This document was released in November 2022. This document will continue to be periodically updated to reflect the growing body of literature related to this topic.

KEYWORDS: Gender identity, Gender expression, Gender dysphoria, Transgender, Non-binary, Trauma-informed urologic care, Gender-affirming environment, Organ inventory.

At the end of this unit, the medical student will be able to:

1. Discuss historical barriers to healthcare facing transgender and gender diverse patients
2. Discuss and differentiate between sex, gender, gender identity, gender expression, and orientation
3. Discuss common gender identification terminology, including cis-, trans-, and non-binary genders
4. Communicate an understanding of proper use of pronouns and name, and how to avoid dead-naming
5. Discuss gender dysphoria, gender discordance/incongruence, and misgendering and how urologists may implement strategies to avoid inducing gender dysphoria and misgendering
6. Discuss gender transition and the various social, medical, and/or surgical elements a patient may undergo
7. Review the World Professional Association for Transgender Health’s current standard of care guideline criteria for gender affirming medical and surgical treatment in adults and adolescents
8. Discuss anticipated effects of hormonal therapy, as well as the side effects and contraindications to masculinizing and feminizing hormonal therapy
9. Discuss recommendations and guidance for post-operative follow up and gender-affirming surgery aftercare
10. Discuss the elements of a gender-affirming environment in urology
11. Define organ inventory and its impact on urologic specific care for transgender and gender diverse patients
12. Discuss the elements of a trauma-informed care approach for transgender and gender diverse patients, and how it may be adapted for use in the field of urology
13. Communicate an understanding and ability to perform a gender-affirming and trauma-informed history
14. Review recommended health maintenance and screening guidelines for transgender and gender diverse patients
15. Discuss special considerations when approaching genitourinary and pelvic examinations in transgender and gender diverse patients
16. Discuss potential urologic complications and differences in physical examination findings secondary to gender-affirming medical and surgical treatment

BACKGROUND

Medical student and residency curriculums historically have provided limited exposure and education on transgender and gender diverse (TGD) patient specific care.  While medical education has recognized the importance of addressing the existing knowledge gaps in medical trainees, there remains significant barriers to basic health care for TGD patients. Experiences of prejudice, discrimination and trauma in healthcare, access to knowledgeable and competent providers, and microaggressions and inappropriately pathologizing gender incongruence during patient encounters are just some of the many barriers facing this population (1). It is also crucial for providers to understand the cultural factors contributing to the potential physical and mental health conditions resulting from societal intolerances, and an awareness that being transgender or non-binary is not a medical illness itself. Many TGD folk have experienced some level of discrimination or rejection from former support systems, birth families, jobs, and even endured emotional or physical abuse in their communities.

With more insurance providers and health care systems now offering coverage for gender-affirming care, the number of TGD patients seeking to establish care is projected to increase in the coming years (2). Consequently, the demand for health care providers and physicians who are well-educated and sensitive to the needs of TGD patients is also anticipated to increase, especially in regards to urologic care (2). Therefore, there is an exceeding importance for urologic trainees to receive a more expansive education on the common reasons why TGD patients may seek urologic care – understanding it may not necessarily be related to gender transition and may be related to kidney stones, hematuria, or cancer screenings – as well as on the respectful language and approaches that accompany creating a gender-affirming environment for TGD patients.

SEX, GENDER AND ORIENTATION – DEFINITIONS

Sex, gender, and orientation are distinct components of a person’s experience. Sex, or sex assigned at birth, refers to a person’s status as male, female, or intersex based on physical characteristics and the appearance of the external genitalia at birth (3).While many people who were assigned male (AMAB) or female (AFAB) at birth may identify with a male or female gender, respectively, that is not always the case. Gender identity refers to one’s own innate knowledge of who they are, their internal sense of self and their gender, which exists on a spectrum and can be male/man, female/woman, both, or neither, and does not depend on sex (4).

It is important for trainees to become familiar with the most common terminology utilized in gender identification. Cisgender, or the adjective “Cis-“, is a term used by people whose gender identity currently aligns with the sex they were assigned at birth. For example, a cisgender female is someone who was AFAB and whose current gender identity is female. Transgender, trans, or a person of trans experience, is a term used by most people whose gender identity and/or gender expression differ from the sex they were assigned at birth. For example, a transgender male is someone who was AFAB but whose current gender identity is male. Of note, “trans” or “transgender” should be used as an adjective (as in “trans people”), and never as nouns (as in “transgenders”) and never as verbs (as in “transgendered”) (3). Older terminology such as female-to-male (FtM) or male-to-female (MtF) are now no longer commonly used (3). Not all people identify as transgender as it is itself a binary term. Non-binary is a term used by people with gender identities outside the gender binary, and may have an identity that blends elements of male, female, or a gender identity that is different from either binary (3). While non-binary is the most common terminology used by these persons, other related terms include “genderqueer”, “gender diverse”, “demigender”, “agender”, “gender fluid”, and “bigender” (4,5).

