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Caring for the Transgender Person

Contact Hours: 4

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Contact Hours: 4

This educational activity is credited for 4 contact hours at completion of the activity.

Course Purpose

The purpose of this course is to provide healthcare professionals with a brief overview of caring for transgender individuals by covering definitions, psychosocial challenges faced by this population, terminology, types of hormone replacement therapy, and various surgical interventions that may be encountered in the healthcare setting.

Overview

In recent years, increasing awareness and recognition of diverse gender identities have highlighted the importance of healthcare professionals being well-versed in the care of transgender individuals. This is particularly important as an estimated 2.6 million Americans identify as transgender, accounting for 1% of the nation’s adult population. This course examines the facets of competent care for transgender individuals, covering definitions, psychosocial challenges faced by this population, and terminology. It also discusses available therapies, such as hormone replacement therapy and surgical interventions, in addition to nursing considerations to enhance inclusivity in a healthcare setting.

Course Objectives

Upon completion of this course, the learner will be able to:

  • Define gender identity as is relates to the transgender person.
  • Recognize discrimination that the transgender person may experience in gaining employment, housing, and access to healthcare.
  • Review hormone replacement therapy and surgical interventions for gender affirming care.
  • Understand current federal legislation and how state laws may vary regarding transgender care.
  • Review nursing considerations for providing care to a transgender person in a healthcare setting.

Policy Statement

This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.

Disclosures

Fast CE For Less, Inc and its authors have no disclosures. There is no commercial support.

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Definitions
Affordable Care Act (ACA)Comprehensive health care reform law enacted in March 2010.The law has 3 primary goals: Make affordable health insurance available to more people. Expand the Medicaid program. Support innovative medical care delivery methods.
BinaryThe classification of gender into two distinct forms of masculine and feminine, whether by social system, cultural belief, or both simultaneously. 
Biological SexRefers to one’s status as female, male, or intersex depending on their chromosomes, reproductive organs, and other characteristics.
BisexualSexually or romantically attracted to both men and women, or to more than one sex or gender:
Body DysmorphiaA mental disorder defined by an overwhelming preoccupation with a perceived flaw in one’s physical appearance.
Bottom SurgeryPlastic surgical procedures that are performed on the genitals to give the look, and in some cases, functionality that matches gender identity. 
CisgenderA person whose gender identity corresponds with the sex registered for them at birth.
Conversion TherapyAny emotional or physical therapy used to “cure” or “repair” a person’s attraction to the same sex, or their gender identity and expression. 
DSM-5 (Diagnostic And Statistical Manual Of Mental Disorders, Fifth Edition)A classification of mental disorders with associated criteria designed to facilitate more reliable diagnoses of these disorders. 
Enzyme AromataseThe enzyme responsible for the conversion of androgens to estrogen in many tissues.
Equal Employment Opportunity Commission (EEOC)A federal agency that was established via the Civil Rights Act of 1964 to administer and enforce civil rights laws against workplace discrimination.
EstrogenA category of sex hormone responsible for the development and regulation of the female reproductive system and secondary sex characteristics.
Facial Feminization Surgery (FFS)A surgery that involves the cosmetic modification of your facial characteristics.
Facial Masculinization Surgery (FMS)A set of plastic surgery procedures that can transform the patient’s face to exhibit typical masculine morphology.
GenderThe social, psychological, cultural, and behavioral aspects of being a man, woman, or other gender identity.
Gender DysphoriaA condition where a person experiences discomfort or distress because there is a mismatch between their biological sex and gender identity.
Gender IdentityThe personal sense of one’s own gender.
Gender Non-ConformingA term given to people who do not conform with the gender norms that are expected of them.
Gender-Affirming CareA range of social, psychological, behavioral, and medical interventions “designed to support and affirm an individual’s gender identity” when it conflicts with the gender they were assigned at birth.
GenderfluidA non-fixed gender identity that shifts over time or depending on the situation. 
GenderqueerDenoting or relating to a person whose gender identity does not correspond to conventional binary gender distinctions.
Gnrh AgonistsFunction as agonists of the Gnrh receptor, the biological target of gonadotropin-releasing hormone (Gnrh).
HarassmentThe act of regular and unwarranted actions against a victim, such as racial epithets, annoying remarks, or malicious acts.
Health Insurance Portability And Accountability Act (HIPAA)A federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.
HeterosexualSexually or romantically attracted to people of the opposite sex.
HomosexualSame-sex attraction.
Hormone Replacement Therapy (HRT)Medication that contains female hormones
Housing And Urban Development (HUD)Is one of the executive departments of the the US federal government that administers federal housing and urban development laws. 
Housing DiscriminationThe historical and current barriers, policies, and biases that prevent equitable access to housing.
HysterectomyA surgical procedure to remove all or a part of the uterus.
LaryngoplastyA procedure that moves the vocal fold margin medially to improve glottic closure and voice quality for patients with vocal cord paralysis.
MetoidioplastyA surgery that uses the tissue from the clitoris to create a neophallus, a new penis.
NeophallusConstruction of a new penis.
Neovagina Is surgery used to create a vagina.
Non-BinaryA term for people whose gender identity falls outside of the binary, such as man or woman. 
PansexualSexually or romantically attracted to people regardless of their sex or gender.
PhalloplastyThe construction or reconstruction of a penis or the artificial modification of the penis by surgery. 
ScrotoplastyA type of surgery to create or repair the scrotum.
Secondary Sex CharacteristicsPhysical features related to the sex of an organism that emerges during puberty, or the phase of sexual maturity.
Sexual OrientationAn enduring personal pattern of romantic attraction or sexual attraction (or a combination of these) to persons of the opposite sex or gender, the same sex or gender, or to both sexes or more than one gender. 
TestosteroneThe primary male sex hormone and androgen in males.
Title VII Of The Civil Rights Act Of 1964A landmark civil rights and labor law in the United States that outlaws discrimination based on race, color, religion, sex, and national origin.
Top SurgeryA surgical procedure used to address gender dysphoria for people who identify as binary, nonbinary, or transmasculine. 
TransgenderSomeone whose gender identity differs from that typically associated with the sex they were assigned at birth.
VaginoplastyAny surgical procedure that results in the construction or reconstruction of the vagina.
Introduction

In recent years, increasing awareness and recognition of diverse gender identities have highlighted the importance of healthcare professionals being well-versed in the care of transgender individuals. This is particularly important as an estimated 2.6 million Americans identify as transgender, accounting for 1% of the nation’s adult population.

