Clinical Care of the Transgender Patient

Course #61920 - $60 • 10 Hours/Credits


Study Points

  1. Define terms used to describe the spectrum of gender expression.
  2. Review the historical perspective of the treatment of gender dysphoria.
  3. Assess current theories and quality of evidence that pertains to the etiology of gender dysphoria.
  4. Discuss efforts to determine the prevalence of transgender individuals in the population.
  5. Describe the unique healthcare needs of the transgender population.
  6. Summarize the unique barriers to care in this population.
  7. Facilitate the management of psychological issues experienced by transgender individuals.
  8. Discuss the potential benefits, limitations, and risks of hormonal and non-surgical procedures and associated care involved in the treatment of transgender individuals.
  9. Describe the care transgender patients require in undergoing various surgical procedures.
  10. Summarize lifelong healthcare needs unique to transgender patients.
  11. Discuss the unique needs of transgender children and adolescents.
  12. Summarize the state of the education of healthcare professionals in the care of transgender patients.

    1 . An individual who was assigned female at birth but who currently identifies as a man is termed a
    A) cisgender man.
    B) cisgender woman.
    C) transgender man or transman.
    D) transgender woman or transwoman.

    DEFINITIONS

    Transgender man (transman): A transgender individual who, assigned female at birth, currently identifies as a man. In this course, the terms transgender man, female-to-male transgender person, and FTM are used interchangeably.

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    2 . In the DSM-5, individuals who experience distress based on the incongruence between their experienced or expressed gender and their assigned gender fall under the diagnosis of
    A) transsexualism.
    B) transgenderism.
    C) gender dysphoria.
    D) gender identity disorder.

    HISTORICAL PERSPECTIVE

    The DSM-IV abandoned the term "transsexualism" and instead used the term "gender identity disorder" [10]. The DSM-5 now uses the term "gender dysphoria." This is defined as "the distress that may accompany the incongruence between one's experienced or expressed gender and one's assigned gender" [11]. The critical element of this diagnosis is the presence of clinically significant distress associated with the condition, as the American Psychiatric Association (APA) points out that gender nonconformity is not a mental disorder. The intent of this change was to better characterize the experiences of affected children, adolescents, and adults and to avoid stigma and ensure clinical care for individuals who see and feel themselves to be a different gender than their assigned gender [11].

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    3 . While the definitive etiology for gender dysphoria has not been found, evidence seems to indicate
    A) physiological causes.
    B) psychological causes.
    C) hormonal imbalance.
    D) chromosomal abnormalities.

    ETIOLOGY OF GENDER DYSPHORIA

    At present, scientific investigation has neither established the true incidence nor clarified the etiology of non-conforming gender identity formation [17]. Genetic, physiological, and psychological causes have been investigated, and available evidence seems to support physiological causes. Gender dysphoria cannot be explained by variations in chromosomal patterns or identifiable hormonal abnormalities, nor is there convincing evidence that psychological factors (e.g., being exposed to certain family dynamics or being raised as a member of the opposite sex) cause this condition [18].

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    4 . Difficulties in trying to estimate the prevalence of transgender individuals are the result of
    A) the variety of terminology used.
    B) the differences in presenting symptoms.
    C) a reluctance to disclose this because of the social stigmatization related to this condition.
    D) All of the above

    PREVALENCE OF TRANSGENDER INDIVIDUALS

    Because of variability in terminology and definitions, differing modes of presentation, and reluctance to disclose for fear of social stigmatization, it is difficult to obtain accurate data about the prevalence of transgender individuals in the general public [28]. However, as society becomes more accepting and familiar with transgender individuals, more transgender individuals are willing to "come out." The result is that this condition is more prevalent than previously thought.

