Release Date : January 28 2022
ACOG Committee Opinion on Health Care for Transgender and Gender Diverse Individuals (2021)
About the Guideline
- The committee opinion was created by the American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice and the Committee on Health Care for Underserved Women, in collaboration with committee members Beth Cronin, MD, and Colleen K. Stockdale, MD, MS.
- The opinion offers guidance on affirming and inclusive care, preventative care, and hormone therapy.
- Inclusive health care for this patient population has been difficult, and compromising health care for many of these patients often leads to adverse health outcomes.
- Referral networks for specialists and continuity of care are difficult to navigate, and health care professionals should understand the best referral options for their patients.
Key Clinical Considerations
Become familiar with the recommendations and best-practice statements provided in this guideline.
Background
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- Historically, society at large has not treated the transgender or gender-diverse population with acceptance or an understanding of their physical and emotional needs.
- Access to health care and gender-specific care needs are not adequate for many people.
- The term “transgender” is used in this summary to identify transgender, gender-diverse, and genderqueer people. It is a term used to encompass all those who identify as a gender that differs from the gender they were born with.
- Social and economic impacts on transgender individuals throughout the U.S. have contributed to poor health outcomes, both physically and mentally.
Recommendations and conclusions
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- Discrimination based on gender identity should be actively discouraged by all health care service levels, from insurance companies to the entire health care continuum.
- Health care offices for patients should be designed to be comfortable for and appealing to all patients. Staff should be educated in the accurate medical and gender terminology to be used with these patients (for example, using the term “non-binary” for patients who do not identify as exclusively female or male).
- Prior to beginning any hormonal or surgical changes, the patient and medical team need to discuss if there is a plan for parenting or pregnancy in the future.
- Because medications for gender transition are common, any health care provider with prescriptive authority and appropriate training can safely prescribe them.
- Gender dysphoria makes hysterectomy (with or without bilateral salpingo-oopherectomy) medically necessary for those patients requesting this operative procedure.
- Contraception should not be offered based on hormone therapy status alone.
- Preventative health care should be continued for all remaining anatomy, such as gonads, regardless of the patient’s gender preference.
Barriers to health care
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- There is a lack of knowledge in the health care community regarding the best care practices for transgender patients.
- Insurance obstacles are common, as companies routinely deny coverage for surgical transition and hormone treatments.
- Inappropriate treatment when receiving care has included emotional, physical, and sexual abuse by office staff. This results in patients not seeking health care (as many as 23% of patients) due to a lack of trust and fears about the way they may be treated.
- Traditionally, obstetrician-gynecology offices are seen as offering care for women only, and are therefore considered “exclusive” to that gender. All office staff should be given education to help them understand the unique needs of transgender patients and how to best support their health care needs without bias.
Gender transition
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- Each patient will approach the transition process through differing methods and interventions. There is not one pathway to help a patient achieve their desired outcome.
- A mental health professional evaluation will often be completed before any transition can begin. A medically based transition may be started using an informed consent without requiring a mental health evaluation, however.
- Legal changes for transition depend on the laws in each state. Supportive documentation for the patient seeking to make a legal transition should be completed as requested. Medical or surgical treatments are not necessary to make a legal transition to another gender.
- Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People, published by the World Professional Association for Transgender Health, is recommended as an excellent resource for health care professionals who work with transgender patients.
Fertility, pregnancy, contraception, and abortion
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- Reproductive options should be discussed with the patient during counseling regarding their transition. These discussions should include the risk of pregnancy, plans for fertility or preservation of reproductive capabilities (such as using a sperm bank, embryo preservation, or oocyte preservation), and the use of contraception or abortion. The cost to the patient should be researched, as many states and insurance companies will approach coverage for transition- and pregnancy-related outcomes differently.
- Transmasculine individuals can achieve pregnancy safely if they cease taking testosterone prior to attempting pregnancy. Undesired pregnancy may occur in this patient group, which will require further supports for options for pregnancy termination or adoption.
- Transmasculine patients may wish to be called something other than “mom” or “mother” after delivery, so health care staff need to be educated to approach these patients in ways that make them more comfortable, such as using the term “parent.”
- “Chest feeding” is the term often used by transgender patients and should be supported postpartum. As testosterone may suppress milk production, the patient may want to postpone restarting testosterone until nursing is stopped. Lactation suppression can cause increased “transgender dysphoria,” which health care workers need to be sensitive to. Medications to suppress milk production should be discussed with these patients. Note that testosterone has not been proven to pass into breast milk, so timing when to restart it should be discussed with the patient.
