Gender

Overview of Gender-affirming Care

What is gender-affirming care?

A gender-affirming model of care recognizes that gender expression and identity exist along a wide spectrum and may be fluid within an individual over time. Rather than viewing identities and expressions that transgress cultural norms as pathologic, a gender-affirming philosophy views the diversity of the gender spectrum as an expected part of the human experience. Unlike a corrective approach which redirects gender nonconforming behaviors or expressions with the goal of reducing them, the gender-affirming model promotes a person’s rights to explore gender in a way that is safe and comfortable for them, without assuming a fixed trajectory regarding gender identity.1

Healthcare clinics and organizations have several opportunities to explicitly demonstrate their commitment to caring for TGD patients.

1. Avoid gendered language whenever possible (e.g., “reproductive health center” versus “women’s health center”).
2. Offer inclusive restroom options, including all-gender restrooms.
3. Display non-discrimination policies and images of gender-diverse people in waiting rooms.
4. Distribute pins or stickers of LGBT or Transgender pride flags and staff members’ pronouns. These images signify awareness, sensitivity, and openness to caring for TGD patients.
5. Many electronic health records (EHR) have fields for chosen or affirmed name, pronouns, gender identity, sex assigned at birth, legal gender marker, and aspects of gender-affirming care that have been received. Various methods of collecting these data exist, including training front desk or registration staff to ask sexual orientation gender identity (SOGI) questions in a respectful manner or using electronic or paper forms to collect this information, either at check-in or at home prior to a visit. EHRs can be designed to display chosen name, pronouns, and gender identity prominently, making it easier for staff to correctly address a patient while also indicating clinically relevant information such as the patient’s sex assigned at birth and reproductive anatomy. Many systems include an organ inventory feature, which allows the clinician to indicate the presence or absence of individual sexual/reproductive organs. This can serve as a reference to indicate whether a pregnancy test may be needed (if a uterus is present), what types of shielding will be needed for radiology exams, what types of organs may contribute to a differential diagnosis, and, in a preventive care setting, what types of cancer screening are needed. One consideration when utilizing these fields is to inform patients that this will be viewable to all providers within the organization, and sometimes (due to increasing interconnectivity) beyond the organization to other healthcare organizations.
6. Healthcare organizations can demonstrate their commitment to TGD patients by creating organizational policies or position statements that can be publicly visible to patients, families, and staff (Appendix G). These statements not only hold staff members accountable but also describe a commitment for high-quality care coming from the highest level of the organization. Creating an organizational working group to improve gender-affirming services may help to coordinate efforts and bring together multiple stakeholders across the organization.

Gender-affirming best practices
While managing treatment for gender dysphoria lies outside the scope of practice for LEO medical providers, all medical providers should offer care that recognizes and respects a person’s affirmed gender identity and expression.

• Greet patients respectfully: Avoid making assumptions about a patient’s gender identity based on their name, gender expression, or legal documentation, which may not be reflective of their gender identity for several reasons. Avoid gendered language such as “miss,” “ma’am” or “sir” which can be intended to show respect but may also lead to incorrect assumptions about gender identity. Ask the patient how they would like to be addressed by asking “How would you like to be addressed today?” or “What name and pronoun would you like me to use?” This information should be obtained in a confidential manner, and the name/pronoun that the patient designates should be used in all interactions unless otherwise instructed by the patient.
• History-taking: “Broken arm syndrome” is a phrase that has been coined to describe the phenomenon when healthcare providers assume that all medical issues are a result of a person being TGD.2 Providers should consider carefully whether questions would remain relevant if the patient was cisgender. When sensitive information is necessary for evaluation, providers should preface the question by explaining why they are asking a personal question. Questions should be asked respectfully and should not be avoided for fear of provider or patient discomfort. If there is a need to discuss a question pertaining to genitals, providers should ask “Do you have any preferred language for your body parts or any words that you would like to avoid?” Gender-neutral terms such as “chest” or “genitals” may be preferred.
• Exams: Clinicians should utilize a trauma-informed approach to care and should recognize that as a population TGD individuals are more likely than others to have experienced trauma (physical assault, sexual, emotional, or psychological). Shared decision-making and informed consent, with discussion of potential benefits, risks, and alternatives of an examination, should be utilized. Providers should be aware that pelvic exams for trans-masculine or non-binary people might be stressful and even traumatic and thus should only be done when a true clinical indication exists. Once a patient has provided consent, ask if there is anything that makes a person comfortable during an exam (e.g., listening to music, having a support person present). Trans-masculine and non-binary patients who are using testosterone may experience less natural vaginal lubrication due to estrogen suppression and use of lubricating jelly may facilitate a more comfortable exam. Exams that require patients with chest dysphoria to remove chest binders may also be anxiety provoking.
• Practice humility: Simple and sincere apologies go a long way. “I’m sorry for using the incorrect name/pronoun. I’d like to be respectful” can be helpful phrases.

Overview of treatment for gender dysphoria
TGD LEOs represent a heterogeneous group of persons with different experiences and transitioning goals. Many, but not all, experience gender dysphoria, distress that arises from the incongruence between an individual’s gender identity and their assigned sex at birth. TGD people who do not experience gender dysphoria may benefit from mental health support focused on developing problem-solving skills and coping strategies to address stigma or discrimination that they may encounter due to gender diversity. For TGD people who do experience gender dysphoria, care should be tailored to address the individual’s source(s) of discomfort and may include a combination of mental health support, social, medical, and surgical interventions. Providers should be familiar with treatment strategies commonly used to address gender dysphoria (for additional discussion see Appendix C).