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    5 . Transgender individuals have a higher incidence of HIV for all the following reasons, EXCEPT:
    A) Unprotected sex
    B) Intravenous drug use
    C) Sharing needles for illicit hormone injections
    D) Blood transfusions associated with sex reassignment surgery (SRS)

    UNIQUE HEALTHCARE ISSUES

    Transgender individuals are at risk for HIV as a result of engaging in unprotected sex and from sharing needles used for hormone injections [35]. A significant percentage of transgender individuals engage in sex work; 11% of transgender respondents in a large national survey reported engaging in sex work for income, compared with 1% of women in the United States [34]. This survey has been the largest to date of the transgender population, involving 6,450 transgender and gender non-conforming individuals across all 50 states, as well as the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands. The study was conducted on behalf of the National Gay and Lesbian Task Force and the National Center for Transgender Equality.

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    6 . The Veterans Administration does NOT provide transgender veterans with
    A) SRS.
    B) postsurgical care.
    C) hormone therapy.
    D) mental health care.

    ACCESS AND BARRIERS TO CARE

    Before 2014, the Centers for Medicare and Medicaid Services (CMS) did not cover the cost of SRS based on a 1981 evaluation that described the surgery as experimental and cited "the lack of well-controlled, long-term studies of the safety and effectiveness" and "a high rate of serious complications" [50]. However, long-term studies done in Europe have found that SRS is effective, with low complication rates [1]. This policy banning SRS was overturned in May 2014, but because policy guidelines are issued from Medicare contractors by region, widespread implementation has been slow [46]. While the Veterans Administration (VA) has policies in place to provide comprehensive care to transgender veterans, including ongoing hormone therapy, mental health care, and long-term care following SRS, the VA specifically does not cover SRS, on the basis of a VA regulation excluding gender alterations from the medical benefits package [51].

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    7 . The American Medical Association, the American Psychological Association, the American Congress of Obstetricians and Gynecologists, the American Academy of Family Physicians, and the National Association of Social Workers have called for
    A) a ban on SRS.
    B) insurance coverage for SRS.
    C) more funding for transgender research.
    D) increased numbers of transgender physicians.

    ACCESS AND BARRIERS TO CARE

    Sufficient time has not yet elapsed for the ACA requirement of coverage for transition-related care to apply to grandfathered policies. The ACA bans coverage denial based on being transgender as a pre-existing condition [14]. Although the ACA prohibits discrimination on the basis of sex, including gender identity, in any hospital or health program that receives federal funds and The Joint Commission requires that discrimination on the basis of gender identity is prohibited to maintain accreditation, this information is not widely known and many transgender patients still experience discrimination. The American Medical Association, the APA, the American Congress of Obstetricians and Gynecologists (ACOG), the American Academy of Family Physicians, and the National Association of Social Workers have called for public and private health insurance coverage for this condition [52].

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    8 . The main reason transgender individuals seek psychological therapy is to
    A) come out to self, work, and family.
    B) obtain a referral for hormone therapy.
    C) understand the meaning of their feelings.
    D) follow up on information found on the Internet.

    PSYCHOLOGICAL MANAGEMENT

    While obtaining a referral for hormone therapy is the main reason that transgender individuals seek psychological therapy, other reasons include understanding the meaning of their feelings; whether to externally express those feelings; coming out to self, work, and family; seeking to network following a negative experience; or following up on information obtained on the Internet. In some cases, an individual may have been "caught" expressing his or her gender variance by a spouse or significant other or when there has been a program on transgender issues in the popular media [63]. Coming out trans is a time of heightened vulnerability [64]. Not everyone transitions. Some learn to live comfortably in their role consistent with their assigned birth sex, and others may transition partially or totally [7].

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    9 . Which of the following is a predictor of suicide among transgender individuals?
    A) Parental rejection
    B) Past psychiatric hospitalizations
    C) Previous suicide attempts or near attempts
    D) All of the above

    PSYCHOLOGICAL MANAGEMENT

    Research on the incidence of suicide in transgender people is scarce, but transgender people are believed to have similar suicide risks as other people who experience major life changes, relationship difficulties, chronic medical conditions, or discrimination on the basis of minority status. The incidence of suicide ideation is as high as 64% and suicide attempts as high as 38% in the adult transgender population [67]. These rates are significantly higher than in the general population [67]. Predictors of suicide among transgender individuals are similar to those of the general population, most notably previous suicide attempts or near attempts, past psychiatric hospitalizations, and past psychiatric treatment. Parental rejection is one of the highest risk factors for suicide among transgender youth [64].

