Medical problems of transgender people

Transgender persons are at increased risk for certain types of chronic diseases, cancers, and mental health problems. Below is a list of the key health concerns transgender persons should consider discussing with their doctor.

=Access to healthcare=

Transgender persons may avoid medical care for fear of being rejected. Many have been turned away by healthcare providers due to bias and discrimination in the medical community (especially fundamentalists of the Abrahamic religions) or had other negative experiences. Not all providers know how to deal with specialised transgender issues. Often, transgender health services are not covered by insurance (see below). For these reasons, transgender persons may not be able to access the care they need.

Transgender persons should find a personal doctor who understands transgender health issues. General healthcare for these patients is much the same as it is for others. However, there are certain guidelines that may be helpful to physicians as they approach primary care for transgender patients. One important rule is to remember that medical care should focus on the body parts a person has, whether those are congruent with the gender identity or not. For example, a transman may still have a cervix, in which case he should be followed up with PAP smears. A transwoman most likely still has a prostate, in which case she should be screened for prostate cancer at the appropriate age.

=Hormones=

Many transgender people choose to take hormones so that their bodies more fully match their gender identities. This hormone treatment is often under the care of a primary care physician, and sometimes an endocrinologist. The World Professional Association for Transgender Health (WPATH), in its 'Standards of Care' suggests that a person live full-time in the chosen gender for a year before beginning hormone treatment. Some physicians follow the WPATH standards directly, and others use them as a rough guideline, but do not require their patients to follow the WPATH standards directly. Newer models, such as that proposed by Dr. Maddie Deutsch at the 2008 Gay and Lesbian Medical Association Conference, give patients more autonomy and use 'informed consent' to begin hormone treatment in adults who desire it.

Some patients realise that they are transgender before or when they are first entering puberty. Under the guidance of a therapist and an endocrinologist, these patients may be treated with Gonadotropin Releasing Hormone (GnRH) analogues, such as Lupron, that delay puberty until the patient and parents are ready to make a decision about cross-sex hormones, usually at age 16.

Hormonal therapy causes physical and psychological changes that make the patient feel more like their gender identity, limit the psychiatric morbidity and increases the patients’ quality of life. In contrast, refusing to administer hormone therapy to a patient is a risk factor for self-treatment with illegally obtained hormones and sharing needles for hormone treatment.

However, hormonal therapy has risks. Testosterone can damage the liver, especially if taken in high doses or by mouth. Oestrogen can increase blood pressure, blood glucose (sugar), and blood clotting. Anti-androgens, such as spironolactone, can lower blood pressure, disturb electrolytes, and dehydrate the body. Hormone use should always be supervised by a doctor.

Transgender persons wishing to use hormones should only do so under the supervision of a doctor who can prescribe an appropriate dose and monitor its effects. However, its adverse effects may not be covered by insurance.

=Surgical care=

Some transgender people opt to have sex-reassignment surgery so that their bodies more fully match their identities, while others do not desire or cannot afford surgery.

Surgeries for affirmed males include 'top' surgery, (conversion of the chest from a female appearance to a male appearance), hysterectomy (removal of the uterus), metoidioplasty (release of the suspensory ligament of the clitoris to create a small phallus without standing urination), ring metoidioplasty (rearrangement of the urethra so that standing urination is possible through a small phallus), testicular implants, and phalloplasty (creation of a penis from skin on another part of the body, such as the forearm).

Surgeries for affirmed females include breast augmentation, genital surgery (creation of a vagina, labia and clitoris), and tracheal shave (reduction of the thyroid cartilage to minimize the 'Adam’s apple').

The disadvantages of sex-reassignment surgery include the prohibitive cost, the lack of experienced surgeons and post-operative complications.

=Cancer=

Trans men who still have a uterus, ovaries, or breasts are at risk for cancer in these organs. Trans women are at risk for prostate cancer, though this risk is low. Cancers related to use of hormones are rare, but counseling is still needed.

Transgender persons should be screened for cancers of the reproductive organs.

=Injectable silicone=

Many transgender persons use silicone injections to enhance their appearance. The injection of silicon by non-medical persons is a dangerous practice that can lead to serious health problems. Silicone, when administered by someone who is not a doctor, can move through the body and disfigure it. Also, silicone injected outside of a health care setting is typically not medical grade, may be contaminated, and is often injected using shared needles, which can transmit hepatitis.

Transgender persons need to be counseled about the risks of injecting silicone.

=Substance abuse=

Transgender persons use substances at higher rates compared to others. Substances used include amphetamines including crystal meth, marijuana, ecstasy, and cocaine. Use of these drugs has been linked to higher rates of HIV transmission through impaired decision making during sex. Although the long-term effects of these substances are unknown, evidence suggests that their prolonged use is likely to have serious negative health consequences.

Transgender persons should be screened for substance use and get appropriate education and risk-based counseling.

=Mental health=

There is much controversy surrounding transgender identity and the field of mental health. At the moment, transgender people often receive medical care under the diagnosis of Gender Identity Disorder in the Diagnostic and Statistical Manual of Mental Disorders IV-TR. Many people believe that transgender identity is not a mental disorder and should be a medical, rather than psychiatric, diagnosis. Most people recognise that even if transgender identity is a medical issue, the social stigma associated with the identity can create a difficult situation for those with transgender feelings.

