1. The T in LGBT stands for transgender: an umbrella term with many meanings. This module will provide an overview of the diverse ways in which individuals express their gender. The primary focus of the module, however, will be on the primary healthcare of transgender individuals, with special attention to transsexuals (those who identify and/or express their gender as the opposite of their biologic birth sex, and often seek hormonal and surgical treatment).
At the outset it is important to note that the language used to describe transgender individuals and their healthcare is in flux, both in the medical arena and in general society. In the module, we tried to use terms that are most widely known and used among transgender health specialists and transgender individuals to date. However, we encourage you, as clinicians, to listen and talk to your own patients to determine which terms are preferable to them.
**We’d like to acknowledge and give very special thanks to Christine Duffy for her very careful review of this module, and for her multiple contributions. We’d also like to thank Ruben Hopwood and Alex Solange for their helpful comments.
© The Fenway Institute, 2009 1

2. As clinicians, it is important to keep in mind that the lives of transgender individuals can take many directions with a wide spectrum of experiences. While there is a great deal in the literature about mental health issues and emotional concerns, many transgender individuals live very happy, healthy lives.
This is a photograph of a family in which one of the parents underwent sex reassignment surgery (gender affirmation surgery).

3. It is also important to keep in mind that many transgender individuals experience discrimination, stigmatization, and acts of hatred. This is a photograph of Duanna Johnson, who was beaten by the police, filed a complaint, and six months later was killed in the community where she lived. One cannot overemphasize the negative environment that many transgender individuals face at home, at work, and in the community, and the impact that this environmental pressure can have on their ability to live a happy, healthy, productive life. As a result, many transgender individuals experience significant isolation, and suffer from depression and suicidal thoughts. They also have one of the highest levels of unemployment and underemployment, and are often not covered by health insurance.
In June 2008, the American Medical Association House of Delegates passed a resolution entitled “Removing Financial Barriers to Care for Transgender Patients”, which states: “Resolved, that our American Medical Association support public and private health insurance coverage for treatment of gender identity disorder as recommended by the patient’s physician.”

5. To better understand what it means to be transgender, it can be helpful to distinguish between sex, gender role, and gender identity.
Sex is a biological term referring to genetics and anatomy (were you born with male, female, or indeterminate anatomy?).
Gender Role refers to the traditional behavioral differences between men and women, as defined by the culture in which they live.
Gender Identity refers to a person’s internal or perceived sense of their gender (do you feel like you are male or female?).
Most people have a gender identity that aligns with their birth sex, and behave as expected by their culture. That is, their gender identity and gender expression are aligned.
However, some people have a gender identity that does not align with their birth sex. See next slide. 5 5

6. Transgender has been defined in many different ways and the definition is evolving. Although there isn’t one accepted definition of transgender, it is generally viewed as an umbrella term that
comprises anyone who does not conform to traditional gender norms. This includes:
Those who identify and/or express their gender as opposite their birth sex (often referred to as transsexuals, particularly after undergoing medical and hormonal treatment). For example, a person born with female anatomy may feel his true gender identity is male. This person might refer to himself as a man, may take on male mannerisms and style of dress, and may medically and/or surgically alter his body to affirm his male gender identity.
There is a wide array of terms that have been used to describe people within this group, including MTF, FTM, transwoman, transman, transsexual, gender-affirmed female, gender-affirmed male, and gender affirmed person.
Surgical intervention is not a requirement for an individual to fall within this group.
2) Those who define their gender as outside the binary construct of just male or just female. This includes those who identify with a fluid or changeable gender; those who prefer not to define themselves by any gender; those who feel their gender comprises both male and female elements; and those who feel gender cannot be restricted to just the two categories of male and female. Some people will use different labels for this, like genderqueer, queer, or gender fluid.
3) Those who for various reasons reflect the outward manifestations of different gender roles and cross-dress to varying extents. That is, people who wear clothing, jewelry, and/or make-up not traditionally associated with their anatomical sex, and who generally have no intention or desire to change their sex. Cross-dressing is more often associated with men, and is usually done on an occasional basis. Cross-dressing may be engaged in for numerous reasons, including a need to express a feminine/masculine side, artistic expression, or erotic enjoyment. “Cross-dresser” should be used instead of the term “transvestite” (which is considered pejorative).
Some, but not all transsexuals go through a “cross-dressing” period as they sort out their feelings. Cross-dressing can provide them temporary emotional (as opposed to sexual) relief from their feelings of being in the wrong anatomical body. Indeed, it might be said that some of these people aren’t cross-dressing at all because when they exhibit a gender expression that is opposite their birth sex, their gender identity and gender expression are then aligned.  6 6