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    10 . In the MTF individual, estrogen therapy
    A) increases libido.
    B) increases muscle mass.
    C) induces breast development.
    D) causes an increase in vocal pitch.

    HORMONAL AND NON-SURGICAL MANAGEMENT

    There are several choices of hormone therapy for the MTF transition and maintenance (Table 1). The goals of hormone therapy prescribed for MTF transsexuals are to induce breast formation and a more female distribution of fat and to reduce male-pattern hair growth while neutralizing the biological effects of endogenous androgens [18]. Additional effects include decreased muscle mass and strength, softening of skin, decreased libido, decreased sperm production and testicular volume, and less frequent and less firm erections [62]. Commonly, hormonal treatment of MTF individuals will include an anti-androgen along with an estrogen.

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    11 . Side effects of the anti-androgen medication spironolactone include all of the following, EXCEPT:
    A) Hypotension
    B) Hypokalemia
    C) Gastrointestinal upset
    D) Increased urinary output

    HORMONAL AND NON-SURGICAL MANAGEMENT

    Anti-androgens reduce endogenous testosterone levels, allowing the full effect of estrogen therapy. The anti-androgen of choice in the United States is usually spironolactone (Aldactone), a potassium-sparing diuretic that directly inhibits testosterone secretion and inhibits androgen binding to the androgen receptor. It is usually given orally at a dose of 50 mg twice daily [72]. Side effects of spironolactone include gastrointestinal upset, hyperkalemia, increased urinary output, and hypotension. It is contraindicated in patients with renal insufficiency or with serum potassium levels greater than 5.5 mEq/L. Spironolactone should not be given with digoxin, angiotensin-converting enzyme inhibitors, other potassium-sparing diuretics, and angiotensin receptor blockers [72]. Patients taking spironolactone should have baseline levels of electrolytes, blood urea nitrogen (BUN), and creatinine, and repeat levels in two months or at every dose change, and then every six months when the dose is established [72].

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    12 . Estrogen administered sublingually, transdermally, or parenterally
    A) is easy to titrate or stop.
    B) has a higher incidence of side effects.
    C) avoids first pass metabolism and have less effect on liver enzymes.
    D) has increased vascular complications in patients older than 40 years of age.

    HORMONAL AND NON-SURGICAL MANAGEMENT

    Estrogen can be given orally, transdermally, or parenterally, and each type of delivery has advantages and disadvantages. Estrogen given sublingually, transdermally, and parenterally avoids first-pass metabolism (with less effect on liver enzymes) and are associated with fewer vascular complications in patients older than 40 years of age [17]. Oral forms of estrogen have the additional advantage of being easy to titrate or stop. One study of long-term cross-sex hormone usage revealed that the use of ethinyl estradiol in MTF individuals was associated with an increased risk of death from thrombotic events [76]. This is one reason that the Waddell protocols and WPATH Standards of Care no longer recommend ethinyl estradiol as a safe medication for feminizing hormone therapy [62,72].

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    13 . The goal of voice therapy for MTF individuals is
    A) changing the choice of language.
    B) changing intonation (the rhythm of speech).
    C) raising or "feminizing" the resonance of the voice.
    D) All of the above

    HORMONAL AND NON-SURGICAL MANAGEMENT

    Voice therapy involves the conscious manipulation of the vocal mechanism to produce a more feminine-sounding voice [83]. The goal of therapy is not merely raising the pitch of the voice, but also "feminizing" the resonance, intonation (rhythm of speech), rate of speech, volume, intensity, choice of language, articulation, and social rules of communication [84]. The process includes an assessment of the individual's current voice, resonance, articulation, spoken language, and non-verbal communication. The patient is also assessed for vocal health and current practices that may be damaging to the voice.