Transgender persons have higher rates of depression and anxiety compared to others. They may experience shame and anxiety over their bodies and, when seen clinically, should not be asked to disrobe unless absolutely necessary. Another important point to remember is that the stereotypical maleness or femaleness of a person’s body is not an indication of the gender dysphoria suffered by the individual. In Singapore, the sex on one's birth certificate is one's sex for life, even if one has undergone sex-reassignment surgery.

Mental health problems are often worse for those who do not have adequate social support or who are unable to express their gender identity because of negative reactions to sex and gender transitioning from peers and authority figures.

Transgender people are believed to be victims of violence more often than others. One study showed that 27% of participants were victims of violence. Murders of transgender people have been reported in 20 states and 89 cities across the United States.

Suicidal ideation is increased in transgender individuals, especially amongst teenagers and young adults, and may be up to 64%. In studies, suicide attempt rates range from 16-37%. Suicidal thoughts and attempts are believed to be mostly due to the difficulties encountered by transgender people when attempting to be themselves in an unfriendly world. Current mental health services and treatment programs are thought to lack the needed cultural sensitivity to effectively help this population.

Lack of health insurance or health care coverage is a problem for many transgender people. There are high rates of unemployment and poverty in this population, partly because of the difficulty navigating the working world as a gender-nonconforming person.

Transgender persons should be screened for signs and symptoms of depression and anxiety and should seek appropriate mental health services as needed.

=Sexually transmitted infections=

Transgender persons are at risk for sexually transmitted diseases. These include infections for which there are effective cures (gonorrhea, chlamydia, syphilis, pubic lice or crabs), as well as those for which treatments are more limited (HIV, hepatitis A, B, or C, human papilloma virus). Safe sex, including the use of barriers, is key to preventing STIs.

Transgender persons who are sexually active should be routinely screened for sexually transmitted diseases. Transwoman sex workers are at especially high risk for HIV infection.

However, as with any other population, it is the individual’s activities that confer risk, so not every transwoman is at high risk for HIV, and some may have no risk at all. Transgender patients should disclose to their doctors their health histories and activities that would lead them to develop particular problems.

= Alcohol=

Studies have shown that transgender persons have higher rates of alcohol abuse and dependence. Although limited alcohol use, such as one drink a day, may not be unhealthy, any use can be a problem for a transgender person with an alcoholrelated disorder. Alcohol abuse is a common problem among transgender persons and can increase the risk for being injured or becoming the victim of a crime.

All transgender persons should be screened for alcohol dependence and abuse, and alcohol use should be limited.

=Tobacco=

Transgender persons smoke and use tobacco products at much higher rates than others. This can lead to a number of serious health problems, including heart disease, high blood pressure, lung disease, and lung cancer.

Transgender persons should be screened for tobacco use and offered tobacco cessation programs.

=Heart disease=

Transgender persons are often at higher risk for heart disease because of hormone use, smoking, and obesity. All transgender persons should have their blood pressure and cholesterol checked as generally recommended. Also, transgender persons should learn about the signs and symptoms of heart disease and stroke.

Transgender persons should have their blood pressure checked at least once a year and their cholesterol screened at least every five years.

=Electronic medical records=

Patients may wish to be labeled 'Male' or 'Female' according to their gender identity and expression, their legal status, or according to the way they are registered with their insurance carrier. They may wish to be referred to as 'Female' in one situation (e.g., in their record with the physician's office and in personal interactions with the physician and staff), but 'Male' in other situations (e.g., on forms related to their insurance coverage, lab work, etc.). This application of terminology could change at any time as individuals come to understand or evaluate their gender.

Electronic medical records (EMR) systems that do not have transgender-specific options make it more difficult for transgender people to change the sex designator under which they will be classified, or such systems may permit a change but will retain a record of that change which will be visible to numerous people outside of the physician or patient's control, leaving transgender and transsexual patients vulnerable to exposure and discrimination. Clinics are encouraged to adopt flexible systems or develop a workaround.

=Insurance Issues=

Health insurance policies often overtly exclude treatments for transgender or transsexual people's health care needs, even when these needs are not related to a gender transition. Some policies are beginning to offer transgender-inclusive plans where employers (who provide the plans as an employee benefit) have demanded that the carriers do so. Much of the difficulty that transgender people experience with respect to insurance is due to coding systems that provide certain procedures for individuals of one or the other sex. For example, if a transman who is enrolled in the insurance system as a male (which facilitates coverage for his labs that compare results with 'male' values) develops uterine fibroids and requires a hysterectomy, the insurance carrier typically denies coverage with the rationale that hysterectomy is only covered for females. Once the carrier labels the patient as transgender or transsexual, many types of coverage may be routinely denied, where they would be covered for patients who are not identified as transgender or transsexual. Physicians or their support staff members may need to interact with insurance claims processors on behalf of their transgender or transsexual patients to insist that medically necessary treatments are covered. In such interactions it will be necessary to support the patient's preferred gender in relationship to the insurance company in the best interests of the patient's health.

=See also=


 * Transgender people in Singapore

=References=


 * Key transgender health concerns, Program for LGBT health, Vanderbilt University School of Medicine.
 * Transgender Health Resources, American Medical Student Association.
 * Insurance issues, Centre of excellence for transgender health, University of Southern California Medical Centre.