New provider recommendations aimed at doctors caring for trans patients were published on July 1 in the Annals of Internal Medicine, including changes that overall make it easier to identify trans patients and provide medical care for trans individuals. Written by Joshua D. Safer, M.D., of Mt. Sinai Health System, and Vin Tangpricha, M.D., Ph.D., of Emory University School of Medicine, the guidance proposes the following changes to relationship between health care/service providers and transgender people in the U.S.:
1: You Should Be Counted as Transgender on the Basis of Your History, Not Gender Dysphoria Diagnosis
This new guideline recommends that a patient can be counted as trans based on their history alone, without specifically diagnosing for gender dysphoria. In contrast to guidelines from the World Professional Association for Transgender Health (WPATH) and the Endocrine Society, which recommend diagnosing trans patients with gender dysphoria prior to medical treatment, this new guideline recognizes that not all trans people have dysphoria. It advises providers to establish patients as transgender based on the following criteria:
- A persistent gender identity that does not align with sex recorded at birth
- Capacity to make medical decisions
- Potential confounding mental health conditions (e.g., anxiety, depression, suicidality, etc.) are addressed to make sure that these are not confusing a patient who is not actually trans
This new type of assessment does not require providers to declare one as gender dysphoric, which alleviates decades of historical stigma and trauma attached to such a diagnosis despite its intention to better characterize, without pathologizing, the discomfort felt by some persons from misalignment between gender identity and the sex recorded at birth. The requirement for persistence with being trans does not involve a specific time frame, but there have been typically multiple years of having a gender identity that does not align with sex recorded at birth, extending as far back as childhood. For those with a shorter time frame, the recommendations ask explicitly that providers further assess the timing of therapy and explore underlying factors such as mental health conditions that can interfere with reliable history-taking, along with the individual's goals for gender change.
2: Transgender Medicine Should Be Expanded to Include Primary Care Providers
Under these recommendations, the determination for establishing adult patients as trans and providing transgender care can be made by any clinician, including primary care providers, with sufficient knowledge of transgender care medicine. This also includes having primary care providers and other clinicians initiate and routinely monitor hormone therapy, in tandem with administering cancer screenings and infection prevention strategies such as pre-exposure prophylaxis (PrEP) for HIV prevention, on the basis of tissue and organ present, regardless of gender identity, given that certain gender-affirming care (e.g., hormone therapy) can increase risks for cancer and thrombosis (i.e., blood clots).
Consultations with other clinicians, such as mental health providers for addressing confounding mental health conditions or endocrinologists for questions about hormone therapy initiation, are highly encouraged when deemed necessary. As such, one of primary care providers' key roles is being comfortable enough to identify and make referrals, co-managing with specialized clinicians. Primary care providers also must triage and counsel trans patients about the risks and benefits of each gender-affirming service and treatment before initiation.
For children and adolescents, a team of clinicians (e.g., primary care provider, pediatrician, mental health professionals) are recommended for proper assessment. This includes having clinicians be mindful and sensitive about navigating certain family circumstances (e.g., trans children or adolescents whose parents are not aware of the child's gender identity) that can influence care, and, foremost, to maintain respect and confidentiality for patients.
The expansion of primary care providers' role in transgender medicine is particularly important given that primary care providers are generally more accessible to larger trans communities, compared to specialized providers.
3: Providers Should Discuss Fertility/Reproductive Health Options ...
As some hormone therapy and gender-affirming surgeries could impact fertility options (i.e., loss of reproductive potential), the recommendations explicitly encourage health care providers to promote discussion with trans patients about their fertility considerations before starting transition-related medical interventions. Specifically, primary care providers must ascertain fertility and family planning in advance of transition medical procedures and establish appropriate expectations about the procedures' impact on sexual functions. Some options for fertility security include cryopreservation of oocytes, embryos, or sperm.
4: ... as Well as Hormone Therapy Options
While there are many combinations of treatment for hormone therapy, these recommendations recognize the conventional approaches. For transfeminine hormone therapy, it means decreasing testosterone levels by starting on estrogen and antiandrogen (e.g., spironolactone) regimens concurrently, though some trans patients may need a different regimen (e.g., progestin) to effectively suppress testosterone. For transmasculine hormone therapy, the goal is to administer testosterone at an appropriate dose to achieve and maintain hormone levels in the male range, though maximum dosing is not required. In both approaches, providers must closely monitor hormone levels to lower risks for negative outcomes like thrombosis.
5: Hormone Therapy Should Not Be Required for Gender-Affirming Surgery
While not all trans patients seek surgical interventions, previous gender-affirming surgical options required transgender patients to be on hormone therapy for a period of time (usually at least a year). Separating hormone therapy from surgical requirements was previously not specified by WPATH and Endocrine Society guidelines. However, these new recommendations state explicitly that hormone therapy before gender-affirming surgeries is not obligatory. These surgeries can include facial feminization surgeries, breast augmentation, and genital reconstruction surgeries (e.g., vaginoplasty, orchiectomy) for trans women, and chest reconstruction surgery, oophorectomy and/or hysterectomy, and genital reconstruction surgeries (e.g., vaginectomy, metoidioplasty, phalloplasty) for trans men.
How to Use These Recommendations to Advocate for Your Care
While these recommendations are specific to health care providers, trans patients can utilize them to advocate for themselves and their transition goals. Like with any new recommendations, it is pertinent to note that these changes to guidelines will take time to be adopted by health care providers. However, trans patients can begin initiating these dialogues with their provider. It is vital for trans patients to locate a trusted health care provider who can help them manage their gender goals.
According to the recommendations, these are some helpful questions to ask providers during visits:
- Do you have experience caring for transgender patients?
- Are transgender medical and surgical interventions covered by my insurance?
- What are the risks and benefits of hormone therapy?
- When will I start to see changes in my body after starting hormone therapy?
- I would like to have children one day. How can I preserve my fertility?
In tandem with the highlights listed above, trans patients should expect the following procedures from their providers during their first visit:
- Take a detailed medical history.
- Ask questions to find out how long a patient's gender identity has differed from the sex recorded on their original birth certificate.
- Assess the patient's ability to make medical decisions.
- Referral to a mental health professional if the doctor believes their patient would benefit from one.
In addition to finding a trusted health care provider, it is also vital for trans patients to look for elements of a successful care environment within health care facilities from which they will receive care. This includes seeking health care facilities that have transgender-specific staff and provider training (not just one training, but periodic refreshers), a transgender-friendly system such as inclusive bathroom-use policies, and updated electronic medical records that collect and adapt to changes in a patient's name, sex on birth certificate, current gender identity, and pronouns.
Health Insurers Also Have a Role to Play
As these recommendations support the current global move to eliminate gender dysphoria as a diagnosis (the World Health Organization plans to remove gender dysphoria entirely, U.S. insurance companies should follow in tandem with this new recommendation. While not all trans people experience gender dysphoria, many will continue to need specific transgender medical and surgical affirming interventions even in the absence of gender dysphoria. As such, insurance companies should aim to align themselves with these recommendations and provide reimbursable services specific to transgender medical and surgical affirming interventions.
The American College of Physicians recommends complete insurance coverage for transgender medical care, and these new recommendations do as well.