Transgender and gender-diverse care: a committee opinion

BACKGROUND

Who are TGD people?

Transgender, gender diverse, and gender nonbinary people have a gender identity that differs from the sex assigned at birth. Throughout this guideline, the abbreviation ‘‘TGD’’ for transgender and gender diverse will be used to represent these varying identities. Estimates for the sizes of these populations are highly heterogeneous because of limitations in data collection (1, 2). Self-report-based estimates from the United States (suggest populations of approximately 1.4 million transgender adults (0.6% of US adults aged >18 years), 150,000 transgender adolescents (0.7% of the US adolescents ages 13–17 years), and 1.2 million nonbinary US adults (42% of whom identified as transgender) (3–5). There are as many experiences of being TGD as there are TGD people. TGD people often experience stigma and discrimination in areas such as healthcare, employment, housing, and family and community support (6).

Who provides healthcare for TGD people?

Comprehensive healthcare for TGD people may be provided by a multidisciplinary care team (7, 8). TGD people have both general healthcare needs and potential healthcare needs related to gender transition. Gender transition may involve gender-affirming hormones and/or gender-affirming surgeries. Gender-affirming hormone care is often provided by primary care providers, endocrinologists, and obstetrician-gynecologists (including reproductive endocrinologists). Gender-affirming surgical care is often provided by plastic surgeons, urologists, and obstetrician-gynecologists. Other members of the care team include mental health providers (i.e., psychologists, psychiatrists, and social workers), speech-language pathologists, and care coordinators. Welcoming clinical environments for TGD people typically use gender-neutral terminology wherever possible and have intentional policies and practices around names, pronouns, documentation, forms, and restrooms (9).

How has healthcare for TGD people progressed over time?

Access to gender-affirming healthcare has generally improved over time, with reduced pathologization and increased guidance for providers. The American Psychological Association’s Diagnostic and Statistical Manual (DSM) has attempted to depathologize TGD identities with a shift from gender identity disorder (4th edition) to gender dysphoria (5th edition) (10, 11). More recently, gender incongruence was selected by the World Health Organization ICD-11 (12). These diagnostic categorizations may aid in healthcare access but may still perpetuate stigma. Despite limitations in formal medical training, there are increasing numbers of guidance documents and supports for providers of TGD healthcare (13). The World Professional Association of Transgender Health (WPATH) publishes the standards of care, which is currently in its 8th edition (SOC8) (7). The Endocrine Society publishes clinical practice guidelines regarding endocrine treatment for TGD people (8). There are several resources for healthcare providers to seek guidance on TGD healthcare (14, 15). Despite increased guidance and research attention, many gaps in knowledge still remain, and research efforts with broader methodologies and grounded in meaningful community engagement are needed to expand the evidence base for TGD clinical care (16–18).

This committee opinion outlines comprehensive multidisciplinary medical/surgical care for TGD people. The goal is to establish a base of knowledge sufficient to provide sensitive and appropriate care for transgender patients seen in the reproductive and fertility care setting. Family-building options and special considerations for fertility preservation and infertility care of TGD patients are covered in a separate ASRM Committee Opinion. Additionally, a glossary of inclusive language relative to LGBTQ+ populations and considerations for creating an inclusive clinical environment are included in the ASRM glossary, ‘‘Inclusive language and environment to welcome lesbian, gay, bisexual, transgender, queer, questioning, intersex, and asexual+ patients’’ (19).

MEDICAL MANAGEMENT

Gender-affirming hormone therapy (GAHT) is an essential part of gender affirmation for many TGD individuals (7). These treatments have been shown to improve well-being and quality of life (20). Hormonal protocols can broadly be grouped into puberty blockers, testosterone-based, and estrogen-based regimens. Although these will be reviewed separately, it is important to acknowledge that under certain circumstances, there may be some overlap. For example, TGD individuals assigned male at birth (AMAB) are occasionally prescribed low-dose testosterone after gonadectomy to improve libido (21).

The initiation of hormone therapy should follow an extensive discussion with the patient about goals, expectations, risks, and side effects, acknowledging the limitations of data and the paucity of long-term and trans-specific data. Notably, none of the hormonal medications are Food and Drug Administration (FDA) approved for transgender affirmation. It is important to avoid assumptions about binary gender presentation and embodiment goals and to discuss affirmation as a flexible, continuous process, rather than a ‘‘one and done’’ event. Until recently, the WPATH guidelines recommended a documented evaluation and counseling by a mental health provider on the appropriateness of hormonal care. Others have advocated for the use of an informed consent model (22). The newly published WPATH SOC8 has a more flexible approach. Although it maintains an ‘‘assessment’’ model, it also ascertains that the assessment may well be performed by the prescribing provider themselves (7). Emerging data question the effectiveness and utility of such assessments (14). An alternative, more equitable approach is that of parity, by which trans- and cis-gender-affirming hormones are prescribed using a similar process. For example, the use of oral contraceptive pills (OCPs) or spironolactone to address hirsutism in polycystic ovary syndrome is gender-affirming for cisgender women. Prescribing similar hormones with similar goals to TGD women should follow a similar process, while accounting for differences in impact, such as differential impact on gamete production.

Peripubertal teenagers and puberty blockers

Preteens and teens who express gender incongruence at the peripubertal stage can be offered gonadotropin-releasing hormone (GnRH) agonists for puberty suppression. In TGD adolescents, endogenous puberty can cause significant distress. Some physical changes affected by endogenous hormones are either permanent or difficult to reverse when a person transitions after puberty. Gonadotropin-releasing hormone agonists can be useful in those cases to delay puberty. These are usually started when the adolescent is at Tanner Stage 2, enabling delay of endogenous puberty until the adolescent and their family are ready to initiate gender-affirming sex steroid treatment, which is generally initiated no sooner than age 13 or 14, or they make the decision to discontinue therapy and complete natal puberty (7, 8, 14). Because of concerns over potential bone loss, it is not recommended to continue GnRH agonists as the sole therapy for pubertal suppression for longer than a few years (14). For youth with a uterus who are not yet ready to start testosterone, but in whom GnRH agonists are either unattainable or unindicated, progestins can be used for menstrual suppression to decrease menses-associated dysphoria (7).

GAHT for patients AFAB

The goal of GAHT for TGD patients assigned female at birth (AFAB) is to induce more traditionally ‘‘male’’ secondary sexual characteristics while concomitantly aiding in the regression of more traditionally ‘‘female’’ secondary sexual characteristics. Gender-affirming hormone therapy for TGD patients AFAB is primarily testosterone-based.

Testosterone formulations and administration

Testosterone can be administered intramuscularly, subcutaneously, or transdermally (Table 1 (8)). In the United States, the most commonly used formulations are testosterone cypionate or testosterone enanthate, which can be injected weekly or every other week (23). Compared with intramuscular injections, subcutaneous injections of the same dose achieve similar serum testosterone levels and masculinizing effects, with higher patient satisfaction (24, 25). The transdermal gels and patches offer a less invasive application option. Notable disadvantages include the need for daily application, erratic absorption, skin irritation, low long-
term compliance rates, and the risk of testosterone transfer to close physical contacts. An oral testosterone formulation was approved in 2019 for cisgender men with a boxed warning regarding hypertension and increased risk for cardiovascular disease (CVD) and stroke (26). The oral formulation is currently rarely covered by insurance and is costly to purchase out of pocket. A long-term testosterone implant in the form of a pellet is available and may present a good alternative for those seeking to avoid regular injection or daily gel application (27). Doses should be titrated to appropriate serum levels and patient preference.

Physical effects of testosterone

Although the onset of masculinizing effects of testosterone therapy can appear 1–6 months after initiation, it can take up to 5 years to see the full effect (8). Permanent changes include voice deepening, clitoral enlargement, and potentially male-pattern baldness (depending on the genetics of the individual). For patients who are bothered by male-pattern hair loss, a 5-alpha reductase inhibitor can be employed without interfering with the masculinizing effects of testosterone. Increased terminal facial hair and body hair can take up to 5 years to stabilize and an equal time frame to resolve if testosterone is discontinued. Reversible changes include body fat redistribution, an increase in muscle mass, an increase in skin thickness, acne, and cessation of menstrual bleeding (8). Most TGD men will achieve amenorrhea within a few months of testosterone treatment, but those who do not may want additional treatment to achieve amenorrhea (8). These methods are discussed further in the Gynecologic care section of this document.

Potential risks and side effects of testosterone

Acute complications are rare when testosterone is prescribed and monitored appropriately, but the long-term health risks of testosterone are poorly understood (8). Erythrocytosis (hematocrit >50%) occurs in as many as 1 in 6 patients on gender-affirming testosterone, and if left uncontrolled, can increase the risk for thrombosis (28, 29). Options for patients with erythrocytosis include a decreased testosterone dose, a change in route of administration from injections to transdermal as applicable, or serial blood donations. Other causes of erythrocytosis, such as smoking and obstructive sleep apnea, should be explored.

Testosterone can also have negative effects on cardiometabolic health. Specifically, testosterone is known to increase low-density lipoprotein levels, decrease high-density lipoprotein levels, increase visceral fat, and be associated with an increased risk of hypertension. All of these changes can indirectly contribute to the risk of CVD; however, there is no evidence for an increase in cardiovascular events in TGD men on testosterone (30, 31). Previous concerns over testosterone-associated liver failure have not been substantiated with more recent studies investigating formulations typically used for GAHT (8).

There is a paucity of data on any long-term effects of testosterone-based GAHT on future reproductive capacity, although there are reports of successful in vitro fertilization (IVF) with testosterone-exposed oocytes, as well as pregnancy in individuals who have been on gender-affirming testosterone (32, 33). A case series of histopathological investigation of testosterone-exposed human ovaries has conflicting results, with some studies showing an increase in polycystic morphology and others showing normal-appearing ovaries with functional oocytes (34, 35). Animal models have shown reversibility of testosterone-induced ovarian changes after testosterone cessation, and similar IVF outcomes in testosterone-exposed mice compared with controls (36, 37). Of course, it remains to be seen whether these results translate to humans, and there are limited data on offspring born from testosterone-exposed oocytes. Because of the current uncertainty, the ASRM, the Endocrine Society, and WPATH all recommend fertility preservation counseling before initiation of any hormone therapy (7, 8, 38). Fertility preservation and family building for TGD patients are further described in a separate ASRM Committee Opinion.

Breakthrough uterine bleeding appears to be common among people on testosterone who have a uterus (39). Ongoing bleeding or spotting, in the presence of male-range testosterone levels with adequate estrogen suppression, may require further investigation, including but not limited to an ultrasound to assess endometrial thickness or an endometrial biopsy. Local (levonorgestrel-releasing intrauterine device [IUD]) or systemic progestins (oral or injectable medroxyprogesterone acetate), or combined OCPs, can be used and may be effective. Scant data exist regarding uterine cramping secondary to testosterone initiation (40).

