What are the key components of a comprehensive care management plan for a female to male (FTM) transgender individual?

Comprehensive Care Management for Female-to-Male (FTM) Transgender Individuals

Primary care physicians should serve as the central coordinators of FTM transgender care, directly prescribing and monitoring testosterone therapy while addressing mental health, preventive screening, and creating an affirming clinical environment that reduces discrimination-related health disparities. 1

Creating an Affirming Clinical Environment

The foundation of quality FTM transgender care begins with systematic documentation and communication practices:

• Document the patient's chosen name, pronouns, and gender identity separately from legal name and sex assigned at birth in the electronic health record. 1
• Flag charts to alert all staff members to consistently use the patient's preferred name and pronouns, as this directly reduces psychological distress and suicidal ideation. 2, 3
• Ask patients directly what terms they prefer when referring to their anatomy (e.g., "chest" instead of "breasts"), as using patient-preferred terminology reduces psychological distress and improves clinical outcomes. 2, 4
• Remove honorifics from standard workflows and add pronouns to all clinical documentation. 3

These documentation practices are not optional courtesies—they are evidence-based interventions that reduce suicide risk and improve mental health outcomes. 2

Hormone Therapy: The Cornerstone of FTM Care

Pre-Treatment Assessment

Before initiating testosterone therapy, complete the following baseline evaluation:

• Complete blood count (to establish baseline hemoglobin/hematocrit before testosterone-induced erythrocytosis) 2, 1
• Comprehensive metabolic panel including liver function tests 2, 1
• Lipid profile (testosterone may reduce HDL cholesterol) 2, 1
• Fasting glucose 2, 1
• Baseline hormone levels (testosterone, estradiol) 2, 1
• Cardiovascular risk assessment 2

Provide mandatory fertility preservation counseling before initiating testosterone, as hormone therapy may permanently affect fertility. 2 This is a critical step that cannot be deferred, as testosterone can cause irreversible changes to reproductive capacity.

Testosterone Initiation Protocol

Initiate testosterone cypionate or enanthate 50 mg subcutaneously weekly, with dose adjustments to achieve serum testosterone levels of 300-1,000 ng/dL (the typical cisgender male reference range). 2, 1, 5

Alternative dosing from FDA labeling includes 50-400 mg intramuscularly every 2-4 weeks, though weekly subcutaneous administration provides more stable levels and is generally preferred. 5

Expected physical changes include:

• Deepening of voice (permanent) 6, 7
• Development of facial and body hair (permanent) 6, 7
• Variable increases in muscle mass 6, 7
• Cessation of menses (typically within 2-6 months) 6
• Clitoral enlargement 6
• Changes in fat distribution toward male pattern 6

Monitoring Schedule

Check testosterone levels and complete blood count at 1-3 months after initiation, then every 3-6 months during the first year, then annually if stable. 2, 1

Critical monitoring parameters include:

• Serum testosterone levels: Target 300-1,000 ng/dL 2, 1
• Hemoglobin/hematocrit: Monitor for polycythemia/erythrocytosis (testosterone stimulates red blood cell production) 2, 1, 5
• Lipid profile: Monitor for HDL reduction 2
• Blood pressure: Monitor for elevation 2
• Liver function tests annually 1

Common Pitfall: Reference Range Confusion

After 6 months of testosterone therapy, use male reference ranges for laboratory interpretation, including creatinine, body composition calculations, and medication dosing. 1 Continuing to use female reference ranges will lead to misinterpretation of results and inappropriate clinical decisions.

Mental Health Integration

FTM transgender individuals experience significantly higher rates of mental health conditions due to discrimination, stigma, and minority stress:

• Depression and anxiety are substantially more prevalent than in cisgender populations 3, 8
• Suicide risk is markedly elevated, particularly without access to gender-affirming care 3

When FTM individuals receive medically appropriate testosterone therapy, they experience a 20% decrease in depression after 1 year and a 5.5-point increase on a 10-point quality of life scale. 1 Additionally, testosterone therapy is associated with statistically significant improvements in quality of life scores compared to those not receiving hormone therapy. 9

Do not require mental health clearance before initiating testosterone therapy in adults with clear gender dysphoria, as this creates unnecessary barriers and delays care that directly improves mental health outcomes. 1 The informed consent model is appropriate for most adult patients.

