Primary Care Initiated Gender-Affirming Therapy for Gender Dysphoria: A Review of Evidence Based Guidelines [Internet]

“Transgender” is an umbrella term used to describe individuals with gender diversity. Transgender people include those whose gender identity or expression differs from that assigned at birth. Gender dysphoria refers to the discomfort or distress caused by the discrepancy between a person’s gender identity (their psychological sense of themselves as men or women) and the sex assigned at birth and the associated primary or secondary sexual characteristics and/or expected social gender role. Changes to social role and presentation are typically observed in transgender people. Individuals with gender dysphoria may identify as men and women, or as gender variant, transgender, transsexual, transvestite, non-gender, pangender, polygender, gender queer, androgyne, neutrois or many other terms. The current population estimates of transgender and gender nonconforming people range from 0.17 to 1,333 per 100,000 worldwide. In British Columbia, the number of transgender people was estimated to be over 23,157 (based on a prevalence of 0.5%) in 2014. However, the proportion of this population is likely underestimated. The pressures associated with unmanaged dysphoria and/or the social stigma that can accompany gender diagnosis and transition may result in clinically significant levels of distress that would require medical assistance, in particular, specialist experience of the field.Historically, medical care for transgender people has been provided in highly specialized gender centers, where mental health professionals, endocrinologists or other specialists carried out appropriate assessment and subsequent treatment if necessary. These treatments can include a combination of medical (cross-sex hormone therapy), surgical (genital reassignment surgery and non-genital surgical procedures), mental health and other related treatments and services (e.g. speech and voice therapy).,, However, delayed treatment initiation and barriers to access are common, because the specialists are usually located in major centers. According to a project in Ontario, approximately 70% of transgender people live outside the Greater Toronto Area, although urban centers are often sought out by those who wish to access healthcare.Since the last decade, there has been increasing recognition that people with gender dysphoria may be well-served in primary care settings and, with additional training, family physicians and nurse practitioners may provide some gender-affirming services., The role of primary care providers may include performing initial examinations, working with referring psychiatrists (to make sure there is support available between referral and appointment if needed). Also in the longer term, in a primary care setting, physicians can be responsible for the life-long monitoring of their patient’s wellbeing, which involves conducting simple monitoring tests, examinations and medication reviews as recommended by the specialists. In addition to transgender-specific care, transgender people also require ongoing primary and preventive care, such as the need for cervical screening in transmen and breast cancer screening in transwomen. In this way, transgender-specific healthcare needs are assumed to be addressed in a timely and effective manner in the context of primary care. Survey results from a group of 11 adult transgender patients in Ontario echoed that most transgender people expected care to be delivered by family physicians when it is possible. In another interview with 13 physicians from Ontario, the doctors identified barriers when providing healthcare services to transgender patients, such as challenges accessing resources, a lack of knowledge, ethical considerations regarding medical transitioning treatments, or the process of diagnosing gender identity disorder.The objective of this report is to review and critically appraise the evidence-based clinical practice guidelines regarding primary care-initiated gender-affirming therapy for adults with gender dysphoria.