Eduovisual
Ethics, Communication & Professionalism
LGBTQ+ patient care: communication and clinical considerations
— LGBTQ+ encompasses lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, and other sexual/gender minority identities
— Estimated 7–8% of US adults identify as LGBTQ+; ~1.6 million adults and adolescents identify as transgender
— Sexual orientation (attraction/identity) and gender identity are distinct from sex assigned at birth and from sexual behavior — all four must be assessed separately in clinical care
— LGBTQ+ patients experience documented health disparities: higher rates of depression, suicide, substance use, intimate partner violence, HIV/STIs, certain cancers, cardiovascular disease, and delayed care
— Disparities are driven by minority stress, structural discrimination, and prior negative healthcare encounters — not by identity itself
— Up to 30% of LGBTQ+ patients report avoiding or delaying care due to anticipated discrimination
— Every adult and adolescent preventive visit: routinely ask about sexual orientation, gender identity, sex assigned at birth, and sexual behavior (the SOGI + behavior framework)
— New patient intakes, sexual health visits, mental health visits, prenatal/preconception counseling, adolescent well-checks
— Any visit involving HIV/STI screening, contraception, cancer screening recommendations, or hormone therapy
— Use the patient's stated name and pronouns, even if they differ from the legal/EHR record
— Screen by anatomy present, not gender identity (e.g., cervical cancer screening for any patient with a cervix; prostate considerations for any patient with a prostate)
— Avoid assumptions about partners, sexual practices, or family structure
Board pearl: A 28-year-old transgender man (assigned female at birth) with an intact cervix still needs cervical cancer screening per USPSTF age-based guidelines — screen the organ, not the identity. Discomfort with pelvic exams is common; offer self-collected HPV swabs when available, topical lidocaine, and a trusted clinician.
— Introduce yourself with your own pronouns: "I'm Dr. Lee, I use she/her — what name and pronouns do you use?"
— Normalize the questions: "I ask all my patients about sexual orientation, gender identity, and sexual health so I can give the best care"
— Ensure privacy; ask sensitive questions without family/partners in the room when possible, especially for adolescents
— Partners: number, genders ("Do you have sex with men, women, both, or others?"), new vs ongoing
— Practices: oral, vaginal, anal — receptive vs insertive (determines exposure site for STI screening)
— Protection: condoms, barriers, PrEP, PEP awareness
— Past STIs: including HIV, syphilis, gonorrhea, chlamydia, HPV, HSV
— Pregnancy/prevention: contraception, fertility goals — do not assume sterility based on identity or hormones
— Sex assigned at birth, current gender identity, name/pronouns
— Stage of social, medical, and/or surgical transition (if any)
— Current hormone use (prescribed vs non-prescribed/online sources)
— Surgical history: top/chest surgery, hysterectomy, orchiectomy, vaginoplasty, phalloplasty, metoidioplasty — affects which organs to screen
— Depression and suicidality (LGBTQ+ youth 4× higher attempt rate; transgender youth higher still)
— Intimate partner violence (occurs at equal or higher rates than in cisgender heterosexual relationships)
— Family rejection, housing insecurity, school/work harassment
— Substance use, particularly tobacco, alcohol, methamphetamine, and "chemsex" patterns
Key distinction: Sexual orientation (who you're attracted to) ≠ sexual behavior (who you have sex with) ≠ gender identity (who you are) ≠ sex assigned at birth. A woman who identifies as straight may still have sex with women; a transgender woman may have sex with men, women, or both. Ask all four domains explicitly rather than inferring.
— Explain every step before touching; obtain verbal consent for sensitive exams (chest, genital, pelvic, rectal)
— Offer a chaperone regardless of clinician/patient gender
— Use neutral anatomic language when preferred by patient ("chest" rather than "breasts"; "genitals" or patient's own terms)
— Ask which terms the patient uses for their body
— Transgender men post-chest surgery: residual breast tissue often remains — palpate scar margins and axilla
— Transgender women on estrogen ≥5 years: developing breast tissue; follow screening guidance below
— Patients who bind chest: inspect for skin breakdown, fungal intertrigo, rib pain, restrictive symptoms; counsel on safe binding (≤8 hours, properly sized binder)
— Often a site of significant dysphoria and prior trauma — consider deferring if not urgent, or splitting the visit
— Use the smallest speculum that allows adequate visualization; topical lidocaine gel; vaginal estrogen pre-treatment for transgender men on testosterone (atrophic changes are common)
— For neovaginas (post-vaginoplasty): tissue is typically penile inversion or intestinal graft — no cervix, but examine for granulation tissue, stenosis, hair (if scrotal skin used), and dilator adherence
— Tucking practices in transgender women: assess for testicular discomfort, hernia, candidiasis
— Document anatomy inventory separately from gender marker
— BMI interpretation: hormone therapy alters fat distribution; use clinical judgment
Step 3 management: A transgender man presents for a routine Pap — vaginal atrophy from testosterone causes high rates of "unsatisfactory" cytology. Pre-treat with topical estrogen for 1–2 weeks, schedule extra time, offer anxiolytic if needed, and consider primary HPV testing or self-swab where validated. Document the encounter in trauma-informed language to support future visits.
