Barriers to care

Seeking gender-affirming medical care can prove to be challenging for many transgender individuals. An individual’s ability to receive gender-affirming care may be limited by location or lack of medical providers with both competence and willingness to provide gender-affirming care. Additionally, health insurance coverage for gender-affirming care is inconsistent, oftentimes requiring prior authorization, and sometimes outright precluding coverage. Depending on location, some individuals may not be able to seek gender-affirming care at all due to legal restrictions. Finally, many individuals are unable to seek gender-affirming medical interventions due to fear of violence, loss of employment, housing, or family and intimate partner acceptance. Due to a multitude of circumstances, medical transition may not be an option for some individuals who would otherwise desire it.

WPATH standards of care guidelines

The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) provides guidelines for both medical and surgical interventions for transgender individuals. The goal of the SOC is “to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment” [ ]. The SOC represents a global consensus on the criteria for medical and surgical interventions provided and establishes best practices related to the care of this patient population. The SOC provides clinical guidelines, but individual care providers may modify them based on their own clinical judgment and unique patient needs.

Gender-affirming hormone therapy

Gender-affirming hormone therapy can be initiated and managed by a variety of providers including but not limited to primary care physicians, obstetrician-gynecologists, urologists, pediatricians, endocrinologists, and advanced practice providers such as physician assistants or nurse practitioners. Individuals can be assessed for readiness for hormone therapy either by a mental health provider, or any provider who is comfortable with assessment of gender dysphoria [ ]. Historically, a “referral letter” from a mental health provider has been required in order to initiate gender-affirming hormone therapy, but the SOC recognizes both this method and an informed-consent model, where the prescriber evaluates for decision-making capacity, as valid [ ].

Puberty blockade

The use of puberty blockers is a common intervention for transgender youth and adolescents. GnRH (gonadotropin-releasing hormone) agonists account for the majority of puberty blockade. GnRH agonists function by providing continuous stimulation as opposed to the typical pulsatile stimulation that the pituitary gland responds to. This continuous stimulation suppresses gonadotropin release and thus prevents the production of sex hormones. This intervention can delay or halt the development of secondary sexual characteristics with the aim of affording younger individuals additional time to explore gender identity further, prior to the initiation of cross-sex hormone therapy as described in the following sections. Puberty blockade is typically initiated around Tanner stage 2. After a period of puberty blockade, if the decision is made to proceed with gender transition, cross-sex hormone therapy can be initiated to allow the individual to experience puberty as appropriate for their affirmed gender. If the decision is not to proceed with gender transition, the puberty blockers are withdrawn, and puberty consistent with the individual’s natal sex resumes.

Feminizing therapy

Feminization therapy typically takes a two-pronged approach, which includes the administration of exogenous estrogen and the suppression of endogenous androgen with an antiandrogen medication. Estradiol is typically administered as 17-beta estradiol, which is bioidentical (identical in structure to estradiol secreted by ovaries). While estrogen itself will suppress testosterone, it will usually not suppress it into the female range; so typically, an additional antiandrogen is required to suppress testosterone to goal levels in most cases.

Estrogen therapy: Exogenous estrogen comes in the form of estradiol tablets, estradiol valerate for intramuscular (IM) or subcutaneous (SQ) injection, and estradiol transdermal patches.

Antiandrogen therapy: Most commonly, spironolactone is used to decrease testosterone levels. Spironolactone, a potassium-sparing diuretic, when given in higher doses, has antiandrogen effects. As alternatives or second-line agents, 5-alpha reductase inhibitors such as Finasteride or Dutasteride may be used, as well. These medications decrease the masculinizing effects of testosterone by preventing the conversion of testosterone to the more potent dihydrotestosterone. Less commonly, alternative antiandrogens such as Bicalutamide and Cyproterone acetate are also used by some.

Masculinizing therapy

Masculinization through hormone therapy is achieved by administering exogenous testosterone, typically targeting serum testosterone levels at the middle of the cisgender male lab value range. Testosterone can be administered through multiple routes including either IM injections or SQ injections (testosterone cypionate or testosterone enanthate), transdermal gel, transdermal patches, implantable pellets, or oral capsules. Modality of administration and regimen varies from region to region and from individual to individual. Decisions are typically made based on insurance coverage, cost, and patient and provider preference.

Surgical gender affirmation

Surgical gender affirmation is a less easily accessible intervention for transgender individuals than hormone therapy. Due to the limited number of surgeons with expertise in gender-affirming surgery, wait times are often long, and in many instances, long-distance travel may be required to access this form of care.

Common gender-affirming surgical interventions for transfeminine individuals include:

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  Vaginoplasty: creation of neovagina

  
  
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  Clitoroplasty: creation of clitoris

  
  
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  Vulvoplasty: creation of vulva

  
  
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  Penectomy: removal of penis

  
  
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  Orchiectomy: removal of testes to lower testosterone levels

  
  
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  Breast augmentation

  
  
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  Facial feminization

  
  
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  Vocal feminization

  
  
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  Thyroid cartilage reduction

  
  
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  Body contouring

Common gender-affirming surgical interventions for transmasculine individuals include:

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  Phalloplasty: creation of a neophallus using a skin flap from the arm, the thigh, or the latissimus dorsi

  
  
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  Hysterectomy

  
  
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  Salpingo-oophoretomy

  
  
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  Mastectomy and chest masculinization

  
  
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  Vaginectomy

  
  
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  Scrotoplasty

  
  
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  Metoidioplasty: creation of a neophallus from a testosterone-enlarged clitoris, with or without urethral lengthening

Criteria for gender affirmation surgeries

Gender-affirming surgeries, when performed out of medical necessity, must be performed only after assessment by a qualified mental health provider [ ]. Breast and chest surgeries require one letter of referral. Genital surgeries and surgeries that involve reproductive organs require two referrals. For all surgeries, patients should have persistent and well-documented gender dysphoria, the capacity to consent for treatment, and be of the age of majority. Additionally, medical or mental health concerns, when present, should be reasonably well controlled [ ].

Hormone therapy is not a requirement for chest surgery but is recommended (unless contraindicated) in feminizing chest surgery to maximize potential breast growth and esthetic outcomes. In addition to the criteria above, for hysterectomy, salpingo-oophorectomy, and orchiectomy, 12 continuous months of hormone therapy is required (unless contraindicated). For metoidioplasty, phalloplasty, or vaginoplasty, 12 continuous months of living in a gender role congruent with the patient’s identity is required, in addition to the required criteria for other gender-affirming surgeries [ ].

Conclusion

The care of transgender patients has historically been poorly presented in formal medical education. Fortunately, in recent years, interest has been widely growing. However, there remains significant discomfort and lack of confidence in the general medical community when it comes to the care of transgender patients.

The medical process of transition represents a massive opportunity for the medical community to support transgender individuals in making significant strides toward physical and mental health, social acceptance, and alleviation of gender dysphoria. It remains an area largely dependent on anecdotal evidence and clinical experience, necessitating the presence of thought leaders and constant interdisciplinary collaboration. The paucity of data available highlights the necessity of further well-designed research studies in efforts to guide the development of evidence-based practice for the future of transgender health.