Safer JD, Tangpricha V. Care of the Transgender Patient. Ann Intern Med. 2019;171:ITC1–ITC16. doi: 10.7326/AITC201907020
Transgender persons are a diverse group whose gender identity differs from their sex recorded at birth. Some choose to undergo medical treatment to align their physical appearance with their gender identity. Barriers to accessing appropriate and culturally competent care contribute to health disparities in transgender persons, such as increased rates of certain types of cancer, substance abuse, mental health conditions, infections, and chronic diseases. Thus, it is important that clinicians understand the specific medical issues that are relevant to this population.
Transgender and gender-incongruent persons have gender identities that differ from their sex recorded at birth (typically determined by examination of external genitalia). Studies estimate that 0.6% of U.S. adults, or 1.4 million persons, are transgender (1). This population faces disproportionate challenges in accessing health care services and may experience medical mistreatment (2–5). The largest barrier to care reported by transgender persons is a lack of knowledgeable providers (6). Barriers to accessing appropriate and culturally competent care play a significant role in health disparities among transgender persons, such as increased rates of certain types of cancer, substance abuse, mental health conditions, infections, and chronic diseases (3, 4, 7–13). Historically, care was largely limited to select facilities. Improving access to medically and culturally competent care requires involvement of primary care providers outside such specialized settings (14).
What is the initial approach for a patient who presents with gender incongruence?
Transgender persons present in myriad ways (14). Some may be confident in their gender identity and have clear treatment goals. Others may be less able to articulate their gender identity and may benefit from greater support from mental health providers. Finally, some are clear about their gender identity but less clear about their desire for medical intervention to align their identity and appearance. This last group may benefit from guidance from both mental health providers and providers who can help set expectations about medical interventions.
In the clinical setting, transgender identity can be established on the basis of history alone. The patient should have persistent gender incongruence and the capacity to make treatment decisions. The clinician should also address mental health conditions that may confound the determination. The requirement for persistence does not have a specific time frame, but multiyear histories extending as far back as childhood are typical. Development of gender incongruence over shorter periods (for example, not measured in years) should prompt further exploration of underlying factors and individual goals. Transgender persons have higher rates of anxiety, depression, and suicidality, so clinicians should be alert to signs and symptoms of these conditions.
For assessment, relevant mental health conditions are those that would interfere with reliable history taking. For example, there have been reports of patients presenting as transgender who had obsessive compulsive disorder or well-masked psychoses rather than true gender incongruence. Transgender persons can certainly experience obsessions, compulsions, and psychoses, and in such instances, a multidisciplinary approach to assessment and care that involves a mental health provider would be prudent.
Although the Endocrine Society guidelines state a preference for involvement of mental health providers in transgender determination for adults, they acknowledge that any sufficiently knowledgeable provider can make this determination. The provider should be knowledgeable enough to be able to identify mental health conditions that might confound the assessment or should refer the patient to a mental health provider who can help address this. Although the criteria for determining whether someone is transgender are the same for children and adolescents as for adults, children may articulate their gender identity in a more heterogeneous fashion. Thus, the Endocrine Society guidelines recommend that assessment of children and adolescents involve a team of clinicians, including mental health professionals.