With an increasing number of Americans coming out as transgender, today's OB/GYNs are bound to encounter trans patients in their practice. In particular, trans men — people who were assigned female at birth (AFAB) but identify as male — have a number of health needs that require care from an informed physician.
Yet, only about one-third of gynecologists responding to a survey published in the American Journal of Obstetrics and Gynecology say they feel comfortable providing gynecological care for trans men. Less than half say they are familiar with health maintenance and screening recommendations for this population.
It is critical that OB/GYNs take a comprehensive approach to gynecological care for trans people, particularly those who choose to pursue medical and surgical transition.
Create a Welcoming Environment
First things first, you'll want to make sure all your patients feel welcomed and comfortable when they arrive for care. When introducing yourself, include your pronouns and ask your patients for theirs. Avoid gendered language, such as "well-woman visit," and ask patients what words they use to describe their anatomy. Make the practice as gender-neutral and inclusive as possible by removing gendered language on intake forms and signage as well.
Stay on Track With Recommended Screenings
Routine screenings can still be part of gynecological care for trans men who have a uterus, ovaries, breast tissue or a combination of these. For example, a transmasculine patient who has a cervix and uterus should undergo regular Pap smears and pelvic exams, while one who retains breast tissue should get regular mammograms after age 40.
Yet, according to research published in Contemporary OB/GYN, transgender men are less likely than cisgender women to be up to date on such exams. This is largely due to the discomfort and gender dysphoria that these patients may experience. You can help ease some of the trauma associated with gynecological exams by discussing the need for any pelvic or physical exams in advance. Explain the purpose of an exam, its importance for a particular diagnosis and what it entails.
Address Side Effects of Hormone Therapy
Men and AFAB nonbinary people who pursue medical transition typically use supplemental testosterone, which can suppress menstruation and trigger physical characteristics that a patient may desire as part of their gender presentation, such as increased body hair and fat redistribution. However, patients using exogenous testosterone can also experience unwanted side effects, including abnormal or irregular vaginal bleeding.
This tends to occur as the result of inappropriate dosing and ebbs over time. One recent study published in the International Journal of Transgender Health of 267 transgender men on testosterone found that 17.9 percent of men reported persistent vaginal bleeding after three months on testosterone therapy; 26.8 percent reported spotting. Yet by 18 months of testosterone therapy, none of the patients experienced these issues. Abnormal bleeding is more likely to occur with testosterone gel than with injectable testosterone, according to UCSF Transgender Care.
However, some cases of abnormal vaginal bleeding in trans men can have similar causes as in cisgender women. If a transvaginal ultrasound is necessary to shed further light on abnormal bleeding, OB/GYNs should work with their patients to minimize discomfort and dysphoria during this exam.
Other side effects of gender-affirming hormone replacement therapy can include vaginal dryness and atrophy, although the latter tends to be less common.
Help Patients Prepare for Surgery When Needed
Some trans people choose to transition only socially, whereas others use hormone therapy and still others pursue surgery. Gender-affirming surgeries for trans men include "top surgery" (chest reconstruction) and "bottom surgery" (metoidioplasty or phalloplasty), as well as hysterectomy and oophorectomy. Some trans men will undergo all possible gender-affirming procedures; many choose a combination. For instance, a patient may choose to undergo phalloplasty (surgical creation of a penis) but retain their uterus. While some surgeons perform vaginectomy in conjunction with metoidioplasty or phalloplasty, some patients may forgo this procedure.
To help guide your patients through surgery, you will need to stay up to date on the latest recommendations and outcomes. The World Professional Association for Transgender Health (WPATH) releases standards of care for gender-affirming surgeries, including information on eligibility and other criteria. For example, some top and bottom surgeries require documentation of persistent gender dysphoria by a qualified mental health professional. Additional criteria can include preparation and treatment consisting of hormone therapy and one year of continuous living in a gender role that is congruent with the patient's gender identity.
OB/GYNs should work with the other members of their patients' healthcare teams — including primary care providers, endocrinologists, surgeons and mental health professionals — to help ensure seamless care before and after any gender-affirming surgical procedures.
Consider Mammography Needs
Depending on their choice of procedures, trans men may still require breast cancer screening. Research published in the British Medical Journal suggests that trans men may have a decreased risk of breast cancer compared to cisgender women. However, current recommendations still suggest that trans men who have not undergone mastectomy should undergo mammography after age 50, particularly if they have used hormone therapy for more than five years.
Although mammography generally is not feasible in trans men who have undergone subcutaneous mastectomy, some experts advise they should still conduct regular self-exams, given that they may retain minimal residual breast tissue.
Offer Contraceptive and Reproductive Guidance
As with all sexually active patients, gynecological care for a transgender person should include counseling about sexually transmitted infections and contraception, particularly if a patient retains a uterus and ovaries and engages in penetrative vaginal intercourse.
Trans men who wish to conceive biological children in the future should be counseled about their fertility preservation options and assisted reproductive technology that can help.
Know Your Patients' Rights
With few exceptions, it is illegal for health insurance plans to discriminate against transgender people by refusing to cover gender-affirming care that is deemed medically necessary. Despite this, insurance coverage of gender-affirming care can often be complex, and you may need to help advocate on your patients' behalf. Ensuring coverage of gynecological care for trans men in the form of pelvic exams and Pap smears is one example. You may also be asked to provide a signed letter for patients whose state of residence requires it to update their gender on a driver's license, passport or other identifying documents.
Like all patients, trans men can have complicated and nuanced health needs and require a team of engaged and informed clinicians to provide quality care. OB/GYNs can play an integral role on this team by offering screening, evaluation and treatment for their transmasculine patients.
