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Clinical Crossroads
Clinician's Corner
February 6, 2013

Management of Transgenderism

Author Affiliations

Clinical Crossroads Section Editor: Edward H. Livingston, MD, Deputy Editor, JAMA.

Author Affiliations: Dr Spack is Associate in the Endocrine Division of Boston Children's Hospital and Cofounder/Codirector of the hospital's Gender Management Service and is Assistant Professor of Pediatrics at Harvard Medical School, Boston, Massachusetts.

JAMA. 2013;309(5):478-484. doi:10.1001/jama.2012.165234

Gender identity disorder (transgenderism) is poorly understood from both mechanistic and clinical standpoints. Awareness of the condition appears to be increasing, probably because of greater societal acceptance and available hormonal treatment. Therapeutic options include hormone and surgical treatments but may be limited by insurance coverage because costs are high. For patients seeking male-to-female (MTF) change, hormone treatment includes estrogens, finasteride, spironolactone, and gonadotropin-releasing hormone (GnRH) analogs. Surgical options include feminizing genital and facial surgery, breast augmentation, and various fat transplantations. For patients seeking a female-to-male (FTM) gender change, medical therapy includes testosterone and GnRH analogs and surgical therapy includes mammoplasty and phalloplasty. Medical therapy for both FTM and MTF can be started in early puberty, although long-term effects are not known. All patients considering treatment need counseling and medical monitoring.

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    1 Comment for this article
    Improving Health Care for Transgender People
    Henry Ng, MD, MPH | Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
    As a provider whose practice is composed of over 25% self-identified gender variant, genderqueer or transgender patients, I very much appreciate Dr. Spack’s Clinician’s Corner and CME activity, for education on the medical management of transgenderism is not yet a routine part of medical education. A median of five hours is spent dedicated to the topics of LGBT health at most allopathic medical schools in the United States with little time spent on the medical, psychological and social issues facing transgender patients (1). In a 2011 national survey of transgender people, 50% of respondents had to teach their health provider about their care (2). Inclusion of the health needs of Transgender people into health professional education and continuing provider education is critical in improving access to quality primary care and hormonal care for medically vulnerable population.Dr. Spack’s case study illustrates many fundamental concepts in for caring for transgender patients. Some additional points include recognizing barriers to care unique to T ransgender patients. Although Dr. Spack uses the diagnosis of Gender Identity Disorder, a mental health diagnosis, other providers in the field of Transgender Medicine use other medical diagnoses in providing care as these are not seen as stigmatizing or pathologizing to patients. Anecdotally, some Transgender patients report being denied medical care and/or insurance coverage for health conditions associated with their present anatomy as a result of being labeled with GID. Moreover, some transgender patients face financial burden s for population of patients who are uninsured. Among the National Transgender Discrimination survey participants, many respondents postponed medical care when they were sick or injured, due to discrimination (28%) or inability to afford care (48%) (3). Routine laboratory testing can be seen as an oppressive financial barrier to care for some patients who wish to have medically supervised hormonal use.Despite these challenges, what I have learned over the four years that I have been providing care for Transgender people in northeast Ohio is that the approach to care is not necessarily as complicated as it first seems. Caring for LGBT people and those in the genderqueer spectrum begins with a degree of cultural humility and willingness to learn from our patients. It also requires learning skills outside of those taught in medical school, residency and fellowships. For some, that may mean spending time with a local endocrinologist to learn more about care protocols and recommendations, or exploring the World Professional Association for Transgender Health (WPATH) Clinical Guidelines which include informed consent models of care (4). Others may turn to the University of California at San Francisco’s Center of Excellence for Transgender Health which offers providers evidence and experience based protocols of care, including recommendations for medically essential lab testing (5). Finally, attending educational conferences such as GLMA’s Annual Conference or the Philadelphia Transgender Medical Education Institute can offer health professional students, trainees and practitioners the opportunity to develop their clinical skills and refine their understanding of Transgender Health (6,7).Henry Ng, MD, MPHhng@metrohealth.orgReferences:1. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, Gay, Bisexual, and Transgender–Related Content in Undergraduate Medical Education. JAMA.2011;306(9):971-977. doi:10.1001/jama.2011.1255.2. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the National Transgender Discrimination Survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011.3. Ibid4. World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th ed. Minneapolis, MN: World Professional Association for Transgender Health; July 2011. http://www.wpath.org/documents/SOC%20V7%2003-17-12.pdf. Accessed February 7, 20135. Center of Excellence for Transgender Health: http://transhealth.ucsf.edu. Accessed February 6, 20136. GLMA: Health Professionals Advancing LGBT Equality. http//www.glma.org. Accessed February 6, 2013.7. The 12thAnnual Philadelphia Trans-Health Conference. http://www.trans-health.org/. Accessed February 6, 2013.
    CONFLICT OF INTEREST: I am the Clinical Director of the PRIDE Clinic, a LGBT Health Service Line at MetroHealth Medical Center in Cleveland, OH and the President-elect of GLMA: Health Professionals Advancing LGBT Equality.