ACOG Advises on Care for Transgender Patients

Transgender patients have unique needs regarding obstetric and gynecologic care as well as preventive care, and ob.gyns. can help by providing support, education, and understanding, according to new guidance from the American College of Obstetricians and Gynecologists.

“The American College of Obstetricians and Gynecologists opposes discrimination on the basis of gender identity, urges public and private health insurance plans to cover necessary services for individuals with gender dysphoria, and advocates for inclusive, thoughtful, and affirming care for transgender individuals,” according to the committee opinion, published in the March issue of Obstetrics & Gynecology. The opinion was developed jointly by ACOG’s Committee on Gynecologic Practice and Committee on Health Care for Underserved Women, led by Beth Cronin, MD, of Brown University, Providence, R.I., and Colleen K, Stockdale, MD, of the University of Iowa, Iowa City.

“Lack of awareness, knowledge, and sensitivity, as well as bias from health care professionals leads to inadequate access to, underuse of, and inequities within the health care system for transgender patients,” the authors wrote.

The committee opinion provides guidance for ob.gyns. on topics including inclusivity, routine screening, fertility and reproductive issues, hormone therapy, medication use, and surgery.

“One of the most incredible things about being an ob.gyn. is that this field is a hybrid of primary care and surgical practice,” said K. Ashley Brandt, DO, in an interview. “Many patients seek out care from ob.gyns. for routine screening such as a Pap test, for initiation of hormone therapy, or for postoperative management,” said Brandt, an ob.gyn. and a plastic surgeon at Reading Hospital/Tower Health System in West Reading, Pa. “Many of my colleagues are starting to see an increase in transgender and gender-nonconforming individuals and do not know where to access resources or information on basic care needs. I think ACOG issuing this guidance is a great first step in providing an overview for the ob.gyn., who otherwise haven’t had formal training in transgender medicine,” she emphasized.

Brandt said she was not surprised by any of the recommendations. “These recommendations, while evolving and updating as new data emerge, have been in place by WPATH (the World Professional Association for Transgender Health) and the Endocrine Society for quite some time,” she noted. “However, this updated committee opinion is a summary of recommendations that are relevant to the clinical practice of an ob.gyn.”

“Since the publication of Care for Transgender Adolescents (2017) and Healthcare for Transgender Individuals (2011), there has been an exponential increase in data that have helped to improve and guide best practices for this patient population including better defining risks, needs, therapy, and follow-up,” said Nancy Sokkary, MD, a specialist in pediatric and adolescent gynecology in Macon, Ga., in an interview. “This document also served as an opportunity for ACOG to educate ob.gyns. about health inequities and emphasize need for gender-affirming and inclusive care,” she said.

“These recommendations are consistent with literature that has been published over the last several years,” she added. “It is certainly important for ob.gyns. to have a document unequivocally supporting hysterectomies and bilateral salpingo-oophorectomy as medically necessary for transgender patients that desire these procedures for their transition.”

Inclusive Environment

Approximately 1.4 million adults and 150,000 youth aged 13-17 years in the United States identify as transgender, but these individuals are often marginalized socially and economically, which can lead to worse health outcomes, according to the committee. “Creating a safe and affirming health care environment for all patients, including transgender individuals, is essential,” the authors said. Steps to create a supportive office setting include educating staff to avoid assumptions about sex and gender, and ask appropriately about choice of pronouns and orientation. Use patient forms that reflect a full range of options and places for patients to write in a response. Also, use electronic medical records to track information on use of names other than legal names. “Ob.gyns. play an important role in caring for gender-nonconforming people,” said Sokkary. “Ob.gyn. providers may have varying levels of participation in gender-affirming hormone or surgery provision, but they can universally conduct routine health maintenance, contraceptive and fertility counseling, and obstetric care in a respectful and inclusive environment,” she said.

Track Transition Issues

The opinion notes that many gender-transition medications can be prescribed not only by ob.gyns., but by a range of health care professionals with training and education. When it comes to medication and surgery, neither medication nor surgery is required for legally changing one’s name or gender, but patient desires vary from those seeking only letters of support for such legal changes to those who want to pursue hormone therapy or procedures such as chest surgery, hysterectomy, or phalloplasty.

Transgender patients seeking care from ob.gyns. include transmasculine and transfeminine individuals who are seeking various degrees of masculinizing or feminizing therapies.

