Principles of Transgender Health Care

Transgender and gender diverse people have a gender identity that differs from the sex assigned at birth. Gender incongruence (ICD-11) is a condition related to sexual health, not a mental disorder. Gender dysphoria (DSM-5-TR) is the clinically significant distress that may accompany incongruence. Not all transgender people experience dysphoria or seek medical treatment.

Terminology:

• Transgender man (trans masculine): assigned female at birth, identifies as male.
• Transgender woman (trans feminine): assigned male at birth, identifies as female.
• Non-binary, genderqueer, gender fluid: identities outside the male-female binary.
• Gender-affirming care: social, psychological, medical and surgical interventions that support a person's gender identity.

Epidemiology:

• About 0.3 to 1% of adults and up to 1 to 2% of young people identify as transgender or gender diverse in recent surveys, with referrals rising over the last decade.

Health disparities:

• High rates of depression, anxiety and suicidality (lifetime suicide attempt rates of about 30 to 40%), related to stigma, discrimination, rejection, violence and minority stress.
• Higher rates of HIV (especially trans women), substance use, homelessness, and barriers to health access.

Principles of care:

• Person-centred, informed consent model, respecting autonomy, using the person's affirmed name and pronouns, and avoiding pathologising language.
• Multidisciplinary: primary care, endocrinology, mental health, speech-language therapy, surgery, fertility, and sexual health services.
• Standards: assessment of gender incongruence with a diagnostic approach in adolescents, and an informed consent or minimal-gatekeeping approach in adults.

Treatment goals: alleviate dysphoria, align physical characteristics with identity (when desired), improve mental health and quality of life, and minimise health risks.

Presentation:

• Persistent incongruence between identity and assigned sex, with distress about primary and secondary sex characteristics, desire to live in the affirmed gender, and for many, desire for hormones or surgery.
• Children may show early cross-gender identification. Adolescents may present at puberty with distress about body changes. Adults may present later in life.

Initial assessment:

• Gender identity history, onset and persistence, social transition, goals of treatment, and expectations.
• Mental health assessment (depression, anxiety, suicidality, autism spectrum conditions, trauma, substance use), psychosocial context, support, safety, housing and employment.
• Medical history: cardiovascular risk, thrombosis history, liver and kidney disease, cancer history (breast, prostate), migraine, smoking, diabetes, obesity, epilepsy, and fertility wishes.
• Sexual health history: HIV and STI risk, contraception, and cancer screening needs.
• Examination: BMI, blood pressure, breasts, genital examination only when relevant to care, and Tanner staging in adolescents.

Red flags for urgent action: suicidality, self-harm, self-treatment with unregulated hormones, injection of non-prescribed silicone, domestic violence, homelessness, and severe untreated mental illness.

Differential or comorbid conditions that need assessment but should not delay care unnecessarily: body dysmorphic disorder, psychosis, dissociative disorders, and autism spectrum conditions.

Diagnosis is clinical and based on criteria:

• ICD-11 gender incongruence: marked and persistent incongruence between experienced gender and assigned sex, with desire to transition. In adolescents and adults, onset is usually at puberty. In children, the diagnosis requires pre-pubertal criteria and a period of at least 2 years.
• DSM-5-TR gender dysphoria: incongruence for at least 6 months, accompanied by distress or impairment.

Baseline investigations before hormone therapy:

• BMI, blood pressure, CBC (haematocrit), creatinine and eGFR, liver enzymes, fasting glucose or HbA1c, lipid profile, and prolactin (trans women). Testosterone, oestradiol, LH and FSH at baseline.
• Pregnancy test (trans men with a uterus and potential for pregnancy). HIV, hepatitis B and C and syphilis serology as part of sexual health care.
• Bone density (DEXA) for those with risk factors or on long-term hormone blockade.
• Consider karyotype only where intersex variation is suspected. Thrombophilia testing only if personal or family history.
• Fertility counselling and discussion of sperm, oocyte or embryo cryopreservation before treatment.

Adolescent evaluation:

• Full biopsychosocial assessment over time, with confirmation of Tanner stage 2 or higher before puberty suppression, and parental or guardian consent. Evidence is evolving and some jurisdictions have restricted use, so follow local policy, with research and multidisciplinary review.

Psychosocial care

• Affirming mental health support, treatment of anxiety, depression and substance use, and psychological therapy when desired. Support for social transition (name, pronouns, clothing, hair), family and school liaison, peer support, and legal gender recognition.
• Voice and communication therapy with speech-language therapy (trans women), and hair removal (laser or electrolysis) for facial and genital hair.

Puberty suppression in adolescents (where permitted)

• GnRH analogues, such as leuprolide 3.75 to 7.5 mg IM monthly or 11.25 mg every 3 months, triptorelin 3.75 mg monthly or 11.25 mg every 3 months, or histrelin implant 50 mg yearly, start at Tanner 2 to 3 after careful assessment. Monitor growth, bone density, mood and Tanner staging. Review every 3 to 6 months. Gender-affirming hormones may follow after a period of multidisciplinary review and typically at age 14 to 16, with adult-approach dosing at 16 and over, depending on local regulation.

