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A Guide to Primary Care for Transgender Patients

The term “trans healthcare” might bring to mind hormones and surgery. While those are vital pieces of the puzzle, they’re not everything. Trans patients don’t only need to go to the doctor for reasons related to gender affirmation. Like anyone else, they need primary care throughout their lives. 

But, while efforts to improve healthcare for the transgender community have increased, primary care is often overlooked. When transgender people go to the doctor, research suggests their visits focus most on gender-affirming hormone therapy and mental health and least on physical illness. “General health, including cancer, is the least researched aspect of the transgender global burden of disease initiative,” wrote study authors in one 2020 review paper

To get the consistent, high-quality primary care they need, trans patients can establish relationships with trans-affirming doctors and study up on their own specific medical needs. With help from experts, we put together a guide to primary care for trans patients — what to look for in a PCP, which healthcare services different groups of trans patients need, what challenges to be ready for and more.

What should I see a primary care provider for?

Your primary care provider is your “regular” doctor — your first point of contact in the healthcare system. This is who you’d see not only for preventive services performed during checkups, like blood pressure checks and flu shots, but also to manage chronic conditions such as diabetes, evaluate symptoms when you’re not feeling well, refer you to specialists and more. 

The precise list of services patients receive from PCPs versus when they see other types of providers isn’t set in stone. A PCP’s expertise overlaps with that of many specialists, and patients often have some discretion about what falls under the primary care umbrella.

For trans patients, Zil Goldstein, a licensed nurse practitioner and associate medical director for transgender and gender nonbinary health at Callen-Lorde Community Health Center in New York City, recommends finding a PCP who can also manage your hormonal transition. 

“We know that people are more likely to be adherent to preventive care screenings and other medical issues if they’re seeing the same person for HIV care and primary care,” she says. “You want to have as positive of a relationship as possible with the medical provider who’s doing the majority of your care, and so that’s the big reason why I think hormone care belongs in primary care.”

Additionally, experts recommend that trans patients see PCPs who are sensitive to their specific healthcare needs. Typically, these providers are called “trans-affirming.”

How can I find a trans-affirming primary care provider?

Routine visits might be more daunting for trans patients than cisgender ones. Doctors who aren’t familiar with trans patients may make incorrect assumptions about their body parts, lack the vocabulary to properly discuss their gender identity or not know which preventive screenings, among other services, are appropriate. Finding a trans-affirming doctor can make a big difference.

There are local and national specialized resources for trans people seeking primary care. Dr. Søren Estvold, a family/LGBTQ+ medicine doctor at the Medical College of Georgia and a board member of Equality Augusta, recommends using the GLMA Provider Directory. GLMA, which previously stood for Gay and Lesbian Medical Association, lets patients search for a variety of providers with a number of helpful LGBTQ+-specific filters, including which transition services they provide and whether the care is provided in an LGBTQ+ space.

Dr. Bhavik Kumar is a family medicine doctor at Planned Parenthood Gulf Coast in Texas and New Orleans, where he serves as the medical director for primary and trans care. On a more local level, he recommends asking your local Planned Parenthood for referrals. Some but not all Planned Parenthood centers provide primary care; either way, most are able to refer patients to local PCPs who’ve been vetted for trans-friendliness. Your local LGBTQ+ center can also likely direct you to affirming providers, while Estvold suggests good old word-of-mouth referrals. 

“If one person finds a good doctor that can provide for them,” he says, “usually they tell their friends, who then tell their friends.” 

Lastly, whether or not a provider has specifically been recommended to you or somehow designated as trans-friendly by a trustworthy source, Goldstein suggests asking how many trans patients they see. “The higher someone’s patient volume is with transgender patients, the more they’re going to have thoughts about the issues that we bring for medical providers,” she says. “That means they’re going to have better and more thorough answers and be more likely to follow the literature.”

Is my assigned sex at birth ever relevant to my primary care needs?

Yes and no. While this can be an uncomfortable topic for many trans people, Goldstein says that providers often “use the question of sex assigned at birth” as shorthand for asking what organs you have.

In other words, Kumar says, when it comes to primary care, physicians are “really thinking about the organ system that’s involved,” whether that’s the cardiovascular system, reproductive system or whatever else might need attention. “There are some parts of your body that are going to be affected by hormones or surgery,” he says. “Some of those things may vary person to person, so it’s important for your provider to know what body parts you have or don’t have.”

A number of preventive services specifically concern the reproductive system.

Preventive services, a subset of primary care, are a set of tests, immunizations, and screenings for cancer and other diseases. These services are intended to help doctors catch health issues early or even before they develop. A PCP can address many preventive services during checkups, while others require separate visits with a specialist. All recommended preventive services must be covered by insurance carriers at no cost to patients. 

Preventive health recommendations for US adults are issued by an organization called the US Preventive Services Task Force. These evidence-based recommendations outline protocols for which preventive services patients need and how often. Some recommendations are universal — everyone’s supposed to get a flu shot annually. But most vary based on age, individual level of disease risk, and sex — framed in a binary, cisnormative way. For example, mammograms are recommended biennally for women aged 50-74 who don’t have an elevated risk of breast cancer. 

