Chapter 42: Care of Transgender Patients

Care of Transgender Patients begins by establishing necessary terminology, distinguishing between gender identity, gender expression, and natal sex, while emphasizing the adverse health outcomes and barriers to care—such as discrimination, violence, and avoidance of medical services—prevalent in this population. A key focus is the clinician's role in creating an inclusive environment through practices like using preferred names and pronouns, maintaining confidentiality, and utilizing the two-step method for gathering demographic data regarding gender identity and assigned sex at birth. The text details the clinical management of gender-affirming interventions, including the expected physical changes, timelines, and risks associated with feminizing and masculinizing hormone therapies (estrogen and testosterone), as well as the use of GnRH agonists for puberty suppression in adolescents. It also categorizes various surgical options, from chest reconstruction and hysterectomy to vaginoplasty and facial feminization. Significant attention is given to the organ inventory framework, which directs physical examinations and cancer screenings (such as Pap smears, mammograms, and prostate exams) based on the anatomy present rather than the patient's gender identity. Additionally, the chapter addresses specific health concerns related to gender-affirming practices, such as skin issues and pain from chest binding in transgender men, or hernias and urinary symptoms from genital tucking in transgender women. Diagnostic reasoning is further applied to differential diagnoses for complaints like pelvic pain, vaginal bleeding during testosterone therapy, and complications arising from illicit soft-tissue silicone injections.