7. There are different ways to conceptualize gender identity which can impact the way people feel about themselves and the terminology they and others use to describe them.
In the individual construct, at some point possibly in childhood, an individual begins to feel that aspects of their body are at odds with their gender identity which is based in their mind or soul. These individuals feel that any surgery is done to “affirm” their birth gender. They may refer to themselves as transmen or transwomen (or gender-affirmed men or gender-affirmed women, or simply as men and women) rather than think of themselves as having transitioned from FTM or MTF. (Hembree at al., 2009)
In the more traditional medical construct, one’s gender is generally defined by anatomy at birth. People whose gender identity does not develop consistently with their birth sex are considered to have gender identity disorder.
The distinction can affect how surgery and hormone therapy changes are perceived by patients, the medical community, and the public at-large. Are they changing or transitioning their bodies to the opposite sex, or are they affirming their gender identity by changing things about themselves which are inconsistent with who they have always been?

8. Gender Dysphoria: Strong feelings of discontent experienced by persons who feel their bodies are at odds with the gender they identify as their own. Often described as feeling trapped in someone else’s body.
Gender Identity Disorder: There are a variety of DSM IV and ICD10 Categories which characterize different conditions associated with variations in gender identity. While the “diagnoses” are generally thought of as psychiatric diagnoses, many feel they should be considered medical diagnoses and be used as the basis for allowing reimbursement for treatment of genuine medical conditions.
Some do not want to label variations in gender identity as a “disorder”. Instead, they prefer to view these variations as normal expressions of gender identity.
Some of the advantages to keeping the GID diagnosis are that 1) it may make it easier to obtain insurance coverage for medical care, such as hormone treatment, and for mental health support if needed, (e.g.., for depression or anxiety related to feelings of isolation/rejection, etc.); 2) it can help guide and support research into transgender health needs.
The main disadvantage is that the diagnosis appears to label variations in gender identity as a mental disorder, rather than a normal variation of gender identity. In fact, being transgender is not a disorder; however, living in a culture that does not yet really understand, support, or outright rejects transgender people can lead to mental health issues. Note, however, that not all transgender individuals struggle with their gender identity
Gender Difference/Variation: Terminology which suggests that one’s expression is a variant of normal. Less pejorative

9. There are a number of variations of the diagnosis Gender Identity Disorder in the DSM IV as well as similar definitions in the ICD10. While categorization as a disease may help achieve greater coverage for related hormonal and surgical treatments, clinicians may find they can develop a better relationship with a patient if they consider these feelings as normal variations of gender identity.
The other DSM diagnoses related to gender identity are:
Gender Identity Disorder in Children
Gender Identity Disorder in Adolescents or Adults
Gender Identity Disorder Not Otherwise Specified
This category is included for coding disorders in gender identity that are not classifiable as a specific Gender Identity Disorder. Examples include:
Intersex conditions (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia) and accompanying gender dysphoria
Transient, stress-related cross-dressing behavior
Persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex
4. Transvestic Fetishism: The diagnostic criteria for this are: a. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing. b. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

10. An important concept to understand is that gender identity and sexual orientation are distinct concepts. As explained in previous slides, transgender refers to a person’s gender identity and expression, and not to the gender(s) to which they are attracted. As with anybody, a transgender person can be attracted to men, women, both, neither, or other transgender people; and they may identify their sexual orientation as gay, straight, bisexual, asexual, or some other label. 10 10

11. “Intersex” or “variations of sex development” refers to a spectrum of conditions involving anomalies of the sex chromosomes, gonads, reproductive ducts, and genitalia. The most traditional definition of intersex refers to individuals born with both male and female genitalia, or genitalia that is not clearly male or female. A person may have elements of both male and female anatomy; or have different internal organs than external organs. The medical community recently adopted the term “Disorders of Sex Development” when referring to intersex conditions because of previous stigma and confusion associated with the term “intersex.” The new term has not been widely accepted in the intersex community or medical community, however, but is perhaps the most official term to date. Some prefer the term “Variations in Sex Development” as it avoids labeling one as having a disorder.
Intersex conditions are generally apparent at birth, but sometimes do not become evident until puberty, when unexpected secondary sexual characteristics arise.
People who are born intersex have medical, ethical, and surgical concerns that differ from transgender patients. However, they do share some similarities in terms of experiences of discrimination and misunderstanding within society and the healthcare system, and some intersex people identify as transgender, or as a gender minority. 11 11

