The Clinician's Guide to Transgender Care
Key strategies necessary to provide comprehensive, sensitively delivered care

Putting Transgender Medical Care Into Context for Practitioners

Chapter 1 provides an overview of this evolving field, including its history, critical definitions, and a view toward cultural implications to offer a wider perspective for clinicians.

The demand for medical care among individuals who are gender affirming or transitioning has reached a tipping point, challenging clinicians to have a greater sense of proficiently in and sensitivity to the care of these patients.

The authors share the medical model they have developed as an educational resource to EndocrineWeb to foster a 21st-century approach to trans medicine care that is evidence-based and patient-centered.    

The material will be presented in 4 chapters.

Chapter 1:  History, Definitions, Cultural Implications

Transgender is a term used to reflect persons whose gender identity does not match their sex as recorded at birth, which is typically determined by external sexual anatomy. Going forward, the trans* will be used as the encompassing term for a person whose sexual orientation is non-conforming.

Trans* patients need clinical awareness to deliver appropriate medical care.

Prevalence of Patients Who are Transgender 

The Williams Institute researchers estimate that about 150,000 adolescents identify as transgender, based on data for youth who identify as transgender across the United States. Needless to say, these are likely underreported as many who may be trans* may hesitate to share their status publicly.

In anticipating the medical needs of this population, it is insightful to appreciate the estimated proportion of Americans who identify as trans* across the United States; the data follow:

  • 10% of teenagers ages 13 to 17 years old
  • 13% of young adults ages 18 to 24 years old
  • 63% of adults ages 25 to 64 years old

Individuals identifying as trans may use the terms: transgender, gender fluid, gender-nonconforming, gender-variant, gender-queer, and transsexual. Transgender has evolved as an umbrella term, but has been challenged recently as too limiting by people of color; hence, the use of trans in which the asterisk avoids any representation to specific sex or gender.

The Evolution in Transgender Care: A Brief History

The first documented case of a person who was recorded as female at birth but chose to take testosterone and then live as a man was Michael Dillon, a physician, in 1939.2

His status as a physician may have given him an advantage in gaining acceptance since very few clinicians were prescribing hormone therapy at that time. Rather, the treatment for transgender individuals was focused on psychoanalysis with the intent to counsel individuals to deal with their gender incongruence; it would prove to be ineffective.4

Decades later, Harry Benjamin, MD, (b.1885-d.1986), an endocrinologist and self-trained sexologist, began to advocate for hormone use in those who had gender incongruence and gender dysphoria. He advanced the field by documenting nearly 20 years of clinical experience working with people who identified with gender incongruence. He reported that providing cross-sex hormone therapy was effective in providing relief to patients struggling with their gender identity.

Gender incongruence reflects a mismatch between gender identity and sexual anatomy. Gender dysphoria, described in the Diagnostic and Statistical Manuel of Mental Disorder-5, is defined as the distress caused by that incongruence.

Dr. Benjamin founded the Society for the Scientific Study of Sexuality, in 1957, as a multidisciplinary professional organization whose mission has been to encourage clinical research, including transgender identity and sexuality, and to share the findings among professionals, legislators, and the public.

By documenting his nearly 20 years of experience in working with people who identified as having a gender incongruence. Dr. Benjamin advanced the field in his writings, The Transsexual Phenomenon,6 which was published in 1967. 

He reported that counseling alone not only was not constructive and didn't work but that it was harmful.  Later, he reported that cross-sex hormone therapy was effective for gender incongruent and/or gender dysphoric individuals.

In the 1970s, Dr. Benjamin helped organize an international organization for providers of transgender identity care, which is known as the World Professional Association of Transgender Health (WPATH).7  The WPATH promotes clinical and academic research to further the clinical care of trans* individuals.

Fluency in Transgender Terminology

The selection of terms, which is by no means comprehensive, is offered to highlight those preferred by trans and gender non-conforming patients and those that most commonly appear in published clinical guidelines and related research.

Sex and Gender: Broad categories that may include physical characteristics, chromosomes, other biology, and expression. Sex describes biology while gender reflects external influencers.

Gender expression:  Outward self-expression, including hairstyle, clothing, make-up, speech, and mannerisms. This should not be confused with gender identity as a girl may choose a close-cropped, haircut just as a boy may grow his hair long...these choices are more culturally related than having any bearing on a person's identity.

Gender identity: An individual's self-proclaimed, internally based, sense of own gender.

Trans, Transgender: a person whose gender identity does not align with the sex recorded at birth (usually having related to external sexual anatomy).

  • Trans male (female to male, FtM) is someone recorded female at birth with male gender identity.
  • Trans female {male to female, MtF) is an individual recorded male at birth with female gender identity.

Gender non-conforming: This refers to a person who does not assume the gender identity that correlates with the sex recorded at birth but also doesn't accept the opposite gender identity. For example, a transmasculine person whose birth sex was female but has a gender identity somewhere on the male spectrum and the reverse for someone presenting as transfeminine. Genderqueer is another term indicative of an individual with a more complex range of identities. Non-binary refers to an individual who does not have an identity as either male or female. 

Sexual orientation: This term refers to sexual attraction, which is individualized among trans individuals just as it is with cisgender (non-transgender) people. For example, a trans woman who is sexually attracted to women would be lesbian while a trans male who is attracted to men is gay.

Transgender Individual in Society: Cultural Implications and Influence

In the last decade, progress has been made in recognizing the medical and mental health needs of transgender people and to foster access to healthcare.8

Organizations, including the Endocrine Society, have issued standards of care for transgender people,9 specifying what should be considered and in which circumstances.

Similarly, the American Psychological Association issued guidelines to direct culturally competent, developmentally appropriate, and trans-affirmative psychological practice of transgender and gender non-conforming (TGNC) individuals.10

Findings indicated that 70% of transgender people reported some type of harassment or maltreatment when seeking medical care.11 These respondents reported that their healthcare practitioners:

  • Refused to touch them
  • Used abusive or harsh language
  • Were physically abusive or rough
  • Blamed the patient for their status.

In that same survey,11 27% of transgender respondents said they were denied health care due to their transgender status. Even those who received health care reported incidents of “being mocked, slurred, laughed at, pointed at or taunted.” Besides the reported medical mistreatment, the gender insensitivity extended to being denied access to the bathroom.

If this seems hard to believe, Kosenko et al, reported that "patients may experience medical mistreatment from their providers in the following ways: gender insensitivity, displays of discomfort, denied services, substandard care, verbal abuse, and forced care."12  As a further indignity, many trans patients indicated having to teach their clinicians about the care they were seeking, such as obtaining a prescription to continue needed hormone replacement.

More troubling, patients fears of unkind care have led to avoidance of necessary medical services as well as self-administration of treatments.13 The perspectives gleaned from the Lamba Legal responses should cause all clinicians to pause, and take note.

According to Lambda Legal report,11 a nonprofit that advocates for the rights of gay, lesbian and transgender people, there has been some improvement in gender-affirming hospital policies. However,  the need for medical school curricula to address the knowledge gap remains necessary to close the gap and increase the comfort in the delivery of quality medical care faced by this subpopulation of patients.12  

The remaining chapters will focus on the needs and health concerns of the trans community to give you the tools necessary to anticipate the care needed by transgender patients at all stages in their transition and into the future as they seek medical care as they age.

Continue Reading:
Quality Clinical Care for Trans Patients: Identifying Barriers, Offering Solutions
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