What are the standards of care for transgender individuals, including hormone replacement therapy (HRT) and mental health support?

Standards of Care for Transgender Individuals

Transgender individuals should receive comprehensive, multidisciplinary care that includes gender-affirming hormone therapy (GAHT), mental health support, and access to surgical interventions when appropriate, with all services coordinated through a team including primary care physicians, endocrinologists, and mental health professionals. 1

Core Principles of Care

The World Professional Association for Transgender Health has established that standards of care must achieve "lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment." 1 This framework prioritizes quality of life and mental health outcomes, which are the most critical endpoints for this population.

Evidence demonstrates that when transgender persons receive medically appropriate, individualized care, they experience improved mental health, a 20% reduction in depression after one year, reduction in suicide rates, and lower overall healthcare costs due to fewer mental health and substance abuse-related expenses. 1, 2, 3

Initial Assessment and Documentation

Medical Record Setup

• Document preferred name, pronouns, and gender identity separately from legal name and sex assigned at birth to prevent dysphoria-inducing interactions 2
• Establish accurate organ inventory (presence of uterus, ovaries, cervix, breasts, prostate, testes) as this directly impacts screening needs and treatment decisions 2
• 28% of transgender patients report harassment and 2% experience physical abuse due to incorrect documentation, making proper record-keeping a safety issue 2

Baseline Laboratory Assessment

Before initiating hormone therapy, obtain: 2, 4

• Complete blood count (to assess for baseline polycythemia)
• Comprehensive metabolic panel with liver function tests
• Lipid profile
• Glucose or hemoglobin A1c
• Baseline hormone levels (testosterone and estradiol)
• Cardiovascular risk assessment

Mental Health Screening

Transgender individuals have significantly elevated rates of psychiatric conditions compared to cisgender populations: 1, 4, 3

• Higher prevalence of autism spectrum disorder
• Increased rates of anxiety, depression, bipolar disorder, obsessive-compulsive disorder, ADHD, and schizophrenia
• These conditions require specific peri-operative and ongoing management considerations

Hormone Replacement Therapy

Masculinizing Therapy (Transgender Men/Transmasculine Individuals)

Testosterone Protocol: 2, 4

• Initiate testosterone cypionate or enanthate at 50 mg subcutaneously weekly
• Adjust dosing to achieve serum testosterone levels within normal male range (300-1,000 ng/dL)
• Monitor testosterone and estradiol levels at 3 months initially, then every 3-6 months during first year, then annually if stable

Expected Physical Changes: 4

• Increased muscle mass and decreased fat mass
• Deepening of voice
• Body and facial hair growth
• Menstrual suppression
• Increased libido

Monitoring Requirements: 2, 4

• Regular complete blood counts to monitor for polycythemia (testosterone increases hematocrit to levels consistent with natal male population)
• Cardiovascular risk assessment (testosterone therapy increases cardiovascular and atherosclerotic risk to levels consistent with natal male population)
• Lipid profile monitoring (may see increased triglycerides, LDL cholesterol, and decreased HDL cholesterol)

Feminizing Therapy (Transgender Women/Transfeminine Individuals)

Estrogen Protocol: 4

• Estradiol is the cornerstone, available in oral, transdermal, or injectable forms
• Anti-androgens typically added to enable lower estrogen doses while achieving adequate testosterone suppression
• Common anti-androgen options: spironolactone, cyproterone acetate, GnRH agonists, bicalutamide, finasteride

Expected Physical Changes: 4

• Breast development (variable results)
• Decreased muscle mass
• Softening of skin
• Decreased body/facial hair
• Decreased libido and reduced erectile function

Monitoring Requirements: 4, 3

• Check estradiol and testosterone levels at 3 months, then every 3-6 months during first year, then annually
• Increased risk of venous thromboembolism, ischemic stroke, and myocardial infarction requires ongoing cardiovascular monitoring
• Weight gain and bone health monitoring

Mental Health Support

The evidence is unequivocal: hormone therapy produces substantial mental health benefits. 2, 3

• 20% decrease in depression after 1 year of treatment
• 5.5-point increase on a 10-point quality of life scale
• No evidence of adverse mental health outcomes from appropriately managed GAHT

Critical Pitfall to Avoid

Never discontinue hormone therapy due to concerns about potential regret or psychiatric medication interactions. 2, 3 Discontinuing GAHT significantly worsens gender dysphoria and mental health outcomes, creating far greater harm than continuing therapy. Any psychiatric symptom worsening should prompt evaluation of psychosocial stressors, medication adherence, and adequacy of psychiatric treatment rather than attributing changes to hormone therapy. 3

