Clinical Pearls & Morning Reports
Gender expression relates to how a person communicates gender identity. Efforts to align physical characteristics with gender identity may be referred to as transition, gender affirmation, or gender confirmation. Data from 2016 from the Behavioral Risk Factor Surveillance System at the Centers for Disease Control and Prevention suggest that in the United States approximately 0.6% of adults, or 1.4 million persons, identify as transgender. Read the latest Clinical Practice article here.
Q: How early may gender identify be expressed?
A: Children may label genders and articulate gender identity by 2 years of age. In surveys, up to 2.7% of children may report gender incongruence, but many such children do not continue to do so later in life. The majority of transgender persons present to clinicians in late adolescence or adulthood. In retrospect, many transgender persons report that their awareness of their gender incongruence began before puberty.
Q: What is known about the mechanisms that inform gender identity?
A: Although the mechanisms that inform gender identity are unknown, current data suggest a biologic underpinning programmed from birth. For example, there are reports of XY chromosome intersex persons raised as female who report male gender identity, and identical twin siblings of transgender persons are more likely than fraternal twin siblings of transgender persons to be transgender.
A: Transgender identity is established on the basis of history alone; gender incongruence should be persistent, typically being present for years. In addition to obtaining a social and sexual history, along with screening for infections if warranted by sexual history, clinician evaluation of transgender patients should include assessment of anxiety, depression, and suicidality, all of which are reported to be more common among transgender than cisgender persons. Providers of mental health care should participate in the assessment of adults if a mental health condition is suspected or identified and participate routinely in the assessment of children and adolescents, who may articulate gender identity more heterogeneously. No medical intervention is indicated before puberty because levels of estrogen and testosterone are not appreciable until that time. Before they start any treatment, patients should be encouraged to consider fertility preservation.
A: Data largely derived from convenience samples from larger clinics with dozens to a few thousand patients suggest that transgender women who receive hormone therapy may be at increased risk for deep venous thrombosis, pulmonary embolism, stroke, and myocardial infarction as compared with the expected rates among cisgender persons. It is not known whether these risks are greater than those reported among postmenopausal cisgender women who take exogenous estrogens. A reported concern with hormonal therapy in transgender women is a rise in prolactin levels (and the potential for development of a prolactinoma). Thus, prolactin monitoring has been recommended. However, reports of elevated prolactin levels are limited to clinics that use estrogen–cyproterone regimens. Androgens stimulate erythropoiesis. Exogenous androgens may be associated with polycythemia, particularly in persons with other risk factors for an elevated hematocrit, such as sleep apnea. The hematocrit should be monitored and, if elevated, possible alternative explanations investigated. Although guidelines note concern regarding increased risks of breast or endometrial cancer in association with androgen therapy and suggest that practitioners consider hysterectomy in transmasculine patients to avoid the risk of endometrial cancer, there are no data that support the existence of such risks.