Roughly 1.4 million adults in the United States publicly identify as transgender — having a gender identity different from the sex they were assigned at birth — according to a comprehensive report by the Williams Institute. OB/GYN clinicians can expect to see an increasing number of transgender patients come under their care.
Yet, according to OBG Management, only about one-third of gynecologists feel comfortable caring for this population, and less than half say they are familiar with health maintenance and screening recommendations for transgender, or trans, patients.
Because transgender adults still experience discrimination in many healthcare settings, often leading them to forgo appointments altogether, it's crucial for gynecologists and their colleagues to take an informed approach in order to provide better care for these patients.
Understanding the Basics
Gynecologists have the opportunity to care for a range of gender identities, including people who are:
- Transmasculine: An umbrella term for those who were assigned female at birth but identify as male.
- Transfeminine: An umbrella term for those who were assigned male at birth but identify as female.
- Nonbinary: People who identify as neither exclusively male nor exclusively female.
Some trans people may transition socially, changing their clothing and pronouns, for example. Others take hormones to alter their physical characteristics, while some undergo surgical procedures to align their bodies with their gender identities.
One of the simplest things clinicians can do to make their practice welcoming to transgender patients, according to the Gay and Lesbian Medical Association, is to use the personal pronouns their patients are comfortable with. This can be as simple as introducing yourself: "Hi, I'm Dr. Smith. My pronouns are she/her/hers. How would you like to be addressed?"
Greeting patients this way signals that the office is a safe space for people anywhere along the gender spectrum. Once a patient's pronouns have been established, ask if you can share them with support staff so everyone is on the same page.
Treating Transmasculine Patients
Transmasculine and nonbinary patients should still receive regular gynecologic care and screening if they have a uterus and ovaries. However, a trip to the gynecologist's office can be traumatic for these patients and exacerbate gender dysphoria.
Clinicians can help ease some of that trauma by discussing the need for any pelvic or physical exams in advance. Explain the purpose of an exam, its importance for a particular diagnosis and what it entails. For patients with severe gender dysphoria, relaxation techniques and anti-anxiety medication may help. These same approaches should be applied to transvaginal ultrasound, which, while extremely useful in helping evaluate abnormal bleeding and pelvic pain, may worsen dysphoria.
If a transmasculine or trans male patient is uncomfortable in stirrups, work with him to find a position that feels less invasive. Keep in mind that patients taking testosterone can experience vaginal dryness, so more lubrication may be necessary. Reassure them that minor spotting is normal following a Pap smear and pelvic exam. Gynecologists should also discuss sexually transmitted infections (STIs) and contraception with transmasculine and nonbinary patients, some of whom may engage in penetrative intercourse.
Avoid using gendered terms such as "well woman visit" for patients who do not identify as women. Consider updating all of the terminology and intake forms in your practice to be as gender neutral as possible.
Transfeminine Patient Care
Gynecologists also play an important role in the lifelong follow-up of transfeminine patients, particularly those who have undergone vaginoplasty, or surgical creation of a vagina. Regular care for trans women can include a vaginal and vulvar exam, counseling on protection against STIs and instructions on the use of regular dilation to maintain the vaginal opening.
Regular breast exams and mammography may be recommended for trans women who take supplemental hormones. Ultrasound can be useful for evaluating the risk of prostate disease in trans patients with a prostate: One study in Facts, Views and Vision found that transvaginal ultrasound had a higher clinical value (and often patient preference) than digital palpation for prostate examination in patients who have undergone vaginoplasty.
It's natural to have questions about the care of transgender patients, but a little self-education can go a long way. If you're looking for more guidance, the American College of Obstetricians and Gynecologists (ACOG) offers more resources for clinicians to improve their treatment of this growing population.