Transgender Care in Primary Care Settings

Introduction to Transgender Care

The American College of Physicians recognizes primary care physicians as integral members of the transgender health care team, positioned to prescribe and monitor gender-affirming hormone therapy 1, 2.

Primary care providers are well-suited to deliver gender-affirming hormone therapy as part of routine practice, with the care team including primary care physicians, endocrinologists, and mental health professionals 2.
The American College of Physicians explicitly supports primary care physicians in providing comprehensive transgender care, including hormone replacement therapy with estradiol or testosterone 1, 2.

Primary care providers need specific knowledge to provide competent transgender care, including understanding hormone therapy protocols, such as prescribing transdermal 17β-estradiol for transgender women and testosterone cypionate/enanthate for transgender men 3, 4.
Monitoring parameters are crucial, with target testosterone levels <50 ng/dL for transgender women and 300-1,000 ng/dL for transgender men, and monitoring every 3 months initially, then every 3-6 months during the first year, then annually if stable 3, 4, 5.
Screening based on anatomy present is necessary, including cervical cancer screening if cervix remains, breast cancer screening for residual breast tissue after chest surgery, and prostate screening for transgender women 1, 4.

Documenting preferred name, pronouns, and gender identity separately from legal name and sex assigned at birth in the electronic health record is essential 4.
Flagging charts to alert staff to use preferred name and pronouns is crucial 1, 6.
Establishing a complete anatomical inventory is necessary, as it directly impacts screening needs 4.

The American College of Physicians publishes comprehensive resources, including The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health, to support primary care providers in creating a welcoming environment 1, 6.

Baseline complete blood count, liver function, lipid profile, glucose, and hormone levels are necessary for transgender women and men before starting hormone therapy 5.
Screening for contraindications, such as history of estrogen-sensitive cancers, uncontrolled cardiovascular disease, and history of venous thromboembolism, is essential for transgender women 3.

Starting transdermal 17β-estradiol patch 50 μg/24 hours is recommended for transgender women, with the addition of spironolactone 50-100 mg daily 3, 5.
Initiating testosterone cypionate or enanthate 50 mg subcutaneously weekly is recommended for transgender men, with adjustments to achieve serum testosterone levels 300-1,000 ng/dL 4.

Checking hormone levels at 1-3 months, then every 3-6 months during the first year, and then annually is necessary for both transgender women and men 3, 4, 5.
Monitoring CBC for polycythemia in transgender men and annual physical examination and laboratory monitoring, including lipid profile and liver function, are essential 3, 4, 5.

When transgender persons receive medically appropriate care, they experience improved mental health, reduction in suicide rates, and lower overall healthcare costs 7, 2.
Testosterone therapy produces a 20% decrease in depression after 1 year and a 5.5-point increase on a 10-point quality of life scale 4.

Not requiring mental health clearance before initiating hormone therapy in adults with clear gender dysphoria is recommended, as it creates unnecessary barriers and delays care 4.
Not using sex-assigned-at-birth reference ranges after 6 months of hormone therapy for creatinine, body composition calculations, or medication dosing is necessary 4.
Not prescribing oral estradiol as first-line therapy due to higher thrombotic risk is recommended, with transdermal formulations preferred 3, 5.

Referral to endocrinology is considered for complex cases with multiple comorbidities affecting hormone metabolism, difficulty achieving target hormone levels, and significant adverse effects requiring specialized management 2.