Monitoring of patients on testosterone-based GAHT

Various protocols have been suggested for the monitoring of testosterone-based GAHT (7, 8, 14). The goal of monitoring is to ensure safety and decrease the risk of long-term negative effects, including cardio-metabolic disease. Monitoring should include a complete blood count to ensure that the hematocrit is not excessively elevated (>50%), a comprehensive metabolic panel, and serum testosterone and estradiol levels (7, 8). Although initial testing may be more frequent, such as at 3-month intervals, the frequency of testing can be gradually reduced to once annually once a stable dose is achieved (8). In complex cases, monitoring albumin and sex hormone-binding globulin every 3 months in the first year may be helpful. With elevated testosterone or hematocrit levels, a reduction in dosage may be warranted. On occasion, hormone levels can help ascertain adequate dosing when clinical goals are not being met (e.g., ongoing menses). The upper end of the cisgender male range for testosterone is recommended as a cutoff (8). Serum testosterone levels below the midphysiologic range may be appropriate for people with nonbinary embodiment goals or who are seeking a gradual physical or social transition process. Keep in mind that many TGD people are wary of being ‘‘cut off’’ from GAHT entirely, so it is essential to discuss the risks and benefits of any dosage change, and a harm reduction approach is recommended.

GAHT FOR PATIENTS AMAB

The goal of GAHT for TGD patients AMAB is to induce more traditionally ‘‘female’’ secondary sexual characteristics while concomitantly aiding in the suppression and minimization of more traditionally ‘‘male’’ secondary sexual characteristics (Table 2 (8)). This is achieved through the suppression of endogenous testosterone production using an antiandrogen in conjunction with estrogen (41). The use of estrogen alone is insufficient to suppress testosterone levels to a normal cis-gender female range (8). GAHT for individuals AMAB may also include the use of a progestogen (42). It must be noted that many male secondary sexual characteristics are permanent and irreversible on completion of natal puberty, including voice deepening, the ‘‘Adam’s apple,’’ and larger bony structures (14). Additionally, although no evidence-based guidelines exist regarding initiation of estradiol, many GAHT providers will start with low doses of estradiol and slowly ramp up to therapeutic doses to more closely mimic female puberty and prevent the theoretical concern for abnormally shaped breasts from high initial estradiol levels or premature rises in progesterone levels.

Antiandrogen formulations, administration, physical effects, and potential risks

Antiandrogens can act centrally, directly, or indirectly to achieve suppression of endogenous testosterone production. Not only do antiandrogens work to minimize ‘‘male’’ secondary sexual characteristics, but they also allow for lower doses of estrogen administration as part of GAHT (8). If a patient undergoes gonadectomy, antiandrogen therapy can be discontinued.

Spironolactone

The potassium-sparing diuretic spironolactone is the most commonly used antiandrogen in the United States (8, 14). This orally administered medication is used as a part of GAHT at higher doses for antiandrogen receptor activity and suppression of testosterone synthesis (43). Spironolactone is also known to have additional estrogenic effects because it is also an estrogen receptor agonist (42). Because of the potential risk of hyperkalemia, spironolactone should be avoided in patients with renal insufficiency. Other side effects of spironolactone are because of its function as a diuretic, possibly leading to polydipsia, polyuria, or orthostasis (14).

5-Alpha reductase inhibitors

The 5-alpha reductase inhibitors, including finasteride and dutasteride, do not directly inhibit the production or action of testosterone. Orally administered finasteride blocks 5-alpha reductase type 2 and 3-mediated conversion of testosterone to dihydrotestosterone (44). Orally administered dutasteride more effectively blocks 5-alpha reductase type 1 found in the pilosebaceous unit and may be more efficacious than finasteride in inducing a ‘‘feminizing’’ effect (44). Although the antiandrogen effects of 5-alpha reductase inhibitors are less pronounced than those seen with direct inhibitors, they are a reasonable alternative for patients with contraindications to spironolactone use.

GnRH Agonists

The GnRH agonists inhibit gonadotropin secretion, leading to the suppression of testicular testosterone. These injectable medications come in long-acting monthly or 3-monthly formulations (42). Although effective, GnRH agonists are less commonly used because of cost (7, 8).

Cyproterone acetate

Outside of the United States, cyproterone acetate (CPA) is the most commonly used antiandrogen. It has progestogenic and antiandrogenic activity. It suppresses gonadotropins, leading to reduced testicular androgen secretion, and it also competitively binds to the androgen receptor (42). Although it is not available in the United States, intramuscular and oral formulations of CPA are available elsewhere in the world. Cyproterone acetate use has been associated with rare reports of fulminant hepatitis (45).

Estrogen formulations and administration

Estrogen can be administered orally, sublingually, transdermally, subcutaneously, or intramuscularly. The 17-beta estradiol is primarily used for gender-affirming estrogen therapy, with conjugated esters (estradiol valerate or cypionate) used for injectable formulations. Conjugated equine estrogen and ethinyl estradiol are not recommended for gender-affirming estrogen therapy because of increased thromboembolic risk (7, 14). Oral and sublingual tablets allow for ease of administration, with oral estradiol resulting in higher serum levels of estrone because of first-pass hepatic metabolism (14). The transdermal estradiol patch offers an equally efficacious and minimally invasive administration option, but transdermal gels and sprays may not achieve serum estrogen levels in the physiologic female range (14). Intramuscular injections of estradiol valerate or cypionate may be difficult for patients to obtain because of limited production by manufacturers (14). Regardless of formulation, estradiol doses should be titrated to appropriate serum levels and patient preference.

Physical effects of estrogen

The onset of the ‘‘feminizing’’ effects of estrogen-based GAHT combined with antiandrogens can appear 3–12 months after initiation (8). Physical changes include decreased body and facial hair, decreased muscle mass, redistribution of fat, and decreased skin oiliness. Breast development can begin within 3–6 months and reach its maximum at 2 years (8). Decreased libido and spontaneous erections are seen with both estrogen and antiandrogen GAHT. For some patients, the decrease in libido and spontaneous erections will be affirming of their gender and decrease genital- and sex-related dysphoria. If these effects are experienced as negative, a decrease in antiandrogen dosing, timed dosing, or use of phosphodiesterase type 5 (PDE5) inhibitors (e.g., sildenafil, tadalafil, and vardenafil) can be used to counteract these effects. Atrophy of the prostate gland and testicles will occur after an extended duration of use (8).

Potential risks and side effects of estrogen

Supraphysiologic levels of estrogen may lead to increased risk of thromboembolic events, CVD, and breast cancer (8). Thromboembolic events, specifically venous thromboembolism (VTE), are a major concern with the use of high doses of estrogen and are most commonly associated with combined equine estrogens, which are not recommended for GAHT. Thrombophilia screening of patients initiating estrogenbased GAHT should be limited to those with a personal or family history of VTE (8). For TGD women with cardiovascular risk factors or established CVD, using the transdermal route of estrogen is preferred because of lower rates of venous thromboembolism and lack of associated changes in lipid profile or markers of coagulation (14). Tobacco use confers an increased risk of VTE in conjunction with estrogen, but is not an absolute contraindication to estrogenbased GAHT (14). Patients who smoke should be counseled on the increased risk of VTE with estrogen use and offered the means and support to assist in possible quitting. Transdermal estrogen administration for GAHT in smokers is recommended to minimize VTE risk (14).

Data are limited regarding the risk for breast cancer in TGD patients AMAB on estrogen-based GAHT. Although risk may be increased compared with cisgender men, patients still have a lower overall risk compared with cisgender women (14). Any active estrogen-sensitive cancer is a contraindication to estrogen-based GAHT.

Data suggest that in patients who retain their testes, long-term estrogen-based GAHT is associated with testicular damage and reduced fertility (8, 14). The restoration of spermatogenesis after GAHT has not been studied extensively (8, 14). The ASRM, the Endocrine Society, and WPATH all recommend fertility preservation counseling before initiation of any hormone therapy (7, 8, 38). Fertility preservation and family building for TGD patients are further described in a separate ASRM Committee Opinion.

Monitoring of patients on antiandrogen and estrogen-based GAHT

Various protocols have been suggested for the monitoring of estrogen-based GAHT (7, 8, 14). The goal of monitoring is to ensure safety and decrease the risk of negative effects. Monitoring should include evaluation of serum estradiol and total testosterone levels for all patients, with the addition of serum electrolytes (particularly potassium) and renal function testing (particularly creatinine) in patients taking spironolactone. Although initial testing may be more frequent, such as at 3-month intervals, with stabilization of dosage, the frequency of testing can be gradually reduced to once annually (8, 14). On occasion, hormone levels can help ascertain adequate dosing when clinical goals are not being met, but clear counseling to set expectations regarding the extent and timing of GAHT-induced changes is necessary from the outset of treatment. Goal serum estradiol levels for GAHT are in the physiologic midcycle range (approximately 100–200 pg/mL) for menstruating cisgender women to minimize risks and side effects of estrogen (8, 14). Lower levels may be appropriate for people with nonbinary embodiment goals, or who are seeking a gradual physical and/or social transition process. Goal serum total testosterone level is <55 ng/ dL (8). In complex cases, monitoring sex hormone-binding globulin may be useful to calculate the level of bioavailable testosterone (14).

Progestogens

The prescription of progestogens as part of the GAHT regimen for patients AMAB remains controversial. Although anecdotal improvements in breast and areolar development have been reported along with improved mood, libido, and overall shape, these benefits have yet to be proven by well-designed studies (7, 14, 46) Quality data in support of the use of progestogens as a part of GAHT for patients AMAB is lacking and existing data suggest potential harm associated with extended progestin exposure (7, 47). Progestogens are most commonly administered orally but may also be administered intramuscularly.

GENDER-AFFIRMING SURGICAL MANAGEMENT

Approaching gender-affirming surgery

The field of gender-affirming surgery has seen rapid expansion and is undergoing a period of continual change (48). Historically, surgical options available to TGD people were entirely binary. The medical field has been shaped by an implicit bias toward reinforcing a binary view of gender. This ‘‘binary bias’’ has percolated and shaped the field of gender-affirming surgery, influencing which surgical procedures are commonly offered. As gender identity is internal and varied, rigid and overly binary surgical options do not always address the needs of many TGD people. Although many individuals will seek a ‘‘binary’’ appearance, not all people will desire conventional surgical outcomes and aesthetics (49). Matching external anatomy to internal gender identity does not always mean reinforcing a gender binary. There does not need to be a directionality to a surgical transition. Ultimately, gender-affirming surgery can be thought of as assisting a person in physically actualizing their internal sense of self.

Gender-affirming surgical procedures can be thought of and grouped into four main domains: facial, chest, body, and genital gender-affirming surgeries.

Facial gender-affirming surgery

Facial feminization surgery. Testosterone produces significant changes to the facial skeleton that result in many of the facial features interpreted as ‘‘male.’’ Because these features are because of the bony structure, they are not reversed with GAHT (50). Because certain facial features are strongly associated with perceived gender, facial feminization surgery can significantly improve both internal and external dysphoria in addition to decreasing the frequency of misgendering in society (51). Most facial feminization procedures address the underlying bony anatomy and architecture and are typically reductive in nature. Adjunctive soft-tissue procedures are used to augment the desired ‘‘feminine’’ characteristics.

Facial feminization surgery is most often described by separating the face into thirds (upper, middle, and lower) (52). However, which procedures are offered will depend on individual anatomy, specific drivers of an individual’s dysphoria, and patient goals and priorities. In-depth discussions with patients are important as some individuals may seek a more nonbinary or androgynous appearance that better fits with their internal identity.