12. At times, transgender people, along with lesbian, gay, and bisexual people, are referred to as “sexual minorities” or “gender minorities.” The research literature in particular has begun to use these terms to describe LGBT populations, particularly in the context of health and other disparities. Using minority terminology is considered helpful when trying to achieve legal or policy protections from discrimination, or when trying to secure funding for research and advocacy.
However, some people reject the use of the term “minorities” to describe LGBT people because they feel it further marginalizes rather than normalizes their sexual or gender identities. Instead, they would prefer to be seen as just another group within the mainstream culture. For similar reasons, some people reject as stigmatizing the terms “queer” and any term with the prefix “trans”. 12 12

13. To date, there are no reliable estimates of the transgender population in the US or abroad. A few studies have attempted to estimate the prevalence of transsexuals in a population using clinic data (e.g., numbers who attend clinics for surgical or medical attention). In 2007, two researchers (Olyslager and Conway, 2007)) presented a re-analysis of several published studies on transsexual prevalence and determined the prevalence to be between 1:1000 and 1:2000. They also presented some more recent data that estimates the prevalence to be as high as 1:500. Until this data was presented, the most frequently quoted estimates were from a Dutch study that estimated the prevalence of MTF transsexuals at about 1 in 12,000, and FTM transsexuals at about 1 in 30,000.
The use of a much broader definition of transgender (as described in previous slides) would significantly increase the prevalence estimate, but no studies or surveys have attempted to do this yet. 13 13

14. Transgender patients are a medically underserved population
Transgender patients are a medically underserved population. Transgender people are socially stigmatized, leading many transgender individuals to maintain a traditional gender role while keeping their transgender issues closeted. A Minnesota study of transgender health seminar participants found that 45% had not informed their family physician that they were transgender (Bockting, 2000). Our hope is through greater understanding of the range of issues a transgender person faces, a clinician can make a large difference in the lives of their transgender patients.

15. We aim not to offer a complete discussion of transgender health, but rather to outline the range of issues commonly of concern in primary medical practice. Like every population, the transgender community is diverse, and the health needs vary greatly from patient to patient. As with the non-transgender population, active consideration of biopsychosocial, socioeconomic, and spiritual health is encouraged as part of holistic primary care of transgender patients.
Transgender healthcare involves addressing two categories of concerns: general medical conditions and those related specifically to transgender issues. Primary care providers do not have to be experts in transgender medicine to meet the health needs of most transgender patients. With appropriate understanding of basic transgender issues, a little experience, and sensitivity to the terminology the their patients prefer, non-expert primary care providers can offer preventive care and health maintenance, acute and chronic disease management, and referral to specialists. Some transgender patients seek medical assistance to feminize or masculinize their bodies through cosmetic treatments, hormones, and/or surgery. While specialists are often involved in this level of care, the primary care provider plays a vital role in an individual’s care.
The primary care provider‘s initial response to a patient’s first attempt to discuss the patient’s gender identity or intersex-related condition can have a tremendous impact on the overall care the patient receives. A negative initial interaction between the provider and patient can result in the patient turning away from seeking clearly needed medical treatment or resorting to obtaining unsupervised assistance, such as ordering hormones over the internet.

16. There are a few helpful clinical guidelines for caring for transgender patients, as included on this slide. The WPATH Standards were the first to be written. They focus primarily on hormonal therapy and surgical treatments. The Vancouver guidelines provide more detail on primary care and behavioral health. The Endocrine Society guidelines provide very detailed information on hormonal treatments.
The WPATH Standards of Care (SOC) present the organization’s professional consensus about the psychiatric, psychological, medical, and surgical management of gender identity disorders. The SOC are meant to be flexible, and their overall goal is to help people with gender identity disorders have “lasting personal comfort with the gendered self” and “to maximize overall psychological well-being and self-fulfillment.” (wpath.org). Until 2006, the SOC were commonly referred to as the Harry Benjamin International Gender Dysphoria Association's Standards Of Care.
The WPATH SOC covers the following topics:
Purpose of the standards of care; treatment goals
Prevalence, natural history and cultural differences of gender identity variance throughout the world;
History of diagnostic nomenclature;
The role of the mental health professional;
Assessment and treatment of children and adolescents with gender dysphoria;
Goals and processes of psychotherapy for adults with GID;
Requirements for, and effects of hormone therapies;
Helping transgender patients adopt to their new gender role or presentation in every day life;
Surgical indications and ethics;
Basic guidelines for breast and genital surgery;
Recommendations for post-transition follow-up.
To review these and other clinical guidelines, see the websites listed in the slide.

