Case Scenario

I work in a private group practice that serves a diverse population. The patients and the clinical staff are of various sexual orientations, and the physicians pride themselves on a philosophy of openness and tolerance.

A 45-year-old female-to-male transsexual firefighter presented to the office concerned about a benign facial lesion. He and his wife and son had been patients of the practice for five years. He presented primarily for urgent care and received limited health maintenance. Although he had been on testosterone for 10 years, the staff, because of their unfamiliarity with transgender health, had never monitored the side effects of his hormone therapy.

When asked about his three-year absence from care, he said that his last visit was negative for him because the physician gave him a rectal examination during a routine physical, despite being reminded that he does not have a prostate. He decided not to return after that experience, but the office continued to fill his testosterone prescription.

During this current visit, his blood pressure was significantly elevated. Routine laboratory tests subsequently showed hyperlipidemia, a total cholesterol level of 270, and erythrocytosis, all of which are known side effects of testosterone thereapy.¹ What is the best approach to this patient so I can ensure respectful care?

Commentary

Transgender persons are those who consider their gender to be different from their biological sex. Hence, a male-to-female person is a biologic male who identifies as a female, and a female-to-male person is a biologic female who identifies as male. The term “transgender” encompasses persons who have undergone surgery and/or taken hormones, as well as those who have not. Transgender persons can, and do, have partners of any gender. A 2007 Newsweek article² and the Oscar-nominated film, Transamerica, have brought transgender lives to the attention of Americans, but medical and cultural information about transsexual health has not entered into mainstream medical journals. However, there are a few excellent protocols specific to transgender health that are available online at no cost.^1,3

Transgender persons are a small but growing minority, and they face daily discrimination within and outside health care settings. Many do not have identification documents that match their current name or gender. This is often combined, at least initially, with a variant gender presentation (e.g., a man in women's clothing), further pushing them to society's margins. Sharing educational and employment history may require disclosing one's transgender status. A recent study found 35 percent of transgender respondents unemployed in a city with an unemployment rate of less than 5 percent.⁴ Nemoto and colleagues found discrimination and stigma to be the key factors pushing many male-to-female transgender persons well below the poverty threshold and into high-risk sexual work.⁵ Human immunodeficiency virus rates among male-to-female transsexuals range from 11 to 78 percent, with blacks showing the highest seroprevalence rate at 44 to 63 percent.⁶

Most transgender persons take estrogen or testosterone, which necessitates regular interactions with the medical system. These visits can be excellent opportunities for preventive health care, health maintenance, and close monitoring of the side effects associated with hormone use. Transgender persons have the same health maintenance needs as the rest of the population, but screening decisions should be based on current anatomy rather than sex or gender. Female-to-male patients with a cervix need regular pap smears, and may use their vaginas for penetrative sex; testing for pregnancy and sexually transmitted disease may be appropriate. Any patient with breasts should have age-appropriate health maintenance. In addition, hormone monitoring should occur every three to six months, as outlined in the Tom Waddell Protocol, a clinical resource for physicians caring for transgender patients.³

The case scenario presented here illustrates how interactions with the medical establishment often frustrates transgender patients. One study reported that 26 percent of transgender patients had been denied medical care specifically because of their transgender status.⁷ Schilder and associates found that when health care professionals did not affirm their patients' gender identity, it was perceived as humiliating and led to avoidance by the patient, which led some of the study participants to buy hormones on the street rather than interact with the medical establishment.⁸

How could the patient-physician interaction from three years ago have gone differently in the scenario being discussed? A key part of creating a safe atmosphere for transgender patients is using appropriate pronouns, vocabulary, and terminology. Transgender persons are addressed according to their chosen gender. For example, a male-to-female patient is a woman, and female pronouns should be used. The office could have had added a “transgender”-labeled box to tick on their patients' forms, giving more information to the staff while welcoming transgender patients. Some offices may use the identifiers of “male,” “female,” and “other” or “transgender” for tick boxes on intake forms as a way to avoid assumptions about patients' genders, whereas others allow patients to fill in a blank for gender. Guessing the proper mode of address can stymie even the most seasoned physician. We have found that simply asking our transgender patients what name and gender they prefer works well. Body parts should be referred to with gender-neutral language whenever possible. Words like “chest” and “genitals”, as well as phrases like “persons with vaginas” are descriptive and accurate, and can substantially increase your patients' comfort levels.

The physician could have thought about the patient's body anatomically by considering his present anatomy, rather than doing a routine physical examination based on his gender presentation. It would have been reasonable and appropriate for the physician to admit his lack of experience with transgender patients, asking him what he expected or needed from the office visit. Inquiring about his previous medical care and the ways in which it had been positive and negative also could have given the physician useful information. Pertinent questions are best asked in a frank and simple manner. Examples of questions to a male-to-female woman include: “Do you still have a penis?”; “Do you use it for sex?” However, lines of questioning should be restricted to addressing the patient's current reason for visiting (e.g., most visits for bronchitis should not include questions about genitals). Using simple, frank questions will make the physician less likely to trip over the asking, and his or her patients will be more likely to hear questions as basic and health-related, rather than curious or intrusive. In addition, given the potential risks of hormone therapy, the office should have been less cavalier about refilling testosterone without monitoring the patient. It is important that physicians periodically discuss the potential risks, side effects, and benefits so patients can make informed decisions.

Concepts of gender are changing, which makes more room for persons to find gender identities that match the way they feel (rather than the way society says they should feel); widens out the middle ground; and allows for more room in traditional gender territories for persons who were not born there. Physicians have an important role to play in welcoming these patients to their new gender and guiding that transition so it is as safe and easy as possible. It's a hard road, but physicians are uniquely qualified to ease the way.