Transgendered people are perhaps the most stigmatized and misunderstood of the larger sexual minorities (Gay, Lesbian, Bisexual, Transgender). In order to better understand transgendered people, it is useful to make a sharp distinction between two terms that are often used interchangeably. Sex is the anatomy and biology that determines whether one is male, female, or intersexed (formerly called hermaphroditic). Gender is a psychosocial construct most people use to classify a person as male, female, both, or neither. Gender Identity is a person's sense of their own gender, which is communicated to others by their Gender Expression. Since most people conform to societal gender norms, they have a Gender Identity congruent with their Gender Expression. However, Gender, like sexuality, is fluid and can change over time, in individuals and in human society. For some people, Gender Identity, Gender Expression and sex do not correspond with each other. Those who cannot or choose not to conform to societal gender norms associated with their physical sex are Gender Variant. Transgender is an umbrella term used to describe Gender Variant people who have gender identities, expressions or behaviors not traditionally associated with their birth sex. Transgender is preferred over transvestite or transsexual, older terms which do not accurately describe all transgendered people, and which also have a clinical or stigmatizing connotation. Transgender also can mean anyone who transcends the conventional definitions of 'man' and 'woman'. Thus transgender also can include Butch Lesbians, Radical Faeries, Drag Queens, Drag Kings and many other kinds of gender variant people who use a variety of terms to self-identify. Transsexuals are individuals who desire to live full time as members of the opposite sex, and who usually seek hormone therapy, cosmetic surgery, and genital surgery in order to approximate more completely the appearance of the gender in which they choose to live (Lawrence et al., 1996). Crossdressers (transvestites) are individuals who dress in clothing of the opposite sex for emotional satisfaction, erotic pleasure, or both. Transgenderists are individuals who live full or part-time as members of the opposite gender. Androgynes are those with androgynous presentations, who deliberately adopt characteristics of both genders or strive to attain a genderneutral or nongendered status. Intersexed persons (hermaphrodites) are individuals with medically documentable physical or hormonal attributes of both sexes. Examples of intersex conditions include androgeninsensitivity syndrome, Kleinfelter syndrome, and congenital adrenal hyperplasia. Drag queens and kings are individuals who crossdress to entertain, to challenge gender stereotypes, or for personal satisfaction.   Buy Zithromax for treating bacterial infections, skin infections, sexually transmitted infectious diseases, urethritis. medicstar.com Buy Propecia Propecia is used to treat hair loss. Propecia is not addictive. www-medic.com Buy Brand Viagra Viagra is applied for the treatment of erectile dysfunction in men. Buy Viagra Super Force Buy Amoxicillin one of the best antibiotic. Amoxicillin used to treat infections caused by certain bacteria. medicstar.com Transgendered people are often categorized by their Gender Vector: Male-to-Female (MTF), or Femaleto- Male (FTM). Although transsexual women (MTFs) have dominated the public's perception of transsexualism and transgenderism, there may be just as many transsexual men (FTMs) and female-bodied transgendered people. There also are transgendered people who do not believe in gender at all, seeing many possibilities beyond the male-female binary system for living their lives and expressing themselves. Transgender is often mistakenly understood to mean Transsexual. Transsexual men (FTMs) and transsexual women (MTFs) actually comprise a minority within the transgender community. They feel profoundly unhappy with their bodies and gender norms associated with their birth sex. This unhappiness, combined with feelings of frustration and anger, are all symptoms of Gender Dysphoria, a psychological condition commonly associated with transgendered as well as transsexual people. In order to seek relief from their Gender Dysphoria, transsexual men and women go through Gender Transition, in order to live full-time in the gender that corresponds with their Gender Identity. While in transition, most transsexual people take hormones (clinically, this is called Hormonal Sex Reassignment) to develop the secondary sexual characteristics that reflect their chosen gender. Some undergo surgical procedures to modify their bodies in different ways. The proper term for the 'sex change operation' is Sex Reassignment Surgery (SRS). Both hormonal and surgical sex reassignment are generally obtained by following a set of guidelines called the Standards of Care, promulgated by the Harry Benjamin International Gender Dysphoria Association (HBIGDA), an international group of sexologists, psychotherapists, physicians, attorneys and social scientists. Hormonal and Surgical Sex Reassignment, along with other cosmetic surgical procedures, psychotherapy and speech therapy are all parts of Transgender Care, which is typically not covered by health insurance plans. Moreover, the sensitivity and awareness of medical providers are very important concerns for transgendered people when accessing routine health care. However, it is important to remember that most transgendered people do not alter their physical anatomy. Those who live full time in genders not associated with their physical sex and take only hormones may identify themselves as Transgenderists or simply Transgenders. Still others who self-identify as Stone Butch or No-ho/No-op live full time without hormonal therapy and sex reassignment surgery. The largest single group of transgendered people are Crossdressers (formerly called transvestites) who wear opposite-gender clothing. Crossdressers are usually heterosexual men who crossdress privately, but there also are women who crossdress. Many transgendered youth prefer the term Gender Queer to describe themselves. Intersexed people (formerly called hermaphrodites) are born with chromosomal and/or physiological anomalies, and/or ambiguous genitalia. Many intersexed infants born with ambiguous genitalia are surgically "normalized" at the wishes of their anxious parents, a controversial procedure which later results in loss of sexual response in adulthood. The Intersex Society of North America (ISNA) has called this practice Infant Genital