- Transfeminine individuals may need to use various means to achieve reproduction. Options such as discontinuing estrogen to raise sperm counts and impregnate a surrogate or partner may be successful. Estrogen is noted to potentially cause testicular damage, but stopping it will improve sperm counts. Sperm banking prior to transitioning may also be an option. Successful breastfeeding has been noted using a modified Newman-Goldfarb protocol (for optimizing lactation).
- Contraception should be discussed with all sexually active patients who have retained their gonads. Education about the hormones being taken and how they will not be reliable at preventing pregnancy even when menses stop should be given. The most common transmasculine methods used for contraception are a hormonal intrauterine device, contraceptive implant, or depot medroxyprogesterone acetate injection, which, although they contain estrogen, do not appear to affect masculinization at recommended dose levels.
Medical transition
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Masculinizing therapy
- Goals for patients include the growth of facial hair, a deepened voice, increased muscle mass, and increased body hair. Other effects may include changes in sweat, receding hairlines, increased libido, cessation of menses, increased size of the clitoris, vaginal atrophy, and changes in subcutaneous fat distribution.
- Absolute contraindications to masculinizing hormone treatment include current pregnancy, unstable coronary artery disease, and polycythemia. Lipid profiles should be monitored, as high- density lipoprotein levels tend to decrease and triglycerides increase in patients receiving testosterone.
- Testosterone levels target ranges of 320 to 1,000 ng/dl. Many forms of testosterone may be used for dosing. Testosterone level and hematocrit should be drawn every 3 months for the first year and then biannually thereafter.
- Menses usually stop within a few months, but should bleeding continue, progesterone may be added to the therapy to avoid hysterectomy or endometrial ablation. Topical estrogen treatments may reduce some of these effects and not interfere with testosterone therapy.
Feminizing Therapy
- Effects of hormone therapy include decreased erectile function, breast growth, decreased testicle size, and increased fat percentage. The voice will not be affected by hormones but can be altered by working with a speech language pathologist. There are no contraindications to using feminizing therapy.
- Risks to feminizing therapy include venous thromboembolism, gallstones, elevated liver enzymes, and hypertriglyceridemia, which can cause cardiovascular disease. It is important to counsel patients to reduce these risks. Monitoring the patient’s blood pressure and potassium levels may also be required, depending on the hormones and hormone agonists used.
- Dosing is based on the ultimate patient goals and physical tolerance. Estradiol levels should be kept to less than 200 ng/ml, and testosterone to less than 55 ng/dl. These levels should be tested every 3 months for the first year and then when patient symptoms cause concerns. Adding potassium and creatinine testing to the 3-month labs should be done if spironolactone is used; thereafter, yearly testing is sufficient.
Surgical transition
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Masculinizing surgery
- Consultation with fertility specialists should be considered prior to surgical procedures. Hormonal therapy should also be discussed in the plan for transition.
- Common surgical procedures are breast or chest reconstruction, genital surgery with hysterectomy with or without the removal of the tubes or ovaries, and aesthetic surgeries such as implants or liposuction. Metoidioplasty to create a neophallus and scrotoplasty may also be included in the transition surgical plan. Insurance companies may require a mental health assessment letter prior to approving coverage for any surgical procedure.
Feminizing surgery
- Breast augmentation, orchiectomy, vaginoplasty, and facial feminization are the most common feminizing surgeries performed. Successful recovery will require follow-up to address requirements for the surgeries used, such as the dilation regime required by vaginoplasty. Education on personal hygiene must also be given regarding symptoms and cleansing instructions.
Cancer Screenings
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- Cancer screenings should be labeled according to the sites they are from, such as “male with cervix” to ensure they are processed by the lab appropriately.
- Transmasculine individuals should have cancer screening based on which female tissues are still intact (for example, breast, cervix, or uterus), per the recommendations for age- and sex-based screening.
- Transfeminine individuals should have cancer screening based on which male tissues are still intact (for example, prostate or testes). Breast cancer screening is recommended if the patient is over the age of 50 and has been undergoing estrogen hormone therapy for a minimum of 5 years.
Additional Considerations for Preventive Care
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- Educate the patient that routine preventive care is important. Screening for domestic violence, substance use, depression, cancer, and sexually transmitted diseases should be implemented annually and as needed.
- Sensitivity to providing careful physical and emotional assessments to reduce trauma and discomfort are essential in the care of these patients.
References
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