Board pearl: Always perform an organ inventory — screening decisions follow anatomy, not identity or pronouns.
— Cervix present (cisgender women, transgender men, nonbinary AFAB): cytology q3y ages 21–29; cytology + HPV co-test q5y or HPV alone q5y ages 30–65
— Breast tissue: cisgender women and transgender women on estrogen ≥5 years — biennial mammography ages 40–74 (USPSTF 2024); transgender men with intact breasts follow female guidelines; post-mastectomy chest wall — clinical exam only
— Prostate present (cisgender men, transgender women): shared decision-making PSA ages 55–69; estrogen lowers PSA baseline — interpret cautiously
— Anal cancer: HPV-driven; consider anal cytology/HRA in HIV+ MSM and transgender women, and HIV– MSM ≥35; ANCHOR trial supports treating HSIL in HIV+ adults ≥35
— Colorectal: standard age 45–75 regardless of identity
— Estrogen therapy (esp. oral): ↑ VTE, possibly ↑ stroke and MI — favor transdermal estradiol in patients >40 or with risk factors
— Testosterone therapy: ↑ hematocrit, ↑ LDL, ↓ HDL, possible BP elevation — monitor lipids and Hct
— Apply ASCVD pooled cohort equations using the sex that aligns with hormonal milieu after several years of therapy (no perfect tool — clinical judgment)
— Hormone non-adherence post-gonadectomy → accelerated bone loss
— DEXA at age 65, or earlier if hormone-discontinued post-gonadectomy, low BMI, glucocorticoid use, or other risk factors
— Annual screening: PHQ-9, GAD-7, AUDIT-C, tobacco use (higher prevalence in LGBTQ+ adults)
— Suicide risk screening at every behavioral health touchpoint
Board pearl: A 45-year-old transgender woman on estrogen ×7 years asks about mammography. Begin biennial screening at age 50 per most expert consensus (Endocrine Society/UCSF) given ≥5 years of feminizing hormones, though absolute risk remains lower than in cisgender women. Cervical screening is not needed — no cervix.
— All adults 13–64: HIV at least once (opt-out)
— MSM: HIV, syphilis, gonorrhea, chlamydia (3-site: pharyngeal, rectal, urethral by exposure) — at least annually; every 3–6 months if multiple partners, condomless sex, or methamphetamine use
— Transgender women, particularly those with male partners: screen as MSM
— Hepatitis: HBV and HCV screening at least once in all adults; HCV annually in MSM with HIV or on PrEP; HAV/HBV vaccination if non-immune
— HPV vaccination: routine through age 26; shared decision-making 27–45
— Offer to any sexually active adolescent/adult at risk: MSM with condomless anal sex, multiple partners, recent STI, partner with HIV with detectable VL, or injection drug use
— Regimens:
— TDF/FTC (Truvada): all genders, all exposures, including receptive vaginal/frontal
— TAF/FTC (Descovy): MSM and transgender women; not approved for receptive vaginal sex (insufficient data)
— Cabotegravir IM q2 months: injectable option, particularly for adherence challenges
— Baseline: HIV Ag/Ab + RNA, HBV, HCV, syphilis, GC/CT (3-site), Cr, urinalysis, pregnancy test
— Follow-up: HIV testing q3 months, STI screening q3–6 months, renal function q6–12 months
— Start within 72 hours of exposure; preferred regimen TDF/FTC + dolutegravir or raltegravir × 28 days
— Transition to PrEP at completion if ongoing risk
Step 3 management: A 24-year-old man requests PrEP after starting a new relationship. Confirm HIV-negative status with 4th-gen Ag/Ab and HIV RNA (to exclude acute HIV — starting 2-drug PrEP during acute infection drives resistance). If both negative, start TDF/FTC daily, follow up in 1 month then every 3 months. CCS pearl: order baseline HBV serologies — TDF treats HBV, and discontinuation can cause hepatitis flare.
