Gender

Terminology in Transgender Care

  • Understanding the terminology used in the transgender community is critical for healthcare professionals to provide respectful and informed care.

Asexual

  • Definition: An individual who does not experience sexual attraction.

  • Nuance: Includes a diverse range of desires (or lack thereof) for romantic or other relationships.

Bottom Surgery

  • Definition: Common terminology for genital surgery, especially among female-to-male trans persons.

  • Also Known As: Lower surgery.

Cisgender

  • Definition: Individuals whose gender identity and expression align with their biological sex.

  • Context: A newer term within the transgender community to refer to those who are not transgender.

Crossdresser

  • Definition: A person who wears clothing, jewelry, and/or makeup not traditionally associated with their anatomical sex.

  • Clarification: Crossdressers do not desire to change their anatomical sex. This term is preferred over "transvestite," which is considered pejorative.

Female-to-Male (FTM)

  • Definition: A person assigned female at birth who identifies, lives as, or hopes to live as a man.

  • Synonyms: Transgender man, transman.

Gender

  • Definition: Social categories differentiated by psychosocial characteristics and role expectations.

  • Assignment: Gender is initially assigned based on biological sex in society.

Gender Dysphoria

  • Definition: The distress and suffering experienced when a person's gender identity and biological sex are not congruent.

Gender Expression

  • Definition: The external manifestation of a person’s gender identity, which may not conform to masculine or feminine stereotypes.

  • Indicators: This may manifest through dress, grooming, mannerisms, social interactions, and speech patterns.

Gender Fluid

  • Definition: A form of gender expression that varies from day to day.

Gender Identity

  • Definition: Individual's internal sense of their gender, which can be man, woman, both, neither, or something else.

  • Concept: Gender identity may not be binary; it is increasingly viewed as a spectrum.

Gender Non-Conforming

  • Definition: Individuals whose gender expression differs from societal expectations and stereotypes.

Intersex

  • Definition: Anomalies of sex chromosomes, gonads, reproductive ducts, and/or genitalia, including individuals with both male and female genitalia or those that are ambiguous.

  • Note: This condition may not be identified until puberty.

LGBTQIA

  • Definition: An acronym encompassing the lesbian, gay, bisexual, transgender/transsexual, queer/questioning, intersex/intergender, and asexual/ally communities.

  • Variations: The acronym may be shortened for convenience or lengthened for inclusivity.

Male-to-Female (MTF)

  • Definition: A person assigned male at birth who identifies and lives as or hopes to live as a woman.

  • Synonyms: Transgender woman, transwoman.

Sex

  • Definition: Attributes that characterize biological maleness or femaleness, including genes, chromosomes, hormones, internal and external genitalia, and secondary sex characteristics.

Sexual Orientation

  • Definition: A person’s relative responsiveness to sexual stimuli, particularly the sex of those to whom one is sexually attracted.

Transgender

  • Definition: An umbrella term for individuals whose gender identity or expression differs from that typically associated with their assigned sex at birth.

  • Subcategories: This includes transsexual individuals, androgynous people, crossdressers, genderqueers, and other gender non-conforming individuals.

  • Transition: Some may desire to transition, while others may not seek medical changes.

  • Abbreviation: Sometimes abbreviated as trans or trans*.

Transgender Man (Transman)

  • Definition: A transgender individual assigned female at birth who identifies as a man.

  • Context: The terms transgender man, female-to-male transgender person, and FTM are interchangeable.

  • Note: These patients are men and do not require further description unless medically necessary.

Transgender Woman (Transwoman)

  • Definition: A transgender individual assigned male at birth who identifies as a woman.

  • Context: The terms transgender woman, male-to-female transgender person, and MTF are interchangeable.

  • Note: These patients are women and do not require further description unless medically necessary.

Transition

  • Definition: The period during which transgender persons change their physical, social, and legal characteristics to align with the gender opposite their biological sex.

  • Nature of Transition: Can be perceived as an ongoing process involving changes in identity on legal documents and social interactions (coming out).

Transphobia

  • Definition: Discomfort or dislike for individuals whose gender identity and/or expression diverges from traditional gender roles.

