Health care for transgender and gender diverse (TGD) people, referred to as gender-affirming care, includes hormone prescribing in the primary care setting per national and international standards of care. Benefits to integrating hormone prescribing with primary care include easier access to hormones for patients, as specialists in this area often serve large geographic areas and may have long wait times for appointments. Yet many primary care clinicians feel unprepared to initiate hormones or to continue an existing prescription for their TGD patients. As a result, patients may seek care at overloaded specialty clinics, take hormones without medical supervision, or be unable to access hormones altogether. Given the known benefits of gender-affirming hormone therapy,1 delaying access can cause significant harm to patients.
Our hope is to make it easier for a motivated primary care clinician to grow their medical knowledge and clinical competency by providing a practical pocket guide. While the content in the Quick Guide is not unique, the way it is presented is novel and targeted for fast, at-the-bedside consultation. In this article, we describe our approach to creating a quick reference, including our process of consensus building, the challenge of synthesizing disparate guidelines, and how to measure the success of a reference tool. Each of the contributors to this guide is either an internal medicine physician with experience caring for the TGD community, a TGD-identified person, or both.
To start, physicians in our workgroup pooled their existing educational resources. Each of us had independently created presentations which we used for educational purposes institutionally, regionally, or nationally. Although there was a great deal of overlap in how we explained concepts to our learners, we benefited from seeing how our peers described fundamental concepts. Several contributors had also created their own cheat sheets for hormone prescribing based on existing guidelines and practice standards. Given our group mission of creating a quick reference, these were taken as the starting point for our hormone guide. We selected a checklist format to convey the material. Although individual patient factors dictate some variability in approach, hormone prescribing in general is an algorithmic process which we felt could be well-described via a checklist.
All contributors use an informed consent approach to hormone prescribing, which we describe and recommend in our Quick Guide. In an informed consent model, a patient who has the capacity to understand and make informed decisions for their health care can decide whether to take hormones based on a demonstration of their understanding of the risks and benefits. This approach is similar to how clinicians prescribe other medications. For example, when we prescribe statins to patients to reduce the risk of heart disease or stroke, we counsel that these medications may cause side effects, such as muscle problems or an increase in the risk of prediabetes or diabetes. Patients can decide for themselves whether the benefits of taking these medications outweigh the risks. We discovered some institutional variation in how informed consent is handled. Some institutions have a standard consent form for hormones while others used a verbal consent process—more similar to other medication prescriptions. In the Quick Guide, we advise each clinician to select the consent process that works best for their practice setting and potential regulatory environment.
We discussed in detail how much clinicians should ask patients about their experience of gender. In particular, we were concerned about the risks of medical voyeurism (e.g., having clinicians ask questions just because they are curious, not because it is important for a patient’s care). We also wanted to prevent clinicians from burdening patients unnecessarily by asking to be educated about gender identity in general. TGD patients value when clinicians are motivated to learn about gender on their own and seek knowledge outside of the clinical encounter. Yet clinicians need some information to be able to document at least six months of gender incongruence and help achieve each patient’s individual gender goals. As a result, we advised clinicians to ask specifically about patients’ goals and expectations as they pertain to the impact of hormone therapy.
Another challenge we addressed was selecting hormone target ranges, as they differed among the five guidelines we consulted:
- Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition
- Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline
- Comprehensive Guidelines for Hormone Management and Titration. Protocols for the Provision of Hormone Therapy
- TransLine Gender Affirming Hormone Therapy Prescriber Guidelines
- Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th edition
Links to each of the above resources are available in the Quick Guide. We note that the assays for hormone measurement vary by lab technique, timing of assessment, and test characteristics. A majority of group members used target ranges from the Endocrine Society3 which was included in the Quick Guide. Some guidelines list higher targets, and lower targets might be appropriate based on individual patient goals. All contributors regularly check hormone levels to determine optimal dosing, although we weigh patient experience very heavily in guiding adjustments. This approach ensures patient safety while balancing patient experience.
Finally, we sought feedback on the Quick Guide from several TGD community members. Historically TGD people have been excluded from research about their own community, and so we felt soliciting input was particularly important. Those who contributed were named as work group members in acknowledgement of their efforts.
To introduce the Quick Guide to a larger number of interested clinicians, we printed pocket-size cards and distributed them at SGIM 2022. The guide includes a QR code and URL that directs users to a pdf version. To measure the effectiveness of our distribution, we are monitoring pdf downloads. We are also incorporating the guide in a medical education project. We will ask internal medicine residents if they would be more likely to prescribe gender affirming hormone therapy if they had access to a tool such as this. We look forward to sharing this data once it is available.
We acknowledge that hormones are only one aspect of gender-
affirming primary care, and that not every TGD person will use hormones as part of their process of gender affirmation.2 Additionally, the physiologic knowledge required to prescribe hormones, while important, is only a piece of gender-affirming primary care. The importance of humility and a compassionate, respectful approach towards patients cannot be overlooked. We hope the Quick Guide makes it easier for interested primary care clinicians to offer guideline-based care to TGD patients. And we strongly encourage clinicians to seek opportunities to connect, form relationships with, and learn from the larger TGD community.
The Quick Guide: Gender Affirming Hormone Therapy by the Primary Care Provider is available for download and printing from: https://bit.ly/GAHT-QUICK-GUIDE. The guide was created by Hedian H, Norwood A, Siegel J, Loeb D. Work Group: Streed C, Ufomata E, Tilstra S, Greene R, Tran P, Kwolek D, and Lee R.
- Baker KE, Wilson LM, Sharma R, et al. Hormone therapy, mental health, and quality of life among transgender people: A systematic review. J Endocr Soc. Apr 1 2021;5(4):bvab011. doi:10.1210/jendso/bvab011.
- James SE, Herman, JL, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. 2016. http://www.transequality.org/sites/default/files/docs/usts/USTS%20Full%20Report%20-%20FINAL%201.6.17.pdf.
- Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An endocrine society clinical practice guideline. J Clin Endocrinol Metab. Nov 1 2017;102(11):3869-3903. doi:10.1210/jc.2017-01658.
Clinical Practice, Health Equity, Medical Education, Research, SGIM, Social Determinants of Health
Dr. Hedian (firstname.lastname@example.org) is an assistant professor of medicine at Johns Hopkins University and the director of clinical education for the Johns Hopkins Center for Transgender Health. Dr. Streed (Carl.email@example.com) is an assistant professor of medicine at Boston University School of Medicine and research lead in the Center for Transgender Medicine and Surgery at Boston Medical Center. Dr. Siegel (firstname.lastname@example.org) is an assistant professor of medicine at Boston University School of Medicine and medical director at the Center for Transgender Medicine and Surgery at Boston Medical Center. Dr. Norwood (Aliza.Norwood@viventhealth.org) is an assistant professor of medicine at the University of Texas Dell Medical School and medical director at Vivent Health in Austin, Texas. Dr. Loeb (email@example.com) is an associate professor of medicine at University of Colorado School of Medicine, co-lead of research and lead of the Community Advisory Board for the University of Colorado Gender Diversity Programs.
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