1. Introduction to the Care of the Transgender Individual
Sandra Mesics, RN, MSN, CNM, HonDSc

2. Disclosures
I have no actual or potential conflicts of interest in relation to this presentation
Neither I, nor any immediate family member has any financial relationship with, or interest in, any commercial interest connected with this presentation.
I will be discussing “off-label” uses of the following medications:
Spironolactone
GnRH agonists
Progesterone
Estrogen
Testosterone

3. Objectives Discuss theories of etiology and prevalence
Provide a broad overview of psychosocial issues faced by transgender individuals.
Describe non-operative care for transgender individuals

4. Definitions
Cisgender: People whose gender identity and gender expression align with their biological sex.
Gender dysphoria: The distress and suffering experienced when gender identity and biologic sex are not completely congruent. This term is used in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and is considered less stigmatizing than "gender identity disorder.“

5. Definitions
Transgender: Generally, an umbrella term for transsexuals, androgynous people, crossdressers, genderqueers, and other gender non-conforming people who identify as transgender. Some, but not all, of these individuals desire to transition gender; some, but not all, desire medical changes to their bodies as part of this process. Sometimes abbreviated as trans or trans*.
Female-to-male (FTM): A person assigned as female at birth but who identifies and lives as or hopes to live as a man. Synonymous with "transgender man" or "transman."
Male-to-female (MTF): A person assigned as male at birth but who identifies and lives as or hopes to live as a woman. Synonymous with "transgender woman" or "transwoman."

6. Incidence/Prevalence
1.4 million Americans identify as transgender: 0.6% of the general population.
770,000 as MTF
458,000 as FTM
0.7 percent of youth aged 13 to 17 (150,000)

7. Etiology/Causation Etiology is poorly understood Likely multifactorial
Not likely caused by psychiatric or psychosocial factors
Not likely chromosomal
Exposure to sex hormones in utero and brain development.

8. Psycho-Socio-Economic Issues
Suicide attempts: Significantly higher in trans* individuals.
Homicide & assault rate
Substance use
Homelessness
Sexually Transmitted Infections rate

9. Access and Barriers to Care
Fear of disclosure to healthcare professionals
Fear of abuse by healthcare professionals
Lack of finances or insurance coverage
Provider lack of knowledge of trans care
Denial of treatment/service
Stigma: bathroom bills, military bans, gender markers on documents

10. Creating a Welcoming Environment
Post a non-discrimination statement in waiting area
Display LGBT symbols.
Adding a “transgender” option to patient forms.
Ask patients about their preferred name and pronouns.
Verbiage: “Relationship status” vs “Marital Status”
Ask open-ended questions.

11. WPATH Standards of Care
Evidence-Based recommendations
Adherence is required by many insurance companies and by American surgeons.
Alternative: the informed consent model

12. The usual pathway: MTF Counseling Hormone therapy (more counseling!)
“Cosmetic” procedures
Hair removal: laser/electrolysis
Voice therapy or vocal surgery
Facial feminization surgery
Breast augmentation
Body contouring
The “Real Life” test (more counseling!)
Gender confirmation surgery
Yet More Counseling

13. The Usual Pathway: FTM Counseling Hormone Therapy (more counseling)
Binding & Packing
Top Surgery
The “Real Life” test
Bottom Surgery & counseling

14. Counseling Usually initiated prior to hormone therapy
Mental health professional with a minimum of a Master's degree.
Familiarity with gender variation
Competence with DSM
Ability to diagnose co-existing mental health concerns

15. First Counseling Session
Sexual history
Screening for sexual trauma, suicidal ideation, and history of self-harm.
Currently seeing a healthcare provider?
Use of hormones, and who is prescribing them
Assessment of the client’s support system
Screening for other mental health issues.

16. First Counseling Session
Common diagnostic presentations in transgender individuals include:
Anxiety
Depression
Conduct disorder
Oppositional defiant disorder
Body dysmorphic disorder
Autism spectrum disorder
Substance use disorder
Eating disorders
Dissociative disorder

17. Hormone Treatment: MTF
Anti-Androgens:
spironolactone (Aldactone)
Finasteride (Propecia or Proscar)
GnRH agonists (Lupron)
Estrogens:
Oral Estradiol (Estrace), conjugated estrogens (Premarin)
Injectable estradiol (Delestrogen or Depo-Estradiol)
Transdermal estradiol: (Climara, Vivelle Dot)
Progesterone:
Oral: Prometrium

18. Hormone Treatment: FTM
Testosterone:
Injectable testosterone enanthate or cypionate
Testosterone gel
Testosterone patch
No oral form available
Progesterone

19. Voice Therapy Usually not needed for FTM transmen
Estrogen does not alter the voice in MTF transwomen.

20. Trans Children and Youth
Gender variance vs. gender dysphoria
Counseling & Family support
Medical treatment:
Puberty suppression: reversible (bone density?)
Hormone treatment: partially reversible
Surgical procedures: non reversible
Emma McIntyre/Getty Images for Unilever/Dove

21. Pearls of Wisdom Don’t make assumptions: Ask questions
Base medical care on what organs are present
Katie Hill and Arin Andrews (Picture: Barcroft)

22. Lifelong Care MTF FTM Breast care Breast care Prostate exam Pap test
Bone health
Genitourinary health
FTM
Breast care
Pap test
CV and DM screening
Bone health

23. For Further Information
World Professional Organization for Transgender Health:
Center of Excellence for Transgender Health UCSF:
Fenway Health:
The National Center for Transgender Equality:

24. References
2015 U.S. Transgender Survey retrieved from:
Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Available at Last accessed June 20, 2018.
Flores AR, Herman JL, Gates GJ, Brown TNT. How Many Adults Identify as Transgender in the United States? Available at