By Ryan DuBosar
Gender-affirming care is integral to primary care, said Jorge A. Ramallo, MD, MPH, FACP, at a Friday morning panel discussion on “Gender-Affirming Care: Health Policy and Practice.”
He pointed out that 7.6% of the population identifies somewhere on the LGBTQ+ spectrum, “so it is not a question of if you will find one of the patients in your practice, but when, and are you equipped to be able to provide the highest level of care for this population when they come to your clinic?”
Gender-affirming care is actually life-saving care for people of all ages, added Dr. Ramallo, an internal medicine physician and pediatrician at a gender care clinic in Virginia. “It is not a single category order of services, but instead a range of services, including mental health care, medical care, and social services at all ages. Clear, well-established, and evidence-based standards of care exist on who can access what form of gender-affirming care and when they are able to receive it.”
To implement these standards, start in the reception area, he said, with messaging in the lobby that informs patients that gender-affirming recognition will be provided. Continue that messaging into the exam room. Be a welcoming space, using lanyards or stickers. Don’t assume assigned sex equals gender or sexual identity. Use preferred pronouns for yourself and ask for a patient’s. It takes just seconds, Dr. Ramallo said.
Get consent for care, because so many gender-diverse patients have experienced trauma. “A lot of these patients, the transgender community especially, has suffered a lot of sexual trauma, health care trauma, so a trauma-informed approach to your physical exam is always wise because we don't know what they've been through,” Dr. Ramallo said.
And if you make a mistake during care, using a wrong pronoun or a wrong name, “just apologize, acknowledge, check in. The patient would really, really appreciate that.”
The basics of gender-affirming care are actually easier than those for asthma, for example. For cross-sex hormone therapy, both transmasculine and transfeminine individuals receive doses mimicking the physiologic range for males and females. Medications can come in injections or pills for estradiol and testosterone, or patches for estradiol. “There's not a huge, huge difference in the medication, how it's provided,” Dr. Ramallo said.
Common concerns about estradiol include the possibility of increased venous thromboembolism (VTE) risk, but this is not as high as previously thought. With testosterone, the main side effect is erythrocytosis. It's typically mild but does require lab monitoring. Spironolactone for testosterone blockade is prescribed in medium to high doses for transmasculine individuals, and doctors should monitor for hyperkalemia. Bicalutamide, which requires monitoring liver function, is sometimes used in place of spironolactone. Progesterone is additive for some transfeminine individuals and can assist with breast development and fat redistribution, with a theoretical increase in VTE risk.
Other monitoring and lab considerations include long-term cholesterol abnormalities for both estradiol and testosterone, with regular lab monitoring required every three months. But “if they’re on stable doses for a while we can spread it out to every six months,” Dr. Ramallo said.
Goals of care should be tailored to the patient’s treatment plan and their sources of dysphoria and goals for transition. Treatment improves mental health for most with true gender dysphoria; mood dysregulation is a concern but less common than previously thought.
Internal medicine has lagged behind in gender medicine compared to family medicine, pediatrics, and obstetrics/gynecology, Dr. Ramallo said, but internal medicine specialists are best positioned to treat this population.
“Please have a broad differential diagnosis. Do not anchor on the hormones as the sole cause” of any unusual results, he said. “Oftentimes, as long as the patient's hormones are in the therapeutic dose range, it is very unlikely for the hormones to be the reason” for morbidity.
Gender-diverse patients are part of every health care setting, Dr. Ramallo concluded. “Providing respectful, affirming care enhances patient trust and health outcomes,” he said. “As medical professionals, we have the opportunity to bridge historical gaps in care and foster a more inclusive field of internal medicine.” ■