17. The clinical approach to individuals who are transgender is multidisciplinary. Most guidelines recommend starting with a complete mental health evaluation, in part to assure other professionals involved in making treatment decisions that individuals who identify as transgender are truly transgender. Once this has been established, the guidelines recommend consideration of hormonal and then surgical interventions, as long as they are consistent with the patient’s desires. Medical and surgical intervention are often concomitant with patients living outwardly in the gender that matched their gender identity for a specified period of time (The Real Life Experience).

18. Clinicians conducting assessment prior to initiation of hormones or surgery are in a “gatekeeper” role that involves a power dynamic which can significantly affect therapeutic rapport. The client often perceives the evaluation not as a desired tool to help them therapeutically determine a plan of action, but rather as a hoop that must be jumped through to reach desired goals, a frightening loss of physical and psychological autonomy. Some providers follow the WPATH standards strictly, while others feel it is important to do careful assessment but do not always follow the letter of various guidelines. (Bockting et al., 2006)
If a patients feel that access to hormones is being unreasonably denied by clinicians, they may resort to acquiring hormones over the internet. This may lead them to experiment with other internet solutions, such as silicone injections.

19. The WPATH standards recommend a period of psychotherapy of a duration specified by the mental health professional after the initial evaluation (usually a minimum of three months) before the administration of hormones begins. Some patients may not understand why they need to meet with a mental health specialist and may wish to begin their hormone treatment earlier.

20. The questions in this slide (taken from Bockting et al
The questions in this slide (taken from Bockting et al., 2006) all relate to gender concerns a patient may have. Other potential areas of inquiry (with sample questions) include:
Medical history: Does anyone in your family have a history of chronic physical or mental health concerns? Do you have any chronic physical or mental health conditions, and if so, what are they? Are you currently taking any medication (including illicitly obtained hormones), vitamins, or herbal supplements, and if so what is the name, dose, and length of time you have been taking it? Have you taken hormones in the past? Have you attempted any body modifications in the past?
Alcohol and drugs: Do you smoke, and if so how much per day? Have you ever had any concerns relating to drugs or alcohol?
Family: People define ’family’ in many ways. Who do you define as being in your family? How would you characterize your relationships with your family members when you were a child, and now? Have you discussed your gender-related feelings with any family members? How are your life partner and/or children handling this?
Sexuality: Do you identify in a particular way in terms of your sexual orientation? Are you attracted to men, women, and/or transgender people, or are you asexual? Are you currently involved with anyone romantically? If so, how do you feel about your relationship? Have you ever had any concerns about sexual abuse or sexual assault?
Social: What are your social supports? When you are under stress, who do you turn to for help? Are you currently working/in school/volunteering? Do you have any concerns relating to work, school, or community involvement? Do you feel connected to any particular communities – e.g., transgender community, cultural community, lesbian/gay/bisexual community, youth groups, seniors’ groups, deaf community…?
Economic: What is your primary source of income? Do you have any current financial stresses? Are you worried about future financial stresses? Are you satisfied with your current housing? Any concerns about housing or work?
Religious: Are you religious? If yes, how does your religion feel about you’re your situation? Are you worried about being shunned by your house of worship?
For a complete list of questions, go to:

21. In addition to assessing an individual’s history and experience regarding lack of congruity between anatomic sex and gender identity, individuals who have struggled with these issues often have related mental and emotional health issues and often seek help to achieve resolution.
Some people with gender dysphoria have a very difficult time gathering the courage to go out in public for the first time dressed in accordance with their gender identity. Sometimes they realize the fear was unfounded. Consider suggesting support groups to patients, especially older patients who may not be savvy with accessing the internet or on-line support groups. If a patient is afraid to reach out to a support group, consider arranging an introduction to another patient (with that patient’s consent) who would be willing to introduce the patient to other members of the support group in a welcoming way, or to take the patient out in public for the first time.
Family members of the transgender patient may also need support to help them deal with the coming out process. Just be mindful of the physician’s primary duty to the patient and how their could be potential conflicts of interest between patient and family. While patients may have been struggling for years to come to terms with their true gender identity, in many cases their family members are just learning about it, and must deal with the transition/affirmation in a very compressed time period. See Handout 7-A for resources.

