I was a third-year internal medicine resident when a 40-year-old male-to-female transgender patient with HIV infection was assigned to my outpatient care. She had recently been hospitalized for a hypertensive emergency. She had not seen a doctor in 6 years. Her previous physician insisted on referring to her as "he" or "him," even after she advised him that she was female in every way, except for her biological makeup.1
We muddled through that first visit, but developed a good rapport. She asked if I would continue her estrogen therapy. She had been buying estrogen from friends and sharing needles for the injections and believed that she had been infected with HIV as a result of needle-sharing.2,3 Although her HIV infection was my major concern, it was stable, and antiretroviral therapy (ART) was not yet available.
Her primary concern was her ability to continue hormone treatment under a doctor’s care. My attending physician instructed me to send her to an endocrinologist, but the consultation report was vague and provided no clear guidance, so I spent countless hours in the medical library searching through textbooks and journals to learn more.
Today, information is at our fingertips because of the Internet; however, even today, resources, medical education, and training for transgender care are lacking.4-6
Care for the HIV-Infected Transgender Patient is a useful tool, especially for medical providers who are inexperienced in the care of these patients. An understanding of gender identity, sexual orientation, and sexual preferences is critical to successful engagement and management. In addition, transgender terminology is constantly evolving and it is important to use terminology that is current and respectful.7 The guideline provides basic terminology that will help to establish mutual understanding and will facilitate conversations about issues affecting the patient.7
HIV-infected transgender people experience stigma on many levels. They are frequently the victims of violence and other forms of discrimination. The guideline walks providers through a psychosocial and mental health assessment specific to transgender-related issues. In addition, the physical examination can be a traumatic experience for some patients; the guideline discusses how to alleviate this anxiety and the need for sensitivity.
HIV-infected transgender patients are sometimes hesitant to accept ART because they are concerned that interactions with hormones will diminish the feminizing or masculinizing effects of cross-gender hormone therapy. A section of the guideline is dedicated to concomitant hormone therapy and ART.
Finally, the guideline provides risk reduction and harm reduction counseling for transgender patients who report potentially harmful behaviors, such as illicit hormone use, silicone use, and needle-sharing.
The guideline contains links to resources that discuss specific aspects of hormonal management. The Harry Benjamin International Gender Dysphoria Association, now known as World Professional Association for Transgender Health, is the foremost resource for medical care of transgender patients.8
My hope is that physicians and other providers will become proficient at caring for this population. As with all other conditions, we should never stop searching and learning.
- Kuehn BM. IOM: Data on health of lesbian, gay, bisexual, and transgender persons needed. JAMA. 2011;305:1950-1951. Abstract
- Herbst JH, Jacobs ED, Finlayson TJ, et al. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. AIDS Behav. 2008;12:1-17. Abstract
- Murrill CS, Liu KL, Guilin V, et al. HIV prevalence and associated risk behaviors in New York City’s house ball community. Am J Public Health. 2008;98:1074-1080. Abstract
- Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94:3132-3154. Abstract
- Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306:971-977. Abstract
- Gorton R, Buth J, Spade D. Medical Therapy and Health Maintenance for Transgender Men: A Guide for Health Care Providers. San Francisco, Calif: Lyon-Martin Women’s Health Services; 2005.
- Gender Identity Project. Trans Basics: Glossary of Terms. New York, NY: The Lesbian, Gay, Bisexual & Transgender Community Center.http://www.gaycenter.org/gip/transbasics/glossary Accessed March 27, 2012.
- World Professional Association for Transgender Health (formerly the Harry Benjamin International Gender Dysphoria Association). WPATH Standards of Care. Minneapolis, Minn: World Professional Association for Transgender Health. www.wpath.org Accessed March 27, 2012.