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    14 . In order to be perceived as female, the fundamental frequency of the voice should be
    A) 120 Hz (110 Hz–130 Hz).
    B) 140 Hz (130 Hz–150 Hz).
    C) 172 Hz (165 Hz–180 Hz).
    D) 190 Hz (180 Hz–200 Hz).

    HORMONAL AND NON-SURGICAL MANAGEMENT

    Feminine voices have a higher pitch and breathier vocal quality, and they resonate at higher frequencies and have different speech rates, inflections, and intonations. The fundamental frequency (pitch) of the adult male voice is about 100 Hz, with a range of 77–482 Hz; the adult female voice has an average frequency of 195 Hz, with a range of 137–634 Hz. There is considerable overlap between the two ranges, but in order to be perceived as female, the fundamental frequency should be around 172 Hz (165–180 Hz). According to a study by King et al., a mean speaking pitch above 180 Hz and maintaining a speaking pitch range of approximately 140–300 Hz appear to be the most powerful acoustic features or markers in the perception of a female voice in MTF individuals [85]. Raising the fundamental frequency near this range is one of the goals of voice therapy.

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    15 . In the FTM individual, testosterone
    A) decreases libido.
    B) decreases skin oiliness.
    C) increases muscle mass.
    D) results in significant breast atrophy.

    HORMONAL AND NON-SURGICAL MANAGEMENT

    The goal of hormone therapy for FTM individuals is masculinization of the body through the use of testosterone (Table 3). Testosterone therapy in FTM individuals results in cessation of menses within three to five months due to suppression of the hypothalamic-pituitary axis. However, ovulation may continue, and pregnancies have been reported in FTM persons even after prolonged testosterone treatment [17,89]. As such, it is important to discuss contraception with FTM individuals who have sex with men. Other effects of testosterone therapy include increased libido, increased facial and body hair, increased skin oiliness, increased muscle, mild breast atrophy, and redistribution of fat mass, usually within three months of the initiation of testosterone therapy.

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    16 . Which of the following physiologic changes due to testosterone therapy is reversible?
    A) Clitoromegaly
    B) Increased libido
    C) Deepened voice
    D) Male pattern hair loss

    HORMONAL AND NON-SURGICAL MANAGEMENT

    Within one year, the voice usually deepens, clitoromegaly occurs, and male pattern hair loss may be apparent [17]. After 13 years of testosterone use, androgenic alopecia occurs in 50% of FTM individuals [82]. On average, the clitoris enlarges to 3–5 cm, and in some cases, testosterone may be applied topically to the clitoris to stimulate growth [89]. These changes in voice range, hair follicles, and clitoral size are permanent. Other effects, such as increased muscle mass, acne, increased libido and energy level, and amenorrhea are reversible if testosterone is discontinued [72]. FTM individuals report a better quality of life after receiving male hormones regardless of the duration of treatment [44].

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    17 . Testosterone should be used with caution in individuals with
    A) pregnancy.
    B) hyperlipidemia.
    C) endometrial cancer.
    D) estrogen receptor-sensitive breast cancer.

    HORMONAL AND NON-SURGICAL MANAGEMENT

    Contraindications to testosterone include estrogen receptor-sensitive breast cancer; uterine, endometrial, and/or ovarian cancer; pregnancy; and hypersensitivity to sesame or cottonseed oil, if injectable testosterone is used. Testosterone should be used with caution in individuals with uncontrolled coronary heart disease or any unstable heart disease, hyperlipidemia, diabetes, liver disease, cigarette smoking, extreme obesity, hypertension, kidney failure, prolactinoma, or active thyroid disease [89].

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    18 . Spontaneous vaginal bleeding in a FTM individual on testosterone is commonly caused by
    A) pregnancy.
    B) weight loss.
    C) vaginal atrophy.
    D) excessive testosterone.

    HORMONAL AND NON-SURGICAL MANAGEMENT

    Spontaneous vaginal bleeding may be caused by missed testosterone doses, excessive testosterone, weight increase, or thyroid disorders. Atrophic vaginitis may occur, resulting in bacterial vaginitis or candidiasis. If bacterial vaginitis is suspected, the vagina should be cultured for atypical bacteria [90]. Pelvic cramping has been noted in some people on testosterone for longer than three to six months, in some cases associated with orgasm. The pain typically lasts 10 to 15 minutes and can be alleviated by pre-medicating with nonsteroidal anti-inflammatory drugs [90].

