Transgender medicine

Question 1

Transgender

Answer 1

an umbrella term for people whose gender is different from their ‘assigned’ sex at birth
o inclusive term describing all those whose gender expression falls outside the typical gender
norms

Question 2

Transsexual

Answer 2

In law, a transsexual person is someone who ‘proposes to undergo, is undergoing or has
undergone gender reassignment (hormones/surgery)
o Somewhat outdated term => now refered to as “gender incongruence”

Question 3

Trans*

Answer 3

umbrella term
o The expression‘trans’is often used synonymously with ‘transgender’ in its broadest sense.
o Recently the asterisk has become an additional symbol of inclusion of any kind of trans and non-binary gender presentation – hence trans* person

Question 4

Transman

Answer 4

female assigned person at birth who is living as a man

Question 5

Transwoman

Answer 5

male assigned person at birth who is living as a woman

Question 6

Transvestite

Answer 6

someone who cross-dresses but does not want to alter their body

Question 7

Non-binary gender identity

Answer 7

people are those who don’t feel male or female. They may feel like both or like something in
between. They may have a gender that changes over time or they may not relate to gender at all

Includes:
 Gender Queer
 Gender Fluid
 Agender

Question 8

Third Gender

Answer 8

a concept in which individuals are categorized, either by themselves or by society, as neither man nor woman.

Question 9

Non-binary pronouns

Answer 9

Most non-binary persons use they, them, their, theirs, theirself

o Other variations:
 Ze, zey, zem, zeir, zeirs, zeirself
 Zie, zim, zir, zirs, zirself
 Ey, em, eir, eirs, eirself
 One

Ask the patient which pronouns they would like you to use

Question 10

What is the WPATH standards of care

Answer 10

World Professional Association for Transgender Health

Worldwide association of multi-disciplinary practitioners working with trans patients

Strong emphasis on the individualization of care

Question 11

What is the ICD-10 classification of transsecualism?

Answer 11

terminology to change to “gender incongruence”

o A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one’s anatomic sex, and a wish to have surgery and hormonal treatment to make one’s body as congruent as possible with one’s
preferred sex

Question 12

What is the ICD-10 classification of Dual-role transvestism?

Answer 12

o The wearing of clothes of the opposite sex for part of the individual’s existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement
accompanying the cross-dressing
o NB: can be necessitated for work reasons
o Includes: gender identity disorder of adolescence or adulthood, non-transsexual type
o Excludes: Fetishistic transvestism

Question 13

What is the ICD-10 classification of Gender identity disorder of childhood?

Answer 13

o A disorder, usually first manifest during early childhood (and always well before puberty),
characterized by a persistent and intense distress about assigned sex, together with a desire to
be (or insistence that one is) of the other sex.
o There is a persistent preoccupation with the dress and activities of the opposite sex and
repudiation of the individual’s own sex.
o The diagnosis requires a profound disturbance of the normal gender identity
 Mere tomboyishness in girls or girlish behaviour in boys is not sufficient.
o Gender identity disorders in individuals who have reached or are entering puberty should not be
classified here
o Excludes: egodystonic sexual disorientation and sexual maturation disorder

Question 14

What is the ICD-10 classification of GFetishistic transvestism?

Answer 14

o The wearing of clothes of the opposite sex principally to obtain sexual excitement and to create
the appearance of a person of the opposite sex.
o Fetishistic transvestism is distinguished from transsexual transvestism by its clear association
with sexual arousal and the strong desire to remove the clothing once orgasm occurs and sexual
arousal declines.
o It can occur as an earlier phase in the development of transsexualism

Question 15

Describe the assessment for hormonal treatment

Answer 15

 Medical history
o Especially migraine history (with aura) => red flag for oestrogen use

 Family history
 Blood pressure
 Weight/BMI should be >35 => surgical restraints

Baseline bloods:
o U+E, LFT, Lipids, Glucose, Thyroid function
o FBC
o FSH, LH, Prolactin, Oestradiol, Testosterone, SHBG (Sex hormone-binding globulin - glycoprotein
that binds to the two sex hormones: androgen and oestrogen)

Question 16

Describe fertility preservation in a female-to-male patient

Answer 16

o More difficult to harvest/store eggs
o Intervention with an area of their anatomy that they may feel extremely uncomfortable about
 Can cause distress
o collection and storage of oocytes
o storage of embryo

Question 17

Describe fertility preservation in a male-to-female patient

Answer 17

o collection of sperm

o storage of sperm

Question 18

What are the crietia for hormone therapy?

Answer 18

persistent, well-documented gender dysphoria
o long history (2-3 years) of persistent thoughts about gender

capacity to make a fully informed decision and to consent for treatment

age of majority in a given country (if younger, follow the Standards of Care outlined in section VI)
o Start with hormonal treatments at age 16 on the UK
o Hormone blockers may be used in younger patients to delay the onset of puberty

if significant medical or mental health concerns are present, they must be reasonably well-controlled
o e.g. if gender identity issues are causing psychosis
o Treat mental illness first and see where they are then

Question 19

What are the medical treatments given to transmen?

Answer 19

Sustanon
o intramuscular testosterone
o 125mg IMI 3 weekly

Alternatively => Testim gel
o 1⁄2 tube daily
o transdermal gel
o provides continuous transdermal delivery of testosterone for 24 hours, following a single
application

 Increase to Sustanon 250mg 3 weekly/ Testim gel 1 tube daily

 Nebido
o 1000mg 12 weekly
o Depot injection of testosterone

Aninjectionof a substance in a form that tends to keep it at the site ofinjectionso that
absorption occurs over a prolonged period

Question 20

What treatments can be given for the supression of menstruation in transmen?

