New guide offers recommendations on caring for transgender patients

The guide provides information for clinicians on common terminology and initial evaluation, medical management, transgender-specific surgical options, medicolegal and societal issues, and practice improvement.

Transgender individuals have increased rates of certain types of cancer, substance abuse, mental health conditions, infections, and chronic diseases. Barriers to accessing appropriate and culturally competent care contribute to these disparities, so clinicians must understand the specific medical issues that are relevant to this patient population, according to authors of a new guide.

The guide, “Care of the Transgender Patient,” was funded by ACP and was published online on July 2 by Annals of Internal Medicine. It is based on a review of current evidence and covers common terminology and initial evaluation, medical management, transgender-specific surgical options, medicolegal and societal issues, and practice improvement.

The guide starts with the basics, explaining that the word “transgender” describes individuals whose gender identity does not align with their sex recorded at birth. While the term “transsexual” previously indicated that a person had received medical and surgical treatment to align their appearance and gender identity, “transgender” has become the preferred term because it is more inclusive. Other words that describe persons whose gender identity does not align with the sex recorded at birth include “trans,” “gender nonbinary,” “gender incongruent,” and “genderqueer.” Transgender men identify as male but were identified as female at birth, whereas transgender women identify as female but were identified as male at birth. Gender-nonbinary and genderqueer persons may identify with a gender that is neither male nor female or has features of both.

In the clinical setting, determination of transgender identity is based entirely on history. Clinicians should establish that the patient has persistent gender incongruence, and the patient should be able to make informed medical decisions, according to the guide. The term “gender dysphoria” is a mental health diagnosis that describes the discomfort of misalignment of gender identity and sex recorded at birth. While not all transgender patients have dysphoria, many U.S. insurance companies require the diagnosis for reimbursement for transgender medical and surgical interventions, the guide said.

In terms of medical management, hormone therapy is reasonably safe when patients are monitored, but clinicians should be aware of potential adverse effects. For example, transgender women who receive hormone therapy may have increased risk for deep venous thrombosis, pulmonary embolism, stroke, and potentially myocardial infarction. Transgender patients also have many surgical options, including facial, chest, and genital procedures. Due to a lack of transgender-specific data, cancer screening and other prevention strategies should be performed on the basis of the tissues and organs present in the patient, irrespective of gender identity.

Multiple medicolegal and societal issues are pertinent to this patient population, such as the proper documentation of a transgender patient's identity in the electronic health record (EHR). The EHR should have the capacity to record patients' preferred pronouns and name, as well as their gender identity and the organs and tissues present in their bodies, the guide said.

Finally, regarding practice improvement, the guide outlined four elements of a successful care environment: transgender-specific staff training (with annual refreshers); transgender-specific clinician training as required; transgender-friendly environment (e.g., inclusive bathroom-use policies); and an updated EHR with legal name, preferred name, sex on birth certificate, gender identity, and pronouns.