Mutilation. Some intersexed infants have even been sexually reassigned – without their consent – and later in life develop gender identity issues strikingly similar to those of transsexual people. Some undergo SRS as adults, but their medical procedures may be covered by health insurance plans. It's easy to become confused about the Sexual Orientations of transgendered people. Many refer to their sexual orientations on the basis of their gender identity, without regard to their existing or former (if a postoperative transsexual) anatomy. Others identify themselves as gay or lesbian, because of cultural reasons or affinity needs, while still others refuse to classify their sexual orientation. However, due to Trans-ignorance, transgendered people are often misperceived to be gay or lesbian because of their appearance, which is often that of a masculine woman or a feminine man – the cultural gendered stereotypes of lesbians and gay men. Because this misperception is so pervasive, transgendered people often become victims of homophobia, which many of them call Transphobia. How much Transphobia they encounter is a function of Passing Privilege – which allows its possessors to pass as non-transgendered. Some but not all transgendered people who seek to live full-time can gain passing privilege, through the medical technologies of Transgender Care. However, it can take years to affect these physiological changes, as well as to adapt to new social roles. Transgender Care also is commonly quite difficult to obtain, due to the lack of willing providers, the lack of health insurance coverage, and its expense. All of these reasons explain why transgendered people are particularly subject to a disproportionate amount of anti-gay violence and discrimination. There is an excellent book about Medical Therapy and Health Maintenance for Transgender Men by Gorton R, Buth J, and Spade D., Lyon-Martin Women's Health Services. San Francisco, CA. 2005 Click here for the link to this comprehensive, 98 page document. Transgender Explained For Those Who Are Not Transgender History (Seal Studies) The Transgender Child: A Handbook for Families and Professionals 10,000 Dresses Medical Care Transgender people suffer from the same illnesses and problems associated non-transgendered and especially with the Gay/Lesbian community, with issues such as HIV to contend with. In addition, transgender people face many unique issues. If the doctor/nurse knows that you’re trans, they will probably ask whether you’ve ever taken hormones or had surgeries. If so, they will want to know the details (when you started hormones, what type/dose you took, when you had surgery, what surgeries were done, any problems or complications, etc.) Even if you have been taking hormones without a prescription or medical supervision, we encourage you to be fully honest. Knowing your history with hormones will give the nurse/doctor a better sense of side effects, risks, and drug interactions to monitor. You may be asked about any future plans you have for hormone therapy or surgeries, and if there are other changes you desire. This doesn’t necessarily mean your primary care provider thinks all trans people should transition, or has another stereotyped idea of what it means to be trans. They may just be trying to let you know that they are OK with talking about hormones and surgery and helping you to explore your options if medical transition is something you want to pursue. You might also be asked how you feel about being trans, and how it has affected important aspects of your life. Some trans people have internalized negative societal messages about trans people (internalized transphobia) and this can greatly impact health and self-esteem. Physical Exam It is standard practice for health professionals to do a physical exam for new patients. The parts to be examined depend on whether you are coming in for a general checkup, or to get symptoms looked at, and also on your health history and risks for specific conditions. A basic exam involves: measuring your height and weight checking your blood pressure listening to your heart and breathing looking at your ears, eyes, and throat testing your vision looking at (and possibly touching) your head, arms, legs, back, breasts/chest, and stomach to get a general impression of health or problems in these areas MTFs: rectal exam (putting a finger in the anus/rectum to check the prostate) FTMs: pelvic exam (putting one or more fingers in the vagina to feel your uterus/ovaries; spreading the wall of your vagina with a speculum to look for sores and taking a small sample of cells to check for cervical cancer) if you have symptoms or are at risk for specific conditions, other exam tests may be added Some trans people find physical exams traumatic. Unless there is an immediate medical condition requiring attention, the Transgender Health Program recommends that exams of sensitive areas (especially breast, pelvic, and rectal exams) be delayed until you have had a chance to get to know and trust the GP/nurse. If you don’t feel you can do the exam on the first visit, it is OK to say that you find physical exams very stressful and that you need to wait until a later appointment. It is also helpful to consider strategies that might help you get through a physical exam. Some trans people feel best if a friend or loved one is there with them for support; others feel embarrassed or humiliated to have another person there. Some people like it to be done slowly, while others like to get it over with as fast as possible. Your care provider may have suggestions based on their experience with other patients who find physical exams stressful. Lab Tests Lab tests may be done if there is a health problem that needs to be evaluated, or to get a better picture of your overall health. The more common lab tests include: testing of body fluids (blood, urine, saliva, feces) X-rays or other scans used to get a visual image of internal structures of your body stress test: used to measure heart function swabs inserted into the body (e.g., throat, vagina, anus) to get a sample of fluids/cells using a scope to see inside the body If you are taking hormones and haven’t had your blood checked in a while, or have never had your blood checked, blood tests will probably be ordered to check both your hormone levels (to make sure they aren’t too low or too high), and the functioning of your liver and other organs that are affected by estrogen and testosterone. Medical Records Your medical chart is a legal record of your medical treatments. Because it is a legal