Step 2 CK · Family & Preventive Medicine

Transgender & Gender-Affirming Care

Name: Transgender & Gender-Affirming Care
Creator: Veli Bakalov, MD

Guideline-based, affirming care: terminology, hormones, and organ-based screening

Family & Preventive Medicine·Special Populations & Occupational Health·4 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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Sex assigned at birth differs from gender identity, and both differ from sexual orientation; transfeminine = assigned male at birth, transmasculine = assigned female at birth.
Gender dysphoria (DSM-5) requires clinically significant distress; being transgender is not a mental illness, and ICD-11 moved "gender incongruence" out of the mental disorders chapter.
Use the chosen name and pronouns and a two-step question (sex assigned at birth plus current gender identity).
Feminizing therapy = estradiol + antiandrogen (spironolactone or GnRH agonist): watch VTE (avoid oral ethinyl estradiol; prefer transdermal 17β-estradiol if over 40 or at risk) and potassium.
Masculinizing therapy = testosterone: monitor hematocrit for erythrocytosis; deeper voice, clitoromegaly, and facial hair are irreversible.
Testosterone is teratogenic and amenorrhea is not contraception; counsel contraception for patients with a uterus.
Screen the organs present: a retained cervix needs Pap screening, and the prostate remains after vaginoplasty (PSA is lowered by androgen blockade).
Counsel fertility preservation (sperm, oocyte, or embryo cryopreservation) before hormones, surgery, or puberty suppression.
Adolescents (WPATH SOC-8): reversible GnRH-agonist puberty suppression from Tanner 2; hormones later; most genital surgery deferred to adulthood, chest surgery considered case by case; affirming care improves mental health.

Terminology and affirming communication

Core terms. Getting the language right is both respectful and tested.

Sex assigned at birth reflects anatomy and chromosomes; gender identity is a person's internal sense of their gender.
Cisgender means the two match; transgender means they differ.
Transfeminine (trans woman): assigned male at birth. Transmasculine (trans man): assigned female at birth.
Gender identity is separate from sexual orientation, which describes who a person is attracted to.

Incongruence vs dysphoria. Gender incongruence is a marked, persistent mismatch between experienced gender and assigned sex. Gender dysphoria (DSM-5) adds clinically significant distress or impairment. Being transgender is not itself a mental illness; the diagnosis targets the distress, not the identity. ICD-11 renamed the condition "gender incongruence" and moved it out of the mental disorders chapter into conditions related to sexual health to reduce stigma.

Communication. Ask for the patient's chosen name and pronouns and use them consistently, including in the chart. Collect gender data with a two-step question: sex assigned at birth and current gender identity. Mirror the patient's own words for their body, ask about anatomy or surgery only when it matters clinically, and if you misgender someone, correct yourself briefly and move on.

Gender-affirming hormone therapy

Two regimens, two risk profiles. Feminizing therapy pairs estrogen with androgen suppression; masculinizing therapy is testosterone. Each has a signature lab to monitor, and some effects are permanent, which matters for informed consent.

Feminizing versus masculinizing therapy

Feature	Feminizing (transfeminine)	Masculinizing (transmasculine)
Regimen	Estradiol plus an antiandrogen: spironolactone in the US, or a GnRH agonist	Testosterone
Effects (months to years)	Breast growth, softer skin, less body hair, fat redistribution, decreased libido and erections	Menses stop, voice deepens, clitoromegaly, more muscle mass, facial and body hair, acne, male-pattern hair loss
Not achieved / permanent	Voice does not rise and existing facial hair persists (speech therapy, electrolysis); breast growth is permanent	Deeper voice, clitoromegaly, and facial hair growth are irreversible
Key risks	VTE (estrogen); hyperkalemia (spironolactone); hyperprolactinemia, gallstones, high triglycerides	Erythrocytosis; acne, dyslipidemia; teratogenic
Monitor	Potassium, hormone levels, VTE risk factors	Hematocrit and hemoglobin, lipids, hormone levels

Reducing VTE risk. Thrombotic risk is highest with oral ethinyl estradiol, which should be avoided. Transdermal 17β-estradiol is safer and is preferred in patients over 40 or with VTE risk factors. Smoking cessation lowers the risk further.

Testosterone and pregnancy. Testosterone is teratogenic and does not reliably prevent pregnancy. Amenorrhea does not mean infertility, because ovulation can continue. A patient with a uterus who has receptive vaginal sex still needs contraception; IUDs and progestin-only methods fit well.

Match the lab to the drug: estradiol plus spironolactone → check potassium (and weigh VTE risk); testosterone → check hematocrit for erythrocytosis.

Organ-based cancer screening

Screen the organs that are present. Cancer screening follows an anatomy inventory, not gender identity. Record which organs the patient has, both natal organs and any surgical changes, and apply the standard screening guideline to each.

Anatomy inventory in practice

Organ	Who	Screening point
Cervix	Transgender man without a hysterectomy	Continue Pap screening on the usual schedule. Testosterone-related atrophy causes more inadequate samples, so note testosterone use on the requisition.
Breast or chest tissue	Transgender man before chest (top) surgery; transgender woman on long-term estrogen	Screen retained breast tissue; after top surgery, examine the chest wall. Consider breast screening for transgender women after long-term estrogen.
Prostate	Transgender woman, including after vaginoplasty	The prostate is retained after genital surgery. Screen as indicated, remembering that androgen blockade lowers PSA.

Skipping a Pap in a transgender man "because he is male," or a prostate evaluation in a transgender woman after vaginoplasty, is the classic error.

Fertility and adolescent care

Fertility first. Discuss fertility preservation before starting hormones or surgery, because both can impair fertility. Options are sperm cryopreservation for transfeminine patients and oocyte or embryo cryopreservation for transmasculine patients. This conversation matters most for adolescents, before puberty suppression.

Tanner stage 2A GnRH agonist can pause puberty. It is reversible, buys time, and reduces distress; monitor bone density because bone mineral accrual slows.
Later adolescencePartially reversible gender-affirming hormones may follow.
AdulthoodMost genital surgery, if desired, is deferred to adulthood; chest surgery may be considered in selected older adolescents. Laws and policies vary by state.

Adolescent gender-affirming care (WPATH SOC-8)

Multidisciplinary care. Adolescent care involves mental-health professionals, the family, and medical specialists working together. Access and recommendations for adolescent medical transition vary by jurisdiction, and the evidence continues to be reviewed.

Health disparities

Minority stress. Transgender patients have higher rates of depression, suicidality, HIV and other STIs, substance use, victimization, and barriers to care. The minority-stress model explains this: chronic stigma, discrimination, and rejection drive worse health, rather than gender identity itself. Screen for depression, suicide risk, substance use, and violence, and offer HIV prevention (including PrEP) when indicated.

Affirming care helps. Respectful, gender-affirming care is associated with better mental-health outcomes and more engagement with care. Build a welcoming, nonjudgmental environment: inclusive intake forms, correct names and pronouns, and staff trained to use them.