22. The majority of research studies on transgender health disparities have focused only on transwomen (MTF), and often in the context of HIV risk behaviors. This limited body of research has found high rates of mental and behavioral health problems, including suicidal behavior and depression, substance abuse, and risky sexual behavior. These issues are likely related to difficulties coping with living in a culture that stigmatizes gender variance. The risky sexual behaviors (e.g., unprotected anal sex) are often done in the context of sex work – an occupation taken up by many transwomen who are unable to find steady employment due to transgender discrimination.
The findings on this slide come from a meta-analytic review of 29 studies (Herbst et al., 2008), which provides weighted averages from these studies, and from a population-based study (Clements-Nolle et al, 2001) of MTFs in San Francisco. For the most part, studies on transwomen focus on HIV behaviors, and use convenience samples which may bias them towards overestimating risk behaviors. There is not enough research on transmen (FTM) populations to determine any trends.
Finally, it should also be noted that transgender people can have difficulty finding social support. Many are rejected by their families and communities of origin, and do not feel welcome by the gay and lesbian community either.

23. The WPATH Standards of Care define the “real life experience” (RLE) as “the act of fully adopting a new or evolving gender role or gender presentation in everyday life”, with the intention of achieving an experiential understanding of the familial, interpersonal, socioeconomic, and legal consequences of gender transition (Hembree et al., 2009; Meyer et al., 2001). This experience is thrilling for some, and disappointing for others who feel the actual experience does not meet their expectations. Many believe it is an unnecessary step they are required to take before affirming their gender identity (Hembree et al., 2009). They feel as if it is something they have been living throughout their lives, and question why an artificially imposed “real life experience” is necessary asking, “what has life been if not real?”.
The WPATH Standards of Care do not require RLE prior to hormone therapy or breast/chest surgery, but do include one year RLE as an eligibility criterion for genital reconstruction surgery. (Meyer et al., 2001). The WPATH standards do not view RLE as a diagnostic test to evaluate ones gender concerns, but view the process as a test of “the person’s resolve, the capacity to function in the preferred gender, and the adequacy of social, economic, and psychological supports”. For gender-affirming males, it is often not possible to live in the desired role without first undergoing chest surgery, so RLE is not required for such surgery.
It is important to note that the RLE is not defined by adherence to stereotypical ideals of masculinity or femininity. Just as there is a range of gender expression among non-transgender women (with many choosing not to wear makeup, dresses, or otherwise displaying attributes), there is a range of expression for transwomen and transmen.
Coming out and going through the RLE can be exhilarating for some people who have denied their gender identity for years. As a result, they may become very active in the trans community or very open about their affirmations.

24. Many transgender individuals seek feminizing or masculinizing hormone therapy – not only do the hormones create physical changes, but just the act of using them feels like an affirmation of gender identity (Bockting and Goldberg, 2006). Studies suggest that hormone therapy of presurgical transsexuals improves psychological adjustment and quality of life (Bockting and Goldberg, 2006). Patients desire a wide spectrum of hormonal changes. Not everyone seeks maximum feminization/masculinization; some prefer a more androgynous presentation (hormonal minimization of existing secondary sex characteristics).

25. While some transgender individuals obtain feminizing/masculinizing hormones from an endocrinologist, primary care providers are well-suited to provide safe and effective masculinizing or feminizing hormone therapy in the setting of comprehensive health care. It is not necessary for the prescribing clinician to be an endocrinology expert, but it is important to be familiar with relevant medical and psychosocial issues.
Hormone therapy must be individualized based on the individual’s goals, the risk/benefit ratio of medications, the presence of other medical conditions, and consideration of social and economic issues (Feldman, 2008). Standards of care cited above suggest a variety of regimens.

27. Prospective, large-scale studies of transgender healthcare outcomes are rare (Heidelbaugh et al., 2007). The best available evidence comes from a Netherlands historical cohort involving 816 male-to-female (MTF) and 293 female-to-male (FTM) transsexual patients, with hormone use ranging over 2 months to 41 years (van Kesteren et al., 1997). No differences in mortality were found compared to the general Dutch population. The only major complication was venous thromboembolism in transsexuals treated with oral estrogens and anti-androgens (fewer cases were observed since the introduction of transdermal oestradiol). The study did not follow the subjects long enough to determine long-term health effects. Experience with extended hormone use in other patients must be used to guide monitoring and follow up.