Within the medical community, the term “intersex” is commonly referred to as a disorder of sexual differentiation (DSD). Being intersex, or having a DSD, is not the same as being transgender or non-binary. Intersex, or a DSD, refers to being born with sex or reproductive characteristics that do not fit binary definitions of female or male (3). The National Center for Transgender Equality and the World Professional Association for Transgender Health (WPATH) provides additional education (Table 1) on terminology and gender-inclusive language.

Orientation, typically denoted as “sexual orientation”, refers to the enduring physical, romantic and/or emotional attraction or preferences a person has or does not have for other persons, whether they may be of the same or other genders. Common terminology used to describe orientation includes lesbian, gay, bisexual, pansexual, and asexual. Sexual orientation is different from gender identity.

Gender expression	External, or public, expression of gender; how a person presents gender through behavior, clothing, voice, hairstyle, or other perceived characteristics. Unlike gender identity, gender expression is outwardly visible to others.   Society categorizes gender expression cues as “masculine” or “feminine”, however what is considered masculine and/or feminine changes over time and is within the context of culture and society.
Gender-expansive	An adjective used to describe a person with a more flexible gender identity and/or expression than might be associated with a typical gender binary; a person who does not conform to gender stereotypes and who may have a gender identity and/or expression that is considered more feminine or more masculine than the societal binary
Non-binary	People with non-binary gender identities may identify as partially a man and partially a woman, or identify as sometimes a man and sometimes a woman, or identify as a gender other than a man or a woman, or not having a gender at all.   Some non-binary people may consider themselves to be transgender or trans, while some do not. Some non-binary people may utilize the shorthand abbreviation “NB” or “enby”.
Trans-masculine	A broad term used by trans and gender diverse individuals who have a gender identity and/or expression that is partially or fully masculine, but do not necessarily identify as a trans man.
Trans-feminine	A broad term used by trans and gender diverse individuals who have a gender identity and/or expression that is partially or fully feminine, but do not necessarily identify as a trans woman.
Cisgender	“Cis-“ is an adjective used to describe a person whose gender identity aligns with the sex they were assigned at birth.
Agender	An adjective used to describe a person who does not identify with any gender.
Bigender	An adjective used to describe a person who identifies with some component of both male and female gender identities.
Disorder of Sexual Differentiation	A term used to describe people with differences in reproductive anatomy, chromosomes, genetics, and/or hormones that do not fit typical definitions of a male or female sex assigned at birth. Intersex can refer to a number of natural variations and is separate from gender.   Ex: A person with XY chromosomes with female sex genitalia and secondary sex characteristics   Ex: A person with XX chromosomes who was born without a uterus and external anatomy that is neither solely associated with male or female sex.
Misgender/Misgendering	Refers to when language is used that does not correctly reflect the gender with which a person identifies. Examples include utilizing incorrect pronouns or form of address (sir, mam, Mr. Ms., etc.)
Transphobia/Anti-Transgender Bias	Refers to the negative attributes, beliefs, and actions concerning transgender and gender diverse people as a group. Transphobia can be: (1) discriminatory policies and practices on a structural level or in very specific and personal ways; (2) internalized, when TGD people accept and reflect such prejudices; (3) a. manifestation of unintentional ignorance rather than direct hostility but, nonetheless, never benign.
LGBTQAI+	An acronym used in common culture for persons who do not fit typical societal norms regarding sex, gender identity and expression, or orientation. The initials stand for Lesbian, Gay, Bisexual, Trans, Queer, those Questioning, Agender, Asexual, Intersex, and the number of other identities (indicated by the plus sign).
Table 1. Additional sex, gender, and orientation terminology. Adapted from The Center for Transgender Equality (4,5) and The World Professional Association For Transgender Health (3,6)

PRONOUNS AND SELF IDENTIFICATION – DEFINITIONS

Asking and addressing a patient by their name and pronouns is one of the most important ways for physicians to first establish rapport and build trust. A person’s pronouns should never be assumed, and they are not always directly provided by patients when you walk into a room. Asking these questions is especially crucial for TGD patients, as many may not initially feel comfortable outwardly communicating their name or pronouns due to fear of judgment or discrimination.

Knowledge of the different pronouns used by persons to self-identify is important, as some individuals may have pronouns not used frequently. Some patients may use she/they or he/they pronouns, which means a person uses both pronouns and may alternate between the two. More information on various pronouns and pronunciation can be found in Table 2 (7).

So how can urologists approach these questions respectfully? Start by introducing yourself with your preferred name and pronouns, and then subsequently ask a patient the same information you just provided – “Hello, my name is Dr. Smith. I use she/her pronouns. How may I best address you today? What are your pronouns?”. This approach allows for a more organic exchange of information regarding one’s self identification and creates a safe space to affirm one’s identity. Furthermore, a mutual exchange of name and pronouns shows that you have an understanding that gender expression does not equal gender identity. It also avoids the potential of misgendering or inducing gender dysphoria via “deadnaming” - when one refers to a TGD person by a name in which they did not ask you to use or by a name they used prior to transitioning, usually the name they were assigned at birth and no longer identify with (1). While every effort must be made to ensure proper and continued use of the preferred name and pronouns given to you by a patient, mistakes may occur. If a mistake is made make sure to apologize before moving on with the patient encounter. 