— Informed consent model: now standard in primary care for most adult patients seeking hormones; mental health letters no longer required for hormones per WPATH SOC-8 (still often required for major surgeries depending on insurer)
— Multidisciplinary: primary care, endocrinology, mental health, surgery, voice therapy, social work
— Align secondary sex characteristics with gender identity
— Reduce gender dysphoria; improve mental health (robust evidence: ↓ depression, ↓ suicidality)
— Individualized — not all patients desire hormones or surgery
— Confirm persistent gender incongruence and capacity to consent
— Discuss fertility implications BEFORE starting hormones: sperm banking (transgender women), oocyte/embryo cryopreservation (transgender men) — fertility may not return after prolonged therapy
— Baseline labs: CBC, CMP, lipid panel, HbA1c, prolactin (estrogen), testosterone, estradiol; HIV/STI; pregnancy test if applicable
— Cardiovascular risk assessment; VTE history; tobacco cessation strongly encouraged before estrogen
— Bone density if risk factors
— Pubertal suppression with GnRH agonists (leuprolide, histrelin) at Tanner stage 2 — reversible, allows time for exploration
— Gender-affirming hormones typically initiated mid-adolescence per WPATH/Endocrine Society
— Surgical interventions generally deferred until adulthood, with rare exceptions (chest surgery in older adolescents)
— State laws vary significantly — know your jurisdiction
Board pearl: Gender-affirming hormone therapy is associated with reduced suicidality and depression in well-conducted cohort studies; denying care is not neutral. Document shared decision-making, discussion of risks/benefits/alternatives, and fertility preservation counseling.
Key distinction: Social transition (name, pronouns, clothing) is fully reversible; pubertal blockade is largely reversible; hormones are partially reversible (some changes permanent: voice deepening, hair growth); surgery is largely irreversible.
— Transdermal estradiol patch 0.025–0.2 mg/day (preferred if ≥40 yo, VTE risk, smoker, migraine — lowest VTE risk)
— Oral estradiol 2–8 mg/day (highest VTE/stroke risk due to first-pass hepatic effect)
— Estradiol valerate IM/SC 2–10 mg weekly or 5–20 mg q2 weeks (peaks/troughs)
— Avoid ethinyl estradiol and conjugated equine estrogens — high VTE risk, not measurable on assays
— Spironolactone 50–200 mg/day: most common in US; monitor K+, BP, renal function; warn about polyuria
— GnRH agonists (leuprolide): effective, expensive — used in Europe, with orchiectomy avoidance, or when spironolactone contraindicated
— Finasteride/dutasteride: for scalp hair preservation, not primary anti-androgen
— Anti-androgens can be discontinued after orchiectomy
— 1–3 months: ↓ libido, ↓ erections, softer skin
— 3–6 months: breast budding, fat redistribution, ↓ muscle mass
— 1–2 years: maximal breast development (often Tanner 2–3), ↓ testicular volume
— Voice does NOT change with estrogen — voice therapy or surgery needed
— Body/facial hair lightens but persists — electrolysis/laser required
— Every 3 months × first year, then 6–12 months: estradiol, testosterone, K+ (if spironolactone), CMP
— Annually: lipids, HbA1c, prolactin, BP, weight
— Screen for VTE symptoms at each visit; consider stopping or switching to transdermal if VTE occurs
Step 3 management: A 52-year-old transgender woman on oral estradiol and spironolactone develops a DVT. Stop oral estrogen, anticoagulate per standard guidelines (DOAC × 3 months for provoked, longer if unprovoked), and after acute treatment transition to transdermal estradiol — which carries minimal excess VTE risk and allows continuation of affirming care.
— Testosterone cypionate/enanthate IM or SC 50–100 mg weekly (or 100–200 mg q2 weeks)
— Testosterone gel 1.62% 20.25–81 mg/day — transfer risk to others
— Testosterone undecanoate IM q10–14 weeks — black box for pulmonary oil microembolism
— Subcutaneous injection is well-tolerated and often preferred
— 1–6 months: acne, ↑ libido, cessation of menses (usually by 6 months), clitoral growth
— 6–12 months: voice deepening (permanent), facial/body hair growth (permanent), fat redistribution, muscle mass increase
— Variable: male-pattern scalp hair loss, vaginal atrophy
— Menses cessation ≠ infertility — ovulation can resume; contraception still needed if pregnancy possible and undesired
— Every 3 months × first year, then 6–12 months: total testosterone (mid-cycle for IM), estradiol, CBC (Hct), lipids, LFTs
— Hct >54%: dose reduce, switch to transdermal, or therapeutic phlebotomy
— BP, weight, mood at each visit
— Continue cervical/breast screening per anatomy
— Chest masculinization (top surgery): double incision mastectomy with nipple grafts, or periareolar — most commonly pursued
— Hysterectomy ± BSO: reduces dysphoria; if BSO, ensure ongoing testosterone for bone health
— Genital surgery: metoidioplasty (releases hormonally enlarged clitoris) or phalloplasty (free flap, often radial forearm or ALT) ± urethral lengthening, scrotoplasty, testicular implants
— Feminizing surgery: orchiectomy, vaginoplasty (penile inversion most common), breast augmentation, facial feminization, tracheal shave
Board pearl: Hct rising on testosterone — first reduce dose or switch to transdermal/SC; consider OSA workup (testosterone worsens OSA, which raises Hct); phlebotomy if persistent and symptomatic. Do not simply stop testosterone unless thrombosis occurs.
