7.3: Therapeutic Options for Transgender and Gender-Nonconforming Patients

An array of therapeutic options must be considered when collaboratively working with transgender and gender-nonconforming patients. Transition, for those who seek it, does not follow a linear model but is, rather, an individualized process based on the patient’s specific needs. Interventions and their sequence differ from person to person. A collaborative approach between the health care professional and patient is of the utmost importance. Additionally, a multidisciplinary approach, one that encompasses primary care providers, mental health clinicians, surgeons, and speech pathologists, results in the best outcomes. The following lists therapeutic options that a transgender and gender-nonconforming patient may undertake:

• Changing gender expression or role, whether living full-time or part-time in the gender expression that aligns with the current gender identity. This may involve chest binding to create a flat chest contour, padding of the hips and buttocks, genital tucking, wearing gaff underwear, or wearing a prosthesis.
• Changing a name and gender marker on identity documents.
• Seeking psychotherapy to understand and investigate the constructs of gender, such as gender identity, gender role, gender attribution, and gender expression. Psychotherapy may also address the positive or negative impacts of such feelings as stigma and address internalized transphobia, if present.
• Undergoing gender-affirming hormone therapy to either feminize or masculinize the patient’s body.
• Choosing gender-affirming surgeries to alter primary or secondary sex characteristics.
• Finding peer-support groups and community organizations that provide social support, as well as advocacy.
• Attending speech or voice and communication therapy that facilitates comfort with gender identity or expression and ameliorates the stress associated with developing verbal and nonverbal behaviors or cues when interacting with others.
• Removing hair through laser treatments, electrolysis, waxing, epilating, or shaving.

The options may seem overwhelming to review, but it is the goal of the health care professional to assist the patient through the journey, regardless of what therapeutic options the patient ultimately chooses. Access to those services requires that the transgender person live in an area where they are available and have adequate health insurance, which is usually provided by employers. Transgender people, particularly trans people of color, however, are less likely to be employed than cisgender LGB people, thus are often deprived of the health insurance that they need.

Criteria for Gender-Affirming Hormone Therapy

Gender-affirming hormone therapy consists of the administration of exogenous endocrine agents to elicit feminizing or masculinizing changes. While some transgender and gender-nonconforming patients may seek maximum changes, others may be content with a more androgynous presentation. The fluidity of this construct should not be minimized, because hormonal therapy must be individualized on the basis of a patient’s goals and thorough understanding of the risks and benefits of medications and an in-depth review of a patient’s other existing medical conditions. Furthermore, initiation of hormonal therapy may be undertaken after a psychosocial assessment has been conducted and informed consent has been obtained by a qualified health professional. . . . The criteria for gender-affirming hormone therapy are as follows:

1. Persistent, well-documented gender dysphoria;
2. Capacity to make a fully informed decision and to consent for treatment;
3. Age of majority in a given country . . . ;
4. If significant medical or mental health concerns are present, they must be reasonably well-controlled.^[37]

Common agents used for feminization regimens are estrogen and antiandrogens, and the common agent used for masculinization regimens is testosterone. Progestins are controversial in feminizing regimens, and clinicians can cite only anecdotal evidence for the hormone’s use in full breast development. A clinical comparison of feminizing regimens with and without the use of progestins found that these agents did not enhance breast growth or reduce serum levels of free testosterone.^[38] Additionally, progestins’ adverse effects outweigh their benefits because depression, weight gain, and lipid changes have been seen with these agents.^[39] However, progestins do play a role in masculinizing regimens and when used in early stages of hormonal therapy assist in the cessation of menses.

Physical Effects of Gender-Affirming Hormone Therapy

A thorough discussion regarding the physical effects of gender-affirming hormone therapy between the health care professional and the patient is warranted. Using endocrine agents to achieve congruency with a patient’s gender identity will induce physical changes, which may be reversible or irreversible. Most physical changes occur within two years, with several studies estimating the process to span five years. The length of time attributed to such changes is unique to each individual. Tables 7.2 and 7.3 outline the estimated effects and the course of such changes.

Table 7.2 Effects of gender-affirming hormone therapy with masculinizing agents

Effect	Onset (months)
Acne	1–6
Facial and body hair growth	6–12
Scalp hair loss	6–12
Increased muscle mass	6–12
Fat redistribution	1–6
Cessation of menses	1–6
Clitoral enlargement	1–6
Vaginal atrophy	1–6
Deepening of voice	6–12

Table 7.3 Effects of gender-affirming hormone therapy with feminizing agents

Effect	Onset (months)
Softening of the skin	3–6
Decreased libido	1–3
Decreased spontaneous erections	1–3
Decreased muscle mass	3–6
Decreased testicular volume	6–12
Decreased terminal hair growth	6–12
Breast growth	3–6
Fat redistribution	3–6
Voice changes	None

Because of the masculinizing or feminizing effects of endocrine agents used in transitioning, the coming out process for someone who identifies as transgender or gender nonconforming may be challenging and may differ from the coming out process of LGB individuals. LGB individuals may keep their sexual orientation concealed, but the effects of hormonal agents on the transgender person are noticeable to others. Transgender and gender-nonconforming individuals may have to come out during social interactions, unless they wish to relocate to a new area, where they may choose not to disclose their transgender identity, often referred to in the community as “living stealth.”