document, there are rules about what must be included. For example, unless you are going to an anonymous clinic (where you don’t have to give a name), your legal name must be on record. Many medical clinics now have two slots – one for legal name and one for preferred name. This takes care of the legal requirement while still being respectful of people’s right to self-identify. Recording “M” or “F” on your medical chart is less clear. On other legal documents it’s considered fraud to say your sex is M if your legal sex is F, but medically there are some situations where it might be appropriate and important to record your sex as M even if your legal sex is still F (see the table below). Part of the purpose of a medical chart is to help maintain continuity of care if you transfer to another health provider, and from this perspective, it’s important that whatever’s recorded is an accurate description of your situation. Recording “FTM” or “MTF” may be best for some trans people, but even these terms are problematic for trans people who don’t identify with being female or male (e.g., androgynous people, bigender or multi-gender people), and also for intersex trans people who have mixed physiology. The M/F dilemma is particularly tricky in lab testing. Some lab tests can be done in the nurse or doctor’s office, but for others you will need to go to a lab, hospital, or another place that has special diagnostic equipment. Typically the nurse or doctor will fill out a “lab requisition” form if you need to get tests done somewhere else. These forms include a box for “M” or “F” as some tests are done differently for males and females, and what is considered a normal result is also dependent on physical sex. This is very challenging for trans people who don’t identify as male or female, or for people whose appearance doesn’t match their identity. It’s also very challenging for nurses and doctors to figure out how to do this in a way that is respectful but still accurate. Your feelings matter, and it is important to be honest with the doctor or nurse about what you can tolerate. If you won’t go get tested because your form says “M” (or “F”), your care provider needs to know that it’s too stressful to put you in that position. If lab accuracy is most important to you, here's a suggestion: Your situation Most physically accurate category for lab form Not taking hormones, haven’t had surgery Sex you were born (if you are intersex, talk with the doctor about how to record this; otherwise, use “F” for FTMs and “M” for MTFs) In the middle of transition Use F in some situations and M in others, depending on what kind of test you’re having and how much your body has changed from hormones/surgery Had ovaries/testicles, removed, taking hormones Sex you have transitioned to (use “M” for FTMs and “F” for MTFs) Medical Complications of Sex Reassignment The most frequent complication of hormone therapy in transgendered women (MtF) is venous thromboembolism—blood clots, usually in the legs, which can sometimes lead to pulmonary embolism or other complications. In their study of mortality and morbidity in transsexual subjects, van Kesteren et al. (1997) reported a 20-fold increase in venous thromboembolism relative to the general population. Smoking increases the risk of blood clots with estrogen therapy, particularly after age 40. Transdermal estradiol administration may considerably reduce the risk of venous thromboembolism. Other complications of male-to-female hormone therapy include infertility, weight gain, emotional lability, liver disease, and the development of benign pituitary tumors. There are reports in the literature of four MtF transsexuals developing breast carcinoma following estrogen administration. The major risks associated with administration of testosterone in transgendered men (female-to-male) are increased cholesterol and lipid levels, heart disease, including myocardial infarction, mood changes, liver disease, including hepatic tumors, male pattern baldness, and acne. Smoking increases the risk of coronary heart disease in individuals using testosterone. Cancer Breast cancer: Male-to-female MTF, no hormone use • There is no evidence of increased risk of cancer compared to natal male people, in the absence of other known risk factors (e.g., Klinefelter’s syndrome). Routine screening, either in the form of regular breast exams or mammography, is not indicated for these people. MTF, past or current hormone use • MTF people who have taken feminizing hormones may be at increased risk of breast cancer compared to natal males, but likely have significantly decreased risk compared to natal females. • The length of feminizing hormone exposure, family history, BMI >35 and use of progestins may further increase risk. • Screening mammography for MTF people receiving hormone therapy is not currently supported by the evidence, but screening mammography is advisable in people over age 50 with additional risk factors (e.g., estrogen and progestin use > 5 years, positive family history, BMI >35). • Annual clinical breast exam and periodic self-breast exam are not recommended. MTF, history of hormone use and breast augmentation • Breast augmentation does not appear to increase risk of breast cancer, although it may impair the accuracy of screening mammography. Breast cancer: Female-to-male FTM, no chest surgery, with or without testosterone use • Breast exams and screening mammography are recommended as for natal females. FTM, after chest surgery, with or without testosterone use • The risk of breast cancer is reduced with chest surgery, but appears higher in FTM people than natal men, based on breast reduction studies in non-transgender women. • Risk is affected by age at chest surgery and the amount of breast tissue removed. • Pre-chest surgery mammography is not recommended unless the person meets usual natal female recommendations. • Yearly chest wall and axillary exams, along with education regarding the small but possible risk of breast cancer, are recommended. Cervical cancer: Male-to-female MTF, following vaginoplasty • If the glans penis has been used to create a neocervix, Pap smear should follow guidelines for natal females. • Consider vaginal Pap smear for MTFs with history of genital warts. • Cervical Pap smears are generally not indicated for MTF people because a cervix is generally not present even after vaginoplasty. Cervical cancer: Female-to-male FTM, cervix intact (sub-total hysterectomy or no hysterectomy) • Pap smears should follow recommended guidelines for natal females. • There is no evidence that