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    19 . The criteria for metoidioplasty or phalloplasty in FTM individuals and for vaginoplasty in MTF individuals include all of the following, EXCEPT:
    A) Two referrals from mental health professionals
    B) Orchiectomy in MTF individuals and salpingo-oophorectomy in FTM individuals
    C) 12 continuous months of hormone therapy as appropriate to the patient's gender goals
    D) 12 continuous months of living in a gender role that is congruent with the patient's gender identity

    SURGICAL INTERVENTIONS

    At some point in transition, transgender individuals typically seek surgical interventions to meet their goals to masculinize/feminize the body. The WPATH guideline suggests separate criteria for non-genital and genital surgery for transgender individuals. The criteria for non-genital surgery include [62]:

    • One referral from a mental health professional

    • Persistent, well-documented gender dysphoria

    • Capacity to provide informed consent

    • Age of majority

    • Reasonable control of significant medical or mental health concerns, if present

    Hormone therapy is not a prerequisite, but 12 months of feminizing hormone therapy is recommended in the case of MTF individuals seeking augmentation mammoplasty, as this will result in better surgical (aesthetic) results.

    Criteria for genital surgery (except for metoidioplasty or phalloplasty in FTM individuals and vaginoplasty in MTF individuals) include those outlined for non-genital surgery as well as:

    • Two referrals from mental health professionals

    • 12 continuous months of hormone therapy as appropriate to the patient's gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones)

    The criteria for metoidioplasty or phalloplasty in FTM patients and for vaginoplasty in MTF patients include all of these criteria plus 12 continuous months of living in a gender role that is congruent with his/her gender identity. This criterion is based on expert clinical consensus that "real-life" experience allows the patient to experience and socially adjust to his/her desired gender role before undergoing irreversible surgery [62]. Occasionally, patients may have unrealistic expectations about what it means to be a member of the opposite sex; it is important that these are brought to light before surgery is done. The real-life experience has been shown to reduce gender dysphoria and improve social and sexual functioning [18].

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    20 . Of the following, the most common complication of breast augmentation surgery is
    A) hematoma.
    B) serious infection.
    C) capsular contraction.
    D) malpositioned implants.

    SURGICAL INTERVENTIONS

    The most common complications of breast augmentation surgery include the general surgical complications of bleeding, infection, or hematoma. Complications specific to augmentation mammoplasty are capsular contraction, asymmetry, malpositioned implants, and altered nipple sensation. Infection is rare [75,97].

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    21 . An MTF individual is preparing for a chondrolaryngoplasty (tracheal shave) to reduce the size of the laryngeal prominence. The provider realizes she needs more education when she states,
    A) "I might have a scar following the procedure."
    B) "I might have a sore throat following the procedure."
    C) "This procedure will also raise the pitch of my voice."
    D) "The surgeon will place the incision in my neck crease."

    SURGICAL INTERVENTIONS

    A chondrolaryngoplasty (tracheal shave) may be requested to remove or reduce the laryngeal prominence (Adam's apple). This procedure is not designed to feminize the voice—only to alter the appearance. A small incision is made on the upper crease of the neck or in a wrinkle in the skin. Using a laryngoscope, the vocal cords are visualized and this location is marked externally. The surgeon then exposes the thyroid cartilage and removes all of the prominent cartilage and its borders above the vocal cord marking. The incision is then closed and cleaned and a bandage is placed over the incision. During the first 24 to 48 hours after the surgery, it is common to experience some bruising and swelling as well as a sore throat. Discomfort is typically minor; however, pain medication is often given in order to keep the patient as comfortable as possible. [99]. Complications may include a scar, changes in vocal quality, pain, and difficulty swallowing [97].