While there have been improvements made in electronic medical record systems regarding patient self-identification, a patient’s medical chart, license, or insurance may be still under their “dead name”. If there comes a time when the name provided to you by a patient does not match what is present in their chart, avoid asking a patient for their “old name” and instead offer asking, “Is there any chance your medical chart could be under a different name?”. Physicians must be aware that some patients may not go by their legal name and that the process of legally changing their name or gender is not always an easy task. Legal gender affirmation is a complex process and can take years to complete. Without a federal standard it varies from state to state, and the challenges encountered in this process cannot be understated. In addition to significant time and financial resources, some jurisdictions require court orders, extensive psychologic evaluations, or a well-documented history of already undergoing medical gender affirmation (8).

GENDER TRANSITION – DEFINITIONS

3rd Person Singular Subjective	3rd Person Singular Objective	3rd Person Singular Possessive	3rd Person Singular Reflexive	Example of use
She	Her	Her	Herself
He	Him	His	Himself
They	Them	Their	Themself	They went to the movies with their friend who loves to hangout with them. The movie pick was theirs. They enjoyed themself.
Ze/Zie   Pronounced /zee/	Zir   Pronounced  /zEEr/	Zir/Zirs   Pronounced  /zEEr/	Zirself   Pronounced  /zEEr-self/	Ze went to the movies with zir friend who loves to hangout with zir. The movie pick was zirs. Ze enjoyed zirself.
Xe   Pronounced /zee/	Xem   Pronounced  /z-EM/	Xyr/Xyrs   Pronounced  /zEEr/	Xemself or Xyrself   Pronounced  /z-EM-self/ or  zEEr-self/	Xe went to the movies with xyr friend who loves to hangout with xem. The movie pick was xyrs. Xe enjoyed xyrself.
Ze   Pronounced /zee/	Hir   Pronounced /hEEre/	Hir/Hirs   Pronounced  /hEErs/	Hirself   Pronounced  /hEEre-self/	Ze went to the movies with hir friend who loves to hangout with hir. The movie pick was hirs. Ze enjoyed hirself.
Table 2. Pronouns and Pronunciation. Source: Adapted from the Duke University Office of Student Affairs, Center for Sexual and Gender Diversity (7).

Gender transition refers to the process a person may take to bring themselves and/or their bodies into alignment with their gender identity or gender expression and/or to address their gender dysphoria (4). Gender dysphoria refers to the psychological, emotional, and/or physical distress that may result from an incongruence between one’s sex assigned at birth and gender identity. Gender dysphoria is also a diagnostic term in the DSM-5 denoting an incongruence between sex assigned at birth and experienced gender accompanied by distress (3). However, not all TGD people experience gender dysphoria in the same way or even at all, and instead experience gender discordance – an awareness of the discrepancy between one’s sex assigned at birth and one’s gender identity. Gender transition is not a single step and transitioning can be social, medical, and/or surgical. However, many patients live their understood gender identity without any medical and/or surgical interventions (Table 3) (9,10).

The WPATH is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, advocacy, and respect in TGD health (3,6). One of WPATH’s main functions is to promote the highest standards of health care through their Standards of Care (SOC) for the Health of Transgender and Gender Diverse People. The SOC provides clinical guidance for health professionals to assist TGD people with safe and effective pathways for social, medical, and surgical treatment for those experiencing gender dysphoria or discordance. It is important to note that WPATH’s SOC guidelines are intended to be flexible in order to meet the diverse health care needs of TGD people globally (3). They exist not to limit treatment for TGD patients but, rather, are adaptable and serve to identify patients who will benefit from treatment using the best available science and expert consensus. In 2022, WPATH released version 8 of their SOC which includes recommendations on criteria for gender-affirming hormonal and surgical treatments in adults and adolescents (3) (Table 4). 

Social Transition

Social transition can include sharing one’s gender identity with family, friends, or community members, updating one’s legal documents, or changing one’s name and pronouns. This is often a first crucial step in one’s gender transition process. Some TGD patients may also seek additional medical or surgical interventions when transitioning their gender, which usually entails a multi-disciplinary care team including primary care physicians, behavioral health specialists or psychiatrists, endocrinologists, gynecologists, and/or urologists.

Medical Transition – Hormonal Therapies

Undergoing medical gender transition interventions usually implies the use of hormonal therapies. While hormonal therapies are primarily managed by a patient’s primary care physician or endocrinologist, it is important for urologists to understand the type, extent, and duration of hormonal therapy due to the potential implications on the genitourinary system.

