1 Population studies estimate that 0.5% of adults (about 25 million people worldwide) identify as transgender (1)
Transgender (trans) is a term used to describe individuals whose gender identity does not align with the sex assigned to them at birth. The term gender-expansive refers to gender identities and expressions that are not strictly masculine or feminine, including nonbinary, genderqueer and genderfluid. (2) Patients should be asked privately what name and pronoun they go by and addressed accordingly. Many pronouns exist, including nonbinary pronouns, such as they and ze.
2 Medical guidelines on providing care for transgender individuals have been published
A primary care physician can deliver most health care needs for transgender individuals. (4) After further training and with expert support, primary care physicians should be able to prescribe hormones, monitor for potential effects of hormone therapy, assess for gender dysphoria and make referrals for transition-related surgeries for transgender people who choose to transition medically. (3,4) Gender-affirming care leads to improved quality of life and psychological outcomes. (4)
3 Transgender men with a cervix are less likely than cisgender women to have up-to-date Papanicolaou screening
In a literature review, transgender men with a cervix were 8.3 times more likely to have an inadequate Pap test, related to testosterone-induced physical changes and examination discomfort for provider and patient, and less likely to be screened appropriately (64.3% v. 73.5%) than cisgender women. (5) Individuals should be kept on the recall list for regular cervical screening. Providers should be trained on transgender-inclusive Pap testing, which can include a baseline Pap test before starting testosterone; short-term topical estrogen before the test; topical lidocaine to the vaginal introitus; use of a pediatric or long, narrow speculum; informing individuals that test results may be inadequate; and communication that prioritizes dignity and autonomy. (5)
4 Fertility preservation should be discussed with transgender individuals before starting hormone therapy
Only 12.4% of transgender adolescents were seen in consultation for fertility preservation before starting hormone therapy in one study. (6) Hormone therapy has gonadal effects that reduce fertility, although the effects are likely partially reversible. (6) Interested individuals should be referred to a fertility preservation program.
5 Transgender individuals should be asked about suicidality and their mental health
Transgender individuals experience discrimination and violence that affect their mental health. (1) Studies in several countries have shown that transgender people are more likely to be diagnosed with depression and anxiety, and have markedly higher rates of attempting suicide and death by suicide, than the general population. (1) In a US study, 41% of transgender participants reported attempting suicide, compared with 1.6% in the general population. (7)
(1.) Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet 2016;388:390-400.
(2.) Abramovich A, Cleverley K. A call to action: the urgent need for trans inclusive measures in mental health research. Can J Psychiatry 2018;63:532-7.
(3.) den Heijer M, Bakker A, Gooren L. Long-term hormonal treatment for transgender people. BMJ 2017;359:j5027.
(4.) Wylie K, Knudson G, Khan SI, et al. Serving transgender people: clinical care considerations and service delivery models in transgender health. Lancet 2016;388:401-11.
(5.) Gatos KC. A literature review of cervical cancer screening in transgender men. Nurs Womens Health 2018;22:52-62.
(6.) Chen D, Simons L, Johnson EK, et al. Fertility preservation for transgender adolescents. J Adolesc Health 2017;61:120-3.
(7.) Grant JM, Mottet LA, Tanis J, et al. Injustice at every turn: a report of the National Transgender Discrimination Survey. Washington (DC): National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011:2.
June Sing Hong Lam MD, Alex Abramovich PhD
CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/180954-five
Competing interests: None declared.
This article has been peer reviewed.
Affiliations: Department of Psychiatry (Lam); Dalla Lana School of Public Health (Abramovich), University of Toronto; Institute for Mental Health Policy Research (Abramovich), Centre for Addiction and Mental Health, Toronto, Ont.
Acknowledgements: The authors thank Drs. Nikki Bozinoff and Renee Logan for their support in manuscript preparation.
Correspondence to: Alex Abramovich, email@example.com