Transsexual Person

  • Definition: An individual whose gender identity does not match their assigned sex at birth, often seeking to live in a gender different from their birth sex.

  • Transition Options: May choose to alter their bodies through hormones or surgery, although this is not universal.

  • Historical Context: The term first appeared in the DSM-III in 1980.

Transvestite

  • Definition: An older clinical term for crossdressers and is now considered pejorative.

  • Recommendation: The preferred term is crossdresser.

  • Historical Context: This term was originally included in the DSM-II.

Medications in Transgender Care

Hormone Therapy Overview

  • Purpose: Hormone therapy may include anti-androgens and estrogens to facilitate physical and psychological transition.

Anti-Androgens

  • Role: Reduce endogenous testosterone levels, allowing for the full effect of estrogen therapy.

  • Choice in U.S.: Spironolactone (Aldactone) is a potassium-sparing diuretic that inhibits testosterone secretion and reduces androgen binding.

Spironolactone

  • Indications: Used for feminization in MTF individuals.

  • Monitoring: Monitor potassium levels due to risk of hyperkalemia.

  • Cost and Regions: Generally expensive and used mainly in Europe.

  • Side Effects: Include gastrointestinal upset, hyperkalemia, increased urinary output, and hypotension.

  • Contraindications: To be avoided in patients with renal insufficiency or elevated potassium levels (> 5.5 mEq/L).

  • Drug Interactions: Should not be given with digoxin, ACE inhibitors, other potassium-sparing diuretics, or angiotensin receptor blockers.

  • Monitoring Requirement: Baseline levels of electrolytes, BUN, and creatinine; repeat levels as specified based on treatment changes.

Other Anti-Androgens

  • Finasteride: A 5-alpha reductase inhibitor that blocks the conversion of testosterone to DHT.

    • Use Case: Second-line therapy for those intolerant to spironolactone; no major food or drug interactions.

  • GnRH Agonists: Block GnRH receptors in the pituitary, decreasing LH and FSH, and thus lowering estradiol and testosterone levels.

    • Examples: Nafarelin (Synarel), Goserelin (Zoladex), Leuprorelin (Lupron).

    • Note: Useful for adolescents due to reversibility; initial testosterone flare can be managed with additional anti-androgens.

Estrogen Therapy in MTF Individuals

  • Effects: Softens skin, stimulates breast development, redistributes fat, and reduces testosterone levels via negative feedback.

  • Timeline: Breast growth is typically maximal after two years of therapy.

Initial Evaluations for Estrogen Therapy

  • Baseline Tests: Liver panel, renal panel, lipid profile, prolactin level, glucose level.

  • Monitoring Schedule: Recheck tests after initiating and upon any dosing changes as specified.

Common Side Effects

  • Include breast tenderness, nausea, depression, dry skin, brittle nails, headaches, increased appetite, weight gain.

  • Rare complications: migraines, gallbladder disease, mood disorders, and increased risk of thrombotic events.

  • Thrombotic Risks: Particularly linked to synthetic estrogens like ethinyl estradiol, especially in older patients or those with risk factors.

Contraindications for Estrogen Therapy

  • Absolute Contraindications: Previous thrombotic events due to hypercoagulable condition, history of estrogen-sensitive neoplasms, end-stage liver disease.

  • Cautions: Use warnings apply for patients with risk factors like obesity, smoking history, cardiac issues, or family history of cancer.

Suggested Laboratory Tests for MTF Individuals

  • Annual Tests: Lipid profile, liver function tests, glucose, prolactin, BUN, creatinine, and electrolytes.

  • Estrogen Management: Estrogen should be ceased prior to surgeries and gradually adjusted post-operative.

Progesterone Considerations

  • Function: Having anti-androgen effects but no proven benefits over spironolactone for MTF patients. Used for perceived effects on breast development and libido maintenance.

  • Risks: Potential for thrombotic events when combined with estrogen; can induce mood changes, weight changes, and other androgenic effects.

  • Usage Cases: May include medroxyprogesterone for patients with suboptimal results on estrogen alone.

  • Adverse Effects: Could involve lipid issues, mood disorders, and increased hair growth.