Answer 20

Testosterone alone
 Depo-Provera (contraceptive injection) => prevent menstruation

Occasionally, use of GNRH analogues is necessary
o Triptorelin (Decapeptyl) 11.25mg 12 weekly
o These flood gonadroptropin pathways and blocks oestrogen production/ovarian cycle

Contraception is indicated:
o If sexual contact with male partner
o Testosterone alone is not sufficient
o Progestagen only method
>Depo-Provera
>Implant/IUS

Question 21

What are the effects of testosterone therapy on transmen?

Answer 21

 Lower voice
 Facial and body hair growth
 Increased muscle bulk
 Amennorrhoea
 Clitoromegaly  created into a micro phallus
 Increased libido
 Tendency to be more aggressive  “roid rage”

Question 22

What are the risks of testosterone therapy in transmen?

Answer 22

 Polycythaemia – bone marrow is stimulated to produce more RBC
o May need to start taking blood off patient to reduce Hb
 Liver dysfunction – occasionally seen
 Increased risk for cardiovascular disease
 Increased weight
 Diabetes
 Mental health disturbance

Question 23

What medical treatment can be given to transwomen?

Answer 23

Tablets => Oestradiol valerate
o 1-2mg daily
o Disadvantage => hepatic first pass metabolism

Transdermal patch => Oestradiol 50mcg/day
o Fewer side effects
o Used in patients >40yrs

Increase to Oestradiol valerate 4-6mg daily
Increase to 100mcg-200mcg patch

Question 24

What is the use of anti-androgen therapy in transwomen?

Answer 24

block testosterone

GNRH analogues
o Triptorelin (Decapeptyl)11.25mg 12 weekly) 

Cyproterone Acetate 50mg daily
o an antiandrogen and progestogen

Finasteride 5mg daily
o 5α-reductase inhibitor => prevents conversion of testosterone to dihydrotestosterone
o Promotes hair growth

Spironolactone 50mg daily
o Significantly depresses plasma testosterone levels
o Often used by patients with self-medication
o Can cause electrolyte disturbances

Question 25

What are the effects of oestrogen therapy in transwomen?

Answer 25

 breast growth
 softer skin
 less facial and body hair
 fat redistribution to hips
 more emotional

Question 26

What are the risks of oestrogen therapy in transwomen?

Answer 26

 Increased risk for VTE (venous thromboembolism)
 Increased weight
 Increased Blood Pressure
 Increased risk for Breast Cancer

Question 27

What surgical treatment is available for transmen?

Answer 27

 Bilateral mastectomy and male chest reconstruction
 Hysterectomy and oophorectomy
 Metoidioplasty - hypertrophied clitoris is released and urethra redirected through
o surgeon separates the enlargedclitorisfrom thelabia minora, and severs itssuspensory
ligamentin order to lower it to the approximate position of the penis

 Phalloplasty
o Radial artery flap  skin from the forearm is removed together with the radial artery and nerves
 Artery is hooked up to femoral artery in the groin
 Nerves are hooked up to clitoral nerve
o Pubic and thigh area are alternative sources of skin
 Tend to have less sensation, so the arm is preferred
o Surgeons implant erectile tubes into the phallus, put a reservoir of fluid in the abdomen with a
pump in the scrotum

Question 28

What surgical procedures are available for transwomen?

Answer 28

 Thyroid chondroplasty (Adam’s apple)
 Penectomy, orchidectomy, clitoroplasty, vulvoplasty and penile inversion vaginoplasty
o Lubrication necessary for sex
o Regular dilation necessary to prevent body from closing it
 Colovaginoplasty => surgical procedure that involves using a section of the end of the large intestine (the sigmoid colon) to create a neovagina
 Breast augmentation

Question 29

Describe urinary tract problems in female-to-male patients after gender reassignment surgery

Answer 29

o Neo-urethral stenosis

o Urethral fistula

Question 30

Describe urinary tract problems in male-to-female patients after gender reassignment surgery

Answer 30

o Urinary spraying

o Increased risk for UTI due to shortened urethra

Question 31

Describe problems in female-to-male patients after gender reassignment surgery

Answer 31

 dislodgement of erectile cylinders
 mechanical failure of erectile mechanism- may need 10-yearly replacement
 hysterectomy and oophorectomy usually with one of phalloplasty procedures, as well as vaginal ablation

Question 32

Describe urinary tract problems in male-to-female patients after gender reassignment surgery

Answer 32

 granulation tissue – may need to be treated with silver nitrate cautery
 neovaginal hair growth  hairballs
 vascular occlusion of arterial supply to neo-clitoris
o blood supply may become cut off
o post surgery, there may be a loss of function with orgasm/no penetrative sex possible
 neovaginal stricture
 ongoing need for dilation

Question 33

Which patients require smear tests following gender reassignment surgery?

Answer 33

FTM
o Still recommended if cervix still present
o Remove from SCCRS after hysterectomy

MTF
o Ensure not on SCCRS recall system

Question 34

What cancer screening services are required following gender reassignment surgery

Answer 34

Prostate:
o MTF less risk due to oestrogen and anti-androgen
o FTM Screen as for non-trans males

Breast:
o FTM - still some breast tissue, self-examination, refer breast lumps as usual
o MTF - offer breast screening