This community may encounter unique healthcare needs related to treatments, mental health support, and preventative care, making it vital for healthcare professionals to understand the specific health concerns and relevant cultural considerations for improved patient interactions and treatment. This course examines the facets of competent care for transgender individuals, covering definitions, psychosocial challenges faced by this population, and terminology. It also discusses available therapies, such as hormone replacement therapy and surgical interventions, in addition to nursing considerations to enhance inclusivity in a healthcare setting.1-3

Defining Gender Identity

Gender identity lies at the core of the transgender experience. Conventional gender identity is built on biological sex, which is the classification of people as male, or female based on physical genetics and physiological attributes. These include chromosomes (XY for male and XX for female), reproductive organs, and secondary sex characteristics.

A person who does not identify with the gender assigned to them at birth, their biological sex, is recognized as transgender. The cause of this gender incongruence has been studied for decades, with some research pointing to genetic and hormonal influences during prenatal development. However, the specific mechanisms are not fully understood. Other studies have explored differences in brain structure and function between cisgender and transgender individuals. While these studies provide some insights, more research is needed to establish definitive links and understand the complexity of these differences. Psychological factors, such as cognitive and emotional processes, have also been noted to contribute to the development of gender identity. There is a general acknowledgment of the interplay between a person’s self-perception and societal expectations, which can influence their gender identity. Social and cultural factors, including family dynamics, peer relationships, and cultural attitudes toward gender diversity, also play a significant role in shaping a person’s understanding and expression of gender.3,4

Defining Gender Dysphoria

Gender dysphoria is a psychological term used to describe the distress that may arise when a person’s gender identity does not align with the sex assigned to them at birth. It is important to emphasize that gender dysphoria is not synonymous with being transgender, as there are transgender people who do not experience this condition. Rather, gender dysphoria reflects the emotional and psychological challenges that can accompany the incongruence. This distress can manifest in different ways, such as dissatisfaction with one’s social roles associated with the assigned sex, discomfort with physical appearance, specifically secondary sex characteristics, and the desire for interventions. The diagnostic criteria for gender dysphoria, as outlined in diagnostic manuals such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), emphasize that the distress is persistent for a significant duration, typically a minimum of six months. 3,4

Gender dysphoria should not be confused with body dysmorphia, a separate condition. The distress in gender dysphoria is specifically related to gender identity and the societal expectations or physical characteristics associated with one’s assigned sex. Body dysmorphia, on the other hand, is a mental health condition characterized by obsessive concerns about perceived flaws or defects in physical appearance that are not observable or are minor to others. Individuals with body dysmorphia may engage in repetitive behaviors or mental acts in response to these concerns. Body dysmorphia is not specific to gender identity but rather revolves around a person’s perception of their physical appearance.3,4

Transgender Population Statistics

Transgender people often experience significant health disparities, including higher rates of mental health issues, substance abuse, and suicide attempts compared to the general population, which is attributable to societal stigma, discrimination, and a pervasive lack of understanding. The heightened prevalence of suicide attempts and substance use is even more pronounced among transgender people of color and those with disabilities.

In recent surveys, 39% of transgender respondents reported experiencing serious psychological distress, in contrast to the 5% reported within the broader U.S. population. 40% of these respondents had attempted suicide in their lifetime—nearly nine times the attempted suicide rate found in the U.S. population (4.6%). 3-6 Transgender-focused surveys also shed light on the mistreatment experienced within healthcare facilities.

Approximately one-third (33%) of those seeking healthcare encountered at least one negative experience related to their transgender identity, including instances of verbal harassment or refusal of treatment. An estimated one-quarter (23%) of respondents refrained from seeking necessary healthcare during the same period due to apprehensions about mistreatment as a transgender person. Studies also indicate that transgender women, particularly transgender women of color, face an increased risk of HIV infection. In the U.S., 0.3% of the population lives with HIV, while the rate is nearly five times higher within the transgender population (1.4%) and  22 times higher in the Black transgender community (6.7%). Black transgender women experience a disproportionately higher burden of HIV, with approximately 19%  of Black transgender women living with the disease.3-6

Transgender people encounter housing discrimination, with manifestations ranging from outright denial of accommodation to eviction and harassment from landlords or neighbors. Research suggests that an estimated 24% of transgender Americans experience housing discrimination related to their transgender identity. This population has also been shown to have a significantly lower likelihood of homeownership, estimated at 16% as compared to 63% in the general U.S. population. 3-6

Nearly one-third (30%) of this population has been found to have experienced poverty and homelessness at some point in their lives. This rate is more than twice that of the general U.S. population, which is approximately 12%. This inequality is further exacerbated among transgender people of color, who are more than three times as likely to be living in poverty as the general population. A substantial contributor to the high poverty rate is the high rate of unemployment in the transgender population, standing at 15%—three times higher than the U.S. population’s unemployment rate of 5%.3-6

