Fat distribution and muscle mass changes are reversible if someone discontinues hormones. Acne is a common side effect of testosterone and is usually worse in the first year of therapy. Treatment is similar to those of cisgender patients with acne and may be helped by dermatologic consultation. Maintaining physiological testosterone dosing and avoiding large peak/trough dosing regimens may help decrease the incidence of acne. Enlargement of clitoral tissue can be expected with testosterone treatment, though the degree of enlargement varies widely by individual. This is a permanent change. Increased libido is generally noted with testosterone treatment and is a reversible change.
Additional metabolic changes can be expected in both short and long-term follow-up, and findings suggest overall safety. Overall, it seems that there may be increased cardiometabolic risk, but overall mortality is not increased. The details of these metabolic changes are beyond the scope of this chapter.
Gender Affirmation Surgeries
Surgery may be an element of transition for many transmasculine people. There are a number of different surgeries and many different names of these surgeries within transmasculine communities. “Top surgery” refers to chest reconstruction surgeries that serve to masculinize the chest. Details regarding this procedure are described in Chapter 9 , Breast and Chest Surgery for Transgender Patients .
“Bottom surgeries” may refer to a number of different procedures. This could include hysterectomy, hysterectomy with bilateral or unilateral salpingo-oophorectomy, or vaginectomy. WPATH recommends 1 year on testosterone prior to proceeding with hysterectomy/bilateral salpingo-oophorectomy. This should be interpreted as a guideline and patients should be considered on an individual basis. Some patients may never be interested in taking testosterone but would like a hysterectomy as part of their gender affirmation or to eliminate the need for suppression of menses. If not on testosterone, ovaries may be retained for the purpose of bone and cardiovascular health, and potentially for overall improved general mortality outcomes until approximately the age of natural menopause or 50. Some transmasculine people may opt to retain one or both ovaries if they would like to retain possible fertility options or might be interested in coming off testosterone and would like the ability to produce endogenous hormones. Removing the ovaries may allow for a decrease in testosterone dose postoperatively; however decreasing the dose routinely after gonadectomy is not advised. If a patient would like to decrease their testosterone dose following oophorectomy, Follicle Stimulating Hormone (FSH)/Luteinizing Hormone (LH) levels should be followed to assure they remain in the premenopausal range. If adhering to the recommendations of 1 year of testosterone treatment (for patients for whom this is relevant), providers should not postpone hysterectomy for patients with other indications for hysterectomy other than gender affirmation. Other gynecological indications for hysterectomy could include: abnormal uterine bleeding unresponsive to medical management, cervical dysplasia, endometrial hyperplasia, symptomatic leiomyomata, or adenomyosis.
With regard to reconstructing external genitalia, there are in general two common procedures: metoidioplasty and phalloplasty. Metoidioplasty involves using native clitoral tissue that has undergone hypertrophy after testosterone therapy. This may or may not include urethral rerouting through the clitoral tissue/phallus. Phalloplasty is a procedure that requires use of flaps or grafts to construct a larger phallus. This is a staged procedure that often involves the use of penile and scrotal implants. Vaginectomy may be performed with either or both of these procedures, but is generally considered necessary if vaginal obliteration is performed concurrently with either of these procedures. Details regarding these procedures can be found in Chapter 11 , Genital Confirmation Surgery for Patients Assigned Female at Birth .
Amenorrhea, abnormal bleeding, and pelvic pain
Amenorrhea is usually achieved with adequate testosterone treatment; however if breakthrough bleeding occurs or menses cannot be suppressed, other options can be considered as discussed previously. If a transmasculine patient is not on testosterone and is of reproductive age, their menstrual patterns should be evaluated as one would a cisgender woman’s. Oligomenorrhea, intermenstrual bleeding, heavy, painful, or irregular bleeding warrants investigation.
