Written by: Dr. Charissa Ho
For most of us, there was very little (if any) exposure to transgender medicine or people who identify as gender diverse during our training. I was fortunate to have the opportunity to locum for Dr. James Makokis in Edmonton, who guided me through my introduction to caring for people who are gender diverse. In my current practice, I continue to be supported by an amazing group of gender medicine providers of all backgrounds. With the training, resources and supports that I have, I hope this guide can provide you with confidence in providing care for folks on the gender spectrum.
- Gender diverse – gender is not a binary, people can identify anywhere on the masculine to feminine spectrum. Gender diverse or gender diversity refers to people who do not identify as the binary.
- Cis male/female – someone who identifies as the same gender they were assigned at birth
- Trans male/female – someone who identifies as a different gender they were assigned at birth
- Assigned male at birth (AMAB) – someone who was born with a penis and testicles that would produce testosterone
- Assigned female at birth (AFAB) – someone who was born with a vagina, uterus, and ovaries that would produce estrogen
- Gender non-binary – someone who identifies as neither male nor female. People who are non-binary may be more comfortable being more feminine or more masculine. They may choose to pursue hormone replacement therapy, or surgery, or both, or none
USE PREFERRED NAMES AND PRONOUNS
In medical school, we were taught to ask how someone would like to be addressed. This is the same, except the name the person goes by may not be written on their health care card. When a person is called the name they no longer go by, they are “dead-named”. It can be dysphoria-inducing, for some, it can be traumatizing. It is okay if you use the wrong pronoun or the wrong name, acknowledge it, apologize, and remember to use their preferred name and pronoun next time. This also goes for EMR records and the name and pronouns used by clinic staff.
PEOPLE WHO ARE GENDER DIVERSE HAVE “TYPICAL” HEALTH NEEDS TOO
People who have a cervix still need cervical cancer screening if they have been sexually active. People who have a prostate and are on estrogen can still get prostate cancer. People who have breast tissue still need to be screened for breast cancer at appropriate ages. Everyone can still get sinusitis, eczema, GERD, hypertension, depression, etc. Most conditions have no relevance to their gender identity or their hormones. We have the knowledge and training to evaluate and treat conditions within primary care’s realm, the same principles go for people who are gender diverse.
DIAGNOSIS OF GENDER DYSPHORIA
The DSM-V criteria for Gender Dysphoria can be summarized as follows:
A marked incongruence between one’s gender experience (being more drawn to opposite gender-typical activities, feeling uncomfortable in their own body, desire to have the other gender’s secondary sexual characteristics) and their gender assigned at birth. This experience should be present for at least six months in duration and be associated with significant distress.
Below is the full DSM-V criteria for Gender Dysphoria:
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months duration, as manifested by at least two of the following:
- A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).
- A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
- A strong desire for the primary and/or secondary sex characteristics of the other gender
- A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
- A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
- A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)
B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
If you are comfortable with starting and/or providing hormones for gender folks, this is a rough how-to guide. A patient does not need to be formally diagnosed with gender dysphoria in order to start hormone therapy as long as the person is clear on why they are pursuing hormone therapy, the effects it can and cannot have, and possible side effects. Of note, the Endocrine Society suggests that feminizing and masculinizing hormone therapy are “safe without a large risk of adverse events when followed carefully for a few well-documented medical concerns”. Hormones should be viewed as therapy provided with informed consent rather than therapy that providers gate-keep.
For male transitioning to female or trans-feminine, there are two primary components: anti-androgen and estrogen. Most common anti-androgen is a medication we are all familiar with – spironolactone. Another agent is cyproterone, which can have more potent effects and be a bit more expensive. Estrogen formulations are the same that we use for menopause hormone replacement therapy: estradiol oral tablets, estrogen patches, and estrogen gel. The formulation chosen depends on patient preference and drug coverage.