The unemployment rate among transgender people of color is as high as 20%, four times higher than the U.S. unemployment rate. In the realm of employment, transgender people have experienced substantial workplace discrimination, which has caused elevated rates of unemployment and job instability. Surveys have reported that approximately 30% of transgender respondents have encountered employment discrimination due to their gender status. This includes being fired, denied a promotion, or experiencing some other form of mistreatment in the workplace, such as being verbally harassed or physically or sexually assaulted at work. The disparities were notably pronounced among transgender people of color. 3-6

Transgender people are disproportionately subjected to violence, with crowd-sourced reports, news articles, and surveys revealing heightened rates of harassment, physical assault, and even fatal incidents based on gender identity. According to surveys, one in ten of those who openly disclosed their transgender identity to immediate family members reported experiencing violence from a family member due to their transgender status. Also, 8% faced eviction from their homes solely because they identified as transgender. The prevalence of violence extends beyond familial and housing contexts. 3-6

Transgender individuals commonly encounter harassment, physical assault, and verbal abuse in public spaces, experiencing 86.2 victimizations per 1000 persons compared to 21.7 per 1000 persons of cisgender individuals. In the United States, estimates indicate that Black and Latina transgender women comprise nearly 93% of all transgender homicide victims, a murder rate higher than those of Black and Latina cisgender women.3,7-9

Transgender students consistently contend with elevated rates of bullying and discrimination within educational settings. National surveys revealed that 54% of openly transgender or perceived transgender students reported experiencing verbal harassment while in school. Furthermore, 24% endured physical attacks, and 13% faced sexual assault solely because of their transgender identity. The severity of mistreatment led 17% of respondents to leave school. The repercussions of discrimination and inadequate support extend beyond immediate safety concerns to impact the academic performance and mental well-being of transgender students. The hostile environment within educational institutions can adversely affect the overall learning experience for these individuals, hindering their pursuit of higher education. 3-6

Transgender individuals encounter significant challenges in obtaining accurate legal recognition, with recent surveys showing only 11% had all identification documents reflecting their preferred name and gender. 3-6 The financial burden associated with changing identification documents emerged as a primary barrier, with 35% of those who had not legally changed their name and 32% of those who had not updated their gender marker. 3-6

The cost implication not only underscores economic disparities but also reveals an impediment to the right of transgender individuals to be legally recognized in accordance with their gender identity. Beyond financial constraints, nearly one-third of respondents who presented identification congruent with their gender identity faced repercussions, including verbal harassment, denial of benefits or services, eviction, or physical assault. 3-6

Gender Identification Terminology

Given below are the prevalent terms used to describe gender identity. These terms may be subject to change as language around gender identification continues to evolve. A person who identifies with the biological sex assigned to them at birth is referred to as cisgender. A person born as male identifies with the pronouns he/him/his, while a person born female uses the pronouns she/her/hers.

A transgender male is a person who was assigned female at birth but identifies as male. This person prefers male or gender-neutral pronouns (they/them/theirs). A transgender female is a person who was assigned male at birth but identifies as female, preferring female or gender-neutral pronouns. Historically, the term “transsexual” was used to describe a transgender person, particularly one seeking to transition from one gender to another through medical interventions. However, this term has fallen out of favor in recent years as language around transgender identities continues to evolve. Many individuals prefer the term “transgender” as a more inclusive and encompassing term that does not necessarily imply a specific medical aspect to one’s gender identity. In contemporary discussions, the use of the term “transgender” is more common and widely accepted.1,2,10

Like cisgender identification, transgender identification adheres to the binary notion of gender as there are only two assignments, and a person can only be one. However, there are additional identifications that diverge from this binary framework, such as non-binary, genderfluid, and genderqueer. Non-binary refers to individuals who do not exclusively identify as male or female. A non-binary person may identify as a mix of both genders, as neither gender, or as a different gender entirely. Genderqueer is an umbrella term that may also be used in this context. A person whose gender identity is not fixed to a single description but fluctuates periodically, be it daily or yearly, is referred to as genderfluid.

For example, this person may identify as female one day and male the next day or may identify as nonbinary some days and male other days. Their identity and pronouns may similarly fluctuate. For a person who does not identify with any gender, the term gender non-conforming is used. It is a term based on the belief that gender is a social construct and, therefore, is not confined to binary categories or predetermined expectations. A gender non-conforming person does not identify with the social construct of gender and generally does not conform to any gender identity, whether it be cisgender, transgender, non-binary, or genderfluid. Their pronouns may vary, but gender-neutral pronouns are typically appropriate. 1,2,10

It is crucial to emphasize that gender identity and sexual orientation are distinct aspects of a person’s identity. Even though these two attributes are often confused, they are fundamentally different. Gender identity refers to a person’s internal alignment with the sex assigned at birth. In contrast, sexual orientation relates to the emotional, romantic, or sexual attraction one experiences towards others, such as being heterosexual, homosexual, bisexual, or pansexual.