Surgical Interventions

Decision-Making Framework

The decision to pursue gender-affirming surgery is made collaboratively between the patient and their healthcare team (primary care physicians, endocrinologists, mental health professionals, surgeons). 1 Multiple major medical organizations—including the American Medical Association, American Psychological Association, American Psychiatric Association, American Congress of Obstetricians and Gynecologists, and American Academy of Family Physicians—consider gender transition-related medical services medically necessary. 1

Common Surgical Options

For transgender men/transmasculine individuals: 2

• Chest masculinization surgery
• Hysterectomy with bilateral oophorectomy (consideration for those on long-term testosterone)

For transgender women/transfeminine individuals:

• Vaginoplasty
• Breast augmentation
• Facial feminization surgery
• Tracheal shave

Ongoing Screening and Preventive Care

Cancer Screening Adjustments

Cervical cancer screening: 2

• Continue if cervix remains present, regardless of gender identity
• Use standard screening intervals per general population guidelines

Breast cancer screening: 2

• For transgender men: Continue screening for residual breast tissue after chest surgery
• Use breast MRI to determine volume of residual tissue for screening decisions
• For transgender women: Follow screening guidelines for cisgender women after sufficient time on estrogen therapy

Prostate cancer screening (transgender women): 2

• In those with low testosterone, lower the PSA reference range upper limit of normal to 1.0 ng/mL

Laboratory Value Interpretation

After 6-12 months of hormone therapy, use gender identity-based reference ranges for: 2, 4

• Red blood cell indices
• QTc interval
• Body composition calculations
• Chemotherapy dosing (use gender identity in ideal body weight calculations after ≥6 months of GAHT)

Continue using sex assigned at birth for: 2

• Troponin reference ranges
• Spirometry interpretation

Special consideration: 4

• Cystatin C is preferred over creatinine for evaluating kidney function in transgender individuals on hormone therapy

Fertility Preservation

Fertility counseling must be provided before starting hormone therapy, as both feminizing and masculinizing treatments may affect fertility. 4 Patients may require cessation of gender-affirming hormones for fertility treatment (egg retrieval for transgender men, sperm banking for transgender women), which can result in partial reversal of physical changes and worsen dysphoria. 1 This represents a particularly sensitive time requiring additional mental health support.

Healthcare System Barriers

Insurance Coverage Issues

19% of transgender persons lack any health insurance. 1, 2 Many health plans issue blanket exclusions on transgender health care or do not cover certain services for transgender persons as they would for cisgender persons. 1 For example, insurance may cover post-hysterectomy estrogen replacement for cisgender women but deny similar hormone therapy for post-operative transgender women. 1

Discrimination and Safety Concerns

Transgender individuals face substantial healthcare discrimination: 1

• 78% report harassment
• 35% report physical assault
• 12% report sexual violence
• More than 90% report workplace harassment or discrimination
• Double the unemployment rate of the general population

Healthcare facilities should implement: 1

• Gender-neutral bathrooms and facilities
• TGD-focused cultural sensitivity training for all staff
• Welcoming imagery and language without strong binary gender associations
• TGD-specific support groups and resources
• Comprehensive nondiscrimination and antiharassment policies that explicitly include gender identity

Special Populations

Adolescents

For gender-dysphoric adolescents who have entered puberty at Tanner Stage G2/B2, treatment with GnRH agonists for puberty suppression is recommended. 5 Gender-affirming hormones may be added after a multidisciplinary team confirms persistence of gender dysphoria and sufficient mental capacity to give informed consent (typically by age 16, though compelling reasons may exist to initiate earlier). 5

Pregnancy

Transgender men and non-binary patients who become pregnant should be referred for anesthetic assessment early in antenatal care. 1 Care should be led by senior anaesthetists and obstetricians, with consideration that testosterone therapy increases cardiovascular and atherosclerotic risk to levels consistent with natal male populations. 1

Common Clinical Pitfalls to Avoid

Do not: 2

• Use sex-assigned-at-birth reference ranges after 6 months of testosterone therapy for creatinine or body composition calculations
• Require removal of chest binders for all procedures (ask individuals to complete spirometry with and without binder)
• Mandate urine pregnancy testing without offering serum beta-hCG alternative (triggers significant gender dysphoria)
• Assume insurance coverage exists

Do: 2

• Proactively discuss future fertility before initiating hormone therapy
• Monitor for worsening gender dysphoria and offer support early
• Use non-gendered patient-reported outcome measures to track symptoms
• Maintain hormone therapy even when psychiatric medications are needed