If a transgender man or trans masculine individual elects to proceed with hormonal therapy, they typically are started on masculinizing hormonal therapy with exogenous testosterone. Target testosterone levels are similar to levels of cisgender men of the same age and typically reach peak level after 1-2 years of treatment. Patients’ testosterone levels and hemoglobin/hematocrit should be documented at baseline and monitored every 3 months after dose adjustment during the first year and then 1 to 2 times per year thereafter to monitor for appropriate response (11). Masculinizing changes expected as a result of starting testosterone hormonal therapy include increased facial and body hair growth, vocal changes (deepening of voice), increased muscle mass, reduced fertility, atrophy of breast tissue, cessation of menses, weight gain, increased libido, possible clitoral virilization, or vaginal atrophy (9). If a transgender woman or trans feminine individual elects to proceed with hormonal therapy, they typically are started on feminizing hormonal therapy, which requires both exogenous estrogen for feminization and anti-androgens (ex: spironolactone, cyproterone acetate) to suppress testosterone levels. Anti-androgens are usually given in combination to minimize the dose of estrogen needed to achieve feminizing effects (9).  Target estrogen levels are similar to levels of cisgender women of the same age. Transgender women and trans feminine, including gender diverse and non-binary, patients should have their estrogen and testosterone levels monitored every 3 months in the first year and then 1 to 2 times per year thereafter (11). Additionally, in patients receiving combination spironolactone, should have serum electrolytes (especially potassium) and kidney function (especially creatinine) monitored closely (11). Feminizing changes expected after starting estrogen hormonal therapy include decreased facial and body hair growth, skin softening, vocal changes (higher toned voice), increased breast tissue development, increased muscle and fat redistribution, or testicular and penile atrophy (9). Patient’s should be screened for contraindications and higher risk criteria and also monitored for potential unwanted side effects of hormonal therapies (Table 5) (9,10). Additional recommendations on hormone monitoring in transgender and gender diverse people receiving gender affirming hormone therapy are reviewed in the Endocrine Society Guidelines (11).

Surgical Transition

TGD patients may elect to undergo various transition related masculinizing or feminizing surgeries to align more with their felt gender identity. Gender-affirming procedures can entail any single or combination of surgeries to one’s body, face, chest and/or anatomy. Masculinizing surgical procedures include subcutaneous mastectomy (chest) and lower body surgeries (reproductive organs and genitourinary system) such as a hysterectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty, phalloplasty, urethral reconstruction, scrotoplasty, or testicular prosthesis. Feminizing surgical procedures include breast augmentation mammoplasty (chest) and lower body surgeries such as vaginoplasty, vulvoplasty, penectomy, orchiectomy, or urethral reconstruction. Additional non-chest, non-lower body surgeries may include facial feminizing/masculinizing surgery, vocal surgery, thyroid cartilage reductions, hair transplants, or laser hair removal (9).

Aftercare and Post-Operative Follow Up

In addition to monitoring for post-operative complications, the following should also be discussed with patients before and after undergoing a gender-affirming procedure (3):

• Pre- and post-operative resources: safe housing, resources for travel and follow-up care
• Health-positive habits: personal hygiene, healthy diet and exercise, urinary tract infection and sexually transmitted infection prevention
• Post-operative limitations: bathing, physical activity, exercise, nutrition, sexual activity
• Post-operative resumption of medications: hormones, anticoagulants
• Detailed post-operative self-care: post-vaginoplasty dilation and hygiene regimens, penile prosthesis cycling/activation, strategies to optimize post-phalloplasty urinary function
• Post-metoidioplasty/phalloplasty: encouragement of life-long follow up to monitor for sexual and urinary function complications (i.e. urethral stricture/fistula, meatal stenosis, incontinence, prosthesis related complaints)
  • Follow up includes bladder ultrasound measurement of post void residual (to screen for urethral stricture), fluoroscopic urethrography (to identify stricture or fistulae), cystourethroscopy to examine the bladder and urethra.
• Post-vaginoplasty: encouragement of routine follow up with their primary surgeon, primary care physician, and gynecologist

Gender Transition Epidemiology

30% of transgender persons have not undergone any social, medical, or surgical steps in their transition process

23% of transgender persons are already living their felt gender without any intervention

23% of transgender persons report completely transitioning – self defined and could include medical or surgical interventions

Medical Interventions: 46% of transgender women currently use hormone (medical) therapies 39% of transgender men currently use hormone (medical) therapies

Surgical Interventions: 21% of transgender women underwent orchiectomy (most common surgical procedure) 15% of transgender women underwent vaginoplasty 0.4% of transgender men underwent phalloplasty

Table 3. Gender Transition Epidemiology. Source: Adult Transgender Care in Urology (9), TransPULSE study survey (10)

Adults Assessment Process and General Recommendations Health care professionals assessing TGD adults seeking GAMST liaise with professionals from different disciplines within the field of trans health for consultation and referral, if required. Only 1 letter of assessment from a health care professional who has competencies in TGD health is required to recommend GAMST For non-binary people, health care professionals should consider medical interventions in the absence of “social gender transition” and should consider gender-affirming surgery in the absence of hormones unless hormones are required to achieve desired surgical result (i.e. metoidioplasty) Criteria for hormones Gender incongruence is marked and sustained; other possible causes for incongruence have been identified and excluded Person demonstrates capacity to consent for specific gender-affirming hormone treatment Mental health and physical conditions that could negatively impact the outcomes of treatment have been assessed, with the risks and benefits discussed Person understands the effect of gender-affirming hormone treatment on reproduction and they have explored reproductive options Criteria for surgery Same criteria for hormones Stable on their gender-affirming hormone treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or medically contraindicated)

