Obstetrician-gynecologists must offer sensitive and supportive care to transgender adolescents, a new committee opinion from American College of Obstetricians & Gynecologists (ACOG) recommends. The recommendations are important because one of the first places a transgender adolescent may express their feelings of gender dysphoria may be at their obstetrician-gynecologist's office. The committee opinion was published online December 21 and in the January 2017 issue of Obstetrics & Gynecology.

Transgender individuals have gender identities that differ from the sex they were assigned at birth. According to estimates from the World Professional Association for Transgender Health, about 1 in 11,900 individuals assigned a male gender at birth are transgender females, and about 1 in 30,400 individuals assigned a female gender at birth are transgender males. Obstetrician-gynecologists, who are increasingly seeing transgender patients, can provide both support and essential care to these individuals, according to ACOG's Committee on Adolescent Health.

"We have a responsibility to approach transgender adolescents in an informed and thoughtful fashion, positioning ourselves as part of their support network during what can often be a complicated and emotionally fraught process," Veronica Gomez-Lobo, MD, coauthor of the committee opinion and director of pediatric and adolescent obstetrics and gynecology at MedStar Washington Hospital Center/Children's National Health System, District of Columbia, said in a news release.

One of the first steps gynecology offices can take is to create a welcoming and supportive environment by offering gender-neutral forms, brochures, and other information for sexual minorities, and training all staff to be sensitive to the needs of this population, recommends the committee.

It is important for obstetrician-gynecologists to be familiar with treatment options for transgender individuals so they can counsel patients and refer them for specialist care when appropriate. When a transgender adolescent has been assessed and found to be ready for medical treatment, they may begin treatment to suppress puberty followed by use of cross-sex hormones starting at age 16 years, according to the committee. For example, transgender male patients receive testosterone. Physicians should be aware of the potential adverse effects of these treatments, which are outlined in the opinion. Some patients also may pursue surgery, although most procedures are performed after the age of 18 years. Obstetrician-gynecologists should discuss patients' potential fertility preservation options, such as egg or sperm preservation.

Transgender patients also require more routine psychosocial and physical care: Transgender adolescents often face rejection and harassment from parents or peers and have high rates of homelessness and attempted suicide. The committee recommends that physicians be prepared to assess and refer transgender patients to maintain their safety.

Transgender patients are at increased risk for sexually transmitted infections and should be counseled about prevention and undergo screening according to the committee.

Physicians should remain vigilant for potential symptoms of gynecologic conditions even when their patient's outward appearance is male. Transgender males may have female reproductive organs and may be at risk for pregnancy, gynecologic cancers, and other gynecologic conditions. Routine gynecologic work ups should continue, according to the committee.

"The essential components of our role as health care providers do not change because an adolescent patient is transgender," Dr Gomez-Lobo said. "Care should always include education about their bodies, deliberate and thoughtful assessment of symptoms or concerns, and preventive care services, like screenings and contraception. We are simply adding more nuanced cultural and medical understanding to those practices."

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2017;129:e11-e16. Full text

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