For instance, a person who identifies as homosexual is sexually attracted to people of the same gender, while a person who identifies as heterosexual is attracted to individuals of the opposite gender. A person who is bisexual is attracted to people of both genders, while a person who is pansexual is attracted to individuals regardless of gender. As gender identity and sexual orientation are not inherently linked, a transgender person can have any sexual orientation, just like a cisgender person. 1,2,10

Gender-Affirming Care

Gender-affirming care refers to medical, psychological, or social interventions and support provided to transgender people to help align their physical appearance, gender identity, and overall well-being with their affirmed gender. The goal of gender-affirming care is to enhance the individual’s mental health, quality of life, and overall satisfaction by acknowledging and supporting their gender identity. Gender-affirming care may include various components, depending on the individual’s needs and preferences. Some key aspects of gender-affirming care include mental health support, hormone-replacement therapy, gender-affirming surgeries, social support, and legal recognition.2,10-12

Mental health support refers to access to mental health professionals who specialize in gender-related issues. These healthcare providers help in addressing the emotional and psychological stability of transgender individuals, particularly those experiencing gender dysphoria. Hormone Replacement Therapy (HRT) is for transgender people seeking to physically transition from their assigned gender to their affirmed gender. For transgender females, this is known as a male-to-female (MTF) transition, and for transgender males, a female-to-male (FTM) transition. Hormone replacement therapy has been shown to induce changes in secondary sex characteristics, like body fat distribution and voice pitch. Gender-affirming surgeries are for those individuals seeking to further align their physical appearance with their gender identity. Social support involves creating environments that respect gender identity using correct names and pronouns and ensuring inclusive language. Legal recognition allows transgender people to obtain accurate identification documents that reflect their affirmed gender through name changes and gender marker updates. 1,2,10

Maintaining Confidentiality

Like all patients, transgender patients have a right to privacy regarding their personal information, including their gender identity and medical history. Respecting confidentiality reinforces trust between healthcare providers and patients. Trust is a foundational element in the patient-provider relationship and demonstrates a healthcare provider’s commitment to respecting individual rights and fostering a trusting and supportive environment.

More importantly, trust creates a safe space where patients are comfortable in sharing their experiences, concerns, and medical history, and healthcare providers can better understand and address the unique needs of their patients. As these medical discussions often involve sensitive topics related to gender identity, gender dysphoria, or gender-affirming interventions, a heightened commitment to maintaining privacy is vital to safeguard the patient from unwarranted judgment or mistreatment. The disclosure of a transgender status may expose individuals to potential stigma, discrimination, or harassment, both within healthcare settings and in broader societal contexts. 1,2,10

Maintaining confidentiality also enhances engagement in regular healthcare. Transgender individuals are more likely to seek medical attention when they feel confident that their personal information is secure. This timely access to preventive and necessary medical care can lead to improved health outcomes, helping a population that is known for experiencing healthcare disparities and a history of being underserved.

Patient privacy is not only an ethical obligation but also a legal requirement in healthcare settings as dictated by laws such as the Health Insurance Portability and Accountability Act (HIPAA). The health insurance portability and accountability act sets forth stringent guidelines and standards for the collection, storage, and dissemination of patient data. Healthcare providers and the healthcare facilities they operate within are legally compelled to adhere to these regulations. In the event of a breach, the repercussions may include legal actions, such as lawsuits and disciplinary measures. 1,2,10

Providing Support

To establish unbiased and inclusive care, healthcare providers must offer support and treat transgender patients like any other. It is well-documented that transgender individuals face systemic barriers to accessing adequate healthcare, resulting in serious health consequences. Most insurance policies often exclude medically necessary care for transgender people, including mental health therapy, hormonal therapy, and surgeries.

Discrimination in healthcare settings leads to delays or avoidance of necessary health services, putting overall health at severe risk. These challenges exacerbate the health disparities faced by gender-diverse individuals, contributing to increased risks of suicide and self-harm among those who have been denied care. Despite increased awareness and the development of evidence-based standards of care, persistent barriers prevent transgender individuals from receiving equitable and timely healthcare. Addressing these challenges requires healthcare providers to support their transgender patients, ensuring that they receive comprehensive and affirming care that prioritizes their overall health and well-being.11,12

Types of Hormone Replacement Therapy

Hormone replacement therapy (HRT) for transgender adults involves the use of hormones to promote physical changes in secondary sex characteristics that align with their gender identity. The specific hormones vary and are based on whether someone is undergoing feminizing or masculinizing HRT, along with individual health conditions and medical history. It is important to note that despite this treatment, some degree of pre-existing masculinity and felinity persists in transgender females and transgender males, respectively, such as height, subcutaneous fat distribution, and skeletal dimensions.14-15

For masculinizing hormone therapy, patients are primarily prescribed testosterone to suppress female features and induce male secondary sex characteristics. Occasionally, aromatase inhibitors may also be given to prevent the conversion of testosterone to estrogen. Testosterone results in the cessation of menstrual cycles (amenorrhea), an increase in facial and body hair, alterations in skin texture, and a rise in acne. Changes in fat distribution are also seen away from the hips, thighs, and buttocks, and gains in muscle mass are also evident for a more masculine physique. In addition to these effects, heightened libido is commonly reported.

Over time, further masculinizing effects manifest, including the deepening of the voice, atrophy of the vaginal epithelium, and an increase in clitoral size. Male pattern hair loss may occur because of the androgenic interaction with skin pilosebaceous units. Formulations include testosterone enanthate, 1% testosterone gel, and testosterone patches. While generally well tolerated, long-term use of testosterone may have other health implications, such as an increased risk of cardiovascular issues and changes in cholesterol levels.

Aromatase inhibitors (AIs) also help limit the feminizing effects of estrogen by blocking the activity of the enzyme aromatase, which is responsible for converting androgens (like testosterone) into estrogens. While AIs are not typically used in masculinizing hormone therapy, they may be considered when testosterone therapy alone does not achieve sufficient suppression of estrogen levels. Two commonly used aromatase inhibitors are anastrozole and letrozole. Side effects of using AIs include joint pain, decreased bone mineral density, and changes in lipid profiles. 14-15

For feminizing hormone therapy, patients may receive anti-androgens, estrogen, and progestin to suppress masculine features and induce feminine features. Ant-androgens are typically given  4 – 8 weeks before starting estrogen first to diminish the effects of testosterone, the primary male sex hormone. Anti-androgens help reduce masculine features such as facial hair growth, body hair density, and a deepening voice.