The upper facial third is the most frequently addressed area with facial feminization surgery. A longer forehead, low and flat brow, bossed frontal and orbital contour, and receded hairline are features that are most associated with a ‘‘masculine’’ facial appearance. Common procedures to address and ‘‘feminize’’ these areas include hairline lowering, forehead shortening, forehead contouring, frontal sinus setback, orbital contouring, and brow lifts. These procedures are typically performed in combination to achieve an overall ‘‘feminine’’ appearance of the upper facial third (53).

The middle facial third refers to the nose, cheeks, and the upper lip. Rhinoplasty is frequently requested as part of facial feminization surgery, with common goals being to reduce width and projection (54). An upper lip lift is an effective soft-tissue adjunct, especially in older patients, to shorten upper lip length and increase the amount of visible vermilion or ‘‘red’’ lip (55). Midface fat grafting can be performed to augment the malar region and create fuller and softer cheeks (56).

The lower facial third includes the jawline and the thyroid cartilage. The appearance of these structures varies between individuals. Procedures to address the jaw include reduction of the mandibular angles and mandibular body, as well as chin contouring (57). The overall goal is to soften and create a more oval jawline, as opposed to a square jawline. The thyroid cartilage or ‘‘Adam’s apple’’ can be reduced with a chondrolaryngoplasty (58). Surgical procedures are also available to ‘‘feminize’’ the voice, frequently targeted at raising the pitch (59). Frequently, this is offered only after voice therapy has been optimized (60).

Facial masculinization surgery. Because of the effects of gender-affirming testosterone on the skin and facial hair growth, facial masculinization surgery is much less common than facial feminization procedures. Testosterone will significantly masculinize facial features over time (61).

Procedures available for facial masculinization mostly focus on skeletal augmentation. Examples include facial im-
plants for augmentation of the jawline, chin, and mandibular angles. Another area of augmentation includes the forehead/ supraorbital region of the face (50). New techniques are also available to create an ‘‘Adam’s apple’’ with the augmentation of the thyroid cartilage (62).

Gender-affirming chest surgery

Mastectomy. Gender-affirming mastectomy (often referred to as ‘‘top surgery’’) is the most commonly performed gender-affirming surgical procedure (63). There is substantial evidence to support significant improvements in various quality of life metrics for TGD people AFAB individuals who undergo mastectomy (64).

Current WPATH SOC8 guidelines do not specify a specific duration of GAHT before undergoing gender-affirming chest surgery (7). Of note, many individuals who seek gender-affirming mastectomy will not desire GAHT as part of their transition at all.

The most frequently performed technique is the ‘‘double incision with free nipple graft’’ where the breast tissue and excess skin are removed, in addition to removing, resizing, re-shaping, and replacing the nipples as free grafts. This technique works in nearly all chest shapes and sizes (63). There are several other techniques that keep the blood supply to the nipple intact and better preserve sensation. These additional techniques mainly address only the removal of breast tissue, with minimal to no skin excision or resizing and shaping of the nipple and areola. Examples include circumareolar and periareolar (keyhole) techniques. These are only viable options for people with minimal breast tissue, minimal skin excess, and appropriate pre-existing nipple position (65). It is increasingly common for patients to request not keep their nipples and have a ‘‘no-nipple’’ chest. This may be related to a nonbinary gender identity or may simply be related to a desire for a future chest tattoo, easier healing, or reasons other than those noted here (66).

There is not yet a well-established consensus on screening requirements for breast cancer before and after gender-affirming mastectomy. This represents an area of ongoing research and development. Before surgery, the common recommendation for breast cancer screening is to follow the guidelines established for cisgender women. If a patient does not meet screening criteria, there is no need for a preoperative mammogram. Of note, a gender-affirming mastectomy is not the same as an oncologic mastectomy. Therefore, some cells of breast tissue will invariably be left behind with a gender-affirming mastectomy. Patient education to this effect is important to allow for chest awareness long term (67).

Chest reduction. Chest reduction surgery is less common than requests for a formal gender-affirming mastectomy. However, some patients with nonbinary identities desire a reduction in chest size to manage chest-related dysphoria as opposed to a mastectomy. Requests like this are increasingly common as awareness and advocacy have improved regarding the need for treatment options outside of the binary. These requests can be managed using standard breast reduction techniques or, depending on the degree of reduction, can be addressed using a double incision mastectomy and nipple graft approach, leaving more breast tissue behind. The greater volume of breast tissue that remains should be discussed with patients regarding the importance of continued breast cancer screening.

Breast augmentation. Breast augmentation is most frequently accomplished with the use of breast implants. A minimum of 12 months of GAHT with estrogen should take place before considering or evaluating an individual for breast augmentation, as substantial breast growth can occur (68). Before augmentation, it is important that the breast size is stable and not undergoing continual change.

Breast augmentation with implants is most commonly performed using silicone as opposed to saline implants. These can be placed in a subglandular, subfascial, or submuscular plane. Smooth shell implants are most frequently used for augmentation because of the link of textured-surface implants to breast-implant associated anaplastic large cell lymphoma (69). Under current FDA recommendations, patients should be counseled about various risks of implant augmentation, such as breastimplant illness. Additionally, life expectancy of the breast-implant device, recommendations for implant screening, and implant-specific risks, such as rupture and capsular contracture, should be thoroughly discussed with patients. Current recommendations for screening after breast augmentation include magnetic resonance imaging five years after implantation, then repeated every two years thereafter (70).

Some individuals will not desire or feel comfortable pursuing augmentation with the use of an implant. Although uncommonly performed in the TGD population, breast augmentation can be accomplished with serial fat grafting. This technique requires multiple surgeries to achieve the desired volume and can typically only accomplish augmentation to a lesser degree than seen with breast implants (71).

Genital gender-affirming surgery

If GAHT is part of an individual’s transition, current WPATH SOC8 guidelines recommend a minimum of 1 year of hormonal therapy before genital surgery (7). Because many genital surgeries will affect future fertility and family planning, reproductive counseling is an important and critical discussion that should take place before undergoing genital surgical intervention.

Genital gender-affirming surgery for AMAB anatomy

Orchiectomy. Gender-affirming orchiectomy is a simple procedure to remove the testicles. This can allow an individual to stop antiandrogen medical therapy while additionally making practices such as ‘‘tucking’’ easier and less uncomfortable. Current evidence suggests that performing orchiectomy before vaginoplasty is safe and does not appear to have a significant impact on future vaginoplasty outcomes (72).

Vulvoplasty. Gender-affirming vulvoplasty refers to the construction of an external vulva. The procedure is the same as a gender-affirming vaginoplasty except for the creation of a neovaginal canal. This procedure is sometimes referred to as ‘‘shallow-depth’’ or ‘‘zero-depth’’ vaginoplasty. The aesthetics, function, and sensation of the vulva are the same as those seen after a vaginoplasty procedure. Individuals may choose vulvoplasty over vaginoplasty for a wide range of reasons, including better alignment with gender identity, a desire to avoid the need for postoperative dilation, no need for preoperative hair removal, no desire for sexual penetration, no dysphoria from the absence of a vaginal opening, a desire to minimize risk of rectal injury, or reasons other than those stated here (73).

Vaginoplasty. The traditional genital gender-affirming procedure offered to individuals with AMAB anatomy is a penile inversion vaginoplasty. In all vaginoplasty techniques, similar tissues and steps are used to create the vulva. They differ mainly in the tissue used to line the constructed neovaginal canal. In the traditional penile inversion vaginoplasty, the canal is lined with penile shaft skin and scrotal skin graft (74). Alternatives to this approach have previously included using vascularized bowel to create the neovaginal canal. More recent approaches line the neovaginal canal with the use of vascularized peritoneal flaps (75). This is most commonly done using robotic surgery and is referred to as robotic-assisted peritoneal flap gender-affirming vaginoplasty. The robotic approach allows for a larger majority of the genital skin to be used for the construction of the vulva, because less skin is needed for the neovaginal lining. This can avoid the need for extra-genital skin graft donor sites in patients with limited genital tissue and prior pubertal suppression. Regardless of the approach that is used, preoperative hair removal is important to avoid intravaginal hair growth, in addition to a rigorous postoperative dilation regimen to maintain neovaginal canal length and depth over time (74).

Infrequent requests and nonbinary genital surgeries. Not all patients will desire or be adequately treated with a binary surgical procedure. There are several techniques emerging because of increasing requests for genital surgery that do not fit a binary model of anatomy. Two examples in people with AMAB anatomy include penile-sparing vaginoplasty and genitoplasty (sometimes referred to as nullification surgery). In penile-sparing vaginoplasty, an orchiectomy and scrotectomy are typically performed, and a neovaginal canal is created while the penis remains in place. Gender-affirming genitoplasty is perhaps the procedure that is the most extreme example of lying outside of a binary view of genital anatomy. In this procedure, the testicles, penis, and scrotum are removed. The genital region is left with a smooth appearance, with a perineal urostomy created for the purpose of voiding. Erogenous tissue is typically preserved on its nerve and blood supply and buried underneath the skin, where it can still be stimulated. No outcome data after these procedures is yet available in the literature, with descriptions mainly limited to surgeons’ websites and patient information forums. However, it is important for providers to be aware of these variations as they are increasingly being requested in consultations. Discussions are ongoing regarding whether uterus transplantation may be a strategy used to enable pregnancy or for gender affirmation in TGD individuals.

Genital gender-affirming surgery for AFAB anatomy

Hysterectomy with or without oophorectomy. Many individuals AFAB are interested in a hysterectomy as part of their gender affirmation, either with or without GAHT and additional reconstructive surgeries. Such hysterectomies can be approached vaginally, laparoscopically, or using a combined laparoscopic-assisted vaginal approach. Abdominal hysterectomies, being the most morbid, should be reserved for cases in which medical or surgical needs preclude a less invasive approach. Under most circumstances, a total hysterectomy should be performed, along with an opportunistic salpingectomy to decrease the risk for epithelial ovarian cancer in the future (76).

There is little data to guide decisions regarding oophorectomy at the time of hysterectomy (77). A shared decision-making process balancing patient preferences with potential long-term implications should be used.

Vaginectomy. A vaginectomy may be done concomitantly with the hysterectomy, metoidioplasty, or phalloplasty procedure, or it can be performed in isolation. If an individual is only dysphoric from the presence of a vaginal canal, then an isolated vaginectomy may be a good option for them. This would also necessitate a hysterectomy.

Genital gender-affirming reconstructive surgery. Genital gender-affirming reconstructive surgery for individuals with AFAB anatomy falls into two main categories: metoidioplasty and phalloplasty. In both categories, the main differentiating factor between the various surgical options is the desire to stand to urinate.

Simple metoidioplasty. All types of metoidioplasty involve the release of the clitoral suspensory ligaments and the use of the local-regional tissue. Typically, the labia minora is used to cover the exposed clitoral shaft and ultimately increase the visible length of the clitoris to resemble the appearance of a small phallus. In simple metoidioplasty, no lengthening of the urethra is performed, and the patient continues to urinate through the natal urethral meatus. The vaginal canal is usually left in place. If desired, simple metoidioplasty can be performed in conjunction with a scrotoplasty using the tissue from the labia majora (78).