CCS pearl: Post-vaginoplasty patients require lifelong dilation to maintain neovaginal depth — ask about adherence; granulation tissue responds to silver nitrate.
— Often lack traditional family support; "chosen family" common — clarify decision-makers and emergency contacts
— Higher rates of social isolation, depression, and economic insecurity
— Many lived through the HIV epidemic and pre-Stonewall stigma — anticipate medical mistrust
— Long-term care environments: screen for re-closeting; advocate for facilities with non-discrimination policies
— No mandatory upper age limit; continue if benefits outweigh risks
— Transdermal estradiol preferred in patients >40 — markedly lower VTE/stroke risk
— Reassess after VTE, MI, stroke, breast cancer, or hormone-sensitive malignancy — often continue at reduced doses or switch routes
— Testosterone: monitor Hct, cardiovascular status, prostate (if present)
— Spironolactone: reduce or avoid in CKD stage 4–5 (hyperkalemia) — consider GnRH agonist or post-orchiectomy regimen
— Oral estrogens: avoid in hepatic impairment; transdermal acceptable
— Adjust PrEP: TDF requires CrCl ≥60; TAF acceptable down to CrCl 30; cabotegravir no renal adjustment
— HIV ART selection per renal/hepatic function — coordinate with ID
— Spironolactone + ACEi/ARB/NSAIDs → hyperkalemia
— Estrogen + tamoxifen/aromatase inhibitors → conflict; oncology input
— Testosterone + warfarin → potentiation; monitor INR
— Finasteride affects PSA interpretation (×2 correction)
Step 3 management: A 68-year-old transgender woman on estradiol patch and spironolactone presents with new AKI (Cr 2.1, baseline 1.0) and K+ 5.8. Hold spironolactone, treat hyperkalemia, evaluate AKI cause. After recovery, transition anti-androgen strategy — consider GnRH agonist or, if she's interested, orchiectomy to eliminate need for anti-androgen entirely.
Board pearl: Advance care planning is critical — designate healthcare proxy in writing, as biological family may not be supportive or may not match patient's wishes.
— Confidentiality is paramount — review state laws on minor consent for STI/contraception/mental health care
— Screen all adolescents for SOGI, bullying, family support, housing stability (LGBTQ+ youth are overrepresented in homelessness)
— Suicide screening at every visit — connect to The Trevor Project (1-866-488-7386) or 988 lifeline
— Affirming care reduces suicidality; family acceptance is the single strongest protective factor
— Transgender men and nonbinary AFAB patients can become pregnant — even on testosterone
— Testosterone is teratogenic (virilizes female fetus) — discontinue immediately if pregnancy desired or confirmed; counsel on contraception if not
— Pregnancy care in transgender men: chest dysphoria with growth, prenatal vitamins, may continue/resume testosterone postpartum; chestfeeding possible (lactation reduced if prior top surgery)
— Use gender-neutral language: "pregnant person," "chestfeeding" if preferred
— Lesbian couples: donor sperm with IUI or reciprocal IVF
— Gay men: gestational surrogacy + donor egg or partner egg
— Transgender patients: pre-transition gamete preservation (sperm bank, oocyte cryopreservation); post-transition options limited
— Adoption and foster care — counsel on legal variability by state
— All methods generally appropriate for queer cisgender women based on partners and behavior
— Transgender men on testosterone: still need contraception if engaging in penile-vaginal sex; progestin-only methods or IUDs preferred (avoid estrogen-containing); LARCs excellent
Board pearl: A transgender man on testosterone with amenorrhea presents with nausea and fatigue. Order a pregnancy test — amenorrhea on T is not contraception. Step 3 commonly tests this counterintuitive scenario.