Examples include spironolactone, finasteride, cyproterone acetate, and GnRH agonists such as leuprolide. Side effects of these drugs include: a decrease in sexual desire (libido), changes in erectile function, including a potential decrease in spontaneous erections, and testicular atrophy, which results in a reduction in the size of the testicles over time. Anti-androgens can also result in a reduction of sperm production, leading to reduced fertility. It is important for individuals considering anti-androgen therapy to discuss fertility preservation options with their healthcare provider if future biological parenthood is a concern. Long-term use of anti-androgens may also have an impact on bone density and may be associated with a slightly increased risk of blood clot formation. 14-15

Estrogen softens the skin, decreases hair growth, decreases muscle mass, and promotes the development of secondary sex characteristics for females, including breast development, and redistributes body fat towards the hips, thighs, and buttocks, contributing to a curvier and more traditionally feminine silhouette. This redistribution also helps to soften angular features. However, the extent of fat reallocation can vary among individuals, as not all aspects of body composition are solely influenced by hormone therapy.

Genetics and lifestyle factors also play roles in determining how fat is distributed throughout the body. Examples of estrogen used in HRT include estradiol, estrone, and conjugated estrogens. Side effects of estrogen HRT include breast tenderness and soreness, a decrease in libido, mood swings, and changes in emotional sensitivity. In several studies, estrogen has also been shown to slightly increase the risk of blood clot formation. In some male-to-female transition cases, progestins such as medroxyprogesterone acetate and micronized progesterone are also prescribed to accelerate feminizing effects and decrease testosterone production. These drugs are believed to contribute to breast development by stimulating the development of mammary glands and promoting the growth of breast tissue. When combined with estrogen, progestins may enhance the feminization of the chest area. Progestins can have an impact on mood and well-being, increasing bone formation and improving sleep and vasomotor symptom control. Some individuals report enhanced emotional well-being and reduced mood swings with the addition of progestins to their HRT regimen. 14-16

Surgical Interventions

Transgender individuals may choose to undergo surgical intervention to align their physical characteristics with their gender identity, helping reduce the incongruence between their body and sense of self. However, like all surgical procedures, these interventions carry inherent risks and potential complications. The decision to undergo surgery is a highly personal one, and individuals should thoroughly discuss the potential risks and benefits with their healthcare providers. It is essential to recognize that not all transgender people pursue surgical intervention.

The most prevalent surgeries among the transgender population include chest masculinization or feminization (top surgery), genital reconstruction (bottom surgery),  facial feminization surgery, facial masculinization surgery, laryngoplasty, body augmentations, and hair transplantation.17

Chest masculinization for a transgender male involves the complete removal of the breasts via a double mastectomy and the reshaping of breast tissue to create a more masculine appearance. Nipple resizing and repositioning may also be part of the procedure for a more consistent presentation. Common techniques include double incision with nipple grafts, periareolar, or keyhole, depending on the amount of tissue to be removed. For transgender females, chest feminization involves breast augmentation. Silicone or saline implants are placed to enhance breast size and create a more feminine chest contour.

Following both types of top surgery, drainage tubes may be placed to remove excess fluid and reduce swelling. The drainage tubes are usually removed after a week or two. Patients are required to wear compression garments to help minimize swelling and support the healing process, and pain medications are prescribed to manage postoperative discomfort. Following a chest masculinization surgery, long-term scar management is important. While they typically fade over time, some transgender males may consider scar revision surgery if necessary. Engaging in chest exercises once determined safe by a healthcare provider can enhance muscle development and further masculinize the chest. Following a breast augmentation, transgender females over age 50 are advised to have regular mammograms if they have been on hormone replacement therapy for greater than 5 years.18,19

Genital reconstruction for transgender men focuses on masculinizing the genital area via a phalloplasty or metoidioplasty. A phalloplasty constructs a neophallus using tissue grafts, often from the forearm or thigh. The surgery is typically done in multiple stages, as it also includes urethral lengthening and, for some, the implantation of an artificial penile implant (penile prosthesis implantation).

A metoidioplasty releases the clitoris to resemble a smaller penis. It may include urethral lengthening and scrotoplasty to create or refine the scrotal region. This surgical intervention requires a lengthy recovery period, and patients typically need to follow strict postoperative instructions, such as adequate rest, avoiding strenuous activities, and specific hygiene guidelines to prevent infection. Regular follow-up care is crucial to monitor the healing of the prosthesis (if implanted) and address any issues. Potential revisions may be necessary for aesthetic refinement. A hysterectomy, which involves the removal of the uterus, is a common procedure for transgender men. While it does not impact external appearance, it is considered part of gender-affirming care.20-22

Genital reconstruction for transgender women focuses on feminizing the genital region. Typically, a vaginoplasty is performed, which results in the creation of a neovagina using penile and scrotal tissue to construct the vaginal canal, labia, and clitoral region. During this procedure, testicles are usually removed (orchiectomy) along with a clitoroplasty to refine the appearance of the clitoris. For further refinement of the labia, a labiaplasty may be done to enhance the external appearance of the genitalia. Following this reconstruction, proper wound care, hygiene, and dilation techniques are vital to prevent infection and maintain the depth and width of the neovagina. Lifelong dilation is often necessary to prevent the neovagina from contracting. Regular follow-ups with healthcare providers are also important for ongoing monitoring, assessing aesthetic outcomes, and addressing concerns. 20-22

