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1/5/2021

Transgender Care

The terms transgender male or transgender man describe individuals who were sex-assigned female at birth who identify on the more masculine spectrum of gender identity. The transgender and gender-diverse experience is as varied as is people’s expression of their identity. Transgender men may choose a number of medical or surgical therapies to help align their bodies with their gender identity. Individuals may choose to use masculinizing hormone therapy or undergo surgical procedures such as bilateral mastectomy (“top surgery”), hysterectomy with or without gonadectomy, or phalloplasty/metoidioplasty (“bottom surgery”).

The obstetrician and gynecologist is uniquely trained to help transgender men with several medical needs, including fertility, family planning, cervical and breast cancer screening, menstrual dysphoria, pelvic pain, and gynecologic surgeries.

The most important job of the physician is to provide safe, affirming care. Transgender and gender-diverse persons often experience discrimination in health care settings. Obstetricians and gynecologists should avoid judgments and assumptions, recognizing we may have unconscious bias toward western binary models of gender. One way to mitigate our biases and welcome gender-diverse patients is to collect and use gender data, including chosen name, pronouns, gender identity, and sex.

Providers should limit historical questions to those that are relevant to the current visit. For example, spending significant time asking about gender issues could distract from the chief concern of a particular visit. Taking an anatomic inventory allows the physician to tailor the physical examination and screening tests. If patients have breasts, they should be screened according to guidelines for non-transgender (cisgender) women. No reliable evidence exists to guide the screening of transgender men who have undergone mastectomy. Masculinizing chest surgery leaves some breast tissue, as it is not a radical mastectomy. There are unknown risks associated with this residual breast tissue and mammography may not be technically feasible.

A sexual history is essential for providing contraceptive, reproductive, and HIV/sexually transmitted infection counseling and care. It is important to directly ask if patients are sexually active with men, women, or both and if they are sexually active with people who have penises. Patients at risk for pregnancy should be offered contraception regardless of testosterone use, as testosterone is not a contraceptive. All patients should be offered fertility preservation before medical or surgical transition.

Patients with a cervix should be screened for cervical cancer according to guidelines, regardless of gender identity. The health care provider should adjust the pelvic examination in order to be sensitive and supportive. Options include using a pediatric speculum, encouraging the patient to distract themselves with music/videos, having a support person present, and administering preexamination benzodiazepines. Of note, testosterone use significantly increases the incidence of an unsatisfactory cytology result. More research on self-collected HPV swabs may lead to a more acceptable screening modality.

Health care providers should be aware that most patients experience secondary amenorrhea after 6 months of testosterone use. Any abnormal uterine bleeding (bleeding beyond the first year while on testosterone or new-onset bleeding) should be evaluated using standard gynecologic protocols. Transgender men may seek the expertise of a gynecologic surgeon to perform hysterectomy and possible bilateral salpingo-oophorectomy. It is important that obstetricians and gynecologists follow guidelines (eg, Endocrine Society guidelines or World Professional Association for Transgender Health standards of care) before scheduling surgical procedures for transgender men. 

Further Reading:

Committee Opinion No. 685 Summary: Care for Transgender Adolescents. Obstet Gynecol. 2017;129(1):234. PMID: 28002306

Deutch M, Amato P, Courey M, et al. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. Center of Excellence for Transgender Health Department of Family & Community Medicine University of California, San Francisco. 2nd edition. Published June 17, 2016. Available at: https://transcare.ucsf.edu/guidelines. Verified September 2020

Committee on Health Care for Underserved Women. Committee opinion No. 512: health care for transgender individuals. Obstet Gynecol. 2011;118(6):1454-1458. PMID: 22105293

Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. [published corrections appear in J Clin Endocrinol Metab. 2018;103(2):699 and J Clin Endocrinol Metab. 2018;103(7):2758-2759]. J Clin Endocrinol Metab. 2017;102(11):3869-3903. PMID: 28945902

Initial Approval: September 2020; Published January, 2021

 

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The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. (“SASGOG”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. SASGOG reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. SASGOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither SASGOG nor its respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

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