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    22 . An MTF individual has met the requirements for SRS and is scheduled for the procedure in six weeks. What instructions should she receive regarding estrogen therapy?
    A) You must discontinue your estrogen 48 hours before SRS.
    B) You must discontinue your estrogen two to four weeks prior to SRS.
    C) You may continue taking estrogen until the night before the procedure.
    D) You must discontinue all medications except for your estrogen two weeks prior to the procedure.

    SURGICAL INTERVENTIONS

    As a prerequisite to SRS surgery, patients often undergo genital electrolysis to remove hair from the scrotum and base of the penis in order to prevent intravaginal hair growth in the neovagina [96]. If the individual smokes, smoking cessation is recommended for at least one month prior to surgery and six months following surgery. Some surgeons also require that the patient's body mass index be less than 28 [105]. Two to four weeks before the surgery, estrogens are discontinued to prevent potential thromboembolic events. Any other medications that may inhibit blood clotting are also discontinued. The day/evening before surgery, a bowel preparation is necessary to evacuate the bowels. Some institutions also recommend a skin scrub using chlorhexidine prior to surgery, and prophylactic antibiotics may be administered either the night prior to surgery or just before incision. The patient is kept NPO (nothing by mouth) after midnight prior to surgery, which is common to most surgical procedures [96].

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    23 . Ten days after SRS, an MTF patient presents with intrusion of intestinal fluids, gases, and feces into the neovagina. In addition to notifying the surgeon, initial management includes
    A) sitz baths three times per day.
    B) placing the client on a high-protein diet.
    C) having the client stop performing vaginal dilation.
    D) having the client douche with an antiseptic solution.

    SURGICAL INTERVENTIONS

    Potential complications of SRS include bladder damage, nerve injury, rectovaginal fistula, urethro-vaginal fistula, urethral stenosis, vaginal stenosis, granulation tissue, and vaginal prolapse [97]. The main risk of SRS is rectal wall tear resulting in rectovaginal fistula, which is estimated to occur in 1 of 400 vaginoplasties [97]. This complication may develop in the immediate postoperative period or following discharge from the hospital. Symptoms include intestinal distress and intrusion of intestinal fluids, gases, and feces into the vagina. For a small fistula, the only clue may be a brown discharge. If rectovaginal fistula is suspected, a tampon may be inserted into the vagina and an enema of clear water with food coloring administered to determine if the tampon is stained [107]. Some fistulas spontaneously resolve as the neovagina heals. A liquid or low-residue diet will help during the healing process, and dilation and sexual intercourse should be discontinued. If the fistula does not heal spontaneously, surgical repair with skin grafts may be indicated.

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    24 . Which of the following statements regarding sexual sensation following vaginoplasty is TRUE?
    A) The majority of patients do achieve orgasm postoperatively.
    B) The majority of patients do not achieve orgasm following SRS.
    C) Following vaginoplasty, postoperative orgasms may be more easily achieved.
    D) Techniques in which reattachment of the glans onto the dorsal neurovascular bundle is attempted are associated with a greater chance of achieving orgasm postoperatively.

    SURGICAL INTERVENTIONS

    Since the WPATH Standards of Care have been in place, there has been a steady increase in patient satisfaction with the outcome of SRS. The vast majority of follow-up studies have shown an undeniable beneficial effect of SRS on postoperative outcomes such as subjective well-being, cosmesis, and sexual function [62]. A meta-analysis of 32 studies found that positive results were achieved, both aesthetically and functionally, in most cases [104]. One study reported 90% of patients were satisfied with both aesthetic outcomes and orgasmic capability, although only 58% acknowledged sexual intercourse at that time. Orgasmic capability following vaginoplasty ranges from 63% to 92% [103].

    Researchers from one facility reported maintenance of sexual sensation in 98.6% and achievement of orgasm (at least occasionally) in 94% of 71 MTF transsexuals after an average of 4.2 years following vaginoplasty [103]. A separate study reported decreased orgasmic ability but 75% more sex, resulting in high overall sexual satisfaction [103]. Due to the massive reconstruction necessary in vaginoplasty, postoperative orgasms may be more difficult to achieve. In some cases, transdermal testosterone or a phosphodiesterase-5 enzyme inhibitor (e.g., sildenafil, tadalafil, vardenafil) may improve a patient's ability to achieve orgasm [107].