Facial feminization surgery (FFS) is a set of surgical procedures designed to modify facial features to achieve a more oval or heart-shaped appearance, with smoother lines. The specific procedures performed can vary based on individual needs. Still, they may include forehead contouring to reduce the prominence of the brow to reshape the forehead, jaw-chin contouring to reshape the lower face to be less angular and more rounded, cheek augmentation to add volume to the cheeks to create a softer, more feminine contour, and a rhinoplasty for a more feminine nose shape. Tracheal shaving is another common procedure as it reduces the prominence of the Adam’s apple. Other minimally invasive surgeries may also be done, such as a lip lift or augmentation with filler for a fuller, more feminine look. Following an FFS, swelling, bruising, and discomfort are common, and patients must strictly adhere to aftercare guidelines and use prescribed medications for optimal results. Full recovery and final results may take several months.23,24

Facial masculinization surgery (FMS) is a set of surgical procedures aimed at adjusting facial features to create a more masculine appearance. The specific procedures performed can vary based on individual needs. Facial masculinization surgery typically includes forehead augmentation to build up the brow area and make a more projecting forehead, cheek augmentation to enhance the cheeks for a stronger and more defined appearance, jaw-chin augmentation to build up the lower face to create a squared-off, more defined jawline, and rhinoplasty for a more masculine nose shape. A lip reduction may also be done to adjust the lips to achieve the thinner look typically associated with masculinity. To further enhance masculinity, an Adam’s apple prosthetic may be implanted in the front of the neck area. Like other facial surgeries, swelling, bruising, and discomfort are common, and the final results will take several months to become apparent. Aftercare involves strict adherence to the surgeon’s guidelines and regular follow-up appointments to monitor healing and address concerns.25,26

A laryngoplasty and hair transplantation are additional surgical options pursued by transgender people. A laryngoplasty modifies the structure of the larynx (voice box) to achieve a varied voice pitch by reducing or augmenting the vocal cords to achieve the desired vocal characteristics. For feminization, vocal cords are typically shortened to adjust the tension for a higher pitch. For masculinization, vocal cords are lengthened to lower or deepen the pitch. Following surgery, patients usually undergo a period of voice rest to allow for proper healing of the vocal cords. Voice therapy may be recommended to help individuals adapt to their new vocal range and improve vocal techniques. This therapy may be continued to refine and maintain the desired pitch and resonance.27,28

Body contouring options like liposuction, Brazilian butt lifts (BBLs), and abdominoplasty are sought by transgender individuals seeking specific changes in body shape. Liposuction removes excess fat from areas of the body, sculpting the body for a more feminine or masculine appearance, depending on the individual’s goals. For transgender women, it can be used to remove excess fat from areas that are more common in masculine body contours, such as the abdomen, flanks, or back. This adjustment helps create a smoother and more feminine silhouette. For transgender men, liposuction can address areas of stubborn fat in the hips, thighs, or buttocks that contribute to a more feminine appearance. Brazilian butt lifts use liposuction techniques to remove fat from one area of the body, purify it, and then inject it into the buttocks to enhance volume and shape. Transgender women may choose this procedure to achieve a fuller and rounder buttock appearance. Brazilian butt lifts are generally less common for transgender men. In specific cases, they may be used to create a more rounded buttock appearance if that aligns with the individual’s desired outcome. 29

Federal Legislation on Transgender Rights and Healthcare

There have been several federal and state-level initiatives aimed at protecting transgender rights, including those related to healthcare. It is important to note that legislation can change, and new laws may be enacted in the future. Key federal legislation and policies, such as the Patient Protection and Affordable Care Act (ACA), include provisions that prohibit discrimination based on gender identity in healthcare settings. Specifically, section 1557 of the ACA prohibits discrimination based on race, color, national origin, age, disability, sexual orientation, or gender identity in certain health programs and activities. The Equal Employment Opportunity Commission (EEOC) has interpreted Title VII of the Civil Rights Act of 1964 to include protection against discrimination based on gender identity and sexual orientation in employment, while Housing and Urban Development (HUD) regulations have implemented rules to ensure equal access to housing and facilities, for the same. As of April 2022, all U.S. citizens have the option to select an “X” as their gender marker on their U.S. passport application.30,31

While federal laws provide certain protections, the landscape of transgender rights and healthcare can vary significantly at the state level. States have different regulations regarding health insurance coverage for transgender-related care. Some states mandate coverage for transition-related healthcare, while others may not have explicit requirements. Due to this, access to gender-affirming healthcare, including hormone therapy and surgeries, fluctuates substantially. States vary in the extent to which they have implemented non-discrimination protections for transgender individuals in areas such as employment, housing, and public accommodations. Procedures and requirements for changing one’s name and gender marker on identification documents also differ by state, impacting the recognition of a transgender individual’s identity. While some states have implemented bans on conversion therapy, which seeks to change an individual’s sexual orientation or gender identity, the scope and enforcement of these bans differ across state lines. 30,31

Nursing Considerations

Nursing considerations for treating transgender patients involve a multifaceted approach encompassing both clinical and psychosocial aspects. Establishing a culturally competent and non-discriminatory environment is foundational. Nurses with limited experience can improve inclusivity by consistently using the patient’s affirmed name and pronouns, respecting their gender identity, and ensuring confidentiality. Incorporating gender-neutral language and adopting the two-step method can help transgender patients feel at ease. This approach employs two distinct questions to ascertain the patient’s chosen gender identity and their sex assigned at birth. These efforts build trust and facilitate open communication, both central to allowing patients to share their gender-related healthcare goals, concerns, and preferences.2,4,11