Currently established recommendations for cancer screenings from the USPSTF do not explicitly account for non-cisgender patients. Experts have developed some cancer screening guidelines for transgender patients, but they’re adapted from ones designed for cisgender patients. And, because of limited available research on transgender patients, they’re drawn from small case studies. 

For example, Pap smears are recommended periodically for cisgender women to screen for cervical cancer, but if you’ve had a total hysterectomy (removal of the uterus and cervix), you don’t need them since there are no organs to screen. If you have breast tissue, regardless of your assigned sex at birth, you need to be screened regularly for breast or chest cancer. In general, there’s not much data on screening for cancer in transitioning people. 

“With any screening, there are benefits but there’s also downsides,” says Kumar. “Some screenings may expose you to procedures which can have minimal risks; some things may have radiation.”

In the absence of codified screening guidelines for trans patients, Kumar recommends discussing your family and personal medical histories with your provider to determine how beneficial certain screenings may or may not be, especially since your risk for some hormone-sensitive cancers can change depending on how long you’ve been on hormones. 

In short: “You have to keep track of what parts are there and what parts aren’t,” says Goldstein. “If the parts are still in your body, then you have to screen them.”

What are some unique primary care needs for transfeminine people?

Kumar and Estvold both suggest stopping smoking if you’re taking estrogen, since research has shown that tobacco reduces the hormone’s efficacy. Additionally, both tobacco and estrogen can increase your risk of getting lung cancer and blood clots. At the very least, weigh these risks.   

However, when it comes to hormone-sensitive cancers in transfeminine people, Goldstein says the data is lacking. One example is prostate cancer, which depends on androgens. It’s possible for trans women to get prostate cancer, as it is for anyone with a prostate.

But the literature on how anti-androgen therapy might affect this cancer risk is still developing. A recent study found that a cohort of trans women who received hormone therapy from one Amsterdam clinic between 1972 and 2016 were significantly less likely to develop prostate cancer than cis men, but the exact mechanism behind the reduced risk needs elucidation. For now, when it comes to the frequency of prostate screenings, experts recommend that trans women follow current clinical guidelines for cis men at any point during their transition. One important distinction, though, is that doctors need to assess screening results differently. The level of prostate-specific antigen considered normal is much lower for trans women than cis men.  

During standard checkups, Kumar makes sure to ask transfeminine patients who haven’t had bottom surgery or don’t plan to about their tucking habits and hygiene. “How often do you wear things, how often do you wash things, and then have you noticed any changes?” he says. “I trust my patients. They know their body much better than I do.”

However, Kumar says that when tucking habits are causing an increased amount of pain, itching, redness or other skin changes, it can be a cause for concern. “Exploring some of those alternatives can be helpful,” he says. “If there’s breaks that folks can take, perhaps at nighttime or when they’re not out, if that’s comfortable for them, that’s something that can help the skin breathe.” 

If you have had bottom surgery, Estvold recommends pursuing gynecological care six months to a year after surgery. Goldstein recommends a visual examination of the vagina once a year to check for skin cancer, regardless of what tissues were used in the surgery. 

“All of those techniques are so new that we don’t know if there are any implications for health screenings,” she says. “No matter how the vagina was constructed, the visual [examination] is really the most important.” 

What are some unique primary care needs for transmasculine people?

Testosterone can increase your red blood cell count, which can heighten your risk for negative health outcomes, including blood clots. Also, some evidence suggests testosterone can alter cholesterol levels. Because of this, Estvold tests his transmasculine patients’ blood to make sure their levels are within the normal range, while also encouraging healthy lifestyle choices to reduce the risks of cholesterol problems. 

While speculum exams are common for routine gynecology needs, the experience can be dysphoria-inducing for transmasculine people. Kumar says that Planned Parenthood uses a trauma-informed approach to care. 

“We definitely take some time to talk about what’s going to happen beforehand and individualize what’s best for that patient,” he says. This can include using a smaller speculum, using adequate lubrication and checking in with the patient’s comfort throughout the process, stopping when he needs to stop. 

Goldstein offers her transmasculine patients the choice to opt out of speculum exams entirely and get pelvic exams instead. If a patient isn’t comfortable with that either, she offers a self-swab HPV screening option. Research has found the vast majority of transmasculine people prefer the self-swab option, which is still highly accurate at over 70 percent, compared to roughly 90 percent accuracy with a Pap smear. No matter what, “it’s better than nothing,” per Goldstein, since many trans men will avoid cervix screenings altogether. 

If you’re concerned about acne breakouts and/or hair loss, Goldstein encourages transmasculine patients to ask their PCPs about their options.

“You can change testosterone dosing. There are other medications that you can add to prevent hair loss,” she says. “As recently as seven years ago, people thought that balding was just a part of transition for people taking testosterone. And it really doesn’t have to be.”

As with trans women and their tucking habits, Kumar also makes sure to ask his transmasculine patients about their binding habits if they haven’t had top surgery or don’t plan to. 

