Moser, C. (2003). General
medical care of the gender dysphoric*
patient.
Physicians are being called upon to care for an increasing number of
patients who do not fit easily into a simplistic male or female category. These
individuals range from effeminate males and masculine females to those
individuals who transition from one gender to the other. These people often
encounter significant hostility and derision in their lives. They often have
experienced, or are afraid they will experience, hostility from health care
providers and are reluctant to seek medical attention.
Besides their use of hormones and surgical services, these patients also can
suffer from other common medical problems (e.g., diabetes, hypertension,
appendicitis, etc.). They need general medical care just as any other patient
would. Physicians need to understand how the gender issues (and treatments) of
these patients influence their medical care. They are a medically underserved
group, with specific medical concerns and in need of special outreach by the
health care system.
We do not know what causes these individuals to be uncomfortable with or
reject the gender assigned at birth, but preventing them from pursuing their
gender transitions can be devastating. Although the transition process has its
own stresses and problems, it is common to see depressions lift,
physical symptoms disappear and hope return when patients actually start their
transitions. The evaluation process is complicated and beyond the scope of the
present paper.
Gender dysphoria (discomfort with one's assigned gender) can be viewed as a
continuum, from patients' refusal to acknowledge such concerns to actively
seeking out surgical and hormonal interventions. Some want to be seen as
androgynous (their own mix of masculine and feminine attributes) or without
gender. Other patients wish to transition permanently from one gender to the
other, while others choose to be masculine or feminine at different times.
Still others wish to adopt some characteristics of the other sex, but not all.
Usually these individuals are called transgendered,
but there is debate about the exact definition of that term.
Other groups sometimes confused with the transgendered
are transvestites and the intersexed. Transvestites,
who are usually men, find dressing in female clothing to be overtly erotic. The
intersexed are individuals born with sex chromosomes
that do not correspond to the shape of their genitals, have both ovarian and
testicular tissue, or have ambiguous genitalia.
Physicians often make decisions based on gender, both in health care
maintenance and in the diagnostic process. For example, being male is a risk
factor for cardiovascular disease. Should the physician calculate a
female-to-male transsexual's cardiac risk as male or female? Is it better to
err on the side of caution or count the male sex as a cardiovascular disease
risk factor, and expose the patient to intensified treatment and medication
side effects, for questionable benefit?
Should men who take estrogen and develop breasts have regular mammograms?
Exogenous estrogen can cause breast development; although this often appears to
be female breast tissue, it is gynecomastia histologically. These patients often have breast
augmentation, which further complicates the reading of the mammogram. One could
argue that these individuals have not had the length of exposure to estrogen
that genetic women have had, and therefore face less risk.
Genetic women who wish to be men often have bilateral mastectomies, which
can be seen as prophylactic against breast cancer. Nevertheless, we know that
women can still develop breast cancer after bilateral mastectomies. So maybe
female-to-male transsexuals should have regular mammograms as well. Genetic
women who live as men will often go to extraordinary lengths not to be
discovered, and thus avoid physicians who might actually attempt a breast exam.
Building a solid relationship with your patient is obviously very important.
Unfortunately, whether regular mammograms are necessary or desired for either
group is still not clear.
Of course, genetic women have a uterus and should have regular Pap smears.
Acute left lower quadrant pain in a female could be an ovarian cyst or an ectopic pregnancy, both of which would be quite improbable
in a genetic male. Just because a genetic woman has a beard and is taking
testosterone, however does not completely rule out pregnancy or other
"female" diagnoses.
Hormones are available over the Internet as well as from numerous illicit
sources. Patients may not be taking the hormones that were prescribed, may be
taking what they believe are the equivalent (but cheaper) hormones, or may be
taking hormones that were never prescribed. The result may be a medically
inappropriate hormone combination with all its consequent problems.
Unfortunately, many patients will not report the correct dosages to their
physicians or even that they are taking hormones. It is not uncommon for an
overworked resident to skip the complete genital exam on admission only to
discover that Ms. Smith is really Mr. Smith in the morning.
Significant doses of either testosterone or estrogen are given to
individuals to promote a pseudo-adolescence. As in
adolescence, these hormones have the effect of transforming the body. High
doses of estrogen cause breast development, as well as some transfer of fat
from the abdomen to the hips and buttocks. High doses of testosterone cause
enlargement of the clitoris, increased body hair, deepening of the voice, acne,
and often, male pattern baldness. These changes should be considered permanent
and do not necessarily revert with cessation of the hormones. An astute
physician may notice these changes and become concerned about an endocrinologic tumor. Patients may be less than forthcoming
about their use of nonprescribed hormones and an
unnecessary workup may ensue.
Exogenous estrogen and testosterone are given in high doses and can result
in significant adverse events. High doses of estrogen can cause breast masses
(both benign and malignant) and lead to deep vein thromboses, pancreatitis, elevated liver function tests, prolactinomas, hypertension, gall bladder disease, and
lipid abnormalities. High doses of testosterone can lead to exacerbation of congestive
heart failure, generalized edema, polycythemia, and
liver abnormalities.
Genetic males often take antiandrogens to block
their own testosterone or may undergo orchiectomy. In
the
There is debate among physicians concerning whether estrogens need to be
stopped prior to any surgery. Exogenous estrogens are a risk factor for thrombotic complications, which are probably higher in
pelvic surgeries (such as sex reassignment surgery). Stopping estrogens
abruptly can induce a menopausal syndrome complete with hot flashes and
emotional lability. The risks and benefits of
cessation of hormones should be discussed with the patient.
Physicians in the community will inevitably encounter these patients. It is
important to provide a nonjudgmental environment. Physicians should review
their standard forms to make them more appropriate and welcoming to this
patient group. Office staffs need to be trained to deal nonjudgmentally
with these patients. One should endeavor to use the name and pronoun that the
patient prefers in all interactions.
Further information can be found at: The Harry Benjamin International Gender
Dysphoria Association, 1300
*There is great debate within this community about which terms should be
used to describe its members. Some feel that gender dysphoria is derogatory,
but no accepted term has emerged. Dysphoria is used in this article in its
descriptive sense only and no implication of pathology is implied.
Charles Moser, PhD, MD, is a board-certified internist in private
practice. He is pioneering the development of the new medical specialty of
Sexual Medicine. He is a member of SFMS Board of Directors and the Editorial
Board of