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Gender Affirmation Roadmap: Getting Started and Knowing Your Options for Affirming Care

If you are considering medical-affirming care or are seeking additional treatment steps, specialists who are culturally competent in LGBTQ+ health care can help you along your journey.

Gender affirmation is rarely a clear-cut process, and it is unique to each person. Depending on your individual wants and needs, there may be multiple medical or social steps taken, few or none at all.

Jefferson Health has an extensive network of LGBTQ+-affirming providers. We spoke with a few of them – Christopher Huff, LCSW, LCADC (he/him) , behavioral health specialist and licensed clinical drug and alcohol counselor; Marina Khazan, APN (she/her), primary care provider; Jennifer Bidey, DNP, APN, FNP-BC (she/her), primary care provider; and Meredith Stein, CNM (she/her), certified nurse-midwife – to better understand what gender affirmation involves.

How do you know if you would benefit from gender-affirming care?

To understand and be comfortable with your gender identity – or your internal perception of where you fall on the gender spectrum – is the first, most important step, explains Huff.

“Only patients themselves can truly answer this question,” says Khazan, who suggests joining support groups, doing research, working with a behavioral or mental health professional and simply being honest with yourself.

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Differences between social and medical affirmation

Gender affirmation can involve a variety of social and medical components that help those who are transgender or gender-diverse live more affirming lives. Changes may strengthen a person’s gender expression, or the way we show the “outside world” our gender identity, explains Huff.

Social gender affirmation may involve altering one’s appearance, wardrobe and means of grooming. They may also update their name, pronouns and legal documentation.

On the other hand, medical affirmation may involve gender-affirming hormone therapy (GHT), (GAHT) such as estrogen (with or without anti-androgen medication, which blocks the effects of testosterone) or testosterone; chest or top surgery; gender-affirming bottom surgery; or facial surgery, such as shaping of face and hair removal.

“The most important thing to remember about gender-affirming care is that the goal is to affirm your identity,” says Dr. Bidey. “We work with patients to find the safest and most appropriate plan, tailored to individual needs and levels of comfort.”

What is needed before receiving medical-affirming care?

To access GAHT or surgery, you typically need to be cleared by your primary care provider; an endocrinologist may also be able to prescribe GAHT. Letters of medical necessity may be required by your insurance, but medical staff often assist with this part of the process. In some cases, therapy visits are also needed to ensure any current mental health conditions are stable, says Huff.

In addition to mental health, physical health should also be checked – through routine blood work and a physical – before starting hormones or undergoing surgery. This takes any significant health risks into consideration, explains Khazan.

Christopher Huff walking with a physician down a hallway in a clinic
Christopher Huff walking with Marina Khazan at the Haddonfield Primary & Specialty Care, An LGBTQ+ Affirming Practice, in Haddonfield New Jersey. (Photo Credit: Steve Belkowitz)

How can a behavioral health professional help?

Therapy is not always required, but it may be beneficial if you’re just starting gender-affirming treatments. “It’s important to make sure you’re practically prepared by knowing all your options and setting realistic goals and expectations. Therapy may serve as a much-needed support system.”

How long does gender-affirming care last?

Gender-affirming care can last as long as you want it to, or until you achieve the goal you’re looking for, says Huff. It doesn’t have to be rushed.

“Too often, people believe there are a set of boxes they have to check off in gender-affirming care. They have to have GAHT and surgery,” said Dr. Bidey. “This is simply not true. Not every intervention – or any intervention, for that matter – is necessary for every person. It’s a unique journey, that you should take at your own pace.”

How does GAHT work?  

Testosterone is typically injected into fat under the skin of the abdomen (subcutaneously), but it can also be injected into the muscle of the glutes or the thigh (intramuscular). Testosterone can also be administered through a patch, topical gel, or an implanted pellet. Estrogen can be administered through a variety of methods, including pills, gels, skin patches or injections. It’s often taken along with anti-androgen medication.

Most people start with a low dose and have it gradually increased, but it depends on your individual preferences and health status, says Khazan.

What works for one person may not work well for another, which is why it’s crucial to take an individualized approach, adds Dr. Bidey. “We look closely at medical risk factors and comfort level. For example, not everyone is comfortable giving themselves injections; this should always be considered when choosing the safest and most effective GAHT plan.”

Estrogen GAHT changes:

  • Breast development – 3-6 months – irreversible
  • Decreased facial/body hair growth – 3-6 months – reversible
  • Softening of skin/decreased oiliness – 3-6 months – reversible
  • Decreased muscle mass – 3-6 months – reversible
  • Infertility varies
  • Decreased libido/erections – starts within 1-3 months – reversible

Testosterone GAHT changes:

  • Increased muscle mass – 6-12 months — reversible
  • Facial/body hair growth – 3-6 months – varies
  • Body fat redistribution – 3-6 months – reversible
  • Potential cessation of menses (menstrual cycle stops) – 2-6 months – reversible
  • Deepened voice – 3-12 months – irreversible
  • Clitoral enlargement – 3-6 months – irreversible
  • Increased skin oiliness/acne – starts within 1-6 months – reversible
  • Scalp hair loss varies
  • Vaginal atrophy – 3-6 months – reversible
  • Infertility varies and pregnancy is still possible while taking testosterone

Appetite may also change due to a shift in metabolism, explains Khazan. This is often discussed beforehand and, if desired, can be managed with a registered dietitian.