Physiologic natal male levels of testosterone should lead to cessation of menses within 6 months of hormone initiation. For those transmasculine patients who had heavy or irregular bleeding prior to beginning testosterone therapy, achieving amenorrhea may prove more difficult. If the patient has risk factors for, or symptoms concerning for, endometrial hyperplasia or cancer, an endometrial biopsy should be performed. This may include a return to menses after a long period of amenorrhea on testosterone, but inquiry into changes of hormonal regimen and use of anticoagulants should also be investigated. Transvaginal ultrasound and/or sonohysterography may be useful if symptoms are consistent with fibroids or polyps. If transvaginal ultrasound is not possible or is distressing to the patient, alternative imaging modalities such as abdominal ultrasound, computerized axial tomography (CT) scan, and magnetic resonance imaging (MRI) may be considered. Diagnosing and treating structural abnormalities will likely aid in the establishment of amenorrhea once testosterone therapy is initiated. Etiologies of oligomenorrhea prior to initiation of testosterone therapy should also be investigated. Pregnancy should be ruled out in patients who are engaging in penis-in-vagina sexual intercourse with partners who are capable of producing sperm.
Amenorrhea in transgender men after initiation of testosterone ranges from 1 to 13 months. Higher and more frequent doses of testosterone have been shown to decrease time to amenorrhea. Therefore one proposed definition of abnormal uterine bleeding in transmasculine patients would be bleeding that occurs after 12 months of physiologic male testosterone levels in the setting of FSH/LH suppression. Body habitus and route of administration may also affect the timing of menstrual suppression. Patients with larger adipose stores will have higher circulating estrogen levels and likely need longer periods of testosterone exposure prior to achieving amenorrhea.
Treatment of abnormal uterine bleeding should be tailored based on etiology. If there are structural lesions present, such as a polyp or submucosal fibroid, resection should be discussed with the patient. Adjusting the testosterone-dosing regimen may also lead to more rapid cessation of menses. Testosterone has been shown to incompletely inhibit ovulation, and should not be considered adequate contraception. Therefore, patient’s contraceptive needs should also be considered while discussing treatment of persistent bleeding. As mentioned previously, a levenorgestrel-secreting IUD or implanted, intramuscular, or oral progestogen will likely facilitate amenorrhea while also providing effective birth control for those at risk of pregnancy.
If the patient does not desire fertility but has surgical comorbidities or is not interested in hysterectomy, an endometrial ablation is an option for ongoing bleeding. If the patient has risk factors for endometrial hyperplasia or cancer, an endometrial biopsy should be performed prior. Aromatase inhibitors may also be considered for short-term adjunctive treatment of persistent bleeding. As these medications inhibit the peripheral production of estrogen, they will likely be particularly helpful in patients with high body mass index. Weight loss will also decrease the production of peripheral estrogen and likely aid in the cessation of menses.
Pelvic pain for transmasculine patients and cisgender women is a complicated and sometimes debilitating condition that is often multifactorial in origin. Pelvic pain, once chronic, in any individual is generally best treated with a multidisciplinary approach. A full pain history should be elicited. A pain diary may be helpful in documenting inciting factors and frequency, as well as pain patterns. The clinical interview should consider gastrointestinal, urological, gynecological, musculoskeletal, and emotional/psychiatric/trauma components. Etiologies may include postsurgical pain or adhesive disease, pelvic floor muscle dysfunction or hypertonicity, infection, endometriosis, constipation, post-traumatic stress disorder (PTSD), or depression.
Etiologies specific to transmasculine patients on testosterone therapy include atrophic changes to the lower genital tract tissues (including the vulva and vagina) and increased risk of vaginitis and cervicitis due to pH changes from testosterone. If patients present with pelvic pain following hysterectomy and have retained one or both gonads, these remaining organs should be evaluated for pathology. Given the increased risk of violence and assault experienced by trans people, a trauma-informed approach to care should be used as gynecologic exams or invasive studies may cause additional trauma or trigger previous experiences.
A thorough exam should be performed assessing for costovertebral angle tenderness, abdominal pain, or tenderness in the pelvic floor muscles. If a speculum exam is needed and the patient does not use their vagina for penetrative sexual activity, consider starting the exam with a pediatric speculum. Evaluate for vestibulodynia prior to performing a speculum exam (if indicated). If vestibulodynia is present, topical lidocaine will help to establish a diagnosis and decrease the discomfort of speculum insertion. With a speculum, evaluate for atrophic changes of the vaginal and cervical tissues and for abnormalities in discharge. Perform a wet prep, pH test, and consider vaginal culture. Screen for gonorrhea and chlamydia if indicated by risk profile or symptoms.