Social transitioning
Some TGD people with gender dysphoria opt to undergo a social gender transition, which involves reversible changes that allow a person to present in certain or in all settings in their affirmed gender. Whether and how to socially transition is a highly individualized process that each person makes, sometimes with the support of a medical or behavioral health provider, after taking into consideration their goals and safety. Social transitioning may include any combination of changes to hairstyle and clothing, adopting a different name or pronoun, or using restrooms and locker rooms that align with their gender identity. Some socially transitioned people opt to update their name or gender marker on legal documents such as birth certificates, passports, or state identification (Appendix C).

Medical treatment
Currently, two published practice guidelines specifically address the medical needs of TGD persons: the Endocrine Society Practice Guideline for Treating Gender Dysphoric/Gender Incongruent Persons3, and the World Professional Association of Transgender Health (WPATH) Standards of Care.4 Some TGD adults use exogenous gender-affirming hormones (i.e., testosterone or estrogen) to induce secondary sex characteristics that more closely align with their gender identity and, if present, to treat gender dysphoria. Gender-affirming hormone treatment is considered partially irreversible since some of the physical changes induced by testosterone and estrogen are reversible (e.g., fat distribution, muscular changes) and others are irreversible (e.g., estrogen-mediated breast development; testosterone-mediated voice deepening).

Medications

1. Feminizing treatment
   • Estrogen
   • Androgen receptor blockers: spironolactone, cyproterone
   • 5-alpha reductase inhibitors: finasteride, dutasteride
2. Progestins
3. Masculinizing treatment
   1. Testosterone
4. Physical changes – somewhat permanent
   1. 1. Masculinizing hormones – see Table 1A
      2. Feminizing hormones – see Table 1B
5. Risks – See Table 2
6. Monitoring

Surgical treatment
Not all TGD people opt to undergo gender-affirming surgery. For those that do surgeries may involve removing undesired organs (e.g., breasts, ovaries, uterus, penis, testicles) and/or creating desired anatomy (e.g., vagina, penis, breasts). Descriptions of gender-affirming procedures can be found at https://transcare.ucsf.edu/guidelines.

• Feminizing procedures
  1. Chest/breast – augmentation, mammoplasty (implants/lipofilling)
  2. Genital – penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty
• Facial feminization
  1. Voice surgery (rare)
  2. Thyroid cartilage reduction (Adam’s apple)
  3. Hair removal
• Masculinizing procedures
  1. Chest/breast – subcutaneous mastectomy, pectoral implants
  2. Genital – hysterectomy/salpingo-oophorectomy, urethral reconstruction, vaginectomy, scrotoplasty, phalloplasty, metoidioplasty, implants.

Considerations for wellness screening
Many law enforcement departments have wellness programs for their officers. These programs are not fitness-for-duty evaluations, but rather for the well-being of the officers.

Routine screening for cancer should be organ based. That is, if an individual has an organ and meets accepted criteria for screening, screening should be conducted as recommended for the general population.

Existing guidelines recommend sub- and periareolar annual breast examinations if mastectomy has been performed.3 The risk of breast cancer developing in residual breast tissue in TGD people who have undergone mastectomy is unknown.

Biometric screening: Some medical testing has sex-specific differences (e.g., pulmonary function, cardiac risk calculation). The interpretation of these tests in TGD individuals is unknown. The consensus of the Public Safety Medicine Task Group is to consider every TGD LEO who is using gender-affirming hormone therapy as male for the purpose of cardiac risk calculation.

Considerations for sexual/reproductive health
In order to accurately assess an individual’s sexual/reproductive health needs, clinicians must conduct a gender-affirming and inclusive sexual health history that does not make assumptions about a person’s internal organs, sexual partner(s), sexual behaviors, desires related to pregnancy/family planning, or knowledge of contraception. TGD individuals, like people of all gender identities and expressions, are diverse in their sexual identities and practices. Ask about partners and sexual practices respectfully using questions such as “what parts of your body do you use during sex?” and “what kinds of sex do you have?” Providers should be aware that all individuals with a uterus, even if those using testosterone and experiencing amenorrhea, might become pregnant if they are having vaginal sex with a person with a penis. Likewise, clinicians should recognize that menses may provoke gender dysphoria in transmasculine or nonbinary people and it may be a sensitive topic. When possible, using non-gendered language (“people with uterine bleeding” rather than “menstruating women”) may enhance patient comfort.

Table 1A: Effects and Expected Time Course of Masculinizing Hormones*

*Adapted with permission from Hembree et al. (2009). Copyright 2009, The Endocrine Society.
**Estimates represent published and unpublished clinical observations.
***Highly dependent on age and inheritance; may be minimal.
****Significantly dependent on amount of exercise.

Table 1B: Effects and Expected Time Course of Feminizing Hormones*

*Adapted with permission from Hembree et al. (2009). Copyright 2009, The Endocrine Society.
**Estimates represent published and unpublished clinical observations.
***Significantly dependent on amount of exercise.
****Complete removal of male facial and body hair requires electolysis, laser treatment, or both.

Table 2: Risks Associated with Hormone Therapy

*Risk is greater with oral estrogen administration than with transdermal estrogen administration.
**Additional risk factors include age.
***Includes bipolar, schizoaffective, and other disorders that may include manic or psychotic symptoms. This adverse event appears to be associated with higher doses or supraphysiologic blood levels of testosterone.

References

1. Hidalgo MA, Ehrensaft D, Tishelman AC, et al. The gender affirmative model: what we know and what we aim to learn. Hum Dev. 2013;56(5):285-290.
2. Naith P. The dangers of trans broken arm syndrome. Available at: https://www.pinknews.co.uk/2015/07/09/feature-the-dangers-of-trans-broken-arm-syndrome/.
3. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(11):3869–3903. https://doi.org/10.1210/jc.2017-01658.
4. World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender-Conforming People, 2012 [7th Version]. https://www.wpath.org/publications/soc.