Chapter 79: Primary Care of Patients Who Are Transgender

Transgender and gender-diverse individuals represent a substantial portion of the United States population, yet they frequently encounter barriers to healthcare access stemming from societal stigma and provider uncertainty. Primary care physicians play a crucial role in delivering gender-affirming care, which validates an individual's gender identity through legal, social, or medical interventions. Understanding foundational terminology is essential, as gender identity represents a person's internal sense of their gender, which may diverge from the sex assigned at birth. Gender dysphoria, a recognized diagnostic condition, describes significant distress arising from incongruence between one's experienced and assigned gender. Effective patient assessment begins with affirming communication practices, including consistent use of the patient's preferred name and pronouns documented in medical records. Providers must conduct focused histories that explore gender-related surgical procedures, reproductive considerations, and practices such as chest binding or tucking, which can create medical complications including skin irritation or respiratory compromise. The physical examination should be tailored to the organs currently present while maintaining patient dignity and obtaining informed consent. Gender-affirming medical and surgical options vary based on individual goals and needs. Testosterone therapy induces virilization in transgender men, while estrogen and androgen blockers promote feminization in transgender women. Surgical interventions range from chest reconstruction and genital procedures to reproductive organ removal. Pharmacological monitoring requires attention to altered reference ranges, as cross-sex hormones affect laboratory values including hematocrit and testosterone levels, alongside surveillance for serious adverse effects like venous thromboembolism and cardiovascular complications. Long-term health maintenance remains critical, as transgender patients require age-appropriate cancer screenings based on anatomical structures present, bone density assessment to address osteoporosis risk, cardiovascular monitoring, and mental health support. Early access to gender-affirming interventions has demonstrated protective effects against depression and suicidality within this population.