Transvaginal ultrasound should be performed to evaluate for adnexal pathology if gonads are still present. If the patient has undergone vaginectomy, a transrectal approach may allow for visualization. It is critical to take a thorough organ inventory to appropriately direct diagnostic tests. For those on testosterone therapy, understanding when the symptoms began in relation to therapy initiation (and any changes in therapeutic regimen or dose) is critical. If the patient experiences cyclical pain, this may be associated with ovulation and further ovulatory suppression may prove therapeutic. If vestibulodynia is thought to be the primary etiology of pelvic pain, treatment may start with the application of 2% to 5% topical lidocaine.
Testosterone is known to cause atrophy of the genital tract, which can lead to vaginitis and dyspareunia mimicking a postmenopausal state. If the patient’s symptoms and exam are consistent with atrophic vaginitis or cervicitis, vaginal estrogen (in either cream, tablet, or ring preparations) may help alleviate symptoms. As there is limited systemic absorption of vaginal estrogen, patients should not expect feminizing side effects of treatment or need for adjustment of their testosterone doses. Vaginal estrogen in a cream formulation may be applied to external genitalia if patients do not want to place the medication vaginally. If patients are not interested in using estrogen, changing lubrication used during sexual activities (if relevant) or a vaginal moisturizer may also improve their discomfort. Some patients experience pelvic pain immediately following their testosterone dose. The etiology of this is unknown. In addition to the vaginal treatments described above, nonsteroidal antiinflammatories should be considered a mainstay of treatment. Treatment with selective serotonin reuptake inhibitors or tricyclic antidepressants may be considered, though little is known about their efficacy in this particular application.
Treatment of levator myalgia is similar to the treatment recommended for cisgender women, and involves referral to physical therapists specializing in the pelvic floor therapy. It is critical to be aware of the physical therapist’s level of experience and knowledge of trans patients so as to not refer the patient to a culturally insensitive provider which could exacerbate any gender dysphoria, sexual or genital trauma, or prior poor experiences with health care providers. If the patient is not comfortable seeing a pelvic floor physical therapist, or finances are prohibitive, instruction on pelvic floor massage can be provided so that the patient may perform therapy on their own, with a tool, or with a partner.
For many patients with pelvic pain, pelvic examinations may prove traumatic. With transmasculine patients, exams may exacerbate gender dysphoria, and transmasculine patients may decline exams. In these cases, less invasive examinations should be primarily initiated (such as abdominal exams and imaging). If an exam is absolutely clinically indicated and the patient does not feel comfortable being examined in the office, exam under anesthesia or with moderate sedation should be offered where resources allow. PTSD and depression are common among transgender people and are often co-occurring disorders with chronic pain conditions. When present, these conditions should be treated by mental health professionals in a collaborative approach to treatment of pelvic pain.
As hysterectomies are often performed for gender affirmation, this may be considered earlier in the pelvic pain algorithm than with cisgender women. However, fertility plans and pain expectations postoperatively should be discussed with the patient prior to recommending hysterectomy, as pelvic pain may not be improved. The decision to remove gonads simultaneously should also be discussed in the context of planned duration of testosterone therapy, etiology of pelvic pain, and fertility desires.
Gynecological approach to health maintenance and routine screening
If a transmasculine patient has not undergone top surgery (chest reconstruction) or has only had a reduction, they need mammogram screening, similar to cisgender women. This begins at age 40 to 50 depending on risk factors, family history, and choice of guideline adherence. As guidelines vary, risks and benefits should be discussed with patients so that they may make an informed decision. It should be noted that mammography may exacerbate gender dysphoria as mammography centers are generally gendered spaced and many transmasculine patients may not feel comfortable. Anticipatory discussion of the gendered space and potential dysphoric triggers should be included in discussions with patients prior to referral. In referring to a mammography center, it is critical to investigate and then ensure that its providers are capable of delivering culturally sensitive care.