In clinical care settings, nurses should stay informed about gender identification and gender-affirming treatments, including hormonal therapies and surgical interventions. Being knowledgeable about procedures, potential side effects, monitoring parameters, and treatment regimens aids in providing quality care. Regular assessments should encompass both physical and mental health aspects, acknowledging the potential impact of gender dysphoria and the psychosocial challenges faced by transgender individuals. This includes regular screenings for conditions such as depression, anxiety, posttraumatic stress disorder, eating disorders, substance use, intimate partner violence, self-injury, bullying, truancy, homelessness, high-risk sexual behaviors, and suicidal ideations. It is crucial to refrain from assuming an identified concern is inherently linked solely to the individual’s transgender identity. 2,4,11

Transgender patients may encounter discomfort during physical examinations, which can be attributed to persistent gender dysphoria or negative experiences in their medical history. Nurses play a pivotal role in helping them feel respected through the exam by inquiring and paying attention to their comfort levels. This consideration also extends to patient advocacy, by advocating for inclusive policies within healthcare institutions, addressing potential biases, and actively participating in ongoing education to enhance cultural competence. Sensitivity to the potential disparities in healthcare access, such as insurance coverage for gender-affirming treatments is fundamental, and nurses may need to collaborate with healthcare teams to navigate these challenges. 2,4,11

Providing emotional support and connecting transgender patients with relevant community resources or support groups can contribute significantly to their overall well-being. As part of a holistic care approach, nurses should consider the unique psychosocial dimensions of transgender health, aiming to create a healthcare environment that is not only clinically effective but also affirming, respectful, and responsive to the individual needs of transgender patients. Ongoing education, open dialogue, and advocacy efforts within the nursing profession contribute to the creation of healthcare spaces that prioritize the dignity and rights of transgender individuals. 2,4,11

Conclusion

Providing comprehensive care for transgender individuals involves a multifaceted approach that extends beyond medical interventions. It covers an in-depth understanding of the nuances of gender identity, respecting individuals’ autonomy, and recognizing the diverse paths individuals may take in their gender-affirming process. From the medical perspective, hormone replacement therapies, gender-affirming surgeries, and other interventions aid in aligning physical attributes with gender identity. However, equally vital is the recognition of the broader social, psychological, and systemic factors that impact transgender individuals’ health and well-being.

Transgender individuals often experience health disparities, including higher rates of mental health issues, substance abuse, and experiences of discrimination and violence. Acknowledging these challenges requires healthcare providers, educators, and policymakers to develop inclusive and supportive environments. The legislation ensures transgender individuals have access to equitable healthcare and protection from discrimination, yet the complex landscape of federal and state laws underscores the dynamic nature of transgender care.

The healthcare community must prioritize ongoing education to enhance cultural competence, fostering an environment where transgender patients feel seen, heard, and respected. Nurses are a key component of the formula in advocacy, patient education, and the establishment of a safe space for open dialogue. Inclusivity in healthcare not only upholds the principles of patient-centered care but also helps mitigate healthcare disparities and ensures that transgender individuals receive equitable and affirming treatment tailored to their unique needs. By fostering a healthcare environment that is knowledgeable and respectful, providers can contribute to the overall health and well-being of transgender patients and promote a more inclusive and affirming healthcare system.