Masculinizing therapies may result in development of facial hair, deepening voice, and changes in muscle mass, but patients undergoing masculinizing therapies should be reminded of the potential for continued ovulation, according to the opinion. “The only absolute contraindications to masculinizing hormone therapy are current pregnancy, unstable coronary artery disease, and polycythemia (hematocrit greater than 55%),” the authors wrote.

Feminizing therapies have no absolute contraindications, but “risks include venous thromboembolism (VTE), hypertriglyceridemia, development of gallstones, and elevated liver enzymes,” they noted.

Talk About Sex and Fertility

Clinicians treating transgender patients should discuss fertility and parenting early in the process of any gender transition, ideally before the patient undergoes hormone therapy or surgery, according to the opinion. Fertility preservation options for transgender patients are the same as for cisgender patients who wish to preserve fertility for various reasons, and include “sperm banking, oocyte preservation, embryo preservation, and in some cases, ovarian or testicular tissue cryopreservation,” the authors noted.

However, patients who do not desire pregnancy but may have the potential to become pregnant or impregnate others should be counseled on contraceptive options and reminded that gender-affirming hormone therapy alone does not provide effective contraception, they emphasized. In addition, “all patients should be counseled on barrier use for prevention of sexually transmitted diseases,” they said.

Consistent Routine Screening and Preventive Care

The committee opinion also states that transgender patients should undergo routine screening for any anatomical structures that are present, such as breast cancer screening for transmasculine individuals with breast tissue, and cervical cancer screening for those with a cervix. Transfeminine individuals should undergo prostate cancer screening in accordance with the recommendations for cisgender men, the authors said.

“As for all patients, transgender individuals should be counseled about the importance of routine preventive health care,” according to the opinion. “All individuals should be routinely screened for intimate partner violence, depression, substance use, cancer, and other health care needs and should be screened for sexually transmitted infections and counseled about appropriate immunizations based on age and risk factors, including HPV vaccination,” the authors said.

“We continue to see patient discrimination and discomfort with the medical system as a barrier to preventive care among gender-nonconforming individuals,” said Sokkary. “[Ensuring] that your clinic is a safe, inclusive place is a good start. Also, having providers such as ob.gyns. and family medicine physicians provide gender-affirming care in addition to routine screening and testing is helpful,” she said.

One of the ongoing challenges of counseling transgender patients across a range of age groups, from youth through menopause, is a lack of data on the long-term effects of hormone therapy or surgical intervention, Brandt noted. “Since there is a paucity of this information, many of the screening recommendations fall in line with that of cisgender patients; however, this is not always the case as screening is determined by hormonal usage, risk factors, and surgical state. It is important for clinicians to be aware of evolutions in screening that will continue to occur as more evidence becomes available,” she emphasized.

In addition, “This document did not include specific guidance for transgender and gender-diverse adolescents, and there are many factors and recommendations that are unique to this population,” Sokkary said.

Barriers and Overcoming Them

The main barrier to care with transgender and gender-nonconfirming patients is access to care and finding providers who are competent in gender-affirming health, Brandt noted. “Another significant barrier involves caring for transgender male patients in a traditionally ‘women’s health’ specialty,” she said. “While the office of an ob.gyn. can be very affirming for transgender women, it has the potential to exacerbate discomfort in transgender male patients,” she noted. “Having gender-affirming posters and pamphlets in the waiting area are ways to make patients feel more at ease. Another of the ways to overcome this barrier is education of the staff and health care providers,” added Brandt. “Fortunately, this is starting to occur at medical school and residency levels. For ob.gyns. already in practice, articles such as this committee opinion can serve as a resource for providers seeking to understand health care needs of this community,” she said.

“Cost and insurance coverage continue to be barriers, but this has improved immensely: There are now several local and national resources that can help with this depending on the issue,” said Sokkary. “Additionally, we still lack robust data that define cancer risk among transgender individuals, and until we have more evidence-based recommendations providers should follow screening outlined in this document,” she said.

Use the ACOG Opinion as a Starting Point

“This committee opinion is a great introduction and summary for ob.gyns. seeking to understand basic care needs for gender-nonconforming individuals,” said Brandt. “However, I strongly encourage ob.gyns. who wish to truly incorporate gender-affirming care as part of their routine clinical practice to participate in continuing education, read the WPATH standards of care among many of the resources provided in the committee opinion, and attend conferences that are specific to transgender health and medicine,” she said.

The opinion received no outside funding. The authors were vetted by ACOG and had no relevant financial conflicts to disclose. Brandt had no financial conflicts to disclose. Sokkary had no financial conflicts to disclose.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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