Can you suppress your menstrual cycle without GAHT?

If you are interested in solely stopping your menstrual cycle – but no other effects of testosterone – there are additional safe and effective ways to do so, explains Stein. “Patients can take traditional oral contraceptive pills – containing both estrogen and progesterone – continuously, skipping the ‘sugar pills,’ to suppress ovulation. This can usually be achieved within two to three months of being ‘on the pill.’”

Progesterone-only injections, pills or IUDs may also be appropriate, although they can take a little longer to work. Don’t hesitate to speak with an OBGYN or midwife to determine what treatment path is right for you, and what you’re most comfortable with, says Stein.

How does gender-affirming surgery work?

Gender-affirming surgeries affect both appearance and function. Some people may elect to have multiple procedures, while others choose none. With the assistance of your primary care provider and patient navigator, you may be referred to a specialist for any of the following:

Chest Surgery:

  • Top surgery involves complete mastectomy or reduction with or without chest reconstruction based on preference.
  • Breast augmentation enhances breasts using implants and sometimes fat grafting from other areas of the body.

Bottom Surgery: Bottom surgery options vary, which may affect the number of surgeries required to achieve your goals. Some people desire only the removal or construction of genitalia, while others prefer both, which may be done all at once or staged in multiple procedures, explains Huff.

  • Removal: A vaginectomy removes the vagina; hysterectomy removes the uterus; and a bilateral salpingo-oophorectomy removes the ovaries and fallopian tubes. An orchiectomy removes the testes; penectomy removes the penis; and a scrotectomy removes scrotal tissue.
  • Construction: A vaginoplasty, labioplasty, and cliteroplasty typically reconstruct external genitalia to form a vagina, labia, and clitoris. A vulvoplasty creates the parts listed above except for a vagina. Penile construction with or without urethral lengthening is achieved through a phalloplasty or metoidioplasty. Scrotoplasty is the creation of scrotum.

Keep in mind, any surgery inherently poses risks of bleeding, infection, and scarring complications. You should discuss any individual concerns with your surgeon beforehand.

Transgender family planning

Family planning may be nerve-wracking, but an LGBTQ+ affirming OBGYN or midwife can offer many options, says Stein. “We’re here to support your journey however possible. We have preconception visits to determine the best option, can order preconception testing, recommend prenatal vitamins, and connect you with further fertility care when needed.”

Someone on testosterone therapy may choose to stop it temporarily to have their menstrual cycle return and conceive a pregnancy on their own, explains Stein. Some physical attributes of the testosterone may decrease, but they won’t go away completely.

Other families opt for intrauterine insemination (IUI) – which places sperm directly inside the uterus to improve the chances of fertilization – which can be done either at home or in the office, says Stein. Of course, many couples are still able to conceive spontaneously through intercourse.

Why it’s important to continue care

Medical-affirming care is not just a “one and done” situation, says Khazan. Even if you do not desire to medically transition, you should continue your routine health visits to care for every aspect of your well-being.

Being on GAHT long term may pose unique health concerns, adds Khazan. It’s ideal for lab work to be monitored routinely – initially, every three months and, eventually, every six months to a year – to reduce potential side effects. While rare, GAHT can increase the risk for blood clots, elevated blood sugar levels, heart disease, stroke and some cancers.

Follow-up with gynecological care is also particularly concerning, suggests Stein. Studies show that many LGBTQ+ individuals are less likely to seek gynecological care; this may be due to minimal access to LGBTQ+ affirming providers; a general lack of provider knowledge and education regarding the LGBTQ+ population; past negative experiences when seeking care; fear of discrimination by healthcare providers, staff, or other patients; and/or gender dysphoria.

LGBTQ+ affirming providers provide essential screening for chest/breast cancer, cervical cancer, prostate cancer, testicular cancer, and sexually transmitted infections. They can also treat sexually transmitted infections, initiate Pre-Exposure Prophylaxis (PrEP) medication to help prevent HIV, help address sexual performance concerns and much more. Stein explains, “If you haven’t undergone top or bottom surgery, chest exams and Pap smears can prevent cancer development or catch it early, when it’s more curable.”

[Editor’s Note: Read more about why gynecological cancer screening is a must for the LGBTQ+ community here.]

Like anyone else, it’s important that you don’t ignore any health concerns, continues Khazan. The first step is always letting your primary care provider know, so that we can refer you to a dietitian, cardiologist, endocrinologist, infectious diseases specialist, OBGYN or midwife, or any other specialist.

[Main photo credit: Bambina]

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