Key distinction: Pubertal suppression (GnRH agonist) is reversible; gender-affirming hormones affect fertility and may permanently reduce gametogenesis. Fertility counseling must precede hormone initiation.
— Estrogen: VTE (highest with oral/ethinyl), stroke, MI (small absolute risk), hypertriglyceridemia, gallstones, prolactinoma (rare), breast cancer (small ↑ with long use)
— Testosterone: erythrocytosis, acne, androgenetic alopecia, dyslipidemia, sleep apnea, mood lability, hepatotoxicity (oral forms only — rarely used)
— Spironolactone: hyperkalemia, hypotension, polyuria, AKI
— GnRH agonist: bone density loss, hot flashes, mood changes
— Vaginoplasty: rectovaginal/urethrovaginal fistula, neovaginal stenosis, prolapse, granulation tissue, hair growth (if scrotal skin), pelvic floor dysfunction
— Phalloplasty: urethral stricture/fistula (high — up to 40%), flap loss, donor site morbidity, sensation issues
— Top surgery: hematoma, nipple necrosis, contour irregularity, scarring
— Hysterectomy/orchiectomy: standard surgical risks; hormone replacement required post-gonadectomy to prevent osteoporosis and vasomotor symptoms
— Use of non-prescribed hormones from online/informal sources — uncertain dosing, contamination, injection risks (HCV, HIV, abscess)
— Silicone "pumping" (illegal soft tissue fillers) — granulomas, embolism, infection, disfigurement — especially in transgender women of color
— Binding injuries: rib fractures, dermatitis, restrictive lung issues
— Tucking: testicular discomfort, hernia
— Untreated dysphoria → depression, suicidality, substance use
— Minority stress → chronic anxiety, PTSD, eating disorders (especially bulimia and atypical anorexia in transmasculine adolescents)
Step 3 management: A 30-year-old transgender woman injects friend-provided silicone into her buttocks and presents with dyspnea and hypoxemia 6 hours later. Consider silicone pulmonary embolism syndrome — supportive care, oxygen, ICU monitoring; corticosteroids controversial. Counsel on safe surgical alternatives and report illegal silicone injectors.
Board pearl: Always ask about non-prescribed hormone and silicone use — patients may not volunteer this. Offer to provide prescribed therapy as harm reduction.
— Complex hormone management: significant comorbidity, unexpected lab results, prolactinoma, persistent erythrocytosis, intersex variations
— Adolescent pubertal suppression/hormone initiation (in regions where required)
— Failure to achieve target levels despite appropriate dosing
— Patient interest in any gender-affirming surgery: chest, genital, facial, voice
— Verify WPATH SOC-8 criteria with insurer (often: persistent dysphoria, capacity, age requirements, mental health assessment for genital surgery)
— Optimize medical conditions preoperatively: tobacco cessation (mandatory for most flap surgeries), HbA1c <7%, BMI per surgeon, VTE prophylaxis plan
— Suicidal ideation, severe depression, untreated PTSD, eating disorders
— Patients seeking gender-affirming letters for surgery
— Family conflict, especially with adolescents — affirming family therapy reduces suicide risk
— Suicide risk assessment: ideation, plan, intent, means, prior attempts
— High risk: ED for safety evaluation; involuntary hold per state law if imminent danger and refusing voluntary care
— Provide 988 (Suicide & Crisis Lifeline) and Trevor Project for youth
— Safety planning: means restriction, crisis contacts, coping skills
— Dermatology: hair removal (electrolysis/laser pre-vaginoplasty), acne on testosterone, alopecia
— Speech-language pathology: voice feminization (estrogen doesn't change voice)
— Pelvic floor PT: post-vaginoplasty dilation, post-phalloplasty
— Cardiology if ASCVD risk concerns on hormone therapy
CCS pearl: For a hospitalized transgender patient — write orders for the patient's chosen name and pronouns in the chart and at the bedside, room with appropriate gender, ensure hormones are continued during admission (perioperative estrogen may be held 2–4 weeks before major surgery per surgeon), and brief covering teams to maintain affirming care across shifts.