For female transitioning to male or trans-masculine, there is one component: testosterone. Testosterone is available in injectable, gel, and oral. Most commonly, injectable is used. Another consideration for folks assigned female at birth is menstrual cessation. Menstrual cessation for transgender folks is the same for cis folks – progesterone IUD, progesterone implant, oral progesterone, combined OCP, and removal of the uterus.
Not everyone who identifies as gender diverse want to pursue surgery. In 2022 in Alberta, top surgery is covered once the person has been diagnosed with gender dysphoria by a gender provider (someone who practices transgender medicine regularly). For bottom surgery, a psychiatrist diagnosis of gender dysphoria is required, and this is accessed through the Edmonton or Calgary Gender Clinics (pediatrics and adult programs are available in both cities).
Top surgeries available include mastectomy or breast augmentation. Bottom surgeries available include phalloplasty, metoidioplasty, vulvoplasty, and vaginoplasty. Other gender affirming surgeries that do not require a diagnosis of gender dysphoria and are covered by Alberta Health include: orchiectomy and hysterectomy with or without salpingo-oophorectomy. There are many other gender affirming surgeries that are not covered by Alberta Health. These include: facial femin/masculinization, tracheal shave, vocal cord surgery, surgery enhanced fat redistribution, and hair removal.
Learn more on gender affirming surgery coverage.
COUNSELLING AND SOCIAL NEEDS
This is the part where I heavily rely on the primary care network and non-profit organizations that support gender diverse folks. Many people who are gender diverse have experienced significant trauma or mental health struggles in their lives. Many gender diverse folks are also on the autism spectrum and have ADHD. Getting them connected with other supports is crucial! Resources that can help with finances, housing, counselling, peer support, family support, gender affirming gear, etc. can make a world of difference. It helps people feel less alone in their journeys while feeling secured in finances and housing.
Below is a list of resources in Alberta:
Alberta-wide community resource:
Calgary community resources:
Edmonton community resources:
- Edmonton 2 Spirit Society
- University of Alberta Institute for Sexual Minority Studies and Services
- Chew Project
- Pride Centre of Edmonton
- Boyle McCauley Health Centre
Red Deer community resources:
Other Northern Alberta community resources:
- Canadian ADHD Resource Alliance
- Autism Speaks
- Centre for Autism Alberta
- Autism Calgary
- Autism Edmonton
For the purposes of this post, I want to provide a general overview on how referrals can be made.
- The Adult Gender Clinic at the Foothills Medical Centre
- Referrals for adults. From there, referrals are triaged and may be distributed to community gender providers like myself.
- The Metta Clinic at the Alberta Children’s Hospital
- Referrals for children and adolescents
- The Alex Youth Centre
- Referrals for people ages 16-24
- Skipping Stone Foundation
- Community organization that can connect gender diverse folks with gender providers (as listed above and several community gender providers like myself) and community resources
- The Gender Program at University of Alberta Hospital
- Referrals for adults, adolescents, and children. From there, referrals are triaged and distributed to the pediatric program, and may be distributed to community gender providers like myself.
- Skipping Stone Foundation (see above)
CONTINUING MEDICAL EDUCATION
Getting into gender medicine or supporting your gender diverse patients can seem daunting. It doesn’t have to be. There are numerous resources you can turn to. Many of the resources also provide free CME!
- TOP Guidelines
- Rainbow Health Ontario
- Trans Care BC: Training Opportunities and Clinical Resources
- Compilation of many other resources
- World Professionals Association for Transgender Health (WPATH) Standards of Care version 8
I hope this guide can give you confidence in providing care for gender diverse individuals. You ARE the expert in primary care and gender diverse folks are not that different.
Many gender diverse folks are intimidated when it comes to seeking health care. When finding a family physician, going to a walk-in clinic, going to a specialist, or to the emergency room, they are never sure if they would face discrimination or transphobia.
If you are able to take on gender diverse folks for primary care, please reach out to Skipping Stone Foundation and identify yourself as a safe provider.