testosterone increases or reduces the risk of cervical cancer. • As testosterone therapy can result in atrophic changes to the cervical epithelium mimicking dysplasia, the pathologist should be informed of the person’s hormonal status. • Consider total hysterectomy in the presence of high grade dysplasia or if the person is unable to tolerate Pap smears. FTM, after total hysterectomy (cervix completely excised) • If there is no prior history of high-grade cervical dysplasia and/or cervical cancer, no future Pap smears are needed. • If there is prior history of high-grade cervical dysplasia or cervical cancer, people should have annual Pap smears of the vaginal cuff until 3 normal tests are documented, then continue Pap smears every 2-3 years (as recommended for natal females). Ovarian/uterine cancer: Female-to-male FTM, intact ovaries/uterus (no hysterectomy), with or without history of hormones • Consider screening for signs and symptoms of polycystic ovarian syndrome (PCOS). • Consider pelvic exams every 1-3 years in people over age 40 or with a family history of ovarian cancer, or yearly if PCOS is present. • Fully evaluate unexplained uterine bleeding, with trans-vaginal ultrasound, pelvic ultrasound, and/or endometrial biopsy if bleeding is prolonged. • Consider preventive total hysterectomy and oophorectomy if fertility is not an issue, the person is less than 40 years, and the person’s health will not be adversely affected by surgery. Increased incidence of polycystic ovarian syndrome (PCOS) has been noted among FTMs even in the absence of testosterone use. PCOS is a hormonal syndrome complex characterized by some or all of the following: failure to ovulate, absent or infrequent menstrual cycles, multiple cysts on the ovaries (thus the name), hyperandrogenism, hirsuitism, acne, hidradenitis suppurativa, acanthosis nigricans, obesity, and glucose intolerance or diabetes. We include discussion of PCOS in these guidelines not to suggest that PCOS is related to the development of FTM identity, but rather because reports of increased incidence of PCOS are relevant in considering primary health care needs in FTM people. PCOS is associated with infertility as well as increased risk of cardiac disease, high blood pressure and ovarian cancer. The risk of endometrial cancer increases above age 40. While there does not appear to be an increased risk of endometrial carcinoma specifically among people on masculinizing hormone therapy, dysfunctional uterine bleeding is not uncommon. While usually related to missed doses or changes in a person’s testosterone therapy, otherwise unexplained bleeding should be fully evaluated, especially in previously amenorrheic people. If bleeding is prolonged, the endometrium should be evaluated with trans-vaginal ultrasound, pelvic ultrasound, and/or endometrial biopsy, particularly if the people is above age 35. Prostate cancer: Male-to-female MTF, no current/past hormones, no surgery • There is no evidence currently supporting PSA screening in any usual risk population. The risks and possible benefits of PSA screening should be discussed with all people, and routine screening considered in high risk people (African-Canadian, family history of prostate cancer) starting at age 45. • Digital rectal exams should be performed as for natal males. MTF, past or current hormones, with or without surgery • The prostate is not removed in male-to-female genital surgery. • Feminizing hormone therapy appears to decrease the risk of prostate cancer, but the degree of reduction is unknown. • PSA screening is not recommended as PSA levels may be falsely low in an androgen-deficient setting, even in the presence of prostate cancer. Consider screening in high risk people only. • Digital rectal exams should be performed as per natal males, along with education regarding the small but possible risk of prostate cancer. Other cancers Currently, there is no evidence that transgender persons are at either increased or decreased risk of other cancers. Screening recommendations for other cancers (including colon cancer, lung cancer, and anal cancer) should be followed as with non-transgender patients. Cardiovascular disease: All transgender people • Screening and treatment of known, modifiable cardiovascular risk factors is recommended for all transgender people. • It is recommended that cardiovascular risk factors be reasonably controlled before initiating feminizing/masculinizing hormone therapy. • Consider stress testing among people at very high risk or with any cardiovascular symptoms before initiating hormone therapy. • Consider daily aspirin therapy in people at high risk for CAD. Assessing and treating cardiovascular risk factors is an essential primary care intervention for transgender people. Regardless of hormone status, the transgender population as a whole has several risk factors for cardiovascular disease; feminizing/masculinizing hormone therapy further increases cardiovascular risks. Smoking is a concern for both FTM and MTF persons. MTF people tend to present for transgender care at an older age (i.e., early 40’s), and with hypertension, diabetes, hyperlipidemia, or other conditions common in middle age male bodies. FTM people who present with PCOS are at increased risk for hypertension, insulin resistance and hyperlipidemia. Finally, cardiovascular risk factors are often undiagnosed or undertreated among transgender people due to their relative lack of primary care. Early diagnosis and treatment of cardiovascular risk factors, ideally prior to the onset of cardiovascular disease, may decrease risks associated with hormone therapy in these people. Diet and exercise, including consultation with a dietician or nutritionist as needed, may be helpful initial steps in controlling many risk factors (including hypertension, hyperlipidemia and diabetes). CAD, cerebrovascular disease, and hormones: Male-to-female MTF, currently taking feminizing hormones • Close monitoring for cardiac events or symptoms is recommended for MTFs with risk factors, especially during the first 1-2 years of feminizing hormone therapy. • In people with pre-existing CAD, there is increased risk of future events using estrogen and/or progestin. • It may be possible to reduce risks by using transdermal estrogen, reducing the estrogen dose, and omitting progestin from the regimen. In MTFs with pre-existing CAD who are using estrogen and/or progestin, there is increased risk of future events. The extent of risk, resulting morbidity, and mortality is unclear; it may be substantial given that doses used for feminization