FtM transsexuals. Treatment in FtM transsexuals is intended to virilize the individual with testosterone administration. Changes due to testosterone include male-pattern hair growth, degeneration of ovaries and uterus, enlargement of the clitoris, and the cessation of uterine bleeding. Depending on the sexual reassignment surgery, a hysterectomy and oophorectomy may be involved, or the ovaries may be left in place.132

Because androgens are partially metabolized into estradiols, there may be estrogenic stimulation of the remaining breast tissue, which increases risk of cancer. FtM transsexuals are particularly at risk if they have the BRCA1 or BRCA2 genetic mutation.141,142 FtM transsexuals who have not had oophorectomy can develop polycystic ovaries or cancer. FtM transsexuals who have not had a hysterectomy can develop proliferation of the endometrium, and cervical tissue can undergo cancerous changes. Therefore, a periodic Pap smear is necessary.130,132,135

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The patient’s new phallic tissue is derived from skin of the forearm, which is loose tissue. Urethral complications occur in more than 30% of FtM patients, and surgical revision is necessary.143,144 The clinician needs to completely understand the anatomy of the FtM patient in order to make clinical decisions about screening and treating disease.

Long-term treatment. After sex-reassignment surgery, including gonadectomy, hormonal therapy must be continued.130,145 Some MtF individuals continue to have male-pattern hair growth; continued administration of antiandrogens, typically at approximately half the preoperative dose, reduces male-pattern hair growth.135 Continued administration of estradiol is required to avoid symptoms and signs of hormone deficiency, such as vasomotor symptoms and osteoporosis in MtF transsexuals. Observational studies have shown that bone mass is generally maintained with estrogen alone in MtF individuals and with testosterone alone in FtM individuals when prescribed at the doses typically used to treat hypogonadism.146

Cancer. Long-term administration of cross-sex hormones may increase risk of hormone-dependent cancer. In both MtF and FtM transsexuals, estrogen-dependent cancers can develop because in MtF people, estrogen is administered, and in FtM people, testosterone is partially converted into estradiol.135 However, according to Mueller and Gooren,147 there are rare case reports of prolactinomas, breast cancers, and prostate carcinomas in MtF patients and rare reports of ovarian carcinoma, breast cancer, and vaginal cancer in FtM patients. There are also infrequent cases of hormone-dependent tumors in organs other than the reproductive organs due to estrogen.140 However, the available data are from studies that involved relatively short-term exposure. Risks may become more apparent as subjects age and the duration of hormone exposure increases.

STDs. Transgender patients may have sex with men, women, or both. Because of the diverse nature of sexual partners among transgender persons, providers must recognize symptoms of common STDs and screen for asymptomatic STDs on the basis of individual sexual practices.148

Transsexual individuals have high rates of HIV and AIDS.149,150 Herbst and colleagues, in a meta-analysis of four studies, found approximately 28% of transsexuals were HIV-positive.150 Highest rates (56%) were among African-American MtF transsexuals. Within an STD clinic in Los Angeles, California, Edwards and coworkers found that transsexuals had a 35% prevalence rate of HIV infection.151 Grant and associates surveyed 6450 transsexual individuals and found the rate of HIV infection was more than four times the national average, with highest rates among MtF persons.152 Transsexual individuals have a higher rate of HIV diagnosis than other high-risk populations, including MSM or partners of persons infected with HIV.153

Transsexual individuals who were unemployed or who had engaged in sex work had particularly high rates of HIV. Early sexual experiences, having multiple partners, needle sharing, and random sexual contacts increase the risk for HIV/AIDS, especially for MtFs.97,151,154 According to a study by Carobene and colleagues,155 HBV and HCV coinfection is common in transsexual sex workers.

HPV is particularly prevalent in transsexual sex workers. A study of transsexual sex workers in Argentina showed a 97% prevalence rate.156 According to Loverro and colleagues,157 there is a high rate of oncogenic-type HPV infection among transsexual persons that puts them at high risk for anogenital cancer. Periodic Pap smears and HPV vaccination are advised.

According to a study by Fernandes and associates, the prevalence rate of syphilis among transgender women was 35% in Central Brazil.158 Among transgender women, being aged 30 years or older, having more than 10 male sexual partners in the past week, and being infected with HIV were associated with syphilis.

Mental health issues. Transgender individuals can experience social isolation, prejudice, harassment, and violence from others. Screening for violence should be conducted and patients who have experienced trauma should be evaluated for symptoms of post-traumatic stress disorder. Substance abuse can occur in transgender individuals coping with gender dysphoria or stressful environments. Referral for psychiatric illness and substance abuse treatment should be to a mental health provider with an understanding of transgender care issues.128

Transsexual individuals have high rates of depression, self-harm, substance abuse, and suicide.9,100,159,160 Stigma due to nonconformity, sexual experiences at an early age, a history of physical or sexual abuse, and lack of important social support increase risk for suicidality in this population.161 Grant and colleagues reported that 41% of transsexuals in the United States have attempted suicide.152 This is in contrast to the less than 2% of persons who attempt suicide in the general population.162