What initial assessment and questions should be asked to a male-to-female (MTF) transgender patient?

Initial Assessment of Male-to-Female Transgender Patients

Begin by asking the patient's current gender identity first, followed by sex assigned at birth—this two-step approach is superior for accurate identification and demonstrates respect for the patient's identity. 1

Essential Demographic and Identity Questions

• What is your current gender identity? (Ask this before asking about assigned sex at birth) 1
• What sex were you assigned at birth? 1
• What is your preferred name and pronouns? (This may differ from legal documents and should guide all staff interactions) 1
• Have you legally changed your name or gender marker on identity documents? 1

Current Organ Inventory

Document a complete organ inventory regardless of gender presentation—this is critical for appropriate screening and medical care. 1

Ask specifically about presence or absence of:

• Penis, testes, prostate 1
• Breasts (hormone-induced or surgical) 1
• Any surgical procedures completed (orchiectomy, vaginoplasty, breast augmentation) 1

Hormone Therapy History

• Are you currently taking any gender-affirming hormones? 2, 3
  • If yes: What specific medications (estrogen type, anti-androgens), doses, route of administration (oral, transdermal, parenteral), and duration? 2, 4, 5, 3
  • If no: Are you interested in starting hormone therapy? 3
• Have you used hormones in the past? (Including non-prescribed sources) 2, 3
• Any history of venous thromboembolism, stroke, or cardiovascular events? (Critical given thrombosis risk with estrogen therapy) 4, 6

Sexual Health and Trauma-Informed History

Use a trauma-informed approach when taking sexual history, as transgender persons experience sexual assault at higher rates than cisgender persons. 1

• History of unwanted sexual activity or sexual assault 1
• Current sexual activity and practices (including exposure sites) 1
• Condom use and contraceptive practices 1
• History of sexually transmitted infections 1
• Genital dysphoria (affects willingness to undergo genital examinations) 1
• Genital tucking practices 1

Medical and Surgical History

• Cardiovascular risk factors: smoking status, hypertension, diabetes, hyperlipidemia, family history of cardiovascular disease 1, 4, 6
• Thrombotic risk factors: personal or family history of blood clots, genetic mutations (Factor V Leiden), prolonged inactivity 2, 4
• Liver disease history (affects hormone metabolism and choice of estrogen formulation) 1, 4, 5
• Mental health history: depression, anxiety, suicidality 1, 3
• History of discrimination or mistreatment in healthcare settings 1

Social History and Support

• Social support system and participation in support groups 1
• Disclosure of transgender status to partners, family, employers 1
• Employment status and insurance coverage 1
• Tobacco, alcohol, and illicit drug use (smoking significantly increases thrombotic risk with estrogen) 1, 2
• History of injection drug use and needle sharing (HIV risk assessment) 1

Current Medications and Allergies

• All current medications including over-the-counter and supplements 1
• Complementary or alternative therapies 1
• Drug allergies and specific reactions 1

Physical Examination Considerations

Establish trust before performing sensitive examinations unless medically urgent—wait until rapport is built when possible. 1

• Always ask explicit permission before examination and explain what you will do 1
• Offer a chaperone and ask about gender preference for the chaperone 1
• Avoid approaching from behind (can trigger trauma response) 1
• Use guided contact (have patient guide your hand/stethoscope to maintain their sense of control) 1
• Examine based on organs present, not gender identity: prostate examination if prostate present, breast examination if breasts present from hormone therapy 1, 7

Laboratory Monitoring

• Morning serum total testosterone levels (to assess suppression on hormone therapy) 1, 3
• Estradiol levels (to ensure therapeutic range) 3
• Liver function tests (baseline and monitoring, especially with oral estrogen) 4, 5
• Lipid panel and glucose/hemoglobin A1c (cardiovascular risk assessment) 1, 4, 5
• Prolactin levels if nipple discharge present (hormone-induced hyperprolactinemia) 7

Common Pitfalls to Avoid

• Never use legal name if it differs from preferred name in clinical interactions 1
• Do not assume surgical status based on appearance or hormone use 1
• Avoid recommending against practices like tucking without discussing safer methods 1
• Do not skip prostate cancer screening in patients who still have a prostate 1
• Recognize that oral ethinyl estradiol carries higher thrombotic risk than other estrogen formulations 4, 5