in MTFs are typically much higher than post-menopausal hormone replacement therapy. CAD, cerebrovascular disease, and hormones: Female-to-male FTM, currently taking testosterone • Close monitoring for cardiac events or symptoms is recommended for FTMs at moderate to high risk for CAD. • In FTMs with pre-existing CAD, there may be increased risk of future events. • Individualized decision-making is key, but CAD and risk factors should be tightly controlled. The effect of testosterone on cardiovascular events in female-to-male people is unclear. While both exogenous testosterone and hyperandrogen states (e.g., PCOS) clearly increase cardiac risk factors (see above), current evidence of increase in cardiac morbidity or mortality with PCOS is limited. Studies in non-transgender men and women indicate that low endogenous androgens appear to increase the risk for men, while higher endogenous androgens increase the risk for women. In FTMs with pre-existing CAD who are using testosterone, there may be increased risk of future events. The extent of risk, resulting morbidity, and mortality is unclear, given the contradictory effects of testosterone replacement/increased androgens in non-transgender men and women. Hypertension: Male-to-female MTF, not currently taking estrogen • Screen and treat hypertension as recommended in guidelines for non-transgender patients. • Consider a systolic blood pressure goal of less than or equal to 130 mm Hg and a diastolic goal of less than or equal to 90 mm Hg if planning to begin feminizing hormone therapy within 1-3 years. MTF, currently taking estrogen • Monitor blood pressure every 1-3 months. • A systolic blood pressure goal of less than or equal to 130 mm Hg and a diastolic goal of less than or equal to 90 mm Hg is recommended. • Consider using spironolactone (an anti-androgen) as part of an antihypertensive regimen. Exogenous estrogen can increase blood pressure, and transgender people at risk may develop overt hypertension. Hypertension: Female-to-male FTM, not currently taking testosterone • Screen and treat hypertension as recommended in guidelines for non-transgender people. • Consider a systolic blood pressure goal of less than or equal to 130 mm Hg and a diastolic goal of less than or equal to 90 mm Hg if planning to begin masculinizing hormone therapy within 1-3 years. FTM, currently taking testosterone • Monitor blood pressure every 1-3 months. • A systolic blood pressure goal of less than or equal to 130 mm Hg and a diastolic goal of less than or equal to 90 mm Hg is recommended, especially in people with PCOS. Lipids: Male-to-female MTF, not currently taking estrogen • Screen for and treat hyperlipidemia according to guidelines for non-transgender people. • Consider LDL goal less than 3.5 mmol/L if planning to start feminizing hormones within 1-3 years. MTF, currently taking estrogen • An annual fasting lipid profile is recommended. • Transdermal estrogen is recommended for people with hyperlipidemia, particularly hypertriglyceridemia. • Treat high cholesterol to an LDL goal of less than 3.5 mmol/L for low-moderate risk people and less than 2.5 mmol/L for high risk people. Studies in both non-transgender women and MTFs demonstrate increased HDL and decreased LDL cholesterol on estrogen therapy Lipids: Female-to-male FTM, not currently taking testosterone • Screen for and treat hyperlipidemia according to guidelines for non-transgender people. • Consider LDL goal less than 3.5 mmol/L if planning to start masculinizing hormones within 1-3 years. FTM, currently taking testosterone • An annual fasting lipid profile is recommended. • Avoid supraphysiologic testosterone levels for people with hyperlipidemia. Daily topical or weekly intramuscular testosterone regimens are preferable to bi-weekly intramuscular injection. • Treat high cholesterol to an LDL goal of less than 3.5 mmol/L for low-moderate risk people and less than 2.5 mmol/L for high risk people. Diabetes Mellitus: Male-to-female MTF, not taking estrogen • Follow diabetes screening and management guidelines as for the non-transgender population. MTF, currently taking estrogen • People taking estrogen may be at increased risk for Type 2 diabetes, particularly those with family history of diabetes or other risk factors. • Recommend annual fasting glucose test in people with family history of diabetes and/or greater than 5 kg weight gain. Consider glucose tolerance testing (or A1c in people unable to perform a GTT) in people with evidence of impaired glucose tolerance without diabetes. • Diabetes should be managed according to guidelines for non-transgender people, but insulin sensitizing agents are recommended if medications are indicated. • Decrease in estrogen dose may be indicated if glucose is difficult to control or the person is unable to lose weight. Estrogen is known to impair glucose tolerance and there have been case reports of new onset type 2 diabetes among male-to-female transgender people on estrogen. People on feminizing hormones often gain weight and body fat, which may contribute to glucose intolerance. Given the underlying mechanism of insulin resistance, treatment with an insulin sensitizing agent may be warranted for treatment of glucose intolerance and Type 2 diabetes if dietary change is not sufficient. Diabetes Mellitus: Female-to-male All FTMs • Consider screening (by personal history) for polycystic ovarian syndrome (PCOS). Diabetes screening is indicated if PCOS is present. • Guidelines for screening and managing diabetes mellitus are the same as for the non-transgender population. There is limited evidence of a higher incidence of PCOS among female-to-male persons, which carries an increased risk of glucose intolerance. There is no current evidence of an altered risk of Type 2 diabetes in FTMs who are taking testosterone. Testosterone does increase visceral fat among female-to-male people, and older non-transgender women with high testosterone levels are at increased risk of developing Type 2 diabetes as well. HIV and Hepatitis B/C: All transgender people Because HIV and Hepatitis B/C are transmitted by blood as well as through sex, we consider prevention and screening of HIV and Hepatitis B/C separate from sexually transmitted infections. • In people with ongoing risk behaviors for sexual or blood-borne transmission (unprotected penile-vaginal or penile-anal intercourse, history of prior STIs, sharing needles for injection of hormones or illicit drugs, etc.), consider HIV and Hepatitis B/C screening every 6 months. • In all other people, consider HIV and Hepatitis B/C screening