Metoidioplasty with urethral lengthening. The traditional description of metoidioplasty includes both vaginectomy and urethral lengthening. Different techniques exist to lengthen the urethra. The two main techniques are the Belgrade method and the ring metoidioplasty (79). The Belgrade method uses the labia minora, anterior vaginal wall flap, and buccal graft for urethral lengthening, whereas the ring metoidioplasty uses tissue of the labia minora and vestibule (79). Typically, metoidioplasty with urethral lengthening is performed in conjunction with scrotoplasty (80). Individuals will retain erogenous sensation and obtain a masculinized appearance to the genital region, including a straight closure of the perineum, scrotum, and the small phallus. Although the urethra is lengthened, the resulting phallus is small and not always long enough to achieve standing urination in all patients (79).

Phalloplasty with urethral lengthening. The classically described tenets of phalloplasty serve to create a penis that most closely resembles the natal structure. These goals include standing urination, tactile and erogenous sensation, aesthetics acceptable to the patient, and sufficient tissue to tolerate the insertion of an erectile device (81). To accomplish these goals, phalloplasty always requires the transfer of tissue with the use of a pedicle or free flap. The most common donor sites used in phalloplasty include the radial forearm, anterolateral thigh, groin, and lower abdomen. Other donor sites, such as the latissimus dorsi and fibula, have been described but are less frequently used (82).

Current evidence best supports the use of vascularized tissue, typically via the ‘‘tube-within-tube’’ flap design, to create both the phallus and the phallic urethra (83). Graft is less desirable for the creation of the penile urethra because it lacks its own blood supply and has higher rates of complications such as urethral stricture. Phalloplasty can be performed as a one-stage or two-stage surgery, with advantages and disadvantages to each approach (83). Other procedures that are performed as part of phalloplasty with urethral lengthening include glansplasty, vaginectomy, scrotoplasty, perineoplasty, and, frequently, clitoroplasty (burial of the erogenous tissue at the base of the penis). Vaginectomy is typically required if urethral lengthening is performed because of the very high rates of urethral complications if the vaginal canal is maintained. Because the vaginal canal is removed, a preoperative hysterectomy is needed. Phalloplasty with urethral lengthening remains the most common type of phalloplasty procedure in the TGD AFAB population. However, not all individuals who pursue phalloplasty will desire or be candidates for standing urination (82).

Shaft-only phalloplasty. Phalloplasty without urethral lengthening is referred to as ‘‘shaft-only phalloplasty’’. In this variation, a phallus is created without a phallic urethra. The sensation, tolerance of an erectile device, and, with recent modifications, aesthetics are the same as those of the more traditional phalloplasty with urethral lengthening (84). There are multiple variations of shaft-only phalloplasty that can be performed depending on an individual’s goals and priorities. In all variations, an individual will sit to urinate (82).

1. Unchanged genitalia

Some individuals are dysphoric only from the absence of a penis. In people who do not wish to stand to urinate and are not dysphoric from the presence of a vaginal canal, shaftonly phalloplasty with otherwise unchanged genitalia is a good option. Glansplasty is still typically performed to improve phallus aesthetics. In this variation of phalloplasty, a hysterectomy is not required.

2. Vaginal preservation vulvoscrotoplasty

In this variation of shaft-only phalloplasty, a scrotoplasty and glansplasty are also performed. A clitoroplasty may be performed to bury the erogenous tissue at the base of the penis, depending on the patient’s anatomy and preference. An individual may select this option if they are not dysphoric from sitting to urinate, use the vaginal canal for sexual penetration, or are interested in future childbearing. A hysterectomy is not required in this variation of phalloplasty (85).

3. Perineal masculinization with urostomy

The only difference between this option and phalloplasty with urethral lengthening is the absence of urethral lengthening. In this option, glansplasty, scrotoplasty, vaginectomy, and perineoplasty are performed. A clitoroplasty may be performed to bury the erogenous tissue at the base of the penis, depending on individual preference. The urethra is brought to the skin surface of the perineum in the form of a perineal urostomy to allow the individual to sit to urinate (82).

Gender-affirming body contouring

Gender-affirming body contouring mainly refers to liposuction and fat grafting to change the distribution of adipose tissue in the body. In TGD patients AFAB, the most commonly requested procedure is thigh and flank liposuction to help narrow the hips and minimize curves. The TGD population AMAB will often desire abdominal and flank liposuction to narrow the waist. This is often combined with fat grafting to augment the buttocks and hips, accentuating curves that would traditionally be viewed as ‘‘feminine.’’ Currently, these procedures are uncommonly covered by insurance (68). Less commonly described and infrequently performed procedures include clavicular shortening to narrow the shoulders and hip augmentation with implants. Outcomes after these procedures are minimally published in the literature.

Gender-affirming surgery in adolescents

Evidence is accumulating to support improved mental health outcomes in adolescents with earlier access to gender-affirming care. The WPATH SOC8 offers guidelines for approximate age limits for certain gender-affirming procedures. However, it is continually noted that each case must be treated on an individual basis. Decisions regarding gender-affirming care for adolescents are best made with the patient, the family, and a multidisciplinary team (7).

OTHER NONGENDER-AFFIRMING-RELATED MEDICAL CARE

Gynecologic care

For many TGD patients, accessing sexual and gynecological medical care can be difficult and at times traumatizing (86, 87). According to a 2010 Lambda Legal report, 21% of TGD respondents reported experiencing abusive or insensitive language from providers, and 8% reported physically rough treatment during their examination (88). A more recent 2015 report noted that 33% of TGD respondents who had seen a healthcare provider had at least one negative experience related to being transgender (6). Examples of negative experiences included harassment, refusal of treatment, or having to teach a provider about TGD care (6). Although education and awareness surrounding gender-affirming care have certainly improved in the years since these reports came out, TGD communities and the providers who serve them continue to face systematic attacks on access to gender-affirming care, with new and dangerous legislation emerging throughout the United States. For these reasons, along with a longstanding history of mistreatment by the medical community, TGD patients may be fearful, anxious, or avoidant of care, especially care related to sexual and gynecological health.

Sexual health and wellness

Sexual health concerns are similar for patients regardless of gender identity or anatomy. To provide the best care to patients, it is important to be able to accurately assess their level of risk for infections or pregnancy (if applicable) as well as which screenings they need based on their current pelvic anatomy (87). Many TGD patients have experienced invasive questions regarding their anatomy, identities, and sexual practices by providers under circumstances more related to curiosity than clinical relevance. Therefore, for patients of any gender identity, it is good practice to preface a very personal and potentially invasive question with why it is being asked and the intended use of the information (89). For most patients, general questions regarding their concern for exposure to sexually transmitted infections are adequate rather than deeply detailed inventories of sexual activities. It is advisable to avoid gendered statements or assumptions about sexual identity or practices. For example: ‘‘Have you had any new sexual partners or partners with new partners since the last time you had sexually transmitted infections (STI) screening? Do you have any questions regarding your risk of sexually transmitted infections?’’ Especially if this is the first clinical encounter with a patient, developing rapport and trust is critical. Leading with questions that can be interpreted as intrusive questioning can hinder this process. Subsequently, more detailed questions about what body parts go where and whether people are engaging in oral-oral, vaginal-vaginal, penis-in-vagina, penis-in-anus, oral-anal sex, etc., can be helpful to mitigate risk. But these more detailed questions must be asked in the context of trust and safety in standard ways for all patients. A helpful structure for eliciting a gender neutral and TGD-inclusive sexual history has been published (90).

In addition to asking open-ended, gender-neutral questions about sexual partners, it is important to realize that knowing the pronoun and/or gender of a patient’s partner(s) does not elucidate any information regarding the anatomy of those partner(s). Within a fertility context, if the partner’s genetic material or body will be involved in the process of creating a pregnancy, specific questions will need to be asked regarding anatomy/organs present, partners use of gender-affirming hormones or fertility-limiting medications.

Abnormal uterine bleeding

For TGD patients who are not on testosterone and have a uterus, the workup for abnormal uterine bleeding (AUB) is identical to that of cisgender women, with one important caveat: providers should be aware that AUB and/or diagnostic and therapeutic approaches may exacerbate gender dysphoria for some patients. For patients on testosterone, the workup for AUB varies slightly. For patients on physiologic dosing of testosterone (targeting cisgender male levels), suppression of menses should occur within 6 months of initiation (91). For many patients, cessation of menses occurs much more quickly and with <10% bleeding at 12 months, and no patients in a prospective study were still bleeding at 18 months (91, 92). For patients who are on low-dose testosterone or microdosing testosterone, menstrual suppression may not ever be achieved. In these patients, if menstrual suppression is the goal (it may not be for everyone), other modalities such as continuous OCPs, a levonorgestrel-releasing IUD, oral or injected progestogen, or a contraceptive implant should be discussed (93–95). It is important to note that even if a patient is amenorrheic from testosterone, this is not adequate contraception for those in need of pregnancy prevention, and pregnancy is on the differential of AUB for those who have penetrative vaginal sex with partners who produce sperm (93, 96, 97). If patients achieve amenorrhea with testosterone and then have a return of menses (without missing or changing testosterone dose), a workup should be initiated. This may include an office examination to rule out cervical polyps or other visible lesions that could lead to bleeding. For many TGD patients, office examinations may be difficult or painful, and a trauma-informed approach should be used (93). For many patients who have been on testosterone for extended periods of time, vaginal and vulvar atrophy can make pelvic examinations painful (98). For patients who are not able to undergo an examination in the office, an examination under anesthesia should be offered. For most patients who present with AUB, pelvic ultrasounds are a very useful tool for evaluating structural causes and the thickness of the endometrial lining. Similar to postmenopausal cisgender women, some TGD patients AFAB have bleeding as a result of endometrial atrophy. This diagnosis would be supported by a very thin endometrial lining in the absence of any structural abnormalities such as fibroids or polyps. As with the office examination, a transvaginal ultrasound may not be possible for all patients and should be discussed with patients before ordering the study. In certain patients, a transabdominal approach is adequate. For others, additional imaging, such as a computed tomography scan or a magnetic resonance imaging (MRI), should be considered. For those with risk factors for endometrial hyperplasia or malignancy, an endometrial biopsy should be performed. Again, depending on the patient, this may need to be completed under anesthesia. In addition to interrogating the bleeding at the level of the uterus, if a patient has a return of menses or an inability to suppress menses, assessment of serum hormone levels may be helpful. Depending on the route of administration of testosterone, absorption or aromatization may vary and lead to either testosterone levels that are too low to suppress menstruation or estrogen levels that are high enough to stimulate the endometrium.

Pelvic pain

As with the workup of AUB, pelvic pain has a similar algorithm in TGD patients AFAB as it does in cisgender women. The differential diagnosis is broad, and assessment and treatment may need to be multidisciplinary. A review of the full pelvic pain evaluation is beyond the scope of this guideline. Regarding fertility concerns, pelvic pain may be a manifestation of endometriosis, just as it is in cisgender women, that may not be fully suppressed by testosterone. Pelvic inflammatory disease or adhesive disease are also on the differential, and the fertility implications should be thoroughly evaluated with the same algorithms used for cisgender women. Pelvic examinations, pelvic imaging, and procedures can be exceedingly difficult for anyone with a history of pelvic pain. Pelvic pain may be exacerbated for TGD patients based on varying levels of comfort and/or trauma accessing gynecological care. Again, a trauma-informed approach should be used in these scenarios.