Adolescents Assessment Process A comprehensive and multidisciplinary biopsychosocial assessment Involvement of parent(s)/guardian(s) in the assessment process, unless their involvement is determined to be harmful to the adolescent or not feasible Only 1 letter of assessment or written documentation from a member of the patient’s multidisciplinary team to recommend GAMST; should include assessments from both mental and medical professionals Criteria for puberty blockers or hormones Gender incongruence is marked and sustained over time Demonstrates the emotional and cognitive maturity required to provide informed consent for treatment Mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and GAMST have been addressed so that treatment may be provided optimally Informed of the reproductive effects, including the potential loss of fertility and available options to preserve fertility Reached Tanner stage 2 Criteria for surgery Same criteria for puberty blockers or hormones At least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result for gender affirming procedures – including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery (unless hormones are not desired or medically contraindicated)

Table 4. GAMST Criteria and Recommendations. Source: World Professional Health Association for Transgender Health, Standards of Care Version 8 (3)

 

	Hormonal Therapy Side Effects
Exogenous Testosterone	Masculinizing Hormonal Therapy (MHT) Side Effects: Weight gain, Acne, Balding, Sleep Apnea, Liver dysfunction, Hyperlipidemia, Mental health disorders, Coronary artery disease, Cardiovascular disease, Hypertension, Type II diabetes mellitus, Bone density changes. MHT Contraindications: History of testosterone-sensitive malignancies, Significant cardiovascular or cerebrovascular disease.
Exogenous Estrogen	Feminizing Hormonal Therapy (FHT) Side Effects: Venous thrombotic events, Cardiovascular disease, Cholelithiasis, Macroprolactinoma, Liver dysfunction, Hypertension, Hypertriglyceridemia, Weight gain, Type II diabetes mellitus FHT Contraindications: History of estrogen-sensitive malignancies, prior venous thrombotic events, Significant cardiovascular or cerebrovascular disease.
Table 5. Hormonal Therapy Side Effects. Source: Adult transgender care: a review for urologists (9)

General Principles

TGD patients often seek urologic care for reasons outside of gender transition – such as nephrolithiasis, hematuria, urinary tract infections, or lower urinary tract symptoms. However, the inherently “gendered” nature of the genitourinary system and reproductive anatomy poses additional challenges for TGD patients and creates urologic-specific barriers to care (1). Discussion of lower body anatomy can induce significant gender dysphoria and examinations of the genital region can be especially traumatic for this marginalized patient population, with surveys reporting around 47% of TGD experiencing sexual assault at some point in their life (12). It is therefore of crucial importance to create a gender-affirming environment and implement a trauma-informed care (TIC) approach when caring for TGD patients in the field of urology.

Gender-Affirming Healthcare Environment

Creating a gender-affirming environment for urologic care should incorporate, but is not limited to, the following guiding principles provided by Dorian et al (1):

• Providing transgender and non-binary health education to staff.
• Providing pronoun pins/identifiers for staff to wear in clinic.
• Providing intake health forms/questionnaires that are appropriate for the patient’s gender identity and includes an organ inventory – organs a patient may or may not currently have, organs expected at birth, and organs potentially modified via gender affirming medical or surgical treatment (ex: recording the presence of a prostate after vaginoplasty).
• Respecting and using chosen/preferred names and pronouns during visits and documentation.
• Avoiding misgendering, deadnaming, and unnecessary history questions or examinations not relevant to the patient’s current chief complaint.
• Providing gender-neutral bathrooms throughout the clinic.
• Utilizing less “gendered” anatomic terms during visits, and instead asking the patient for their preferred terms for anatomy.
• Practicing a TIC approach in all interactions, especially during examinations.

Trauma-Informed Care Approach

Trauma refers to any individual trauma that results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening, and which has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being (13). The Substance Abuse and Mental Health Services Administration’s (SAMHSA) concept for trauma and guidance for TIC is grounded in four key assumptions and six key principles. The four key assumptions, or 4 “R’s”, are (1) Realization, (2) Recognition, (3) Response, and (4) Resisting Re-traumatization – “a program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands the potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization”. SAMHSA’s six key principles of a TIC approach are (1) Safety, (2) Trustworthiness and Transparency, (3) Peer Support, (4) Collaboration and Mutuality, (5) Empowerment, Voice and Choice, and (6) Awareness of Cultural, Historical, and Gender Issues. These principles support an environment that empowers patients with the understanding that they are in control of the interaction and that their healthcare provider sees and affirms their experience. 

TGD PATIENT HISTORY AND PHYSICAL EXAMINATION

When interviewing a patient and taking a urology specific medical history, keep questions open-ended whenever possible and allow the patient to describe themselves in their own, preferred, language. Do not ask questions that will not directly impact guidance, medical decision making, or management. It is important to only ask what is necessary regarding their visit to avoid the potential of inducing gender dysphoria. Further guidance on recommendations regarding question style are provided below.

Names, Pronouns, Sex, and Gender

• My name is Dr. Smith, I use she/her pronouns. What is your preferred name and pronouns?
• How may I best address you today?
• Could your chart be under another name?
• What name is your insurance under?
• How would you describe your gender identity?
• How would you describe your gender expression?
• What was your assigned sex at birth?