References
  1. What percentage of the US population is transgender? (2023, August 3). USAFacts. https://usafacts.org/articles/what-percentage-of-the-us-population-is-transgender/
  2. Klein, D. A., Paradise, S. L., & Goodwin, E. T. (2018). Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know. American Family Physician, 98(11), 645–653. https://www.aafp.org/pubs/afp/issues/2018/1201/p645.html
  3. December 2016 THE REPORT OF THE. (n.d.). https://transequality.org/sites/default/files/docs/usts/USTS-Executive-Summary-Dec17.pdf
  4. Crowley, D., Cullen, W., & Van Hout, M. C. (2021). Transgender health care in primary care. The British Journal of General Practice, 71(709), 377-378. https://doi.org/10.3399/bjgp21X716753
  5. Pinna, F., Paribello, P., Somaini, G., Corona, A., Ventriglio, A., Corrias, C., Frau, I., Murgia, R., El Kacemi, S., Galeazzi, G. M., Mirandola, M., Amaddeo, F., Crapanzano, A., Converti, M., Piras, P., Suprani, F., Manchia, M., Fiorillo, A., & Carpiniello, B. (2022). Mental health in transgender individuals: a systematic review. International Review of Psychiatry, 34(3-4), 292–359. https://doi.org/10.1080/09540261.2022.2093629
  6. Wesp, L. M., Malcoe, L. H., Elliott, A., & Poteat, T. (2019). Intersectionality Research for Transgender Health Justice: A Theory-Driven Conceptual Framework for Structural Analysis of Transgender Health Inequities. Transgender Health, 4(1), 287-296. https://doi.org/10.1089/trgh.2019.0039
  7. Fouché, T. W., Zakrison, T. L., Schneider, J. A., Kaufman, E. J., Plackett, T. P., Velopulos, C., Slidell, M. B., Voisin, D., Hampton, D. A., Carmichael, H. E., Valdés, D. M., Parker, C., Ross, B., Chaudhary, M., & Cirone, J. (2022). Demographic and Regional Factors Associated With Reporting Homicides of Transgender People in the United States. Journal of Surgical Research, 279, 72-76. https://doi.org/10.1016/j.jss.2022.05.029
  8. Flores, A. R., Meyer, I. H., Langton, L., & Herman, J. L. (2021). Gender Identity Disparities in Criminal Victimization: National Crime Victimization Survey, 2017–2018. American Journal of Public Health, 111(4), 726-729. https://doi.org/10.2105/AJPH.2020.306099
  9. Dinno, A. (2017). Homicide Rates of Transgender Individuals in the United States: 2010–2014. American Journal of Public Health, 107(9), 1441-1447. https://doi.org/10.2105/AJPH.2017.303878
  10. Bhatt, N., Cannella, J., & Gentile, J. P. (2022). Gender-affirming Care for Transgender Patients. Innovations in Clinical Neuroscience, 19(4-6), 23-32. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9341318/
  11. Transgender Health | Endocrine Society. (n.d.). Www.endocrine.org. https://www.endocrine.org/advocacy/position-statements/transgender-health
  12. Milionis, C., & Koukkou, E. (2023). Barriers and Challenges in Caring for Transgender People: Implications for Clinical Practice and the Experience From a Specialized Center. Journal of Doctoral Nursing Practice, 16(1), 44–53. https://doi.org/10.1891/JDNP-2021-0022
  13. Radix, A. (2019). Hormone Therapy for Transgender Adults. Urologic Clinics of North America, 46(4), 467-473. https://doi.org/10.1016/j.ucl.2019.07.001
  14. Standards of Care – WPATH World Professional Association for Transgender Health. (2012). Www.wpath.org. https://www.wpath.org/publications/soc
  15. Hembree, W. C., T, P., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., Rosenthal, S. M., Safer, J. D., Tangpricha, V., & G, G. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869-3903. https://doi.org/10.1210/jc.2017-01658
  16. Prior, J. C. (2019). Progesterone Is Important for Transgender Women’s Therapy—Applying Evidence for the Benefits of Progesterone in Ciswomen. The Journal of Clinical Endocrinology & Metabolism, 104(4), 1181-1186. https://doi.org/10.1210/jc.2018-01777
  17. Lai, A., & Johnson, R. (2023). World professional association for transgender health guidelines: 2022 surgical treatment updates in the standards of care for transgender and gender diverse people. Neurourology and Urodynamics, 42(5), 900-902. https://doi.org/10.1002/nau.25099
  18. Elias, N., Rysin, R., Kwartin, S., & Wolf, Y. (2022). Breaking the Binary: The Approach to Chest Masculinizing Gender-Affirming Surgery in Trangender Men. The Israel Medical Association Journal, 24(1), 20–24. https://europepmc.org/article/med/35077041
  19. Patel, H., Samaha, Y., Ives, G., Lee, Y., Cui, X., & Ray, E. (2021). Chest Feminization in Male-to-Female Transgender Patients: A Review of Options. Transgender Health, 6(5), 244-255. https://doi.org/10.1089/trgh.2020.0057
  20. Al-Tamimi, M., Pigot, G. L., Elfering, L., Özer, M., de Haseth, K., van de Grift, T. C., Mullender, M. G., Bouman, M.-B., & Van der Sluis, W. B. (2020). Genital Gender-Affirming Surgery in Transgender Men in The Netherlands from 1989 to 2018. Plastic and Reconstructive Surgery, 145(1), 153e161e. https://doi.org/10.1097/prs.0000000000006385
  21. Li, V. Y., Demzik, A., Snyder, L., Ogunleye, A. A., Wang, A., & Figler, B. D. (2022). Genital Gender Affirming Surgery. The American Surgeon. https://doi.org/10.1177_00031348221109479
  22. Chen, M. L., Reyblat, P., Poh, M. M., & Chi, A. C. (2019). Overview of surgical techniques in gender-affirming genital surgery. Translational Andrology and Urology, 8(3), 191-208. https://doi.org/10.21037/tau.2019.06.19
  23. Asokan, A., Sudheendran, M. K., Mohandas, M., George, P. S., & Nair, R. M. (2023). Facial Feminization Surgery: Preoperative Planning and Surgical Technique for a Harmonious Outcome. Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India, 56(4), 298-309. https://doi.org/10.1055/s-0042-1759692
  24. Galbraith, L. G., Schnall, M., & Aultman, J. M. (2023). Facial Feminization Considerations for the Transgender Patient. Plastic and Reconstructive Surgery Global Open, 11(4). https://doi.org/10.1097/GOX.0000000000004933
  25. Van Boerum, M. S., Salibian, A. A., Bluebond-Langner, R., & Agarwal, C. (2019). Chest and facial surgery for the transgender patient. Translational Andrology and Urology, 8(3), 219-227. https://doi.org/10.21037/tau.2019.06.18
  26. Bannister, J. J., Juszczak, H., Aponte, J. D., Katz, D. C., Knott, P. D., Weinberg, S. M., Hallgrímsson, B., Forkert, N. D., & Seth, R. (2022). Sex Differences in Adult Facial Three-Dimensional Morphology: Application to Gender-Affirming Facial Surgery. Facial Plastic Surgery & Aesthetic Medicine, 24(Suppl 2), S-24. https://doi.org/10.1089/fpsam.2021.0301
  27. Aires, M. M. (2021). Chondrolaryngoplasty in transgender women: Prospective analysis of voice and aesthetic satisfaction. International Journal of Transgender Health, 22(4), 394-402. https://doi.org/10.1080/26895269.2020.1848690
  28. Pansritum, K. (2021). Forehead and Hairline Surgery for Gender Affirmation. Plastic and Reconstructive Surgery Global Open, 9(3). https://doi.org/10.1097/GOX.0000000000003486
  29. Asokan, A., & Sudheendran, M. K. (2022). Gender Incongruence: Gender Affirming Body Contouring and Physical Transformation in Transgender Individuals. Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India, 55(2), 179-187. https://doi.org/10.1055/s-0042-1749099
  30. The White House. (2022, March 31). FACT SHEET: Biden-Harris Administration Advances Equality and Visibility for Transgender Americans. The White House. https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/31/fact-sheet-biden-harris-administration-advances-equality-and-visibility-for-transgender-americans/
  31. Hassan, A. (2023, June 27). States Passed a Record Number of Transgender Laws. Here’s What They Say. The New York Times. https://www.nytimes.com/2023/06/27/us/transgender-laws-states.html
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