Screen routinely for:

• Depression and anxiety 3, 4
• Substance use disorders (TGD individuals have higher rates than cisgender populations) 3
• Post-traumatic stress disorder (related to discrimination and violence exposure) 3

Preventive Health and Screening

Establish a complete anatomical inventory, as screening needs are based on anatomy present, not gender identity. 1

Cervical Cancer Screening

• If cervix remains present, follow standard cervical cancer screening guidelines for cisgender women. 1
• Testosterone therapy does not eliminate the need for cervical cancer screening. 1

Breast Cancer Screening

• For patients who have not undergone chest surgery (mastectomy), follow standard breast cancer screening guidelines. 1
• For patients with residual breast tissue after chest surgery, individualized screening may be appropriate based on amount of tissue remaining. 1

Cardiovascular Risk Management

• Testosterone therapy may affect cardiovascular risk factors including blood pressure, lipids, and glucose metabolism 2, 7
• A 1.2-fold to 3.7-fold higher rate of myocardial infarction has been reported retrospectively compared to cisgender women, though this risk appears lower than the cardiovascular risks seen in transfeminine patients receiving estrogen 7

Addressing Gender-Affirming Practices

Chest Binding

Many FTM individuals use chest binding to reduce gender dysphoria before or instead of chest surgery. Do not recommend against chest binding despite potential adverse outcomes (rib pain, skin irritation, respiratory restriction), as it significantly reduces anxiety, dysphoria-related depression, and suicidality while improving emotional well-being and confidence. 2

Instead, provide harm reduction strategies:

• Only bind when leaving home, not 24/7 2
• Take regular "off-days" from binding 2
• Avoid elastic bandages and duct tape (use commercial binders designed for this purpose) 2
• Practice adequate skin hygiene 2

Sexual Health and HIV/STI Prevention

FTM transgender individuals face specific sexual health considerations:

• Address sexual wellness using trauma-informed, thoughtful questioning 3
• Offer self-collection options for STI testing to reduce dysphoria associated with genital examination 3
• Consider offering HIV pre-exposure prophylaxis (PrEP) when indicated, as uptake remains low in TGD communities due to provider availability and stigma 3
• Dispel myths about drug-drug interactions between testosterone and PrEP or HIV antiretroviral medications—newer-generation antiretroviral therapies do not interact significantly with testosterone 3

Co-locate gender-affirming care, sexual wellness, PrEP, and HIV services whenever possible to improve access and reduce barriers. 3

Trauma-Informed Physical Examination

FTM individuals have high rates of trauma exposure, with 78% reporting harassment, 35% physical assault, and 12% sexual violence. 3

Employ trauma-informed examination practices:

• Obtain explicit permission before any physical examination 2, 4
• Avoid approaching the patient from behind 2
• Use guided contact where the patient directs instrument placement (e.g., patient guides stethoscope) 2
• Offer chaperone services with the patient's preferred gender 4
• Do not make the patient remove gender-affirming garments (like binders) unnecessarily during examination 4

Insurance Coverage and Access

Public and private health benefit plans should include comprehensive transgender health care services, including hormone therapy and surgical interventions, as these are considered medically necessary by major medical organizations including the American Medical Association, American Psychological Association, American Psychiatric Association, and American Academy of Family Physicians. 3

The cost of including transgender health care in employee health benefits is minimal—two-thirds of employers offering transition-related coverage reported zero costs due to low utilization rates. 3

When to Refer to Endocrinology

Consider referral for:

• Complex cases with multiple comorbidities affecting hormone metabolism 1
• Difficulty achieving target testosterone levels despite dose adjustments 1
• Significant adverse effects requiring specialized management (e.g., severe polycythemia) 1

However, most FTM patients can be effectively managed in primary care settings using the protocols outlined above. 1

Critical Pitfalls to Avoid

• Never discontinue testosterone without thorough evaluation, as this worsens gender dysphoria and overall quality of life 4
• Do not undertreat pain in FTM patients—documented bias and undertreatment of pain exists in transgender populations 4
• Avoid oral testosterone formulations—use injectable testosterone cypionate or enanthate as first-line therapy 1, 5
• Do not fail to provide comprehensive baseline assessment before initiating therapy 2
• Do not overlook cardiovascular risk factors that may be exacerbated by testosterone therapy 2

Multidisciplinary Team Approach

While primary care physicians can and should manage most aspects of FTM transgender care, the optimal care team may include:

• Primary care physician (central coordinator) 1
• Mental health professionals (for comorbid conditions, not as gatekeepers) 3
• Endocrinologists (for complex cases) 1
• Surgeons (for chest surgery, hysterectomy, genital reconstruction if desired) 3

The decision to pursue surgical interventions should be made collaboratively between the patient and their healthcare team, with the patient's goals and preferences guiding treatment decisions. 3