If a transmasculine patient has undergone top surgery, it is important to clarify the extent of surgery performed (mastectomy vs reduction). Chest reconstruction, done for the purpose of gender affirmation, is not usually performed by oncologists and residual breast tissue is left behind for the purpose of contouring the chest. For this reason, it should not be considered a risk reducing procedure. While the incidence of breast cancer in trans men following top surgery is unknown, there are only a few case reports in the literature and it is thought to be exceedingly uncommon. While data are limited, it appears cross-sex hormone administration does not place trans people at increased risk for breast cancer. The incidence of breast cancer in both transmasculine and transfeminine people is comparable to the incidence of breast cancer found in cisgender men.
Mammography is not possible for most transmasculine people following top surgery. Alternative considerations such as ultrasound, MRI, or annual chest wall exams can be considered but are not firmly recommended. If a transmasculine patient is considering top surgery and has a strong family history of breast or ovarian cancer, they should be referred to a genetic counselor for evaluation. Patients with known mutations (such as BRCA1 or BRCA2) should be referred to a breast cancer surgeon who will ideally be able to perform risk reduction surgery in collaboration with a plastic surgeon capable of performing chest masculinization.
Screening for Gynecological Malignancies
When considering cancer risk in all trans patients, a full organ inventory is critical. Reviewing operative reports, when possible, allows for increased accuracy as patients may not remember or fully understand the procedures they have undergone. A lack of complete understanding may be due to lack of physician communication, varying terminology used amongst community members and providers, and/or patient health literacy.
If a transmasculine patient has not had a hysterectomy and is between the age of 21 and 65, they should undergo cervical cancer screening per the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines. Again, if a patient has a history of a hysterectomy, it is critical to know whether or not the cervix was removed, and whether there was a clinically significant lesion prior to cervix removal that would require continued screening.
Routine screening for endometrial or ovarian cancer in transgender men on testosterone is not recommended. Generally the histopathological sequelae of testosterone use in transmasculine individuals includes uterine atrophy rather than hyperplasia and very few cases of gynecological malignancy have been reported. Diagnostic evaluations should be reserved for clinical scenarios in which there is unexplained or irregular bleeding or symptoms, as discussed previously.
Sexually Transmitted Disease/Infection Screening
Screening for sexually transmitted infections in transmasculine patients should be tailored based on sexual history and risk factors. It is critical to take a full sexual history. As discussed previously, GI does not in any way predict sexuality or sexual behavior. The 2015 Centers for Disease Control (CDC) Sexually Transmitted Disease (STD) Screening Guidelines include trans people as a discrete population for the first time but do not give population-specific recommendations other than noting: the few studies that exist suggest that Human Immunodeficiency Virus (HIV) prevalence may be lower in transgender men than transgender women and given the anatomic and behavioral diversity of transmasculine individuals, screening should be individualized for HIV, cervical Human Papillomavirus (HPV), and cervical cancer. However, two small studies suggest that HIV and sexually transmitted infection (STI) burden may be significant among transgender men and thus risk factor assessment and screening in this population should not be overlooked. As with all individuals, the CDC recommends assessing for STD risk based on current anatomy, sexual behaviors, IV drug use or other possible exposures, and symptoms.
Testosterone alone does not serve as reliable contraception. If trans men are engaging in sexual activities that could result in pregnancy (e.g., penis-in-vagina sex) and do not desire to conceive, they should be counseled on the need for contraception. Little data guides contraceptive efficacy and preferences for transgender men. However, anatomic capacity to conceive is retained by many transmasculine people as only 21% undergo hysterectomy and many engage sexually with either cisgender or transgender men. In a study of 41 transgender men who were pregnant and delivered after transitioning, one third of the pregnancies were unplanned. However, it is not clear how many of these unplanned pregnancies occurred in the setting of current testosterone use. As discussed previously, effective contraception can often support other efforts to achieve amenorrhea if patients do not achieve amenorrhea on testosterone alone.