“It’s important that they’re allowing their body and their skin to breathe, and making sure there’s not more irritation being caused than what needs to be caused,” he says. 

How can I talk to my PCP about my sexual health as a trans person?

“I think trans folks should be forthcoming with their medical providers about how they’re having sex,” says Goldstein. While she didn’t always ask patients how they prefer to have sex, it’s something she always asks now when patients are starting hormones. “For people who are on feminizing regimens, we dose the medications a little bit differently if they still want to be able to get an erection,” she says. “So it has all sorts of implications for care.”

If you’re a trans woman who’s had bottom surgery and has vaginal sex, Estvold says, “It’s important to make sure that the vaginal tissue is still healthy, and not dried out or infected in any sort of way, especially if you’re using your new vagina for penetration and sexual intercourse.” 

As for trans men, testosterone can cause what is clinically referred to as vaginal atrophy. However, Goldstein likes to avoid this alienating language, and describes the phenomenon as akin to “symptoms of a UTI, like burning and irritation, without any bacteria in the urine.” If you’re a transmasculine person who has receptive sex in his front hole, Kumar recommends using water or silicone-based lubricant. This can also be remedied with topical estrogen applied locally, which can come in the form of creams, gels or tablets that can be inserted with an applicator. 

Estvold also stresses the importance of discussing contraception with your doctor. While hormonal birth control is estrogen-based, he says, “We’re giving them so much testosterone that it’s going to combat all of that estrogen, but still leave them protected.”

“Any contraceptive that I would prescribe for somebody who’s not on testosterone is the same contraceptive or the same option that any person on testosterone has, so there is nothing different,” says Kumar.

However, Goldstein notes that some hormonal birth control methods “can cause swelling in the chest if there’s any mammary or ductal tissue left.”

She also notes that if you’re on testosterone and you want to take the pill, you have to use it continuously. “Normally, birth control comes with a week that’s just placebo pills,” says Goldstein. “And that’s when people who take estrogen-containing birth controls are supposed to have a period. So if you do need to take it, you need to get a prescription that has enough refills on it that you can skip those weeks.”

Lastly, if you’re having sex with multiple partners, you should be getting screened regularly for sexually transmitted infections. If you’re interested in taking PrEP, the data on the potential interactions between PrEP and hormone therapy is sparse and sometimes contradictory. Some studies suggest that hormone therapy can make PrEP less effective. If you’re on hormones, Goldstein recommends playing it safe and taking PrEP every day, as opposed to intermittently.

“There are certain PrEP regimens that have only been tested in cisgender men,” she adds. “So if someone’s not out to their medical provider and they’re asking for PrEP, then they might get some inaccurate information.”

Kumar also adds that for trans women who are HIV-positive, estrogen is known to have adverse interactions with two antiretroviral medications: amprenavir and unboosted fosamprenavir, otherwise known as Agenerase and Lexiva.
“Otherwise, it tends to be pretty straightforward and does not have an effect on your transition or the medication,” he says.

Is there anything else I should know?

Considering the significantly heightened rates of mental health issues among trans people, Estvold stresses the importance of getting screened for symptoms of depression and anxiety. 

“Every single visit, I try to ask that question to all of my patients, just to make sure I know where their baseline is,” he says. “Even if they’re not depressed, even if they’re not suicidal, it’s good to track those numbers. It’s important to trend those numbers over time and not allow someone to become depressed and suicidal.”

Kumar also emphasizes the importance of addressing your preventive care needs beyond transition-related care or sexual and reproductive healthcare. 

“I think oftentimes what happens is these conversations tend to be about body parts, STIs and contraception,” he says. “But all those other things are just as important, like making sure you get your vaccines, making sure you get your blood work done, mitigating your risk factors.”

Goldstein agrees, adding, “Transition-related care is just regular healthcare for trans people. It’s not something special. Just like everyone else, you want to have conversations with your doctor around how to get the best healthcare.” When she trains providers, she advises them not to “get lost in all of the weeds of hormones and surgery and to think about health holistically.” 

Put simply, Estvold says, “You’re a human being, so I need to make sure that your humanness is being cared for.”

 

Show Comments (2)
  1. Masen

    Thanks for writing this! I’d love to see more articles about trans health. I recently created sample patient forms for my gyno’s office because their current forms are far from inclusive. Even when we’re referred to doctors that claim to be trans-affirming, we may still have to deal with binary, cis-centric language in their patient forms, pamphlets, on their website, etc. All doctors and nurses should be required to take trans health courses. I’ve met far too many who didn’t know what “trans” meant or that some trans people are non-binary. This (the need for trans-informed doctors and medical resources) isn’t talked about enough, but it’s something I think about a lot, as a non-binary and trans masc person who is chronically ill

  2. Jarynet Beltran

    Primary Care Specialist of South Florida is creating a safe haven Transgender Program called ” BB’s Place” I am so excited to be able to offer this soon to all my patients that are in need of these services. Quality caring compassionate care without judgment!!! #gaypride #transgender

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