1. Access to Health Care
Transgender persons are often reluctant to seek medical care through a traditional provider-patient relationship.  Some are even turned away by providers.  A doctor who refuses to treat a trans person may be acting out of fear and transphobia, or may have a religious bias against GLBT patients. It’s also possible that the doctor simply doesn’t have the knowledge or experience he needs.  Furthermore, health care related to transgender issues is usually not covered by insurance, so it is more expensive.  Whatever the reasons, transgender people have sometimes become very ill because they were afraid to visit their providers.

2. Health History
Trans persons may hide important details of their health history from their doctors.  Perhaps they fear being denied care if their history is known. Even many years after surgery, they may omit the history of their transition when seeing a new provider. Patients should see their provider as an equal partner in their health care, not as a gatekeeper or an obstacle to be overcome.

3. Hormones
Cross-gender hormone therapy gives desirable feminizing (or masculinizing) effects, but carries its own unique risks.  Estrogen has the potential to increase the risk of blood clotting, high blood pressure, elevated blood sugar and water retention.  Anti-androgens such as spironolactone can produce dehydration, low blood pressure, and electrolyte disturbances. Testosterone, especially when given orally or in high doses, carries the risk of liver damage. Hormone use should be appropriately monitored by the patient and provider. Some trans people tend to obtain hormones and other treatment through indirect means, bypassing the health care system.  Taking hormones without supervision can result in doses too high or too low, with undesired results.

4. Cardiovascular Health
Trans persons may be at increased risk for heart attack or stroke, not only from hormone use but from cigarette smoking, obesity, hypertension, and failure to monitor cardiovascular risks.  Trans women may fear that a provider who finds them at risk for cardiovascular disease will instruct them to stop their hormones, and so they do not seek medical attention even when they have early warning signs of heart disease or stroke.  

5. Cancer
Hormone-related cancer (breast in trans women, liver in women or men) is very rare but should be included in health screening.  A greater worry is cancer of the reproductive organs.  Trans men who have not had removal of the uterus, ovaries, or breasts are still at risk to develop cancer of these organs.  Trans women remain at risk, although low, for cancer of the prostate.  Furthermore, some providers are uncomfortable with treating such cancers in trans people.  Some cases have been reported in which persons delay seeking treatment, or are refused treatment, until the cancer has spread.

6. STDs and Safe Sex
Trans people, especially youth, may be rejected by their families and find themselves homeless.  They may be forced into sex work to make a living, and therefore at high risk for STDs including HIV.  Other trans people may practice unsafe sex when they are beginning to experience sexuality in their desired gender.  Safe sex is still possible even in transgender relationships.

7. Alcohol and Tobacco
Alcohol abuse is common in transgender people who experience family and social rejection, and the depression which accompanies such rejection.  Alcohol combined with sex hormone administration increases the risk of liver damage.  Tobacco use is high among all trans persons, especially those who use tobacco to maintain weight loss.  Risks of heart attack and stroke are increased in persons who smoke tobacco and take estrogen or testosterone.

8. Depression/Anxiety
For many reasons, trans people are particularly prone to depression and anxiety.  In addition to loss of family and friends, they face job stress and the risk of unemployment.  Trans people who have not transitioned and remain in their birth gender are very prone to depression and anxiety.  Suicide is a risk, both prior to transition and afterward.  One of the most important aspects of the transgender therapy relationship is management of depression and/or anxiety.

9. Injectable Silicone
Some trans women want physical feminization without having to wait for the effects of estrogen.  They expect injectable silicone to give them “instant curves.”  The silicone, often administered at “pumping parties” by non-medical persons, may migrate in the tissues and cause disfigurement years later.  It is usually not medical grade, may contain many contaminants, and is often injected using a shared needle.  Hepatitis may be spread through use of such needles.

10. Fitness (Diet & Exercise)
Many trans people are sedentary and overweight.  Exercise is not a priority, and they may be working long hours to support their transitions.  A healthy diet and a frequent exercise routine are just as important for trans persons as for the public.  Exercise prior to sex reassignment surgery will reduce a person’s operative risk and promote faster recovery.

Author: Rebecca A. Allison, MDBoard of Directors, Gay and Lesbian Medical Association American Medical Association, Advisory Committee on GLBT Issues
Interventional Cardiologist, Phoenix, Arizona