Feminising hormone therapy (trans feminine)

• Oestrogen:
• Transdermal estradiol patch 50 to 200 micrograms/day (changed twice weekly), preferred in people over 40 or with increased thrombotic risk.
• Oral estradiol 2 to 6 mg daily (up to 8 mg), sublingual estradiol in divided doses.
• Injectable estradiol valerate 10 to 40 mg IM every 2 weeks, or estradiol cypionate 2 to 5 mg every week.
• Target estradiol 100 to 200 pg/mL (367 to 734 pmol/L) and testosterone in the female range (below 50 ng/dL or 1.7 nmol/L). Avoid supraphysiological estradiol (above 200 pg/mL) and ethinylestradiol.
• Androgen suppression:
• Spironolactone 100 to 300 mg daily in 1 or 2 doses (monitor potassium and blood pressure).
• Cyproterone acetate 10 to 50 mg daily (not available in the US, monitor liver function, prolactin, mood and meningioma risk at high doses and long duration), usually 12.5 to 25 mg daily.
• GnRH analogues (leuprolide 3.75 mg monthly or 11.25 mg every 3 months).
• Bicalutamide 50 mg daily as an alternative. Finasteride 5 mg daily or dutasteride 0.5 mg daily for scalp hair loss. Orchiectomy removes the need for blockers.
• Progesterone (micronised 100 to 200 mg nightly) is used by some for breast development and mood, but benefits are not well proven.
• Expected effects: breast growth (onset 3 to 6 months, maximum 2 to 3 years), reduced body and facial hair and libido, fat redistribution, testicular atrophy and reduced fertility, reduced erections, and decreased muscle mass (3 to 12 months). Voice, height, and facial bone structure do not change.
• Risks: venous thromboembolism (higher with oral estrogen and age), hypertriglyceridaemia, gallstones, weight gain, hypertension, prolactinoma (rare), hyperkalaemia with spironolactone, and possible breast cancer.

Masculinising hormone therapy (trans masculine)

• Testosterone:
• Testosterone cypionate or enanthate 50 to 100 mg IM or SC weekly (or 100 to 200 mg every 2 weeks).
• Testosterone gel 1% to 1.62%, 50 to 100 mg daily, or patch 2 to 8 mg daily.
• Testosterone undecanoate injectable 750 to 1000 mg IM at weeks 0 and 4, then every 10 to 14 weeks.
• Target mid-cycle trough or mid-interval testosterone 400 to 700 ng/dL (14 to 24 nmol/L) in the male range.
• Expected effects: cessation of menses (1 to 6 months, extra progestogen or GnRH if persistent), voice deepening (permanent, 3 to 12 months), facial and body hair, clitoral enlargement, fat redistribution, increased muscle mass, acne, and male-pattern hair loss. Breast tissue reduction is limited. Reproductive potential is reduced.
• Risks: polycythaemia (haematocrit above 50 to 54% needs dose adjustment), acne, dyslipidaemia (lower HDL), weight gain, sleep apnoea, hypertension, liver enzyme elevation, mood effects, and vaginal atrophy. Testosterone is not a reliable contraceptive, so effective contraception is needed if sexually active with a partner who can impregnate, and it is teratogenic.
• Menstrual suppression options: medroxyprogesterone 150 mg IM every 3 months, norethisterone 5 to 10 mg daily, levonorgestrel IUD, or GnRH analogue.

Monitoring of hormone therapy

• Every 3 months in the first year, then every 6 to 12 months: blood pressure, weight, hormone levels, haematocrit, liver enzymes, lipids, glucose, prolactin (trans women), potassium and creatinine (on spironolactone), and mood. Bone density at baseline and per risk factors, particularly after gonadectomy, with calcium and vitamin D supplementation.
• Cancer screening by organ present: cervical screening for those with a cervix (self-sampling HPV test is an option, with a lubricated speculum or smaller one), mammography for trans men without mastectomy and for trans women after 5 to 10 years of hormone therapy from age 50, prostate review per guidelines, and colorectal screening.

Surgery

• Eligibility: persistent gender incongruence, capacity to consent, control of coexisting conditions, and usually 12 months of continuous hormone therapy for genital surgery, with letters from one or two assessors as per local rules. Chest surgery does not require hormones.
• Trans feminine: breast augmentation, orchiectomy, vaginoplasty (penile inversion, intestinal), vulvoplasty, facial feminisation, tracheal shave, voice surgery, and hair transplantation.
• Trans masculine: mastectomy with chest contouring (top surgery), hysterectomy with salpingo-oophorectomy, metoidioplasty, phalloplasty, vaginectomy and scrotoplasty.
• Preoperative planning: smoking cessation (4 to 8 weeks), BMI optimisation, VTE risk assessment (stop oestrogen 2 to 4 weeks before major surgery in some protocols, or continue with enoxaparin prophylaxis), prophylactic antibiotics (cefazolin 2 g IV), and counselling on complications (strictures, fistulae, loss of sensation, dilation regimen, hair removal for graft sites).
• Postoperative: dilation regimen after vaginoplasty, pelvic floor therapy, wound care, and long-term follow-up.

Fertility and sexual health

• Offer sperm, oocyte or embryo cryopreservation before hormones or gonadectomy. Hormone cessation may allow fertility restoration in some.
• Contraception counselling, HIV pre-exposure prophylaxis (tenofovir disoproxil-emtricitabine 300/200 mg daily, or injectable cabotegravir 600 mg every 2 months), HIV and STI screening, vaccination (HPV, hepatitis B, hepatitis A), and sexual function support.
• Pregnancy and lactation in trans men and non-binary people with a uterus after stopping testosterone.

Care in non-gender-affirming settings

• Use correct names and pronouns, document organ inventory instead of assumed gender, tailor screening, and avoid unnecessary questions. Hormone therapy should be continued during hospital admissions and perioperative care.
• Address violence, discrimination and mental health with accessible services. Provide referral for legal and social support.
• Do not stop hormones after non-specific adverse events, and manage drug interactions (testosterone and oestrogen with anticonvulsants, rifampicin and antiretrovirals).