An additional well-described cause of pelvic pain in patients on gender-affirming testosterone is related to atrophic changes to the genitourinary tract (98). This may present as vulvar pain and dryness, cervicitis from pH changes, pain with penetration, or intermittent or persistent pelvic cramping. Topical estrogen therapy can be very effective in treating this type of discomfort, aside from the deeper pelvic cramping, for those patients who feel comfortable using it. Given its lack of systemic effect, it will not counteract the effects of testosterone, other than with regard to vulvovaginal atrophy. From clinical expert experience, topical estrogen therapy does not inhibit the growth of the clitoris from testosterone.

Contraception

As discussed previously, testosterone is not an effective contraception for those at risk of pregnancy, and studies have reported on the pregnancies that occurred while on testosterone and unmet contraceptive needs of TGD people AFAB (99, 100). There are differences in contraceptive use and pregnancy intention by gender identity, as well as race/ethnicity (101). Relatedly, abortion care must be considered and enhanced to care for people across the gender spectrum. One study found a 19% rate of self-managed abortions among TGD people AFAB (96, 97). Although, to our knowledge, no effectiveness studies have been performed on contraceptive methods, there have been descriptions of specific considerations for applying standard contraceptive methods for a TGD population, and the Society for Family Planning has published guidelines highlighting methods and specific key concepts for shared decision making for patients and providers regarding contraceptive use among TGD people AFAB (90, 93). For patients AFAB on testosterone, any contraceptive method is available to them as none are contraindicated with testosterone therapy. If amenorrheic on testosterone, the bleeding pattern of the contraceptive that is seen among cisgender women should not be of significant concern when deciding between types of contraception, because menses are already suppressed in TGD people AFAB. For those with ongoing bleeding, this should be factored into the decision as discussed above.

The use of estrogen and testosterone blockers decreases sperm indices in TGD people AMAB, but estrogen is not considered effective contraception for patients AMAB with a penis who have sex with patients AFAB with a vagina, uterus, tubes, and ovaries (102).

Vaginitis

For TGD people AFAB who are not on testosterone, the occurrence and persistence of vaginitis is equivalent to that of cisgender female patients. Routine differential diagnoses include contact dermatitis, bacterial vaginosis, fungal overgrowth, and STIs, and their appropriate examinations should be considered. However, for patients on testosterone, the microbiota is different, as the use of testosterone leads to an elevated vaginal pH. This change in pH results in an increased incidence of nonLactobacillus-dominated vaginal microbiota, including the potential for bacterial vaginosis and atrophic vaginitis (103, 104). Treatment with vaginal estrogen for atrophic vaginitis or intermittent boric acid for recurrent bacterial vaginosis should be offered, with or without the addition of estrogen, depending on the presence of atrophy, although investigations into population-specific dosing, preparations, and acceptability are lacking (104, 105). Just as in cisgender female patients, recurrent bacterial vaginosis may also be treated with extended courses of metronidazole.

For TGD people AMAB who have concerns for vaginitis after vaginoplasty, the workup and treatment vary greatly from those of patients born with a vagina. For neovaginas created via penile inversion, the most common source of discharge is retained debris such as sebum or sloughed keratinized skin, lubricant, or semen. Vaginal douching is recommended at varying frequencies depending on the patient's proximity to their surgery. Attention should be paid to how and when to perform examinations, as well as common findings and pathology (106). In a small study of the flora of 30 trans women with neovaginas, yeast was not isolated in any of the participants, and lactobacillus was only found in one (107). Others have begun to describe the microbiome of TGD people AMAB; however, much remains to be done (104). If a patient is experiencing increased discharge, risk-based chlamydia and gonorrhea screening should be performed, as well as a trial of dilute vinegar douching for 2–3 days. If discharge persists, an office examination should be performed if possible. Again, depending on the proximity to surgery and access to postoperative care, granulation tissue is a very common cause of troublesome discharge in the postoperative period and can often be treated in the office.

Breast and chest health

Some TGD people AFAB may have the desire to chest feed and/or produce milk for their children (108–110). Their ability to successfully lactate and/or chest feed is largely dictated by surgical history. Some surgical approaches to top surgery render chest feeding very unlikely (such as double incision with free nipple grafts, which disrupts the neurovascular bundle to the nipple areolar complex) (108). The ability and interest in future chest feeding should be discussed with patients before top surgery because this may alter a patient’s decision regarding the surgical approach to chest recontouring. For some TGD patients, chest feeding may be a source of anxiety or dysphoria, and they may choose to avoid it regardless of surgical history, whereas others may desire this as an option and require support.

For TGD patients, there are a few case reports of induced lactation (111, 112). Here, modifications of the Newman-Goldfarb protocol have been used involving the use of OCPs for 6–8 months before the arrival of the infant, followed by cessation, breast stimulation, and use of a medication (domperidone) that is not available in the United States. The GAHT dosing may need to be adjusted during this time as it may impede lactation.

Prevention of and screening for malignancies

Human papillomavirus (HPV) related cancers affect the cervix, vagina, vulva, penis, anus, and oropharynx (113, 114). Preventative efforts with HPV vaccination regimens recommended by the Centers for Disease Control and Prevention (CDC) have a substantial effect in lowering the risk of HPV-related diseases and cancers in cisgender and TGD individuals (114–116). The HPV vaccination should be offered to all TGD individuals based on age and CDC guidelines if not previously initiated or only partially completed (115).

Screening for malignancies for TGD patients should follow the recommended guidelines for the anatomy they retain. For this reason, it is critical to ascertain which organs a patient has and clarify their surgical history in detail. According to the most recent American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines, cervical cancer screening should begin at age 21 and end at age 65 (dependent on history of significant dysplasia) (117). For patients under 30, cervical cytology may be repeated every 3 years if prior pap smears have been normal. After age 30, cervical cytology combined with HPV screening is initiated and repeated every 5 years, if normal. Thresholds for further testing, such as colposcopy, cervical biopsies, and excisional procedures, follow the same recommendations as for cisgender women. For TGD patients who have a cervix and have been on testosterone, there is a lower likelihood of being up to date on pap smears and a higher incidence of unsatisfactory pap smears. This increased frequency of unsatisfactory pap smear results is because of a dose-response relationship to the length of time on testosterone (118, 119). There may also be a higher incidence of higher-grade abnormalities on pap smear, but more work remains to be done (105). These findings are primarily attributed to diminished cellularity, increased friability from atrophy, and its relationship to the changing microbiome, but may also be attributed to changing gender expression. As discussed previously, pelvic examinations may be particularly difficult or painful for these patients, and sedation or other comfort measures should be offered. For patients who have had a total hysterectomy with removal of the cervix, routine screening for vaginal cancer is not recommended unless the patient had a hysterectomy for cervical dysplasia or cervical cancer, or it was incidentally found on final pathology, in which case ongoing vaginal HPV-based screening is recommended. As with cisgender women, screening for ovarian cancer is not recommended outside of a known genetic mutation that increases risk, in which the specific guidelines of that mutation should be referenced in patients who retain ovaries. Similarly, there is no routine screening for endometrial cancer in the absence of a known genetic predisposition, and one should follow clinical concerns regarding abnormal bleeding patterns.

For TGD patients AMAB who have had penile inversion vaginoplasty, no pap smear or cervical cancer screening is recommended. Given that the neovagina is lined with keratinized epithelium, diseases or dysplastic processes that affect this tissue type, such as melanoma and basal or squamous cell cancers, may occur. Annual neovaginal examinations can be considered vs. symptom-based evaluation. Although most patients who have had penile inversion vaginoplasty have a vagina lined with keratinized cells, more uncommon forms of vaginoplasty involve the use of either intestinal tissue or peritoneal tissue to create the vaginal lining. In these patients, colon cancers, inflammatory bowel disease, intestinal polyps, and precancers, or alternatively, pathology affecting the peritoneum, could present with vaginal lesions.

Most TGD people AMAB will have a prostate and should undergo prostate screening in accordance with the American Urological Association recommendations. It is critical to know that even patients who have undergone vaginoplasty still retain an anatomic prostate. For patients on antiandrogen medications or estrogen therapy, levels of prostate-specific antigen may be artificially lowered, and the lower level of normal may need to be adjusted to 1.0 ng/mL (120). For patients who have undergone vaginoplasty and elect to have prostate screening, the prostate can be palpated vaginally beneath the anterior vaginal wall.

For patients with testicles, there is no routine screening for testicular cancer. Any complaint of palpated masses or testicular pain should be approached using the same algorithms as for cisgender males.

As there is much debate regarding the age of initiation and frequency of breast cancer screening in cisgender women, there is no definitive guideline for TGD people AMAB who are on GAHT. The data are overall sparse, but there is some evidence that suggests that breast cancer in TGD patients AMAB on estrogen-based GAHT regimens follows patterns similar to those of cisgender men (121). It has been proposed that breast cancer screening be initiated at 50 for patients who have been on GAHT for a minimum of 5 years and repeated every 2 years (14). This schedule should be modified based on family history or known oncogene mutation. In patients who have had breast augmentation, the sensitivity of mammography is lower than that of those who have not had such interventions, and it remains the recommended initial screening tool in most patients (122). Transparency about data limitations and shared decision making is encouraged.

For TGD people AFAB who have not had top surgery or who have undergone reductions only, breast cancer screening guidelines are identical to those of cisgender women, regardless of the patient’s history of testosterone therapy. For patients who have had top surgery in which the majority of the breast tissue has been removed, there remains a risk for breast cancer, although it is diminished compared with patients who have not had the majority of their breast tissue removed (123). There are case reports of breast cancer occurring in TGD people AFAB after top surgery with negative preoperative screening and pathology (124). An annual chest wall examination could be considered in addition to patient education regarding the need for evaluation should a lump or skin change be palpated on self-examination. As mammography cannot be effectively performed after the majority of chest recontouring procedures, because of limited remaining breast tissue, alternative imaging modalities, such as ultrasound or MRI, could be considered but are not strongly recommended.

DISCRIMINATION AND BARRIERS TO CARE

Despite advancements in the awareness and affirmation of TGD individuals’ lived experiences, the transphobia and cultural prejudices and stigma evident in many societies are associated with greater risks of harassment, discrimination, and violence compared with their cisgender peers (125). Outside of the public sector, the well-documented barriers to healthcare and risk of abuse and violence by healthcare professionals toward TGD individuals also contribute to the psychological harm of TGD individuals (6, 126, 127). Within this context of decreased safety in one’s immediate and broader social environment, the presence of dysphoria would further add to the emotional burden faced by TGD individuals (128).

The vast array of barriers to care, stressors, and violence faced by TGD individuals is associated with increased risk for psychological (e.g., depression, anxiety, suicidal ideation, and substance use), academic (e.g., poorer grades), social (e.g., family conflict), and healthcare (e.g., delay/avoidance of medical care and unsupervised hormone use) difficulties and violence (128–132). It is important to note that the risk of psychological distress experienced by TGD individuals is not inherent to TGD identity. Rather, evidence that these risks can be mitigated by the presence of gender-affirming behaviors, such as correct name and pronoun use, points to a causal role of the societal challenges faced by TGD individuals (130). Gender-affirming healthcare, including access to safe and supportive reproductive medical care, also results in many emotional and social benefits for TGD individuals (38).

MENTAL HEALTHCARE

The evolution of clinical practice guidelines by various societal bodies has served to decrease stigmatization and improve access and quality of healthcare for TGD individuals (7, 11). Rather than incorrectly pathologizing TGD individuals’ incongruent beliefs between their sex assigned at birth and their gender, the healthcare provided by mental health professionals is now focused on the psychological distress that may be associated with this incongruence.

