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Best practices in LGBT care: A guide for primary care physicians

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Step #5: Initiate or continue hormone therapy for transgender individuals

Hormone therapy often improves the quality of life for patients who desire to have their physical appearance align more closely with their gender identity.29 Moreover, abruptly stopping hormone therapy can have significant psychological consequences.36

Clinicians should feel comfortable starting hormone therapy for patients who have been diagnosed with gender dysphoria by a mental health professional, can demonstrate knowledge about and outcomes of hormone therapy, and have lived as a member of the desired gender (“real-life experience”) for at least 3 months, and preferably 12 months.29 More recently, some practitioners have advocated prescribing hormone therapy for patients without the requirement for real-life experience or a formal letter from a mental health professional recommending hormonal therapy.37 However, mental healthcare is recommended for any patient with moderate to severe mental health conditions, especially if not treated at the time of presentation.37

Providers should continue hormone therapy for patients who are already receiving it, while being aware of the appropriate treatment goals and monitoring parameters. The two main principles of hormone therapy for transgender patients are to reduce endogenous hormone levels and their associated sex characteristics and replace with hormones of the preferred sex.29 Doses and formulations are similar to those used for treatment of hypogonadism. This topic has been reviewed by Spack.10

The only absolute contraindications to hormone therapy are estrogen- or testosterone-responsive tumors. Otherwise, hormone therapy can be initiated or continued with the patient’s informed consent about its benefits and risks.

Estrogen therapy may increase the risk of thromboembolic disease, coronary artery disease, cerebrovascular disease, severe migraine headaches, liver dysfunction, and macroprolactinoma.29 In a cross-sectional study of 100 transgender patients receiving hormone therapy, 12% of transgender women experienced a thromboembolic or cardiovascular event after an average of 11 years of treatment.38 However, many of these patients had additional risk factors for these events, such as smoking. In contrast, results from a recent systematic review39 indicated a much lower rate of venous thromboembolism among transgender women receiving estrogen therapy (1.7%–6.3%). Use of transdermal estrogen may minimize the likelihood of thromboembolic disease, and cessation of hormonal care in the perioperative period is advisable, especially for procedures with greater risk of venous thromboembolism.39

Transgender men are at risk of erythrocytosis (hematocrit > 50%) as a result of testosterone therapy. Although current guidelines indicate that testosterone may increase the risk of breast or uterine cancer, results from a recent systematic review40 indicate that the overall cancer incidence in transgender men is not higher than in natal controls. Both estrogen and testosterone therapy increase insulin resistance and fasting glucose levels, whereas only estrogen increases triglyceride concentrations.40

For transgender women, estrogen levels should be maintained in the normal range for cisgender women of reproductive age (< 200 pg/mL), and testosterone levels should be suppressed to less than 55 ng/dL. Goal testosterone levels for transgender men are between 320 and 1,000 ng/dL and should be measured at intervals specific to the preparation used (ie, measured midway between injections for individuals treated with testosterone cypionate). Estradiol levels should be less than 50 ng/dL.29 Transgender women and men should have estradiol and testosterone levels measured quarterly during the first year of treatment, and then every 6 to 12 months thereafter once goal levels are achieved.

Additional monitoring for transgender women includes measuring serum prolactin at baseline and after 12 months of therapy, and serum electrolytes for those taking spironolactone as antiandrogen therapy. Complete blood cell counts and liver function tests should be done every 3 months during the first year of testosterone therapy for transgender men, and then one to two times per year.29 Reference laboratory values for the patient’s affirmed gender should be used to assess response to therapy as well as effects on end-organ function.

The marked suppression of endogenous hormone levels that occurs during therapy may have adverse effects on the bone mineral density of both transgender women and men. Clinicians should assess patients’ baseline risk for osteoporotic fracture at the time hormone therapy is started and consider bone mineral density testing if appropriate. For those at low risk for fracture, current guidelines recommend screening for osteoporosis starting at age 60.29

Providers should counsel patients who have recently initiated hormone therapy that some changes may occur gradually over time. While transgender women will notice a decrease in libido and spontaneous erections within the first 3 months of therapy, breast growth begins approximately 3 to 6 months after treatment is started. Similarly, for transgender men, fat redistribution occurs during the first 6 months of treatment, but facial and body hair growth occur more slowly and are at maximum 4 to 5 years after starting hormone therapy.29 Amenorrhea typically occurs 1 to 6 months after starting hormonal therapy for transgender men.

