Medical Management

Highlights

• The medical transition of transgender adults can be managed by competent primary care providers.
• The goals of hormonal therapy are to (1) suppress 
endogenous hormone secretion and (2) maintain cross-sex hormone levels within the normal range for the person’s desired gender.
• Primary care physicians who are not comfortable prescribing hormone therapy to patients should complete an initial work-up (referral for official gender dysphoria diagnosis, history, physical, and baseline bloodwork) prior to referral to a specialist.

Overview

The World Professional Association for Transgender Health (WPATH) strongly encourages the increased training and involvement of primary care providers in the area of feminizing/masculinizing hormone therapy. This reduces the burden on specialists and allows for improved continuity of care in terms of managing a patient’s hormonal treatment along with regular healthcare screening and the management of issues unrelated to gender dysphoria.  While formal training programs in transgender medicine do not yet exist, hormone providers have a responsibility to obtain appropriate knowledge and experience in this field.

An experienced hormone provider or endocrinologist should be involved if the primary care physician has no experience with this type of hormone therapy, or if the patient has a pre-existing metabolic or endocrine disorder that could be affected by cross-hormone therapy.

The goal of managing adults who identify as transgender or who have gender dysphoria is to support the patient in achieving gender affirmation. Some will present to your clinic already having started a medical or surgical transition under the care of another physician and others may be seeking management of their gender dysphoria for the first time.

Medical management of transgender patients consists of the administration of hormonal and non-hormonal therapy to feminize or masculinize the body. In FtM patients testosterone is used. In MtF patients a combination of estrogen plus an anti-androgen is recommended. A medical transition is viewed as a necessity by many (but not all) transgender patients.

The goals of hormonal therapy are:

1. Suppress 
endogenous hormone secretion determined by the person’s genetic/biological sex;
2. Maintain sex hormone levels within the normal range for the person’s desired gender.

Patients will desire physical transition to varying degrees. Some patients desire maximum feminization/masculinization while others are seeking an androgynous presentation with minimization of existing secondary sex characteristics.  Importantly, hormone therapy is a prerequisite for some gender-affirming surgeries.

Mental Health Professionals should address at minimum the following aspects of a patient’s presentation prior to providing a referral for hormonal or surgical management:

• Conduct a full assessment of the patient’s gender identity and possible gender dysphoria; diagnose gender identity disorder if appropriate;
• Provide information regarding options for gender identity and expression and possible medical interventions; refer as required to qualified specialists;
• Assess, diagnose, and treat co-existing mental health concerns;
• Assess eligibility, prepare, and refer for hormone therapy as required.

The criteria for hormone therapy are as follows (WPATH):

•  Persistent, well-documented gender dysphoria;
• Capacity to make fully informed decisions and to consent for treatment (informed consent must be provided and documented);
• Age of majority (if younger, see Children & Adolescents);
• If significant medical or mental health concerns are present, they must be reasonably well- controlled.

In certain circumstances it may be acceptable to provide hormones to patients who have not met all of the above criteria (ex: a patient who is taking unregulated/illicit hormones).

Guidelines for physicians who prescribe hormone therapy include (WPATH):

• Perform an initial evaluation that includes discussion of a patient’s physical transition goals, health history, physical examination, risk assessment, and relevant laboratory tests;
• Discuss with patients the expected effects of feminizing/masculinizing medications and the possible adverse health effects. These effects can include a reduction in fertility therefore, reproductive options should be discussed with patients before starting hormone therapy;
• Confirm that patients have the capacity to understand the risks and benefits of treatment and are capable of making an informed decision about medical care;
• Provide ongoing medical monitoring, including regular physical exams and bloodwork to monitor hormone effectiveness and side effects;
• Communicate as needed with a patient’s primary care provider, mental health professional, and surgeon. If needed, provide patients with a brief written statement indicating that they are under medical supervision and care that includes feminizing/masculinizing hormone therapy. Particularly during the early phases of hormone treatment, a patient may wish to carry this statement at all times to help prevent difficulties with the police and other authorities.

Primary care physicians who are not comfortable starting hormone therapy on their own can perform an initial work-up (history, physical, bloodwork) and attain an official diagnosis of gender dysphoria from a qualified mental health professional prior to referring to a specialist (endocrinologist or qualified primary care physician).

The recommended content for a referral letter for hormone therapy includes (WPATH):

• The client’s general identifying characteristics;
• Results of the client’s psychosocial assessment, including any diagnoses;
• The duration of the referring health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;
• An explanation that the criteria for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy;
• A statement about the fact that informed consent has been obtained from the patient;
• A statement that the referring health professional is available for coordination of care and welcomes a phone call to establish this.

The following sections detail the assessment, management, and follow-up of trans men and trans women who desire hormonal therapy.

See the Downloads section for a printable summary of male and female hormone options.