— Persistent, consistent, insistent across contexts
— Identity itself is NOT a disorder — only the distress that may accompany it
— Diagnosis exists primarily to enable insurance coverage of care
— Gender nonconformity without dysphoria: variant gender expression without distress — no medical intervention needed
— Cross-dressing/transvestism: behavior, not identity — does not necessarily indicate transgender identity
— Drag: performance art, not gender identity
— Body dysmorphic disorder: preoccupation with perceived defect, not specifically about sex characteristics or gender — responds to SSRI/CBT, not hormones
— Eating disorders: may co-occur with dysphoria (especially atypical anorexia in transmasculine youth seeking flatter chest, smaller hips)
— Psychosis: delusional gender beliefs (rare) — typically not persistent, lacks consistency, accompanied by other psychotic features
— OCD with gender-related intrusive thoughts: ego-dystonic, distressing thoughts about being a different gender — not affirming, responds to ERP
— Borderline personality disorder: identity disturbance is broader, not specific to gender, includes relationships/values
— Trauma/dissociation: identity confusion may follow severe trauma
— Time, longitudinal observation, mental health partnership
— Treat comorbid psychiatric conditions concurrently — do not delay affirming care indefinitely unless safety is at issue
— Pubertal suppression in adolescents allows reversible exploration
Key distinction: Persistence + consistency + insistence across years and contexts supports gender incongruence; identity questions arising in the context of acute psychosis, OCD, or severe dissociation warrant psychiatric evaluation first.
Board pearl: Reparative or "conversion" therapy aimed at changing sexual orientation or gender identity is ineffective, harmful, and contraindicated — banned for minors in many states and condemned by every major medical organization.
— Hormone-related: dose- and route-dependent
— Secondary causes: OSA (very common — screen!), smoking, COPD, high altitude
— Polycythemia vera: check JAK2 if persistent despite hormone optimization
— Manage by: route change (IM → SC/transdermal), dose reduction, OSA treatment, phlebotomy
— AKI/CKD progression
— ACEi/ARB co-administration
— Adrenal insufficiency
— Lab artifact (hemolysis)
— Underlying thrombophilia (factor V Leiden, prothrombin gene mutation, antiphospholipid syndrome)
— Occult malignancy in age-appropriate patients
— Immobilization, recent surgery, COVID-19
— Workup parallels standard VTE evaluation
— Mild elevations expected; prolactin >100 ng/mL → MRI pituitary
— Other causes: antipsychotics, hypothyroidism, renal failure, prolactinoma
— Expected breast development on estrogen
— Pathologic: unilateral mass, bloody discharge, skin changes → ultrasound ± mammogram, biopsy
— Transgender women have documented breast cancer cases — do not dismiss masses
— Atrophic vaginitis from testosterone
— Endometrial pathology (testosterone can paradoxically thicken endometrium in some patients)
— Ovarian cysts, fibroids, PID (if sexually active with penetration)
— Pregnancy — always rule out
Step 3 management: A 34-year-old transgender man on testosterone × 3 years presents with new pelvic pain and intermittent vaginal bleeding. Workup: pregnancy test, pelvic ultrasound, GC/CT testing, consider endometrial biopsy if persistent bleeding. Testosterone-induced atrophy and inadequate endometrial suppression both occur.
Board pearl: Never attribute a new symptom solely to hormone therapy without ruling out alternative etiologies — affirming care includes thorough medical workup, not dismissal.
— HPV: through age 26 routine; shared decision 27–45 — high yield for MSM, transgender women, immunocompromised
— Hepatitis A: MSM, illicit drug users, HIV+
— Hepatitis B: all adults 19–59; older if risk factors
— Meningococcal ACWY + B: MSM during outbreaks, HIV+
— Mpox (JYNNEOS) 2-dose: MSM with multiple partners, transgender persons with risk factors, HIV+ with sexual risk
— Influenza, COVID, Tdap, zoster, pneumococcal: per general guidelines
— Doxycycline post-exposure prophylaxis (Doxy-PEP): 200 mg within 72h of condomless sex — reduces syphilis/chlamydia (and some gonorrhea) in MSM and transgender women with bacterial STI in prior year (CDC 2024)
— Lifelong if patient desires — no upper age limit, but adjust risk-benefit
— Post-gonadectomy: continue hormones to prevent osteoporosis and vasomotor symptoms
— Switch route as cardiovascular risk evolves (oral → transdermal estradiol)
— Cervix: cytology/HPV per USPSTF; consider self-collection
— Breast/chest tissue: mammography per guidelines
— Prostate (transgender women): shared decision-making, PSA adjusted for estrogen
— Anal: targeted screening in high-risk groups
— Colorectal: standard
— Annual lipids, HbA1c, BP, BMI
— Statin per ASCVD risk
— Aspirin only per general guidelines (not routine primary prevention)
— DEXA at 65 routine; earlier if hormone-discontinued post-gonadectomy or other risk factors
— Vitamin D and calcium adequacy
Board pearl: Doxy-PEP is a 2024 CDC-recommended intervention — 200 mg doxycycline within 72 hours of condomless sex — for MSM/transgender women with bacterial STI in the prior year. Discuss antimicrobial stewardship and resistance monitoring.