Outside of the provision of supportive and affirming psychotherapy, controversy exists regarding the role of mental health professionals in the care of TGD individuals. Requirements that TGD individuals obtain psychological clearance for gender-affirming care, the harmful effects of conversion therapy, and prior editions of the DSM, which pathologized TGD individuals’ beliefs, have likely resulted in a complex relationship for many TGD individuals with mental health professionals. American Society for Reproductive Medicine recommends that TGD individuals undergo prefertility treatment psychological consultation by a qualified mental health professional, similar to patients undergoing medical fertility preservation, but this recommendation may be met with trepidation by TGD individuals (38). It should be made clear to TGD individuals that such consultations are not intended to serve a gate-keeping role, but instead to provide an opportunity to more fully consider future family-building options. It is well known that fertility treatments may cause psychological distress in both fertile and infertile patient populations (133, 134). For TGD individuals, the exposure to gender incongruent experiences (e.g., masturbation, pelvic ultrasounds, and pelvic examinations), the physical and emotional toll of exogenous hormone use in fertility treatments, or the need to delay or halt GAHT to undergo fertility treatments, may pose additional psychological risk for some (135–137). Additionally, some TGD individuals may require the assistance of third-party collaborators should they lack the gametes or uterus needed for pregnancy or if the use of such reproductive materials would risk causing psychological distress. Third-party reproductive treatment may also be associated with a host of emotional concerns and complex decisions (138). Thus, the focus of mental health consultation before treatment for TGD individuals should be on coping with fertility treatment and its sequelae, available coping supports, emotional aspects of decision making, psychoeducation regarding treatment, treatment expectations, disclosure of conception to offspring, and concerns related to receipt of care as a TGD individual.

SUMMARY

• Gender transition may involve gender-affirming hormones and/or gender-affirming surgeries that can significantly improve well-being and quality of life by helping individuals physically actualize their sense of self.
• Gender-affirming hormone therapy may include puberty blockers to halt puberty for individuals who express gender incongruence at the peripubertal stage, as well as testosterone-based and estrogen-based treatment regimens.
• Gender-affirming surgical procedures may include facial, chest, body, and genital gender-affirming surgeries.
• As gender-affirming hormone treatment and gender-affirming surgery may have a temporary or permanent impact on fertility and family planning, reproductive counseling before medical/surgical intervention is critical.
• Many TGD patients have experienced poor treatment in healthcare settings, including invasive questions regarding their anatomy, identities, and sexual practices by providers unrelated and not relevant to clinical care.
• Within the context of fertility care, it is important to know the genetic material, anatomy, and organs present for patients and their partners. Diagnostic and therapeutic approaches, such as pelvic examinations and transvaginal ultrasounds, may exacerbate gender dysphoria for some patients.
• For individuals assigned female at birth, testosterone is not an effective form of contraception for those at risk of pregnancy.
• Screening for malignancies for TGD patients should follow the recommended guidelines for the anatomy they retain.
• Transgender, gender diverse, and gender nonbinary people are more likely to face discrimination and mistreatment when accessing healthcare, compared with cisgender individuals.

CONCLUSION

• As with all patients, questions unrelated to their medical care should be avoided, and it is important to develop a rapport and establish trust in a safe clinical environment.
• When gathering necessary information regarding the presence of gametic material, anatomy, and organs, this information should be elucidated in an open-ended, gender-neutral manner.
• The TGD individuals who experience reproductive health issues such as AUB, vaginitis, and pelvic pain should be evaluated and treated, taking care to consider their medical and surgical histories.
• Alternative approaches, such as examinations under anesthesia and the use of transabdominal ultrasound, may be indicated to alleviate gender dysphoria during diagnostic and therapeutic procedures.
• Within the context of fertility treatment, the focus of mental health consultation before treatment should be on coping with fertility treatment and its sequelae, coping supports, emotional aspects of decision making, psycho-education regarding treatment, expectations, disclosure of conception to offspring, and concerns related to receipt of care as a TGD individual.
• Individuals assigned female at birth taking hormone affirming therapy should be counseled that taking testosterone does not prevent pregnancy, and contraception is needed.

Acknowledgments

This report was developed under the direction of the Practice Committee of the American Society for Reproductive Medicine (ASRM) as a service to its members and other practicing clinicians. Although this document reflects appropriate management of a problem encountered in the practice of reproductive medicine, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other plans of management may be appropriate, taking into account the needs of the individual patient, available resources, and institutional or clinical practice limitations. The Practice Committee and the Board of Directors of ASRM have approved this report. This document was reviewed by ASRM members, and their input was considered in the preparation of the final document. The following members of the ASRM Practice Committee participated in the development of this document: Clarisa Gracia, M.D., M.S.C.E.; Rebecca Flyckt, M.D.; Karl Hansen, M.D., Ph.D.; Micah Hill, D.O.; Tarun Jain, M.D.; Suleena Kalra, M.D., M.S.C.E.; Bruce Pier, M.D.; Denny Sakkas, Ph.D.; Sangita Jindal, PhD; Anne Steiner, M.D., M.P.H.; Cigdem Tanrikut, M.D.; Belinda Yauger, M.D.; Torie C. Plowden, M.D., M.P.H.; Ryan Smith, M.D.; Mark Trolice, M.D., M.B.A.; Suneeta Senapati, M.D., M.S.C.E.; Paula Amato, MD; Robert Brannigan, M.D.; Amy Sparks, Ph.D.; Jared Robins, M.D.; Chevis N Shannon, Dr.Ph., M.B.A., M.P.H.; Jessica Goldstein R.N.; and Madeline Brooks, M.B.A., M.P.H. The Practice Committee acknowledges the special contributions of Micah Hill, D.O.; Molly Moravek, M.D.; Hadrian Kinnear, M.D., Ph.D.; Blair Peters, M.D.; Daphna Stroumsa, M.D.; Juno Obedin-Maliver, M.D., M.P.H.; Gene DeHaan, M.D.; Angela Lawson, Ph.D.; Samantha Estevez, M.D.; and Randi Goldman, M.D., M.B.A. All committee members disclosed commercial and financial relationships with manufacturers or distributors of goods or services used to treat patients. Members of the committee who were found to have conflicts of interest on the basis of the relationships disclosed did not participate in the discussion or development of the document.