    Procedures that maintain attachment of the dorsal portion of the glans penis to the dorsal neurovascular bundle result in lasting neoclitorides and higher levels of sexual satisfaction [104]. Higher risk of sexual dissatisfaction is associated with techniques in which reattachment of the glans onto the dorsal neurovascular bundle was attempted.

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    25 . Metoidioplasty
    A) allows penetrative intercourse.
    B) always allows urination while standing.
    C) has fewer complications than phalloplasty.
    D) results in less erogenous sensation than phalloplasty.

    SURGICAL INTERVENTIONS

    Metoidioplasty involves elongation and reconstruction of the hormonally enlarged clitoris as a small neophallus with erectile function, analogous to penile tissue. During this procedure, the clitoris is released from its surrounding tissue and a flap of skin from the labia minora is wrapped around the clitoris to create a small phallus. The resulting neophallus is sensate. With ring metoidioplasty, a variation of the simple metoidioplasty, the urethra is lengthened using a flap of tissue from the anterior vaginal wall and labia minora to create the urethral extension. This carries urine to the distal end, similar to a natural penis. This procedure is less complex than a phalloplasty, has fewer complications, and has the benefit of providing greater erogenous sensation. However, the resulting neophallus is often not large enough to use for sexual penetration. Using this technique results in an average phallus length of 5.7 cm, with a range of 4–10 cm [112]. Testicular implants may be placed in the labia majora as part of the procedure.

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    26 . An MTF individual, 51 years of age, has been on estrogen for 30 years and had SRS and augmentation mammoplasty with saline implants 20 years ago. What breast cancer screening is recommended for this patient?
    A) She should have an annual breast exam, including mammogram.
    B) She should have an MRI instead of a mammogram.
    C) As breast cancer risk is very low, a mammogram is not indicated.
    D) She should have a breast ultrasound instead of a mammogram.

    LIFELONG PREVENTIVE AND PRIMARY CARE

    Annual breast exam, including mammogram, is indicated in MTF women who are older than 50 years of age who have been taking estrogen for five or more years [49]. While this is recommended as a screening protocol, the actual risk is likely no different than in natal males. In a series of 2,200 MTF individuals studied between 1975 and 2005, there were no cases of breast cancer reported [82].

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    27 . Which of the following should be included in the annual exam of an FTM individual who is 42 years of of age, has used testosterone for 10 years, and has had a bilateral mastectomy but no "bottom" surgery?
    A) Prostate exam
    B) Visual field exam
    C) Pelvic exam and Pap test
    D) Dual-energy x-ray absorptiometry screening

    LIFELONG PREVENTIVE AND PRIMARY CARE

    For patients using androgen therapy who have not had a complete hysterectomy, there may be an increased risk of endometrial and ovarian cancer [49]. Therefore, a regular Pap test is indicated. It is important to be sensitive when performing a pelvic exam on a transsexual man. It may be difficult to get a good sample, as the cervix will be atrophic; intravaginal estrogen cream can be used a few days prior to the Pap test to improve results.

    Aging FTM patients may have an increased risk of cardiovascular disease and diabetes due to the effects of long-term testosterone and should be screened accordingly [28]. A small amount of research indicates that FTM individuals on long-term testosterone therapy do not have an increased risk of low bone mass [122]. Part of testosterone is converted to estradiol at levels that will support bone mineral density [82]. Dual-energy x-ray absorptiometry screening is suggested for FTM individuals older than 65 years of age, or after 50 years of age if not on testosterone [123].