— First year: clinic visit + labs at 3, 6, and 12 months
— Steady state: every 6–12 months
— Each visit: target labs, symptom progress, mental health screening, side effects, adherence, satisfaction with care, identification of new goals (surgery, voice work)
— Q3 months: HIV test, adherence, STI screening (or q6mo if low risk), pregnancy test if applicable
— Q6–12 months: renal function, HCV
— Reassess ongoing indication annually
— Annual comprehensive visit with SOGI re-confirmation (identity and pronouns can evolve), updated sexual history, mental health screen, age-appropriate screening
— Use systems supporting chosen name, pronouns, gender identity, sex assigned at birth, organ inventory as distinct fields
— Document affirming language; avoid pathologizing terms
— Update billing/legal name carefully — insurance denials common when gender marker doesn't match procedure code (e.g., Pap in a "male"-coded chart)
— Use modifier codes (KX, condition codes) or contact payer to override sex-edits
— Tobacco cessation (high prevalence; critical before estrogen and surgery)
— Alcohol/substance use
— Safer sex, PrEP/PEP awareness
— Mental health, social support, family acceptance
— Realistic expectations for hormone changes (timeline, reversibility, individual variation)
Step 3 management: Set up the first hormone follow-up at 3 months with labs drawn 1–2 weeks before the visit. Confirm appropriate dose adjustments via shared decision-making; assess subjective progress; reinforce contraception and STI prevention. CCS pearl: when admitting an LGBTQ+ patient, place a chart note with chosen name/pronouns prominently visible and notify nursing — small actions prevent traumatic misgendering during a vulnerable hospitalization.
— Do not disclose SOGI without patient consent (to family, employer, other providers not involved in care)
— Adolescents: state laws govern minor consent and parental notification for STI/contraception/mental health/gender-affirming care — know your jurisdiction
— "Outing" a patient by careless documentation, billing, or hallway conversation is a breach of professionalism and may be a HIPAA violation
— Document discussion of: risks (VTE, polycythemia, surgical complications), benefits, alternatives, irreversibility of certain changes, fertility implications, and time course
— Assess decisional capacity; involve mental health when capacity is uncertain or in complex adolescent cases
— Per WPATH SOC-8, mental health letters are not required for hormones in most adults but often required by insurers for major surgery
— Intimate partner violence: laws vary; encourage but rarely mandate
— Suspected abuse of minors or vulnerable adults: mandatory in all states
— Some states have controversial reporting requirements regarding gender-affirming care for minors — know current law; advocate within ethical guidelines
— Hospitalization: ensure hormone continuation on med rec; brief covering teams on patient's name/pronouns; advocate for appropriate room assignment and bathroom access
— Surgical patients: coordinate perioperative hormone management (often hold estrogen 2–4 weeks pre-op for high-VTE-risk surgery; resume when ambulating); avoid abrupt discontinuation of anti-androgens
— Discharge: ensure access to outpatient gender-affirming clinician, hormone prescriptions filled, mental health follow-up
— Section 1557 of the ACA prohibits sex-based discrimination including on the basis of gender identity in covered healthcare
— Individual clinician moral objection does not override patient access — must facilitate transfer to a willing provider
— Conversion therapy is unethical; refer to APA, AMA, AAP, Endocrine Society statements
Board pearl: A patient's parent demands access to their 17-year-old's records regarding gender-related counseling. Review state minor consent law — in many states, mental health and confidential reproductive/sexual health services are protected from parental disclosure. When in doubt, consult institutional counsel and the adolescent themselves before releasing records.
— 7–8% of US adults identify LGBTQ+; ~1.6 million transgender
— Screen by anatomy, not identity
— Cervical screening every 3 years (21–29) or HPV-based every 5 years (30–65) for any patient with a cervix
— Transdermal estradiol = lowest VTE risk; avoid ethinyl estradiol
— Spironolactone — check K+ and Cr
— Testosterone — check Hct; target T 400–700 ng/dL
— Estradiol target 100–200 pg/mL; testosterone <50 ng/dL on feminizing therapy
— Testosterone is teratogenic — pregnancy possible despite amenorrhea
— PrEP options: TDF/FTC (all), TAF/FTC (not for receptive vaginal), cabotegravir IM q2mo
— PEP within 72 hours × 28 days
— Doxy-PEP 200 mg within 72h post-exposure for high-risk MSM/transgender women
— 3-site (pharyngeal, rectal, urethral) GC/CT screening per behavior
— Rule out acute HIV with HIV RNA before starting PrEP
— Vaginoplasty patients dilate lifelong
— Phalloplasty urethral complications ~40%
— Hold estrogen 2–4 weeks pre-major surgery (VTE risk)
— Tobacco cessation required for flap procedures
— Transgender woman on estrogen ≥5 years: biennial mammography from age 50
— Anal cytology in HIV+ MSM and transgender women ≥35
— Prostate present → shared decision-making PSA (estrogen lowers baseline)
— Transmasculine + intact uterus: monitor for endometrial pathology with bleeding
— Family acceptance = strongest protective factor for LGBTQ+ youth
— Affirming care reduces suicidality
— Conversion therapy is harmful and unethical
— 988 Lifeline; Trevor Project for youth
— Ask all patients about SOGI + behavior
— Use the patient's name/pronouns
— Apologize and move on if you misgender
Key distinction: Gender identity, sexual orientation, sexual behavior, and sex assigned at birth — four separate axes to assess.