at least once during the lifetime. • Treat all people with STIs and their partners according to recommended guidelines for non-transgender people to reduce risk of HIV/Hepatitis B transmission. • Offer Hepatitis B vaccination to all people who are not already immune. As a whole, the transgender population appears to have a disproportionately high rate of HIV/AIDS, although prevalence varies greatly across gender identity. Reported HIV rates from seroprevalence studies in the U.S. range from 20-35% among individuals in the MTF spectrum, with 2-3% incidence among FTMs. Although there is significant variation in sexual behaviours and risks among transgender individuals, psychosocial cofactors relating to unsafe sex (e.g., poor self-esteem, lack of safety in a romantic relationship, substance use, compulsive sex to affirm identity) have been noted as issues of concern in American studies of transgender women (MTF). The reported prevalence of HIV among FTMs is thus far low, but studies suggest three risk factors of particular concern for possible sexual transmission: lack of knowledge relating to HIV transmission and prevention, misperception that FTMs are intrinsically at low risk for HIV, and failure to consistently use a latex barrier during receptive anal or vaginal intercourse. Co-infection of HIV and Hepatitis B/C among individuals who have contracted HIV through blood-borne transmission is cause for concern. Needle-sharing with injectable hormones (or silicone) is a trans-specific potential risk factor for transmission of HIV and Hepatitis B/C, and people need to be educated regarding the risks as well as safe handling of needles and syringes. The local prevalence of needle-sharing for injection of street drugs is not known. One American study found that 20% of MTF participants had injected street drugs at least once in the past six months, and that nearly 50% of those reporting injection drug use having shared syringes. Musculoskeletal health: All transgender people • Exercise may help MTFs taking feminizing hormones to maintain muscle tone. • To avoid tendon rupture, FTMs who are involved in strength training and are taking testosterone should increase weight load gradually, with an emphasis on repetitions rather than weight. The effects of estrogen, anti-androgens, and testosterone on lean muscle mass are well-known, from both transgender and non-transgender studies. It is estimated that approximately 4 kg lean body mass is lost following initiation of androgen deprivation in MTFs, and approximately 4 kg gained following initiation of testosterone in FTMs. Case reports exist on tendon rupture in both FTM people on testosterone and natal men taking anabolic steroids Osteoporosis: Male-to-female MTF, no hormone use, no surgery • There is no evidence of increased risk of osteoporosis. No screening is recommended except as indicated by additional risk factors. MTF, past or present feminizing hormones, pre-orchiectomy • There is no current evidence that feminizing therapy increases risk of osteoporosis, but long-term prospective studies have not been done. • No screening is recommended except as indicated by additional risk factors. • Calcium and Vitamin D supplementation is recommended. MTF, after orchiectomy • Estrogen therapy is advised to reduce the risk of osteoporosis. If there are contraindications to estrogen therapy, supplemental calcium (1200 mg daily) and Vitamin D (600 units daily) are recommended to limit bone loss. If there are additional risk factors for bone loss, consider weekly bisphosphonate (35-70 mg alendronate, 35 mg risedronate) for osteoporosis prevention. • Consider bone density screening for people over age 60 who have been off estrogen therapy for longer than 5 years. The effect of feminizing hormones on bone density is controversial. Studies in MTF people suggest that feminizing hormone therapy does not result in loss of bone mineral density. It is unclear how much estrogen is needed following gonadal removal to protect against bone loss, but studies in postmenopausal women suggest that very low dose estrogen (.025 mg transdermal estradiol or .3 mg CEE) may be sufficient. Loss of bone density is most likely after orchiectomy in those people with other risk factors (e.g., Caucasian or Asian ethnicity, smoking, family history, high alcohol use, hyperthyroidism), those who are not fully adherent to hormone therapy. Osteoporosis: Female-to-male FTM, no hormone use, no surgery • There is no evidence of increased or decreased risk. Follow recommended guidelines for natal females. FTM, past or present hormone use, no surgery • Opinion is mixed on the impact of testosterone on bone density prior to oophorectomy. Some studies found increased BMD or no change, while others have found BMD loss. • Consider bone density screening in FTMs over age 50 (or sooner in people with additional risk factors for osteoporosis) who have been on testosterone therapy over 5 years. • Supplemental calcium (1200 mg daily) and Vitamin D (600 units daily) are recommended to help maintain bone density. FTM, past or present hormone use, post-oophorectomy (or total hysterectomy) • Limited evidence suggests an increased risk of bone density loss after oophorectomy, particularly if testosterone is reduced or discontinued. • Testosterone therapy is advised to reduce the risk of bone density loss. • If there are contradictions to testosterone therapy, consider weekly bisphosphonate (35-70 mg alendronate, 35 mg risedronate) for osteoporosis prevention. • Consider bone density screening in all FTMs over age 60. • Consider bone density screening in FTMs over age 50, or sooner in people with additional risk factors for osteoporosis who have been on testosterone therapy over 5 years. • Supplemental calcium (1200 mg daily) and Vitamin D (600 units daily) are recommended to help maintain bone density. The effect of masculinizing hormones on bone density is controversial. Although studies have found that exogenous testosterone maintains bone density to some degree in FTMs it may not be sufficient, especially after oophorectomy. It is unclear how much testosterone is needed following gonadal removal to protect against bone loss. Some FTM people may use Depo-Provera™ to produce amenorrhea, which appears to result in bone density loss with long term use in non-transgender women. Sexually transmitted infections (STIs): All transgender patients • Test all sexually active transgender people yearly for gonorrhea, chlamydia, and syphillis. • If the person reports ongoing risk factors (recurrent STIs, unprotected sex with a