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    28 . Which of the following models of therapy for children who display gender dysphoria encourages the child's exploration of gender identity?
    A) Affirming approaches
    B) Supportive approaches
    C) Corrective approaches
    D) Psychoanalytic approaches

    MANAGEMENT OF TRANSGENDER CHILDREN AND ADOLESCENTS

    In general, psychological therapy and support can assist transgender children/adolescents to complete developmental tasks on schedule, achieve self-acceptance and understanding, and manage and cope with social problems (e.g., peer and/or family conflict) and the stress of the change process [126]. Three models of therapy for children who display gender dysphoria have been described. The first of these is affirming approaches, based on the concept that being transgender is not a mental illness [27]. This approach encourages the child's exploration of gender identity and assists the child and his or her family to explore interventions such as social transitioning and hormone therapy. Dreger defines this approach as the "accommodation" mode [128]. The second treatment approach involves supportive therapies—a "wait and see" approach to determine how the child's gender identity unfolds. With this approach, there are no gender-related interventions. The third approach is a "corrective" approach that seeks to align the child's gender identity with his or her biological sex. This approach is also described by Dreger as the "therapeutic" model that views the child's gender dysphoria in terms of familial dysfunction and seeks to guide the child into a less stressful, more sustainable family environment and gender identity [128]. This last approach has been generally dismissed or condemned by organizations like the APA [141].

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    29 . In the first longitudinal study of transgender youth treated with puberty suppression, cross- sex hormones, and SRS, the researchers found
    A) there was a significant rate of regret at having SRS.
    B) overall well-being was comparable to non-transgender peers.
    C) despite treatment, the suicide rate remained high in this population.
    D) body image difficulties persisted even after the administration of cross-sex hormones.

    MANAGEMENT OF TRANSGENDER CHILDREN AND ADOLESCENTS

    Beginning treatment for gender dysphoria at puberty appears to be associated with better psychological outcomes than beginning treatment in adulthood, by which time irreversible secondary sex characteristics may pose lifelong barriers to successful sex reassignment. Additionally, limited observational data from transgender youth have indicated that gender dysphoria is reduced and relationships and academic skills are improved when therapy is started early [18]. The first longitudinal study of 55 transgender youth (22 MTF and 33 FTM) who received puberty suppression, cross-sex hormones, and in some cases SRS, was performed in the Netherlands in 2014 [127]. The researchers reported that gender dysphoria and body-image difficulties persisted through puberty suppression but remitted after the administration of cross-sex hormones and SRS. None of the individuals reported regret during puberty suppression, cross-sex hormone administration, or after SRS. Psychological functioning improved steadily over time, and overall well-being was comparable to non-transgender peers. In fact, a higher percentage of the transgender study group was pursuing higher education than the general public. The researchers speculated that this success was not only due to the medical treatment but also due to access to care (covered by health insurance) and the involvement of a multidisciplinary team of mental health professionals, physicians, surgeons, and supportive parents [127].

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    30 . Researchers have shown that transgender-related care and issues are
    A) best covered in nursing school curricula.
    B) best covered in medical school curricula.
    C) best covered in schools of public health curricula.
    D) lacking in the curricula of all healthcare disciplines.

    EDUCATION OF HEALTHCARE PROFESSIONALS

    Transgender care is generally lacking in medical school curricula. Among 132 U.S. and Canadian medical schools surveyed in 2011, the median reported combined hours dedicated to LGBTQIA content was five hours [131]. One-third of medical schools reported no hours of LGBT content during clinical years, and less than 40% of medical schools taught transgender-related content, such as SRS, body image, or transitioning, despite research that shows that medical students who have clinical exposure to LGBTQIA patients during their training perform more comprehensive histories, have a more positive attitude toward these patients, and possess greater knowledge of LGBTQIA healthcare concerns than students with little or no clinical exposure [48]. In addition, the results of one survey indicate that, contrary to official American Public Health Association policy, public health schools seldom offer planned curricula that address comprehensive LGBT health [132].

    Coverage of transgender care is also lacking from most nursing education. A review of the top 10 nursing journals from 2005 to 2009 found only eight articles (out of nearly 5,000) that focused on LGBT issues and only one that mentioned transgender issues [133]. None of eight articles came from U.S. researchers. In 2010, the National Student Nurses Association adopted a resolution to include LGBT content in nursing school curricula to improve cultural competence [59].

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