28. Once patients have achieved maximal feminizing or masculinizing benefit from hormones (typically two or more years) they remain on a maintenance dose. Maintaining body changes may require lower hormone doses compared to initial induction. The maintenance dose is then adjusted for change in health conditions, aging, or other considerations (e.g., lifestyle changes).
Upon presenting for maintenance hormones, you should assess the patient’s current regimen for safety and drug interactions and substitute safer medications or doses when indicated. The patient should be monitored by physical exam and laboratory testing every six months. Patients may occasionally need to reduce or temporarily stop their hormone therapy in anticipation of upcoming medical procedures, such as surgery or sperm banking. MTF patients, in particular, should discontinue estrogen 2-4 weeks prior to any major surgery to reduce the risk of thromboembolic events. It is helpful to discuss any temporary interruption of hormones with the patient well in advance (Bockting and Goldberg, 2006).

29. A survey of 232 male-to-female transsexuals at least 1-year postoperative (operated on between 1994 and 2000 by one surgeon using a consistent technique) found that patients were happy with their SRS results and that SRS had greatly improved the quality of their lives. None reported outright regret and only a few expressed even occasional regret. Dissatisfaction was most strongly associated with unsatisfactory physical and functional results of surgery. (Lawrence, 2003)
Some patients travel overseas, especially to Thailand, for the surgery.
It is not clear what percentage of gender dysphoric people seek surgery, though the percentage is believed to be low. It is very expensive and rarely covered by insurance. Fewer FTMs have genital reconstruction surgery because of the higher cost and possibly a desire to wait for improved surgical outcomes.

30. Deciding what surgeries are needed is often very difficult for patients, not only because of financial considerations. Some patients might decide they don’t need any surgery. Others may be encouraged by some health practitioners and/or trans support groups to have some or a lot of surgery in order to better pass or to achieve a desired look. The primary care physician can help the patient sort through the competing factors/pressures and reach a realistic assessment of both the patient’s needs and the results to be expected from such surgeries. Transpeople are no different from non-transpeople in having to navigate the social pressures associated with the culture’s current physical attraction standards. Many MTFs assimilate into society without any facial or vocal feminizing surgeries.
Patients who have vaginoplasty and mammoplasty surgeries should still have routine mammograms and gynecological exams.
MTFs will still require periodic prostate screenings even if they have had some form of genital surgery.

32. Concerns about gender identity can occur at any age
Concerns about gender identity can occur at any age. Recently, there have been reports of cases of very young children experiencing gender identity issues. For most children, this experience is transient. For others, it is persistent. These children may insist that they are a boy or girl, despite their anatomy, and will ask to be referred to as the opposite gender. As they approach adolescence and puberty, they often come to resent the changes that begin to occur, and that make them feel more at odds with their own bodies. Even during the preadolescent phase, these children may have desires to change their bodies. Girls want to grow a penis and might fantasize cutting off their breasts as they develop.
Recent developments in treatment of adolescents with persistent feelings that their anatomic sex does not match their gender identity allow physicians to reassure children that at the time of puberty, when feared bodily changes take place, there are treatments that can prevent these changes. Given the transience of GID among children, GNrH treatments are not begun until adolescence when individuals are in Tanner Stage 2 or 3, and the delay in puberty caused is generally completely reversible. (See Hembree et al, 2009). If after treatment with hormone blockers, adolescents feel good about themselves and more comfortable with their bodies, direct hormone therapy which can alter the body to the desired end can be begun usually after a year on GNrH blockers. This approach to treating adolescents has been controversial, and remains so, but is supported by the Endocrine Society (Hembree et al, 2009).
All currently published standards of care suggest deferring any surgical treatments until an individual is 18.

34. In applying knowledge from the non-transgender setting to transgender patients, the primary care provider should look for rigorous studies that are highly relevant to the clinical context. For example, a large prospective study involving non-transgender women on postmenopausal hormone therapy may be relevant for MTFs over age 50 who are taking similar types of hormones for feminizing purposes. Evidence from non-transgender studies can be directly applied to similar transgender patients who have not had surgical or hormonal interventions: e.g., studies involving non-transgender women are applicable to individuals in the FTM spectrum who have not taken testosterone or had masculinizing surgery. (Bockting and Goldberg, 2006)
As with all patients, a sensitive sexual history is important for transgender patients. Let your transgender patients know that you ask these questions of all patients, and that a sexual history is important to know for their overall health. See Module 2 for more on taking a sexual history.