Urology Chief Complaint

Remember that TGD patients commonly present for urologic issues that are not directly related to their gender identity experience or gender transition. However, if a patient has undergone medical or surgical interventions it is important to determine whether their current urologic symptoms are related to their gender transition process. Focus your questions on what the patient’s chief complaint is and ask the necessary urology-specific questions. 

• Tell me more about what is bringing you in today.
• What are your thoughts on what may be contributing to your symptom(s)?
• Are there any activities or behaviors associated with your symptoms?

Social, Hormonal, and Gender Affirming Surgical History

Establish a proper history and timeline on the patient’s experience and, if any, steps were taken in their gender transition process. These steps can include any combination of social, medical, and/or surgical gender transition. Important pieces of information to understand are:

• Tell me more about yourself. Have you pursued any changes to better align yourself with your gender?
• Have you pursued any changes in your appearance, behavior, or body to bring yourself closer to your inner sense of self?
• What are your thoughts on hormones? Have you ever used hormones or are you currently taking any other medications? What type of hormones did you use and when did you start hormones? How long have you been taking hormones? How has currently/previously being on hormones made you feel? Tell me about any positive effects or undesirable side effects.
• Have you ever thought about having or have you already undergone any procedures or surgeries to better align your appearance or body with your gender? What language do you prefer to use when referring to your body? What does your organ inventory consist of?

Sexual, Intimate Partner, and Social History

Sexual history and social history can be sensitive topics for TGD patients. A TIC approach is strongly recommended to avoid causing significant gender dysphoria. Urologists should understand the extent of every patient’s experience to better care for any symptoms related to reproductive or genitourinary organs. Understanding what types of sexual activity and/or forms of intimacy are important when caring for TGD patients. For example, obtaining adequate erectile function may still be an important part of a transgender woman’s sex life and insertional sexual intercourse may be an important part of a non-binary patient’s sex life. Ensure that you are supportive when approaching this line of questioning and that all information shared is confidential. Establish patient consent before proceeding with any questions that may be sensitive. When discussing trauma history, remember to resist re-traumatization and be ready to respond to any trauma disclosed. Knowledge of historical gender issues is especially important when approaching this line of questions. Normalize the patient’s experience and communicate to them that this is a routine part of every patient visit.

• Tell me more about your day-to-day life – How do you spend your time? What do you do for work?
• What do you do to relax/have fun? Any history of alcohol use or smoking? Any history of recreational substance use? What are your thoughts about your substance use?
• Tell me more about the support systems in your life.
• Are you currently sexually active? If so, what is/are the gender(s) of your partner(s)? May I ask you some questions about your sexual partners?
• What type of sex do you have? Any history of insertional or receptive intercourse? If so, what type of insertional or receptive intercourse do you have? What are your thoughts on using protection during intercourse, such as condoms or other barrier protection?
• Do you feel safe with your partner(s)? Have you ever felt unsafe in your current or prior living situations? Have you ever experienced any traumatic life events that you would feel comfortable sharing?

TGD Urologic Health Maintenance and Screening

Historically, TGD patients have been particularly vulnerable to missed or delayed presentation to health screenings due to existing societal and cultural barriers. TGD patients should receive the same age-appropriate health maintenance and screening studies as cis-gender populations. A patient’s organ inventory should be taken into consideration when providing guidance on cancer screenings. In the field of urology, prostate cancer screenings should be performed in all persons who have a prostate included in their current organ inventory, including transgender women and non-binary patients. Remember, chronic use of exogenous estrogen and anti-androgen therapy may result in castrate levels of testosterone and low PSA values. It is also unclear how prolonged estrogen and anti-androgen therapy affects prostate cancer risk (9). Having a history of a gender-affirming surgery such as a vaginoplasty does not exclude a patient from prostate cancer screening, as the prostate is typically not removed during this procedure to avoid further urinary function complications. However, a vaginoplasty may impact the ability to examine the prostate via digital rectal exam and instead require a digital exam via the anterior wall of the neovagina (9). Fertility screening and counseling should also be provided to all TGD prior to medical or surgical transition. This can include discussions on sperm banking or oocyte/embryo freezing prior to starting hormonal therapy. TGD patients taking testosterone should be counseled on the importance of continued contraception use, as use of testosterone is not a form of contraception. Discussion of pregnancy and pregnancy testing has the potential to induce gender dysphoria in many patients. If pregnancy is not possible based on a patient’s organ inventory or sexual behaviors, pregnancy testing may be omitted.

Trauma-Informed Urologic Physical Examination

In the field of urology, adoption of a TIC approach for TGD patients is a crucial step towards establishing a gender-affirming environment. A urology-focused history and examination can be particularly intrusive for TGD, especially during the vulnerable moments accompanying the genitourinary and pelvic exam. In accordance with SAMHSA’s guidance, some key recommendations and techniques to promote a trauma-informed, sensitive, and competent urologic care environment are as follows (3,9,13):

• Having open conversations and preparing patients for what will happen before, during, and after the genitourinary physical examination.
• Explaining to the patient why a physical examination maneuver is being recommended and how it will impact their urologic care.
• Eliciting patient preferences on the timing (during current encounter or opt for during a future encounter) of any sensitive genitourinary examinations.
• Involving patients in their physical examinations and asking them how much they want to know or do not want to know.
• Empowering patients with the understanding of their control over the physical examination and communicating that it may be stopped at any point at their discretion.
• Providing warning before any physical touch.
• Asking the patient for their preferred terminology for their organ inventory and anatomy.
• Communicating to the patient throughout the examination.
• Performing physical examinations in the patient’s preferred positions and inviting patients to make suggestions on measures that will make them more comfortable.
• Keeping the patient’s body covered during the entire examination and only exposing the areas being directly examined.
• Providing chaperones or allow for personal support persons to be present in the room during sensitive examinations.
• Allowing for self-collection of specimens or self-insertion of instruments utilized during the examination (i.e. speculums).
• Offering to perform cystoscopies or digital examinations under general anesthesia to avoid inducing gender dysphoria.