The coming out process may seem daunting to endure and may encompass numerous challenges. Those lacking support or who have been “mistreated, harassed, marginalized, defined by surgical status, or repeatedly asked probing personal questions may . . . [experience] significant distress.”^[40] Additionally, the persistent and chronic nature of these microaggressions have led some researchers to apply the minority stress model to transgender and gender-nonconforming individuals.^[41] Such experiences create a potential for increase in the rate of certain health care conditions, such as clinical depression and anxiety and their somatization, or conversion to physical symptoms.^[42] Transgender people, like all other LGBTQ+ people, need to learn how to become informed consumers of health care services and make informed choices about their physical and mental well-being. The next section explains how to become such a knowledgeable patient.

Care to the Trans* and Gender Non-Conforming Identified Patient

A video from the Montgomery College, Maryland, nursing program provides a case study that focuses on culturally competent health care for trans and gender-nonconforming people. It captures many of the challenges that a trans patient might face during initial interactions with staff and providers at a health care clinic. Access the full video transcript.

• What challenges does Joe face in terms of accessing health care?
• What are some of the mistakes made by staff at the health care clinic?
• How does Nurse Rachel address those mistakes, both in that initial visit to the clinic and afterward?

Being a Smart Patient and Health Care Consumer

As noted throughout this chapter, LGBTQ+ individuals encounter more discrimination in health care compared with the heterosexual population. While some evidence shows that negative experiences for some LGBTQ+ persons are decreasing, discrimination continues. Lack of health care provider education in culturally inclusive LGBTQ+ communication and care is frequently noted as a contributing factor for health professionals’ discrimination. The shortage of educated practitioners and amount of practitioner bias have caused many LGBTQ+ persons to either delay or avoid seeking health care services. A primary reason attributed for this delay or avoidance is that LGBTQ+ individuals often feel invisible to their providers and have experienced discrimination in previous encounters.^[43]

Other factors also contribute to the negative health care experiences of LGBTQ+ individuals. A provider whose value system, religious beliefs, and political party affiliation are hostile to LGBTQ+ people may have difficulty providing the respectful and affirming care that LGBTQ+ persons are entitled to. For LGBTQ+ people to receive respectful and culturally inclusive, patient-centered care from their providers, they must take it on themselves to be informed health care consumers, practice self-advocacy, and shop wisely for providers who are LGBTQ+ affirming. Self-advocacy is essential to optimizing access to quality health services.

Check Your Knowledge

Contributed by Has Arakelyan, Rio Hondo College

Multiple-Choice Questions

1. What is a primary reason many LGBTQ+ individuals delay or avoid seeking health care?
A) Feeling invisible to providers and past experiences of discrimination
B) Lack of transportation
C) High cost of health insurance
D) Limited access to medications

2. Which of the following is a recommended strategy for LGBTQ+ individuals to receive better health care?
A) Avoid discussing their identity
B) Only use emergency services
C) Practice self-advocacy and seek LGBTQ+-affirming providers
D) Rely solely on online health information

3. What is a common barrier to respectful care for LGBTQ+ patients?
A) Overcrowded hospitals
B) Excessive paperwork
C) Too many health care options
D) Providers’ lack of education in culturally inclusive LGBTQ+ care

4. Why might the coming out process be especially challenging for transgender and gender-nonconforming individuals?
A) They have more health insurance
B) Hormonal and physical changes are often visible to others
C) They do not need to see health care providers
D) They always have supportive families

5. What can persistent microaggressions in health care settings lead to for transgender and gender-nonconforming people?
A) Increased rates of clinical depression, anxiety, and physical symptoms
B) Improved mental health
C) Higher income
D) Better access to care

Discussion Questions

1. What are some ways health care providers can make their practices more welcoming and affirming for LGBTQ+ patients?
2. How does provider bias or lack of education impact the health outcomes of LGBTQ+ individuals?
3. Why is self-advocacy especially important for LGBTQ+ people in health care settings?
4. In what ways does the coming out process differ for transgender and gender-nonconforming people compared to LGB individuals?
5. What steps can be taken at the community or policy level to reduce discrimination and improve health care access for LGBTQ+ populations?

Multiple-Choice Questions - Answers

1. A) Feeling invisible to providers and past experiences of discrimination
2. C) Practice self-advocacy and seek LGBTQ+-affirming providers
3. D) Providers’ lack of education in culturally inclusive LGBTQ+ care
4. B) Hormonal and physical changes are often visible to others
5. A) Increased rates of clinical depression, anxiety, and physical symptoms