Clinical Review

Transgender Patients: Providing Sensitive Care

Clinician Reviews. 2017 February;27(2):28-32,40-41,52

Author(s):

What to say? What to prescribe? When to refer? The authors offer advice on how best to communicate with and treat this unique patient population.

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References

1. Pew Research Center. A survey of LGBT Americans: attitudes, experiences and values in changing times. www.pewsocialtrends.org/2013/06/13/a-survey-of-lgbt-americans. Accessed January 13, 2017.
2. Gates GJ. How many people are lesbian, gay, bisexual and transgender? http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf. Accessed January 13, 2017.
3. van Kesteren PJ, Gooren LJ, Megens JA. An epidemiological and demographic study of transsexuals in The Netherlands. Arch Sex Behav. 1996;25:589-600.
4. Bhola S. An ally’s guide to terminology: talking about LGBT people & equality. www.glaad.org/2011/07/28/an-allys-guide-to-terminology-talking-about-lgbt-people-equality. Accessed January 13, 2017.
5. University of California, San Francisco. Transgender terminology. UCSF Center of Excellence for Transgender Health. http://transhealth.ucsf.edu/tcoe?page=protocol-terminology. Accessed January 13, 2017.
6. Istar A. How queer! The development of gender identity and sexual orientation in LGBTQ-headed families. Fam Process. 2010;49:268-290.
7. Goins ES, Pye D. Check the box that best describes you: reflexively managing theory and praxis in LGBTQ health communication research. Health Commun. 2013;28:397-407.
8. American Psychiatric Association. Gender dysphoria. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013: 451-459.
9. World Health Organization. The International Classification of Diseases, 10th rev. Classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. 1992; Geneva.
10. Coleman E, Bockting W, Botzer M, et al; World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgender. 2011; 13:165-232.
11. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endo Metabol. 2009;94:3132-3154.
12. University of California, San Francisco. Assessing readiness for hormones. UCSF Center of Excellence for Transgender Health. http://transhealth.ucsf.edu/tcoe?page=protocol-hormone-ready. Accessed January 13, 2017.
13. Gooren L. Hormone treatment of the adult transsexual patient. Horm Res. 2005;64(suppl 2):S31-S36.
14. Hembree WC. Guidelines for pubertal suspension and gender reassignment for transgender adolescents. Child Adolesc Psychiatr Clin N Am. 2011;20:725-732.
15. Gay, Lesbian, and Straight Education Network (GLSEN). Harsh realities. The experiences of transgender youth in our nation’s schools. www.glsen.org/sites/default/files/Harsh%20Realities.pdf. Accessed January 13, 2017.
16. Berman M, Balingit M. Eleven states sue Obama administration over bathroom guidance for transgender students. May 25, 2016. Washington Post. www.washingtonpost.com/news/post-nation/wp/2016/05/25/texas-governor-says-state-will-sue-obama-administration-over-bathroom-directive/. Accessed January 13, 2017.
17. de Vries AL, Cohen-Kettenis PT, Delemarre-van de Waal H. Clinical management of gender dysphoria in adolescents. 2006. Vancouver Coastal Health - Transgender Health Program. www.amsa.org/wp-content/uploads/2015/04/CaringForTransgenderAdolescents.pdf. Accessed January 13, 2017.
18. TransYouth Family Allies. Empowering transgender youth & families. www.imatyfa.org/. Accessed January 13, 2017.
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Civil rights for the lesbian, gay, bisexual, and transgender population have advanced markedly in the past decade, and the medical community has gradually begun to address more of their health concerns. More recently, media attention to transgender individuals has encouraged many more to openly seek care.^1,2

It is estimated that anywhere from 0.3% to 5% of the US population identifies as transgender.^1-3 While awareness of this population has slowly increased, there is a paucity of research on the hormone treatment that is often essential to patients’ well-being. Studies of surgical options for transgender patients have been minimal, as well.

Primary care providers are uniquely positioned to coordinate medical services and ensure continuity of care for transgender patients as they strive to become their authentic selves. Our goal in writing this article is to equip you with the tools to provide this patient population with sensitive, high-quality care (see Table 1).^4-7 Our focus is on the diagnosis of gender dysphoria (GD) and its medical and hormonal management—the realm of primary care providers. We briefly discuss surgical management of GD, as well.

UNDERSTANDING AND DIAGNOSING GENDER DYSPHORIA

Two classification systems are used for diagnoses related to GD: the Diagnostic and Statistical Manual of Mental Disorders, Fifth Ed (DSM-5)⁸ and the International Classification of Diseases, 10th Rev (ICD-10).⁹

ICD-10 criteria use the term gender identity disorder; DSM-5 refers to gender dysphoria instead. It is important to emphasize that these classification systems represent an attempt to categorize a group of signs and symptoms that lead to distress for the patient and are not meant to suggest that being transgender is pathological. In fact, in DSM-5—released in 2013—the American Psychiatric Association revised the terminology to emphasize that such individuals are not “disordered” by the nature of their identity, but rather by the distress that being transgender causes.⁸

For a diagnosis of GD in children, DSM-5 criteria include characteristics perceived to be incongruent between the child’s sex at birth and the self-identified gender based on preferred activities or dislike of his or her own sexual anatomy. The child must meet six or more of the following for at least six months

A repeatedly stated desire to be, or insistence that he or she is, of the other gender
In boys, a preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
Strong and persistent preferences for cross-gender roles in make-believe play or fantasy
A strong rejection of toys/games typically associated with the child’s sex
Intense desire to participate in stereotypical games and pastimes of the other gender
Strong preference for playmates of the other gender
A strong dislike of one’s sexual anatomy
A strong desire for the primary (eg, penis or vagina) or secondary (eg, menstruation) sex characteristics of the other gender.⁸

Adolescents and adults must meet two or more of the following for at least six months

A noticeable incongruence between the gender that the patient sees themselves as and their sex characteristics
An intense need to do away with (or prevent) his or her primary or secondary sex features
An intense desire to have the primary and/or secondary sex features of the other gender
A deep desire to transform into another gender
A profound need for society to treat them as someone of the other gender
A powerful assurance of having the characteristic feelings and responses of the other gender.⁸

For children as well as adolescents and adults, the condition should cause the patient significant distress or significantly affect him or her socially, at work or school, and in other important areas of life.⁸

Transgender Patients: Providing Sensitive Care

References

UNDERSTANDING AND DIAGNOSING GENDER DYSPHORIA

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