REFERENCES

1. Goodman M, Adams N, Corneil T, Kreukels B, Motmans J, Coleman E. Size and distribution of transgender and gender nonconforming populations: a narrative review. Endocrinol Metab Clin North Am 2019;48:303–21.
2. Zhang Q, Goodman M, Adams N, Corneil T, Hashemi L, Kreukels B, et al. Epidemiological considerations in transgender health: a systematic review with focus on higher quality data. Int J Transgend Health 2020;21:125–37.
3. Herman JL, Flores AR, O’Neill KK. How many adults and youth identify as transgender in the United States? Los Angeles (CA): UCLA School of Law; 2022.
4. Herman JL, Flores AR, Brown TNT, Wilson BDM, Conron KJ. Age of individuals who identify as transgender in the United States. Los Angeles (CA): Williams Institute, UCLA School of Law; 2017.
5. Wilson BDM, Meyer IH. Nonbinary LGBTQ adults in the United States. Los Angeles (CA): UCLA School of Law; 2021.
6. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality. Available at: https://transequality.org/. Accessed June 1, 2026.
7. Coleman E, Radix AE, Bouman WP, Brown GR, De Vries ALC, Deutsch MB, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health 2022;23:S1–259.
8. Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2017;102:3869–3903.
9. Stroumsa D, Wu JP. Welcoming transgender and nonbinary patients: expanding the language of "women's health". Am J Obstet Gynecol 2018;219:585.e1–5.
10. Guze SB. Diagnostic and statistical manual of mental disorders. 4th ed. (DSM-IV). Am J Psychiatry 1995;152:1228, 8.
11. Diagnostic and statistical manual of mental disorders: DSM-5, 5th ed. Arlington, VA, US: American Psychiatric Publishing, Inc.; 2013.
12. World Health Organization. ICD-11: International classification of diseases (11th Revision) [Internet]. Geneva: World Health Organization; 2019.
13. Dubin SN, Nolan IT, Streed CG Jr, Greene RE, Radix AE, Morrison SD. Transgender health care: improving medical students' and residents' training and awareness. Adv Med Educ Pract 2018;9:377–91.
14. University of California San Francisco. Guidelines for the primary care of transgender and gender nonbinary people. UCSF Gender Affirming Health Program. Available at: https://transcare.ucsf.edu/guidelines. Accessed June 1, 2026.
15. TransLine. TransLine: Transgender Medical Consultation Service. TransLine Help Center, Availble at, https://transline.zendesk.com/hc/en-us. Accessed June 3, 2026.
16. Adams N, Pearce R, Veale J, Radix A, Castro D, Sarkar A, et al. Guidance and ethical considerations for undertaking transgender health research and institutional review boards adjudicating this research. Transgend Health 2017;2:165–75.
17. Feldman J, Brown GR, Deutsch MB, Hembree W, Meyer W, Meyer-Bahlburg HF, et al. Priorities for transgender medical and healthcare research. Curr Opin Endocrinol Diabetes Obes 2016;23:180–7.
18. Reisner SL, Deutsch MB, Bhasin S, Bockting W, Brown GR, Feldman J, et al. Advancing methods for US transgender health research. Curr Opin Endocrinol Diabetes Obes 2016;23:198–207.
19. Practice Committee of the American Society for Reproductive Medicine. Inclusive language and environment to welcome lesbian, gay, bisexual, transgender, queer, questioning, intersex, and asexual+ patients. Fertil Steril 2024;121:954–60.
20. Aldridge Z, Patel S, Guo B, Nixon E, Pierre Bouman W, Witcomb GL, et al. Long-term effect of gender-affirming hormone treatment on depression and anxiety symptoms in transgender people: a prospective cohort study. Andrology 2021;9:1808–16.
21. Cocchetti C, Ristori J, Mazzoli F, Vignozzi L, Maggi M, Fisher AD. Management of hypoactive sexual desire disorder in transgender women: a guide for clinicians. Int J Impot Res 2020;33:703–9.
22. Cavanaugh T, Hopwood R, Lambert C. Informed consent in the medical care of transgender and gender-nonconforming patients. AMA J Ethics 2016;18:1147–55.
23. Meriggiola MC, Gava G. Endocrine care of transpeople part I. A review of cross-sex hormonal treatments, outcomes and adverse effects in trans-men. Clin Endocrinol (Oxf) 2015;83:597–606.
24. Mcfarland J, Craig W, Clarke NJ, Spratt DI. Serum testosterone concentrations remain stable between injections in patients receiving subcutaneous testosterone. J Endocr Soc 2017;1:1095–103.
25. Spratt DI, Stewart II, Savage C, Craig W, Spack NP, Chandler DW, et al. Subcutaneous injection of testosterone Is an effective and preferred alternative to intramuscular injection: demonstration in female-to-male transgender patients. J Clin Endocrinol Metab 2017;102:2349–55.
26. Swerdloff RS, Wang C, White WB, Kaminetsky J, Gittelman MC, Longstreth JA, et al. A new oral testosterone undecanoate formulation restores testosterone to normal concentrations in hypogonadal men. J Clin Endocrinol Metab 2020;105:2515–31.
27. Cheng K, Skolnick A. Testosterone pellet use in transgender men. Transgend Health 2023;8:494–9.
28. Wierckx K, Mueller S, Weyers S, Van Caenegem E, Roef G, Heylens G, et al. Long-term evaluation of cross-sex hormone treatment in transsexual persons. J Sex Med 2012;9:2641–51.
29. Byrnes JR, Wolberg AS. Red blood cells in thrombosis. Blood 2017;130: 1795–9.
30. Asscheman H, Giltay EJ, Megens JA, De Ronde WP, Van Trotsenburg MA, Gooren LJ. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol 2011;164:635–42.
31. Wierckx K, Elaut E, Declercq E, Heylens G, De Cuypere G, Taes Y, et al. Prevalence of cardiovascular disease and cancer  during cross-sex hormone therapy in a large cohort of trans persons: a case-control study. Eur J Endocrinol 2013;169:471–8.
32. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol 2014;124:1120–7.
33. Moravek MB, Dixon M, Pena SM, Obedin-Maliver J. Management of testosterone around ovarian stimulation in transmasculine patients: challenging common practices to meet patient needs-2 case reports. Hum Re-
    prod 2023;38:482–8.
34. Moravek MB, Kinnear HM, George J, Batchelor J, Shikanov A, Padmanabhan V, et al. Impact of exogenous testosterone on reproduction in transgender men. Endocrinology 2020;161:bqaa014.
35. Schwartz AR, Moravek MB. Reproductive potential and fertility preservation in transgender and nonbinary individuals. Curr Opin Obstet Gynecol 2021;33:327–34.
36. Kinnear HM, Hashim PH, Dela Cruz C, Rubenstein G, Chang AL, Nimmagadda L, et al. Reversibility of testosterone-induced acyclicity after testosterone cessation in a transgender mouse model. F S Sci 2021;2:116–23.
37. Bartels CB, Uliasz TF, Lestz L, Mehlmann LM. Short-term testosterone use in female mice does not impair fertilizability of eggs: implications for the fertility care of transgender males. Hum Reprod 2021;36:189–98.
38. Ethics Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org. Access to fertility services by transgender and nonbinary persons: an Ethics Committee opinion. Fertil Steril 2021;115:874–8.
39. Grimstad F, Kremen J, Shim J, Charlton BM, Boskey ER. Breakthrough bleeding in transgender and gender diverse adolescents and young adults on long-term testosterone. J Pediatr Adolesc Gynecol 2021;34:706–16.
40. Grimstad FW, Boskey E, Grey M. New-onset abdominopelvic pain after initiation of testosterone therapy among trans-masculine persons: a community-based exploratory survey. LGBT Health 2020;7:248–53.
41. Mamoojee Y, Seal LJ, Quinton R. Transgender hormone therapy: understanding international variation in practice. Lancet Diabetes Endocrinol 2017;5:243–6.
42. Meriggiola MC, Gava G. Endocrine care of transpeople part II. A review of cross-sex hormonal treatments, outcomes and adverse effects in trans-women. Clin Endocrinol (Oxf) 2015;83:607–15.
43. Prior JC, Vigna YM, Watson D. Spironolactone with physiological female steroids for presurgical therapy of male-to-female transsexualism. Arch Sex Behav 1989;18:49–57.
44. Rittmaster RS. 5alpha-reductase inhibitors. J Androl 1997;18:582–7.
45. Bessone F, Lucena MI, Roma MG, Stephens C, Medina-Caliz I, Frider B, et al. Cyproterone acetate induces a wide spectrum of acute liver damage including corticosteroid-responsive hepatitis: report of 22 cases. Liver Int 2016;36:302–10.
46. Wierckx K, Elaut E, Van Hoorde B, Heylens G, De Cuypere G, Monstrey S, et al. Sexual desire in trans persons: associations with sex reassignment treatment. J Sex Med 2014;11:107–18.
47. Safer JD. Research gaps in medical treatment of transgender/nonbinary people. J Clin Invest 2021;131:e142029.
48. Canner JK, Harfouch O, Kodadek LM, Pelaez D, Coon D, Offodile AC 2nd, et al. Temporal trends in gender-affirming surgery among transgender patients in the United States. J Am Med Assoc Surg 2018;153:609–16.
49. Peters BR, Richards HW. Redefining the "Ideal" Phallic Reconstruction: perspectives from a gender-affirming surgeon. Ann Plast Surg 2022;88:251.
50. Deschamps-Braly JC. Facial gender confirmation surgery: facial feminization surgery and facial masculinization surgery. Clin Plast Surg 2018;45: 323–31.
51. Fisher M, Lu SM, Chen K, Zhang B, Di Maggio M, Bradley JP. Facial feminization surgery changes perception of patient gender. Aesthet Surg J 2020;40:703–9.
52. Spiegel JH. Facial feminization for the transgender patient. J Craniofac Surg 2019;30:1399–402.
53. Dang BN, Hu AC, Bertrand AA, Chan CH, Jain NS, Pfaff MJ, et al. Evaluation and treatment of facial feminization surgery: part I. forehead, orbits, eyebrows, eyes, and nose. Arch Plast Surg 2021;48:503–10.
54. Berli JU, Loyo M. Gender-confirming rhinoplasty. Facial Plast Surg Clin North Am 2019;27:251–60.
55. Salibian AA, Bluebond-Langner R. Lip lift. Facial Plast Surg Clin North Am 2019;27:261–6.
56. Glasgold M, Glasgold R, Lam S. Autologous fat grafting for midface rejuvenation. Clin Plast Surg 2015;42:115–21.
57. Morrison SD, Satterwhite T. Lower jaw recontouring in facial gender-affirming surgery. Facial Plast Surg Clin North Am 2019;27:233–42.
58. Sturm A, Chaiet SR. Chondrolaryngoplasty-thyroid cartilage reduction. Facial Plast Surg Clin North Am 2019;27:267–72.
59. Nolan IT, Morrison SD, Arowojolu O, Crowe CS, Massie JP, Adler RK, et al. The role of voice therapy and phonosurgery in transgender vocal feminization. J Craniofac Surg 2019;30:1368–75.
60. Chadwick KA, Coleman R, Andreadis K, Pitti M, Rameau A. Outcomes of gender-affirming voice and communication modification for transgender individuals. Laryngoscope 2022;132:1615–21.
61. Ascha M, Swanson MA, Massie JP, Evans MW, Chambers C, Ginsberg BA, et al. Nonsurgical management of facial masculinization and feminization. Aesthet Surg J 2019;39:NP123–N137.
62. Deschamps-Braly JC, Sacher CL, Fick J, Ousterhout DK. First female-to-male facial confirmation surgery with description of a new procedure for masculinization of the thyroid cartilage (Adam's Apple). Plast Reconstr Surg 2017;139:883e–7e.
63. Lane M, Ives GC, Sluiter EC, Waljee JF, Yao TH, Hu HM, et al. Trends in gender-affirming surgery in insured patients in the United States. Plast Reconstr Surg Glob Open 2018;6:e1738.
64. Lane M, Kirsch MJ, Sluiter EC, Svientek SR, Hamill JB, Morrison SD, et al. Gender affirming mastectomy improves quality of life in transmasculine patients: a single-center prospective study. Ann Surg 2023;277:e725–9.
65. Bluebond-Langner R, Berli JU, Sabino J, Chopra K, Singh D, Fischer B. Top surgery in transgender men: how far can you push the envelope? Plast Reconstr Surg 2017;139:873e–82e.
66. Esmonde N, Heston A, Jedrzejewski B, Ramly E, Annen A, Guerriero J, et al. What is "nonbinary" and what do i need to know? A primer for surgeons providing chest surgery for transgender patients. Aesthet Surg J 2019;39: NP106–N112.
67. Salibian AA, Axelrod DM, Smith JA, Fischer BA, Agarwal C, Bluebond-Langner R. Oncologic considerations for safe gender-affirming mastectomy: preoperative imaging, pathologic evaluation, counseling, and long-term screening. Plast Reconstr Surg 2021;147:213e–21e.
68. Morrison SD, Wilson SC, Mosser SW. Breast and body contouring for transgender and gender nonconforming individuals. Clin Plast Surg 2018;45:333–42.
69. Clemens MW, Jacobsen ED, Horwitz SM. 2019 NCCN consensus guidelines on the diagnosis and treatment of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Aesthet Surg J 2019;39:S3–13.
70. Mckernan CD, Vorstenbosch J, Chu JJ, Nelson JA. Breast implant safety: an overview of current regulations and screening guidelines. J Gen Intern Med 2022;37:212–6.
71. Coleman SR, Saboeiro AP. Primary breast augmentation with fat grafting. Clin Plast Surg 2015;42:301–6, vii.
72. Hehemann MC, Walsh TJ. Orchiectomy as bridge or alternative to vaginoplasty. Urol Clin North Am 2019;46:505–10.