Some patients may be interested in surgery to continue their physical transformation to the desired sex. Patients who have used hormone therapy and participated in a real-life experience or otherwise completed social transition by living as the affirmed gender for 12 months are considered eligible for surgery if they can demonstrate a good understanding of the cost, potential complications, and expected recovery time of the procedure. Guidelines also recommend that the patient demonstrate progress in work, family, and interpersonal issues regarding their new gender.29 Available surgical options include breast augmentation, orchiectomy and penectomy, and vaginoplasty, clitoroplasty, and vulvoplasty for transgender women. Feminizing procedures include voice surgery, thyroid cartilage reduction, and facial feminization surgery. Transgender men may choose to have mastectomy, hysterectomy and salpingo-oophor­ectomy, vaginectomy, scrotoplasty and testicular implant placement, and implantation of a penile prosthesis. Additional virilizing surgeries include voice surgery and pectoral implants.41

Step #6: Screen for intimate partner violence

Intimate partner violence refers to physical, sexual, and psychological harm by a current or former partner or spouse, and it can occur in gay and lesbian relationships. In 2000, a National Violence Against Women survey found that 21.5% of men and 35.4% of women who reported living with a same-sex partner had experienced physical abuse.42 More recent studies confirm rates similar to those in heterosexual relationships. In an online study,43 11.8% of men who have sex with men reported physical violence from a current male partner, and about 4% reported experiencing coerced sex.

Intimate partner violence is uniquely challenging for LGBT people. In addition to the commonly described methods an abuser uses to maintain power and control, forced disclosure or “outing”—publicly revealing someone’s sexual orientation or gender identity—may result in additional psychological violence and harm. Survivors of intimate partner violence who are in same-gender intimate relationships often find that obtaining services through the police, judicial, and social services systems is challenging. Survivors may be required to disclose their sexual orientation or gender identity as part of filing a report or judicial order to obtain help or protection from the abuser. Many male and transgender survivors of intimate partner violence are unable to access traditional shelters. Female survivors may find that their same-sex abusers have the same access to resources and shelters that they do.

Intimate partner violence is associated with negative physical and mental health outcomes. Physical injuries such as bruises, fractures, and burns are some of the more obvious harms survivors sustain. However, the negative psychological impact on survivors cannot be overstated. LGBT individuals are at greater risk of depression and substance abuse as a result of intimate partner violence than their cisgender heterosexual counterparts. The stress resulting from stigmatization and discrimination can be exacerbated by intimate partner violence.44 This can be seen in health outcomes of HIV-positive men who have sex with men, in whom abuse predicts interruptions in care, more advanced HIV disease, and HIV-associated hospitalizations.45

We recommend that providers screen all LGBT patients for intimate partner violence. One commonly used tool is the Partner Violence Screen, which consists of three gender-neutral questions:

  • Have you been hit, kicked, punched, or otherwise hurt by someone in the past year? If so, by whom?
  • Do you feel safe in your current relationship?
  • Is there a partner from a previous relationship who is making you feel unsafe now?

Like other screening tools for intimate partner violence, the Partner Violence Screen is more specific than sensitive.46 Screening and discussions about intimate partner violence should be performed in a private, confidential manner while the patient is alone.

Providers who care for LGBT patients need to be aware of not only the medical and mental health sequelae of intimate partner violence but also the social and legal issues facing survivors. Familiarity with the available community resources and their limitations can better facilitate trust and patient care for those affected by intimate partner violence. In one study, the most frequent requests for assistance from sexual and gender minority survivors were for counseling, safe housing, legal assistance, and assistance navigating the medical system.47 Providers should refer patients to LGBT-focused resources in their community as available, and when no such resources exist, initiate contact with standard domestic violence services, with patient consent, to ask about a program’s ability to assist survivors of LGBT intimate partner violence.

IN A NUTSHELL

Optimizing the care of LGBT patients requires developing both clinical and cultural competency.

Initial steps for creating an inclusive and welcoming clinical environment include becoming familiar with local resources for LGBT patients (support groups, substance and alcohol cessation groups, mental health providers; see sidebar), providing education and training for support staff and nurses, and establishing gender-neutral bathrooms. Waiting areas should include literature relevant to LGBT patients and signage that is relevant to all patients, including gender-nonconforming individuals. Providers should offer all patients universal HIV screening initially and at clinically appropriate intervals and discuss preexposure prophylaxis with emtricitabine-tenofovir for at-risk individuals.

For transgender patients, addressing them by their preferred name and pronouns is central to building rapport. General health maintenance is the same for transgender patients as for cisgender patients and can be guided by the adage “screen what you have.” Hormonal care can be offered using an informed consent method consistent with the World Professional Association for Transgender Health Standards of Care.48 Guidelines exist to assist providers in initiation and maintenance of hormonal care. Cross-gender hormonal therapy is initiated with low-dose medication that is gradually increased over time, with a goal of approximating the pubertal changes of the desired gender over a 2- to 3-year period. Some, but not all, patients may pursue various surgical procedures as part of their gender affirmation process.

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