partner who might be at risk, unprotected anal/vaginal sex with more than one partner, or psychosocial cofactors relating to unsafe sex) consider testing every 6 months. • Treat all transgender people with STIs and their partners according to recommended guidelines for non-transgender people. Data on the rates of STIs (other than HIV) among transgender populations is limited. In a 1999 San Francisco study, 53% of MTF participants and 31% of FTM participants reported a prior sexually transmitted infection, with 36% reported for both groups in a New York survey. While from a population health perspective a significant percentage of the transgender community is at risk for STIs, sexual practices among transgender individuals vary greatly and assumptions should not be made about the gender of a patient’s sexual partner(s), sexual activities, or individual risks. Sexual activities vary depending on the person’s anatomy and preferences, as well as that of their partner(s). While some transgender individuals are strongly dysphoric about their genitals, others enjoy using them sexually. Both MTFs and FTMs may engage in receptive or insertive oral, vaginal, and anal intercourse. While digital penetration/touching or use of dildos is considered low risk for transmission of HIV, Hepatitis B, syphillis, gonorrhea, and chlamydia, other STIs (e.g., herpes, trichomonas, HPV) can be transmitted by sharing of sex toys or by unprotected genital touching. Potentially high-risk sexual behaviours reported by transgender research participants include unprotected sex, sex while intoxicated, and sex with multiple partners. Cofactors related to unsafe sex, such as depression, suicidal ideation, and physical or sexual abuse, are also increased among the transgender population. Studies indicate the need to affirm one’s gender identity can drive high-risk sexual behaviors. Fertility issues Transgender patients considering or currently taking hormones • Discuss fertility issues with your doctor if you are considering hormone therapy. • Testosterone is not a fail-safe contraceptive for FTM patients. Sexual function Transgender people considering or currently taking hormones • Testosterone therapy tends to increase libido among FTM people. • Feminizing hormone therapy tends to reduce libido, reduce erectile function, and decrease ejaculation among MTF people. Following genital surgery • Sexual function (libido, arousal, pain with sex, and orgasm) after genital surgery is variable and depends on pre-operative sexual function, the type of surgery performed, and hormonal status. If an MTF person is concerned about limiting erectile dysfunction while undergoing feminizing hormone therapy, the prescribing clinician should first consider adjusting the dose of hormones, while addressing the patient’s desires regarding the degree of feminization and level of erectile function. If this is unsuccessful, erection-enhancing drugs (e.g., Viagra®) may be considered. One clinicians has noted an increased incidence of acute prostatitis among MTF people in the first few years of transition, and speculated this could be caused by cessation of ejaculation resulting in stagnant prostate secretions. There may also be increased risk for acute prostatitis or urinary tract infection after vaginoplasty (due to the shortened urethra). Venous thrombosis/thromboembolism and feminizing hormones MTF people, considering or currently taking estrogen • Estrogen therapy is contraindicated in MTF people with a history of venous thromboembolic events (VTE) or underlying thrombophilia (e.g. anticardiolipin syndrome, Factor V Leiden, etc). • MTF people over age 40, smokers, and highly sedentary people are at particular risk and may benefit from lifestyle change, transdermal estrogen and lower estrogen doses. • Consider daily aspirin therapy in people with risk factors for VTE who are taking estrogen. As noted in Endocrine Therapy for Transgender Adults in British Columbia: Suggested Guidelines, MTF people on any form of estrogen are at increased risk of venous thromboembolic events – potentially as high as a 20-fold increase. These risks increase with age (greater than 40), smoking, and sedentary lifestyle, but may be reduced somewhat by use of transdermal estrogen in lower doses. People should be warned regarding the risks of VTE, along with the signs and symptoms. Transgender and Sexual Orientation In many cases it is difficult to distinguish transgender issues from those related to sexual orientation since the affected groups overlap so significantly. Many persons who identify as transgendered also identify as gay or lesbian, or did so at one time, and most persons who are visibly transgendered are rightly or wrongly regarded as homosexual by health care providers as well as by the public at large. Moreover, transgendered persons whose gender identities are ambiguous, androgynous, or fluid challenge existing categories of sexual orientation or identity, making it problematic even to define what ‘‘same sex’’ or ‘‘opposite sex’’ might mean in some cases. Childhood gender nonconformity is argued to be the strongest single predictor of adult homosexuality (Bell et al., 1981), and while not all lesbians and gay men are visibly transgendered, a substantial number are, or once were. Even if gender nonconformity is not part of a gay, lesbian, or bisexual person’s identity, the centrality of gender to definitions of sexual orientation essentially defines gay, lesbian, and bisexual persons as transgressors of gender norms. From this viewpoint, they, too, are transgendered. Indeed, some gay activists believe that homosexuality will soon be seen as just one specific manifestation of gender nonconformity, and that eventually most lesbians and gay men will also identify as transgendered Transgendered persons frequently experience social and economic marginalization. Those rejected by family and community and with reduced educational and employment opportunities because of harassment and discrimination commonly experience unemployment, poverty, and homelessness. Unemployment and underemployment result in no or inadequate health insurance, and thus many transgendered persons are unable to afford basic medical and mental health services. A disproportionate number of these individuals are people of color, HIV-positive, or youth, thereby increasing the likelihood they are socially marginalized and medically underserved. The combination of these factors contributes to the numbers of transgendered sex workers, who engage in survival sex, sex for drugs, or trade sex for services. As with