Additional recommendations and special considerations when performing urologic physical examinations or evaluations of the genitourinary and pelvic regions of TGD patients are as follows:

• Some transgender women may have an organ inventory which include a penis, scrotum, testes, or prostate. Do not perform examinations of these organs with the patient standing up. Instead, allow the patient to lay down in bed in the position they are most comfortable in.
• In patients who have undergone a vaginoplasty, use an anoscope for examination of the vagina. Examine for presence of any lesions, stenosis, or other abnormalities. Remember the vagina will end in a blind-cuff and lacks a cervix or fornices. The skin surrounding the scrotum is commonly used in the construction of a neovagina and may result in the presence of body hair within the vaginal canal.
• Some transgender women or gender diverse people who have not undergone gender-affirming surgery may perform behaviors to align their appearance or body with their gender. “Genital tucking” refers to manually displacing the testes upward into the inguinal canal, repositioning the penis and scrotal skin between the legs posteriorly, and then applying underwear, tape, or other special garments to maintain positioning. Having the urethra at closer proximity to the anus places the patient at an increased risk for urinary tract infections including epididymitis, orchitis, prostatitis, and/or cystitis. Hernias and/or localized skin breakdown may also develop along the external inguinal ring.
• Some transgender men may have an organ inventory which includes a vulva, vagina, or uterus. Do not perform examinations of these organs with the patient in the dorsal lithotomy or while in stirrups. Instead, allow the patient to lay down in bed in the position they are most comfortable in and use the smallest speculum available if an internal exam must be performed.
• Some transgender men or non-binary patients may decline vaginal ultrasounds or bimanual exams. Instead offer to perform external examination of abdominopelvic region and offer transabdominal ultrasound imaging.
• In patients taking hormonal therapy, during your physical examination be aware of the common side effects of exogenous testosterone or estrogen use. For example, in transgender men taking testosterone, low estrogen can induce vaginal atrophy and changes in vaginal pH which places the patient at an increased risk for cervicitis and vaginitis. Virilization is also likely to be noticed on exam.

Potential urologic complications or physical examination findings following gender-affirming surgical procedures (9):

• In general, TGD patients may develop urinary storage or voiding symptoms related to mobilization/reconstruction of the urethra and/or issues in the neural innervation of the bladder and pelvic floor musculature. Symptoms can be secondary to urethral stenosis, urethral strictures, overflow incontinence due to retention, stress or urge incontinence, or even possible fistulas. Microscopic and/or gross hematuria can commonly occur in the post operative period. Sexual dysfunction may also develop due to injury of erectile tissues.
• Post vaginoplasty/vulvoplasty – Dissection of the space between the rectum and bladder may impact nerves supplying the bladder, pelvic floor, and urethral sphincters resulting in a myriad of lower urinary tract symptoms, pelvic floor dysfunction, and risk for rectal injury and fistula formation. Post operative hyper-granulation tissue may present as neovaginal bleeding, discharge, pain, irritation, and stenosis. Pelvic floor hypertonicity may also result in painful neovaginal dilations.
• Post-metoidioplasty/phalloplasty – The rate of urethral strictures is high especially between the native urethra, neourethra, and urethral meatus. Post void dribbling is common due to the lack of bulbospongiosum and corpora spongiosum musculature surrounding the neourethra. Penile or testicular implant erosion can present with pain, fever, and localized necrosis of skin surrounding the implant. Necrosis of the neophallus may result from inadequate blood supply.
• Post-orchiectomy – A palpable cord stump may be detectable examination of the inguinal region if the patient did not undergo an sub-inguinal approach to remove the spermatic cord.

RESOURCES FOR HEALTH CARE PROFESSIONALS AND PATIENTS

• The World Professional Association for Transgender Health (3) (https://www.wpath.org/): Information on clinical guidance for health professionals to assist TGD people with safe and effective pathways for social, medical, and surgical treatment for those experiencing gender dysphoria or discordance is provided within their Standards of Care, Version 8.
• The Endocrine Society Clinical Practice Guidelines (11) (https://www.endocrine.org/advocacy/position-statements/transgender-health): Provides standards of care for supporting TGD individuals, including information on pubertal suppression, hormones, and surgery and also standardizes terminology used by healthcare professionals.
• The National Center for Transgender Equality (14) (https://transequality.org/): Provides information for healthcare providers and patients on resources for rights to healthcare, mental health and social support, safe housing, insurance coverage, transition-related financial support, and employment.
• The Center for Excellence in Transgender Health15 (https://prevention.ucsf.edu/transhealth): Resources available include online learning courses for healthcare professionals, manuals and clinical practice guidelines, and fact sheet and summaries on providing optimal evidence-based care for TGD patients.