73. Jiang D, Witten J, Berli J, Dugi D 3rd. Does depth matter? Factors affecting choice of vulvoplasty over vaginoplasty as gender-affirming genital surgery for transgender women. J Sex Med 2018;15:902–6.
74. Shoureshi P, Dugi D 3rd. Penile inversion vaginoplasty technique. Urol Clin North Am 2019;46:511–25.
75. Dy GW, Jun MS, Blasdel G, Bluebond-Langner R, Zhao LC. Outcomes of gender affirming peritoneal flap vaginoplasty using the Da Vinci single port versus Xi robotic systems. Eur Urol 2021;79:676–83.
76. ACOG Committee Opinion No. 774 Summary: opportunistic salpingectomy as a strategy for epithelial ovarian cancer prevention. Obstet Gynecol 2019;133:842–3.
77. Reilly ZP, Fruhauf TF, Martin SJ. Barriers to evidence-based transgender care: knowledge gaps in gender-affirming hysterectomy and oophorectomy. Obstet Gynecol 2019;134:714–7.
78. Lin-Brande M, Clennon E, Sajadi KP, Djordjevic ML, Dy GW, Dugi D. Metoidioplasty with urethral lengthening: a stepwise approach. Urology 2021;147:319–22.
79. Djordjevic ML, Stojanovic B, Bizic M. Metoidioplasty: techniques and outcomes. Transl Androl Urol 2019;8:248–53.
80. Selvaggi G, Hoebeke P, Ceulemans P, Hamdi M, Van Landuyt K, Blondeel P, et al. Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty. Plast Reconstr Surg 2009;123:1710–8.
81. Hage JJ, De Graaf FH. Addressing the ideal requirements by free flap phalloplasty: some reflections on refinements of technique. Microsurgery 1993;14:592–8.
82. Heston AL, Esmonde NO, Dugi DD 3rd, Berli JU. Phalloplasty: techniques and outcomes. Transl Androl Urol 2019;8:254–65.
83. Danker S, Esmonde N, Berli JU. "Staging" in phalloplasty. Urol Clin North Am 2019;46:581–90.
84. Peters BR, Mccreary E, Putnam CA, Berli JU. Shaft-only phalloplasty: technical modifications to optimize aesthetics. Plast Reconstr Surg Glob Open 2021;9:e3645.
85. Chen W, Cylinder I, Najafian A, Dugi DD 3rd, Berli JU. An option for shaft-only gender-affirming phalloplasty: vaginal preservation and vulvoscrotoplasty. A technical description. Plast Reconstr Surg 2021;147: 480–3.
86. Wingo E, Ingraham N, Roberts SCM. Reproductive health care priorities and barriers to effective care for LGBTQ people assigned female at birth: a qualitative study. Womens Health Issues 2018;28:350–7.
87. Moseson H, Zazanis N, Goldberg E, Fix L, Durden M, Stoeffler A, et al. The imperative for transgender and gender nonbinary inclusion: beyond women's health. Obstet Gynecol 2020;135:1059–68.
88. Lambda Legal. When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV. Available at: https://lambdalegal.org/wp-content/uploads/2011/10/whcic-report_ when-health-care-isnt-caring.pdf. Accessed June 1, 2026.
89. Suen LW, Lunn MR, Sevelius JM, Flentje A, Capriotti MR, Lubensky ME, et al. Do ask, tell, and show: contextual factors affecting sexual orientation and gender identity disclosure for sexual and gender minority people. LGBT Health 2022;9:73–80.
90. Krempasky C, Harris M, Abern L, Grimstad F. Contraception across the transmasculine spectrum. Am J Obstet Gynecol 2020;222:134–43.
91. Deutsch MB, Bhakri V, Kubicek K. Effects of cross-sex hormone treatment on transgender women and men. Obstet Gynecol 2015;125:605–10.
92. Defreyne J, Vanwonterghem Y, Collet S, Iwamoto SJ, Wiepjes CM, Fisher AD, et al. Vaginal bleeding and spotting in transgender men after initiation of testosterone therapy: a prospective cohort study (ENIGI). Int J Transgend Health 2020;21:163–75.
93. Bonnington A, Dianat S, Kerns J, Hastings J, Hawkins M, De Haan G, et al. Society of family planning clinical recommendations: contraceptive counseling for transgender and gender diverse people who were female sex assigned at birth. Contraception 2020;102:70–82.
94. Berrahou IK, Grimes A, Autry AM, Hawkins M. Management of menstruation in transgender and gender nonbinary adolescents. Clin Obstet Gynecol 2022;65:753–67.
95. Abern L, Krempasky C, Diego D, De Guzman G, Kiely K, Cook J, et al. The intrauterine device experience among transgender and gender-diverse individuals assigned female at birth. J Midwifery Womens Health 2021;66:772–7.
96. Moseson H, Fix L, Ragosta S, Forsberg H, Hastings J, Stoeffler A, et al. Abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States. Am J Obstet Gynecol 2021;224:e1–11.
97. Moseson H, Fix L, Gerdts C, Ragosta S, Hastings J, Stoeffler A, et al. Abortion attempts without clinical supervision among transgender, nonbinary and gender-expansive people in the United States. Br Med J Sex Reprod Health 2022;48:e22–30.
98. University of California San Francisco. Pelvic pain and persistent menses in transgender men. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. Available at: https:// transcare.ucsf.edu/guidelines. Accessed June 1, 2026.
99. Moseson H, Fix L, Hastings J, Stoeffler A, Lunn MR, Flentje A, et al. Pregnancy intentions and outcomes among transgender, nonbinary, and gender-expansive people assigned female or intersex at birth in the United States: results from a national, quantitative survey. Int J Transgend Health 2021;22:30–41.
100. Cipres D, Seidman D, Cloniger C 3rd, Nova C, O'shea A, Obedin-Maliver J. Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco. Contraception 2017;95:186–9.
101. Stark B, Hughto JMW, Charlton BM, Deutsch MB, Potter J, Reisner SL. The contraceptive and reproductive history and planning goals of trans-masculine adults: a mixed-methods study. Contraception 2019;100:468–73.
102. Adeleye AJ, Reid G, Kao CN, Mok-Lin E, Smith JF. Semen parameters among transgender women with a history of hormonal treatment. Urology 2019;124:136–41.
103. Winston Mcpherson G, Long T, Salipante SJ, Rongitsch JA, Hoffman NG, Stephens K, et al. The vaginal microbiome of transgender men. Clin Chem 2019;65:199–207.
104. Krakowsky Y, Potter E, Hallarn J, Monari B, Wilcox H, Bauer G, et al. The effect of gender-affirming medical care on the vaginal and neovaginal microbiomes of transgender and gender-diverse people. Front Cell Infect Microbiol 2021;11:769950.
105. Lin LH, Zhou F, Elishaev E, Khader S, Hernandez A, Marcus A, et al. Cervicovaginal cytology, HPV testing and vaginal flora in transmasculine persons receiving testosterone. Diagn Cytopathol 2022;50:518–24.
106. Grimstad F, Mclaren H, Gray M. The gynecologic examination of the trans-feminine person after penile inversion vaginoplasty. Am J Obstet Gynecol 2021;224:266–73.
107. Weyers S, Lambein K, Sturtewagen Y, Verstraelen H, Gerris J, Praet M. Cytology of the 'penile' neovagina in transsexual women. Cytopathology 2010;21:111–5.
108. Macdonald T, Noel-Weiss J, West D, Walks M, Biener M, Kibbe A, et al. Transmasculine individuals' experiences with lactation, chestfeeding, and gender identity: a qualitative study. BMC Pregnancy Childbirth 2016;16:106.
109. Hoffkling A, Obedin-Maliver J, Sevelius J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth 2017;17:332.
110. Garcia-Acosta JM, San Juan-Valdivia RM, Fernandez-Martinez AD, Lorenzo-Rocha ND, Castro-Peraza ME. Trans* pregnancy and lactation: a literature review from a nursing perspective. Int J Environ Res Public Health 2019;17:44.
111. Wamboldt R, Shuster S, Sidhu BS. Lactation induction in a transgender woman wanting to breastfeed: case report. J Clin Endocrinol Metab 2021;106:e2047–52.
112. Reisman T, Goldstein Z. Case report: induced lactation in a transgender woman. Transgend Health 2018;3:24–6.
113. Weyers S, Garland SM, Cruickshank M, Kyrgiou M, Arbyn M. Cervical cancer prevention in transgender men: a review. Br J Obstet Gynaecol 2021; 128:822–6.
114. Meites E, Wilkin TJ, Markowitz LE. Review of human papillomavirus (HPV) burden and HPV vaccination for gay, bisexual, and other men who have sex with men and transgender women in the United States. Hum Vaccin Immunother 2022;18:2016007.
115. Centers for Disease Control and Prevention. HPV vaccination recommendations. U.S. Department of Health and Human Services. Available at: https://www.cdc.gov/hpv/hcp/vaccination-considerations/index.html. Accessed June 1, 2026.
116. American College Of Obstetricians, Gynecologists' Committee on Adolescent Health Care ACOO. Gynecologists' Immunization ID, Public Health Preparedness Expert Work G. Human Papillomavirus Vaccination: ACOG Committee Opinion, Number 809. Obstet Gynecol 2020;136:e15–21.
117. Perkins RB, Guido RS, Castle PE, Chelmow D, Einstein MH, Garcia F, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis 2020;24:102–31.
118. Peitzmeier SM, Khullar K, Reisner SL, Potter J. Pap test use is lower among female-to-male patients than non-transgender women. Am J Prev Med 2014;47:808–12.
119. Peitzmeier SM, Reisner SL, Harigopal P, Potter J. Female-to-male patients have high prevalence of unsatisfactory Paps compared to non-transgender females: implications for cervical cancer screening. J Gen Intern Med 2014;29:778–84.
120. Trum HW, Hoebeke P, Gooren LJ. Sex reassignment of transsexual people from a gynecologist's and urologist's perspective. Acta Obstet Gynecol Scand 2015;94:563–7.
121. Gooren LJ, Van Trotsenburg MA, Giltay EJ, Van Diest PJ. Breast cancer development in transsexual subjects receiving cross-sex hormone treatment. J Sex Med 2013;10:3129–34.
122. Miglioretti DL, Rutter CM, Geller BM, Cutter G, Barlow WE, Rosenberg R, et al. Effect of breast augmentation on the accuracy of mammography and cancer characteristics. J Am Med Assoc 2004; 291:442–50.
123. Lawrence AA, Meyer IH, Northridge ME, editors. Transgender health concerns. Boston, MA: Springer US; 2007:473–505.
124. Nikolic DV, Djordjevic ML, Granic M, Nikolic AT, Stanimirovic VV, Zdravkovic D, et al. Importance of revealing a rare case of breast cancer in a female to male transsexual after bilateral mastectomy. World J Surg Oncol 2012;10:280.
125. Langenderfer-Magruder L, Walls NE, Kattari SK, Whitfield DL, Ramos D. Sexual victimization and subsequent police reporting by gender identity among lesbian, gay, bisexual, transgender, and queer adults. Violence Vict 2016;31:320–31.
126. Shires DA, Jaffee K. Factors associated with health care discrimination experiences among a national sample of female-to-male transgender individuals. Health Soc Work 2015;40:134–41.
127. Shaffer N. Transgender patients: implications for emergency department policy and practice. J Emerg Nurs 2005;31:405–7.
128. Olson J, Schrager SM, Belzer M, Simons LK, Clark LF. Baseline physiologic and psychosocial characteristics of  transgender youth seeking care for gender dysphoria. J Adolesc Health 2015;57:374–80.
129. Nahata L, Quinn GP, Caltabellotta NM, Tishelman AC. Mental health concerns and insurance denials among transgender adolescents. LGBT Health 2017;4:188–93.
130. Guss C, Shumer D, Katz-Wise SL. Transgender and gender nonconforming adolescent care: psychosocial and medical considerations. Curr Opin Pediatr 2015;27:421–6.
131. Stroumsa D, Crissman HP, Dalton VK, Kolenic G, Richardson CR. Insurance coverage and use of hormones among transgender respondents to a national survey. Ann Fam Med 2020;18:528–34.
132. Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Ann Emerg Med 2014;63:713–20.e1.
133. Lawson A. Psychological stress and fertility. In: Stevenson EL, Hershberger PE, editors. Fertility and assisted reproductive technology (Art): theory, research, policy and practice for health care practitioners. New York: Springer Publishing Company; 2016:65–86.
134. Wang A, Pasch L, Holley S, Huddleston HG, Jaswa EG. Anxiety and depression in patients undergoing oocyte cryopreservation and infertility. Fertil Steril 2021;116:e360.
135. Armuand G, Dhejne C, Olofsson JI, Rodriguez-Wallberg KA. Transgender men's experiences of fertility preservation: a qualitative study. Hum Reprod 2017;32:383–90.
136. Kerman HM, Pham A, Crouch JM, Albertson K, Salehi P, Inwards-Breland DJ, et al. Gender diverse youth on fertility and future family: a qualitative analysis. J Adolesc Health 2021;68:1112–20.
137. Douglas CR, Phillips D, Sokalska A, Aghajanova L. Fertility preservation for transgender males: counseling and timing of treatment. Obstet Gynecol 2022;139:1012–7.
138. Practice Committee of the American Society for Reproductive Medicine and the Practice Committee for the Society for Assisted Reproductive Technology. Electronic address: ASRM@asrm.org. The Practice Committee for the Society for Assisted Reproductive Technology. Electronic Address AaO. Guidance regarding gamete and embryo donation. Fertil Steril 2021;115:1395–410.