Care of the Transgender Patient

You are meeting with your clinic staff to try and make your clinic more inclusive for transgender and gender diverse individuals. Changes to clinic flow that would accomplish this goal could include:

Instructing check-in staff to use the patient’s legal name only in order to provide HIPAA compliant-care

Provide patients with intake forms containing a blank space to write in their gender

Clearly label restrooms as male or female restrooms

Make the clinic’s non-discrimination policy available only on request

Show Explanation

There are many steps you make take to make your clinic environment more inclusive. Increasing knowledge of health care professionals and avoiding making assumptions when caring for patients are important steps.
All patients should be asked about their name and pronouns. This information should be clearly available in the medical record and has nothing to do with HIPAA.
Ensure that images chosen for signage, educational materials, and artwork represent all individuals who may seek healthcare services.
The office’s nondiscrimination policy should be posted clearly, and not be available only when requested.
At least one restroom should be gender neutral and accessible to all patients.
Patient forms should include blanks in which patients can write in their gender and sexual orientation.

2. A 34-year-old transmasculine individual presents to you as a new patient for discussion of bothersome abnormal uterine bleeding. They started taking testosterone four months ago and since then, they have had continued irregular bleeding. Options for management include

Expectant management

Progesterone therapy

Hysterectomy

All of the above

Show Explanation

Cessation of menses is typical within the first few months of starting testosterone hormone therapy.
If bleeding is persistent and amenorrhea is desired, progesterone-only therapy, including oral progestins or a levonorgestrel IUD, may be sufficient for symptom relief. Cessation of menses does not reliably prevent pregnancy. Estrogen-containing contraceptive methods are not specifically contraindicated, but may be avoided by transmasculine individuals who do not wish to add estrogen to their system.
Hysterectomy with or without bilateral salpingo-oophorectomy is indicated for gender affirmation and/or abnormal uterine bleeding. Surgery may be completed by any route that is otherwise indicated.
While there is a theoretical concern for endometrial hyperplasia or malignancy secondary to aromatization of testosterone and anovulation, it is not supported by data. In fact, most studies have demonstrated that endometrial atrophy is common with testosterone use.

3. A 10-year-old transgender male presents with his parents who are requesting oocyte freezing for fertility preservation. He has Tanner stage 2 breast development. He and his parents are discussing his pubertal transition and considering puberty blockers (gonadotropin-releasing hormone agonist) and eventual androgen therapy. In this patient, the best time to freeze oocytes is

Before puberty blocker treatment

At the time of gender-affirming surgery

Before testosterone initiation

After testosterone initiation

Show Explanation

Puberty blockers like GnRH agonists are used with the onset of puberty to prevent progression of undesired secondary sexual characteristics.
The Endocrine Society recommends starting gender-affirming sex hormone therapy at 16 years or older for adolescents.
Fertility preservation is not recommended prior to use of puberty-blocking medications as these medications do not have a long-term effect on ovarian function after cessation of treatment
Not all transgender men or transmasculine individuals will choose to have an oophorectomy, so postponing fertility preservation until the time of oophorectomy may delay such preservation unnecessarily. The effect and timing of treatment with testosterone on the ability to undergo successful fertility preservation are unclear. Use of testosterone may lead to ovarian stromal hyperplasia and follicular atresia, which may be reversible, but it is unclear how the length of time of testosterone therapy affects the ability to reverse these changes.
Options for fertility preservation include oocyte freezing, embryo banking, or ovarian tissue preservation.