— 32-year-old transgender man, last cytology unknown, on testosterone × 4 years, presents for annual visit. Best next step?
— Answer: Cervical cancer screening per age-based USPSTF guidelines (cytology or HPV); pre-treat with vaginal estrogen given testosterone-induced atrophy
— 23-year-old man requests PrEP after a new partner with HIV. Best next step before prescribing TDF/FTC?
— Answer: HIV Ag/Ab AND HIV RNA testing to exclude acute infection (starting 2-drug PrEP during acute HIV → resistance); also baseline HBV, renal function, STI screen
— Transgender woman on oral estradiol × 3 years develops unprovoked DVT. After acute treatment, next step regarding hormone therapy?
— Answer: Switch to transdermal estradiol — markedly lower VTE risk; do not permanently stop affirming care
— Transgender man on testosterone with amenorrhea, new nausea/fatigue. Best next test?
— Answer: Urine hCG — amenorrhea ≠ infertility
— 16-year-old patient discloses same-sex attraction; parent demands records. Best response?
— Answer: Maintain confidentiality per state minor consent law for sensitive services; engage adolescent in any disclosure discussion
— Transgender man on IM testosterone with Hct 56%. Next step?
— Answer: Reduce dose or switch to transdermal/SC, screen for OSA, consider phlebotomy if persistent
— You misgender a patient during the encounter. Best response?
— Answer: Brief apology, correct yourself, move on — do not over-explain or center your discomfort
— Transgender woman with strong family history of VTE seeks feminizing therapy. Best initial regimen?
— Answer: Transdermal estradiol + spironolactone; counsel on tobacco cessation; consider thrombophilia evaluation if individual history warrants
— Parents ask about therapy to "change" their teen's gender identity. Best response?
— Answer: Decline; counsel that conversion therapy is harmful and ineffective; recommend affirming family-based therapy
Board pearl: When a stem includes a transgender or sexual minority patient, the answer almost always involves affirming, anatomy-based, evidence-based care — not deferral, not gatekeeping, not pathologizing.
Affirming care for LGBTQ+ patients is evidence-based primary care: ask SOGI and sexual behavior of every patient, screen by anatomy rather than identity, deliver gender-affirming therapies under informed consent with route- and risk-tailored hormones, and protect confidentiality, autonomy, and continuity across every transition of care.
— Introduce your pronouns; ask the patient's name and pronouns; apologize briefly and move on if you misgender; document SOGI as four distinct fields (identity, orientation, sex assigned at birth, behavior)
— Cervix → cytology/HPV per USPSTF age; breast tissue → mammography per guidelines (transgender women: biennial from 50 after ≥5 years estrogen); prostate present → shared decision PSA; HIV/STI by behavior with 3-site testing; PrEP for risk; Doxy-PEP per CDC 2024; vaccinations including HPV through 45, mpox, hep A/B, meningococcal as indicated
— Feminizing: transdermal estradiol preferred (lowest VTE) + spironolactone; target E2 100–200, T <50
— Masculinizing: testosterone IM/SC/gel; target T 400–700; monitor Hct, lipids; teratogenic — contraception still needed
— Hold estrogen perioperatively for high-VTE surgeries; continue hormones post-gonadectomy for bone health
— Conversion therapy is contraindicated; affirming care reduces suicidality; family acceptance is the strongest protective factor for youth; protect minor confidentiality per state law; document fertility counseling before hormones; continue hormones across hospitalization with chosen name and pronouns clearly communicated to the care team
Board pearl: When in doubt — ask the patient, screen the anatomy, document affirmingly, and treat the person in front of you with the same evidence-based rigor you'd apply to any other Step 3 case.