SUMMARY

1. Transgender and gender diverse patients have historically faced countless cultural and societal barriers to basic healthcare. Understanding these barriers is crucial towards promoting greater access to competent and sensitive urologic care.
2. Gender identity refers to one’s innate understanding of who they are and their felt gender, which exists on a spectrum, and does not depend on natal sex. Having a transgender identity is not the same as being non-binary, and vice-versa.
3. Using a patient’s preferred pronouns and chosen name is one of the first ways to establish trust and a connection.
4. Gender transition can be a life-long process of social, medical, and/or surgical interventions. Not all transgender or non-binary patients undergo the same steps in their gender transition process.
5. WPATH’s SOC guidelines exist to promote optimal care, not to limit treatment; they are flexible, and each patient’s unique circumstances should be considered when deciding on gender affirming medical and surgical treatment.
6. Creating a gender-affirming environment and utilizing a trauma-informed care approach are strongly recommended for all practicing urologists when caring for transgender and gender diverse patients.
7. Use open-ended questions whenever possible and allow the patient to share their experiences utilizing their preferred language, rather than anatomic terms.
8. Genitourinary and pelvic examinations are inherently gendered and can induce significant gender dysphoria for patients. Education on special considerations and alternative ways to perform examinations of a patient’s organ inventory is crucial for practicing urologists.
9. Transgender and gender diverse patients often seek urologic care for reasons unrelated to their gender transition. However, it is important for urologists to be aware of common complications associated with gender transition interventions.

Case Study

REFERENCES

1. Dorian S, Chung PH, Dugi D, Dy GW. Creating a gender-affirming environment for urologic care. American Urological Association News. Posted 01 April 2021. https://www.auanet.org/membership/publications-overview/aua-news/all-articles/2021/april-2021/creating-a-gender-affirming-environment-for-urologic-care#. Accessed 01 July 2022.
2. Morrison SD, Dy GW, Chong HJ, Holt SK, Vedder NB, Sorensen MD, Joyner BD, Friedrich JB. Transgender-Related Education in Plastic Surgery and Urology Residency Programs. J Grad Med Educ. 2017 Apr;9(2):178-183. doi: 10.4300/JGME-D-16-00417.1.
3. World Professional Association for Transgender Health (2022). Standards of Care for the Health of Transgender and Gender Diverse People [8^th Version]. https://www.wpath.org/publications/soc. Accessed 19 Sep 2022.
4. Understanding transgender people: the basics. National Center for Transgender Equality. Posted 09 July 2016. https://transequality.org/issues/resources/understanding-transgender-people-the-basics. Accessed 02 July 2022.
5. Understanding non-binary people: the basics. National Center for Transgender Equality. Posted 09 July 2016. https://transequality.org/issues/resources/understanding-transgender-people-the-basics. Accessed 02 July 2022.
6. World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People[7^th Version]. https://www.wpath.org/publications/soc. Accessed 08 July 2022.
7. Pronoun pronunciation guide. Duke University Office of Student Affairs, Center for Sexual and Gender Diversity. https://studentaffairs.duke.edu/csgd/pronouns/pronunciation-guide. Accessed 05 July 2022.
8. Restar A, Jin H, Breslow A, Reisner SL, Mimiaga M, Cahill S, Hughto JMW. Legal gender marker and name change is associated with lower negative emotional response to gender-based mistreatment and improve mental health outcomes among trans populations. SSM Popul Health. 2020 May 11;11:100595. doi: 10.1016/j.ssmph.2020.100595. PMID: 32435684; PMCID: PMC7229467
9. Anderson K, Krakowsky Y, Potter E, Hudson J, Cox AR. Adult transgender care: A review for urologists. Can Urol Assoc J. 2021 Oct;15(10):345-352. doi: 10.5489/cuaj.6949. PMID: 33750518; PMCID: PMC8525536.
10. Scheim AI, Bauer GR. Sex and gender diversity among transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. J Sex Res. 2015;52:1–14. doi: 10.1080/00224499.2014.893553.
11. The Endocrine Society. Transgender Health: An Endocrine Society Position Statement. 2020, December. https://www.endocrine.org/advocacy/position-statements/transgender-health. Accessed 09 Sept 2022.
12. James SE, Herman JL, Rankin S, Keisling M, Mottet I, and Anafi M. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf. Accessed 06 July 2022.
13. Center for Substance Abuse T. SAMHSA/CSAT Treatment Improvement Protocols. In: Trauma-Informed Care in Behavioral Health Services. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf. Accessed 09 July 2022.
14. The National Center for Transgender Equality. https://transequality.org/. Accessed 29 Sept 2022.
15. University of California San Francisco, The Center for Excellence in Transgender Health. https://prevention.ucsf.edu/transhealth. Accessed 29 Sept 2022.

Authors

2022

Adam Schneider, MD Candidate
Philadelphia, PA

Paul Chung, MD
Philadelphia, PA

 

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