General Medical Care of the Gender Dysphoric* Patient
This article was first published
in San Francisco Medicine,
Physicians are being called upon to care for an increasing number of patients who do not fit easily into a simplistic male or female category. These individuals range from effeminate males and masculine females to those individuals who transition from one gender to the other. These people often encounter significant hostility and derision in their lives. They often have experienced, or are afraid they will experience, hostility from health care providers and are reluctant to seek medical attention.
Besides their use of hormones and surgical services, these patients also can suffer from other common medical problems (e.g., diabetes, hypertension, appendicitis, etc.). They need general medical care just as any other patient would. Physicians need to understand how the gender issues (and treatments) of these patients influence their medical care. They are a medically underserved group, with specific medical concerns and in need of special outreach by the health care system.
We do not know what causes these individuals to be uncomfortable with or reject the gender assigned at birth, but preventing them from pursuing their gender transitions can be devastating. Although the transition process has its own stresses and problems, it is common to see depressions lift, physical symptoms disappear and hope return when patients actually start their transitions. The evaluation process is complicated and beyond the scope of the present paper.
Gender dysphoria (discomfort with one's assigned gender) can be viewed as a continuum, from patients' refusal to acknowledge such concerns to actively seeking out surgical and hormonal interventions. Some want to be seen as androgynous (their own mix of masculine and feminine attributes) or without gender. Other patients wish to transition permanently from one gender to the other, while others choose to be masculine or feminine at different times. Still others wish to adopt some characteristics of the other sex, but not all. Usually these individuals are called transgendered, but there is debate about the exact definition of that term.
Other groups sometimes confused with the transgendered are transvestites and the intersexed. Transvestites, who are usually men, find dressing in female clothing to be overtly erotic. The intersexed are individuals born with sex chromosomes that do not correspond to the shape of their genitals, have both ovarian and testicular tissue, or have ambiguous genitalia.
Health Care Maintenance
Physicians often make decisions based on gender, both in health care maintenance and in the diagnostic process. For example, being male is a risk factor for cardiovascular disease. Should the physician calculate a female-to-male transsexual's cardiac risk as male or female? Is it better to err on the side of caution or count the male sex as a cardiovascular disease risk factor, and expose the patient to intensified treatment and medication side effects, for questionable benefit?
Should men who take estrogen and develop breasts have regular mammograms? Exogenous estrogen can cause breast development; although this often appears to be female breast tissue, it is gynecomastia histologically. These patients often have breast augmentation, which further complicates the reading of the mammogram. One could argue that these individuals have not had the length of exposure to estrogen that genetic women have had, and therefore face less risk.
Genetic women who wish to be men often have bilateral mastectomies, which can be seen as prophylactic against breast cancer. Nevertheless, we know that women can still develop breast cancer after bilateral mastectomies. So maybe female-to-male transsexuals should have regular mammograms as well. Genetic women who live as men will often go to extraordinary lengths not to be discovered, and thus avoid physicians who might actually attempt a breast exam. Building a solid relationship with your patient is obviously very important. Unfortunately, whether regular mammograms are necessary or desired for either group is still not clear.
Of course, genetic women have a uterus and should have regular Pap smears. Acute left lower quadrant pain in a female could be an ovarian cyst or an ectopic pregnancy, both of which would be quite improbable in a genetic male. Just because a genetic woman has a beard and is taking testosterone, however does not completely rule out pregnancy or other "female" diagnoses.
Medical Complications of Hormonal Treatment
Hormones are available over the Internet as well as from numerous illicit sources. Patients may not be taking the hormones that were prescribed, may be taking what they believe are the equivalent (but cheaper) hormones, or may be taking hormones that were never prescribed. The result may be a medically inappropriate hormone combination with all its consequent problems. Unfortunately, many patients will not report the correct dosages to their physicians or even that they are taking hormones. It is not uncommon for an overworked resident to skip the complete genital exam on admission only to discover that Ms. Smith is really Mr. Smith in the morning.
Significant doses of either testosterone or estrogen are given to individuals to promote a pseudo-adolescence. As in adolescence, these hormones have the effect of transforming the body. High doses of estrogen cause breast development, as well as some transfer of fat from the abdomen to the hips and buttocks. High doses of testosterone cause enlargement of the clitoris, increased body hair, deepening of the voice, acne, and often, male pattern baldness. These changes should be considered permanent and do not necessarily revert with cessation of the hormones. An astute physician may notice these changes and become concerned about an endocrinologic tumor. Patients may be less than forthcoming about their use of nonprescribed hormones and an unnecessary workup may ensue.
Exogenous estrogen and testosterone are given in high doses and can result in significant adverse events. High doses of estrogen can cause breast masses (both benign and malignant) and lead to deep vein thromboses, pancreatitis, elevated liver function tests, prolactinomas, hypertension, gall bladder disease, and lipid abnormalities. High doses of testosterone can lead to exacerbation of congestive heart failure, generalized edema, polycythemia, and liver abnormalities.
Genetic males often take antiandrogens to block their own testosterone or may undergo orchiectomy. In the U.S., these drugs include spironolactone, medroxyprogesterone, or ketoconazole. Each of these drugs has its own set of adverse effects. Removal of testosterone also has a variety of medical ramifications that need to be addressed, including osteoporosis.
There is debate among physicians concerning whether estrogens need to be stopped prior to any surgery. Exogenous estrogens are a risk factor for thrombotic complications, which are probably higher in pelvic surgeries (such as sex reassignment surgery). Stopping estrogens abruptly can induce a menopausal syndrome complete with hot flashes and emotional lability. The risks and benefits of cessation of hormones should be discussed with the patient.
Physicians in the community will inevitably encounter these patients. It is important to provide a nonjudgmental environment. Physicians should review their standard forms to make them more appropriate and welcoming to this patient group. Office staffs need to be trained to deal nonjudgmentally with these patients. One should endeavor to use the name and pronoun that the patient prefers in all interactions.
Further information can be found at: The Harry Benjamin International Gender Dysphoria Association, 1300 South Second Street, Suite 180, Minneapolis, MN 55454. Phone (612)625-1500; fax (612)626-8311; email email@example.com. Or go to the following websites: www.hbigda.org; www.annelawrence.com/professionalindex.html.
*There is great debate within this community about which terms should be used to describe its members. Some feel that gender dysphoria is derogatory, but no accepted term has emerged. Dysphoria is used in this article in its descriptive sense only and no implication of pathology is implied.
Charles Moser, PhD, MD, is a board-certified internist in private practice. He is pioneering the development of the new medical specialty of Sexual Medicine. He is a member of SFMS Board of Directors and the Editorial Board of San Francisco Medicine.