35. The photo is of Thomas Beatie (transman who gave birth to a child in 2008)
Primary care physicians should try to avoid using clinical terms when treating a post-operative patient. For example, if a patient has already had gender-affirming surgery, refer to her vagina as a vagina, not a neo-vagina or his penis as a penis, not a neo penis. Patients do not need reminding that they have had genital surgery.

36. Patients may present for care already on hormones, whether prescribed by a clinician or obtained through other means (e.g., purchased over the Internet). If you are uncomfortable providing long-term hormone therapy, you can provide a 1-3 month prescription for hormones while assisting the patient in finding a clinician who can provide long-term hormone therapy. You should assess the patient’s current regimen for safety and drug interactions. Primary care providers who prescribe bridging hormones need to work with the patient to establish limits as to the time length of bridging therapy. (Bockting and Goldberg, 2006).

37. As mentioned previously, mental health evaluations are recommended for patients who seek surgical treatments for gender affirmation. For any transgender patient, whether they are seeking surgery or not, it is important to talk to them about stress in their lives, including any stress related to disclosure and non-disclosure of their true gender identity.

38. Academic, corporate and healthcare environments have been increasingly accommodating to the needs of transgender individuals, starting with human resource policies and institutional mission statements that prohibit discrimination based on gender identity and expression. Given the difficulty that many transgender people have encountered when seeking health care, it is particularly important that healthcare environments provide appropriate accommodations and a welcoming attitude for transgender individuals, as for all individuals from differing backgrounds. Some strategies to create a welcoming environment include:
Academic, corporate and healthcare environments have been increasingly accommodating to the needs of transgender individuals, starting with human resource policies and institutional mission statements that prohibit discrimination based on gender identity and expression. Given the difficulty that many transgender people have encountered when seeking health care, it is particularly important that healthcare environments provide appropriate accommodations and a welcoming attitude for transgender individuals, as for all individuals from differing backgrounds.
Some strategies to create a welcoming environment include:
Offering unisex bathrooms.
Educating staff about gender identity/expression and transgender health care issues, and training them to use clients’ preferred names and pronouns.
Instructing staff to never assume a caller’s gender by the mere sound of the caller’s voice over the phone (e.g., instead of saying “I’m sorry sir, the doctor is not available”, say “I’m sorry, the doctor is not available”). Even when affirmed female patients have given their female-recognizable first names, staff may still tend to use pronouns and words (e.g., sir) based on the sound of the patients’ voices. It may take practice to overcome this ingrained habit.
Posting your non-discrimination policies in highly visible areas in exam and waiting rooms and on your website;
Using intake forms that include transgender, intersex, and other as options under sex/gender (rather than just male and female), or that simply ask “Gender: ____________” or “Gender Identity: __________”; intake forms should also allow for a range of sexual identities/orientations.
Because some transgender people do not consider themselves as either male or female, when possible, especially in written materials, use plural pronouns (e.g., “they” instead of “he” and “she”; “their” instead of “his” and “her”; and “them” instead of “him” and “her”).
In addition, it is critical for you to listen to your patients – what terms do they use to describe themselves (e.g., a “gender-affirmed person”), what pronouns do they use, what words do they use to explain their medical needs? Don’t make assumptions. If you are not sure what words to use, be forthright and ask your patients what terms they prefer as you want to be as welcoming and accepting as you can be so that they feel as comfortable as possible.
Modules 1 and 2 have more on the topic of creating a welcoming environment and communicating with patients about sexual health and gender identity.
having unisex bathrooms; educating staff about transgender identity and health, and training them to use clients’ preferred names and pronouns; posting your non-discrimination policies in highly visible areas in exam and waiting rooms; using intake forms that include transgender and intersex as options under sex/gender (rather than just male and female), or that simply ask “Gender: ____________” ; intake forms should also allow for a range of sexual identities. During the patient interviews, a transgender patient may use a term you are not familiar with. If this happens, don’t be afraid to ask the patient in a respectful manner to explain what the term means. Modules 1 and 2 have more on the topic of creating a welcoming environment and communicating with patients about sexual health and gender identity.

39. See Handout 7-A for a list of multiple resources
See Handout 7-A for a list of multiple resources. See 7-B for references.