other sex workers, they face many barriers to obtaining appropriate care. Although a large body of evidence demonstrates that effective treatments are available for transsexualism and other severe gender identity disorders, public and private insurers often specifically exclude coverage on the grounds that the treatments are either cosmetic or experimental. Transgendered individuals, even when they receive a formal psychiatric diagnosis such as gender identity disorder (GID), are denied the legal protections such a diagnosis ordinarily provides. Although gender identity disorders ‘‘cause clinically significant distress or impairment in social, occupational, or other important areas of functioning’’, individuals with GID are specifically excluded from the Americans with Disabilities Act and thus do not receive its benefits or protections. Transgenderism as a Mental Disorder The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994) offers four specific diagnoses which are potentially applicable to transgendered persons. These are: Gender Identity Disorder (GID) in adolescents and adults (302.85) and in children (302.6) Gender Identity Disorder Not Otherwise Specified (GIDNOS; 302.6) and Transvestic Fetishism (302.3) The diagnosis of GID is generally reserved for the most severely gender dysphoric adults and adolescents, persons who usually meet the criteria for transsexualism. Transvestic fetishism, a paraphilia, could be the diagnoses given some crossdressers. GIDNOS is the most general of the DSM-IV diagnoses, and is potentially applicable to a wide variety of transgendered persons. Under DSM-IV, any of these diagnoses requires evidence of distress, or impairment in functioning; functional impairment that is solely due to societal prejudice based on perceived social deviance does not meet this criterion. It is thus important to emphasize that being transgendered does not in itself constitute a mental disorder under DSM-IV. Nevertheless, the diagnoses of GID and Transvestic Fetishism are still considered pejorative by many in the transgendered community. They see the diagnosis of GID in particular as stigmatizing of nonnormative gender behavior, in much the same way that homosexuality was pathologized prior to its removal from the list of mental illnesses by the American Psychiatric Association in 1973. While research is inadequate, the little that has been done suggests that transgendered persons exhibit mental health problems that are comparable to those seen in other persons who experience major life changes, relationship difficulties, chronic medical conditions, or significant discrimination on the basis of minority status. These mental health problems include adjustment disorders, anxiety disorders, posttraumatic stress disorders, and depression. Substance abuse also is a serious related concern among transgender persons. Victimization includes subtle forms of harassment and discrimination as well as blatant verbal, physical, and sexual assault. The last may include physical and sexual assault and even homicide. The majority of assaults against transgender persons are never reported the police. This situation exists because transgender individuals have little societal support or access to legal recourse. Sexual violence against MtF transgendered individuals is common, but incidents are rarely prosecuted the criminal justice system Both suicide attempts and completed suicides are common in transgendered persons. Posttransition, suicidal tendencies probably get no worse, and may actually improve. Another form of self-harm in transgendered persons is attempted or completed autocastration or genital mutilation. This is most common among transsexuals and transgenderists, although crossdressers have done this as well. A study of a cohort of transgendered individuals who applied for services at gender identity clinics reported that genital mutilation was attempted by 9% of the males and breast mutilation was attempted by 2% of the females. Almost all research on transgendered youth combines them with gay and lesbian youth in the catchall category, lesbian-gay-bisexual-transgender (LGBT). Moreover, many youth who appear transgendered, and who may later identify as transgendered, initially identify as gay or lesbian. Consequently, little is known about the prevalence of mental health disorders among transgendered youth specifically. It is assumed that, like lesbian, gay, and bisexual youth, transgendered youth are at increased risk for low self-esteem, depression, suicide, substance abuse, school problems, family rejection and discord, running away, homelessness, and prostitution. Intersex It is conservatively estimated that 1 in 2000 newborns are found to have ambiguous external genitalia. Although some conditions do require surgical or hormonal intervention for genuine medical indications, the majority of intersex conditions are found to be physiologically benign. Nevertheless, it is estimated that 100–200 pediatric surgical sex reassignments are performed in the United States annually. Thousands of these procedures have been performed since the practice was institutionalized in the 1950s with the intention of precluding the stigma arising from the lack of clearly defined male or female genitalia. It has been standard practice to recommend surgery for infants with ambiguous genitalia. The parents of these patients are told to raise them unambiguously as boys or girls. As a result, many adults who have had these operations in infancy have never been candidly informed of their medical histories. Kipnis and Diamond (1998) identified a number of limitations to the current clinical management of intersexuality. First, the line that decisively and nonarbitrarily separates male from female is unclear, and perhaps nonexistent. Second, the development of gender identity is not always alterable in these children, despite alteration of their genitalia. Third, it is not possible to predict confidently the gender—male, female, or transgendered—that an intersexed child will find comfortable in adulthood. Whether to surgically alter ambiguous genitalia in infants and children is an increasingly controversial issue, which highlights the conflict between our cultural and biological definitions of gender. Intersexuality, the biologically variant sexual anatomy known more commonly as hermaphrodism, disturbs the distinction between male and female persons which is so fundamental to self-identification and social status, particularly in the United States. go to Part I - Gay and Bisexual Men go to Part II - Lesbian Health