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Transgender and Gender-Nonconforming Populations

The scope of this guide is meant to inform all who interact with it on related issues to transgender and gender non-conforming populations.

A photograph of two individuals holding hands, one of which is wearing clinical scrubs and appears to be in a nursing or health professional position, consoling a patient.

Via Pexels (Opens New Window)

Gender-Affirming and Inclusive Care

Gender-Affirming Care is an umbrella term that relates to the various medical supports for transgender and gender non-conforming people. GAC can include gender-affirming surgeries, hormone replacement therapy, mental health care, or other supports depending on the individual. Select the tabs below to learn more about the various forms of GAC.

Creating Welcoming Spaces

Providing gender-affirming care goes beyond treatment and prescriptions. Trans and gender non-conforming patients should feel comfortable and included in every aspect of their health care experience. The following section highlights some ways that health services can respect and accommodate people of all genders.


Staff Training and Education

All staff should be trained on inclusive and gender-affirming care. From your front desk to the nurses and doctors to the radiation specialist, healthcare staff should be trained on appropriate behavior, language, and procedures for trans and gender non-conforming patients. This training should be ongoing.

Some possible training opportunities:


Inclusive Forms and Paperwork

All paperwork that people fill out or receive should be inclusive. Some things to consider in creating inclusive forms:

  • Asking for preferred name
  • Asking for pronouns
  • Using both a question about gender identity and about the sex assigned at birth
  • Use gender-inclusive language when asking about sexual or relationship history

Including these fields on forms allows for patients to self-identify, and shows that their health providers are sensitive to their preferences and identity.



It is recommended to have all gender-neutral, single-occupancy restrooms available in a facility. If a facility does have gendered restrooms, there should be a gender-neutral bathroom available. In either case, people should be allowed and encouraged to choose which restroom they use based on their own preferences.



People choose pronouns that fit them best and that they are the most comfortable with. All individual people have pronouns that are used to refer to them in the third person. See the table below for a list of pronouns that can be used and that you may encounter with your patients.

Subjective Objective Possessive Reflexive


Her Hers Herself
He Him His Himself
They Them Their Themself
Ze/Zie Zir Zirs/Hirs Zirself/Hirself
Xe Xem Xyr Xemself

Pronouns do not equate to a gender identity - if you are working with a patient who is introduced as "she/her" that does not automatically mean that patient identifies as a woman. This distinction is why it is important to offer opportunities to self-identify one's pronouns, preferred name, and gender identity in their health care.

Sometimes people use more than one pronoun (ex: she/they). In those cases, you can always ask the person if they would prefer one pronoun over the other, or if they would like you to use both pronouns for them interchangably.

Bates' Visual Guide to Physical Examination provides clinical videos demonstrating how to respect personal pronouns and one's preferred name in order to establish good rapport with patients. Click here to access the video in a new tab.



While this guide focuses on gender non-conforming and transgender health care, it is important to remember that a person's gender is not the only part of them that impacts their experiences with health care, their risks, traumas, and concerns. Other identities such as race/ethnicity, sexual orientation, socioeconomic status, and religious beliefs work in tandem to create an individual's cultural background. Each of these identities intersect to color the experiences that a person faces throughout their life, and being sensitive to the intersecting identities (and how they may put some individuals at higher risk than others) is important to acknowledge and understand.

To learn more about intersectionality, you can read a report written by Kimberlé Crenshaw, who conceptualized and coined the term "intersectionality", here (Opens New Window).


Care Guides and Resources

See below for clinical guidelines and care guides on how to provide the best possible patient experience for transgender and genderdiverse populations. All of the following resources open in a new window when selected.

Surgical Procedures

Trans individuals who experience gender dysphoria may feel inclined to undergo surgery in order to affirm their gender identity. Depending on the individual's personal preferences, level of development, and medical need, the surgical procedures may vary. The trans-affirming surgical process is also an incredibly personal one, and requires a lot of trust in a medical provider to respect the patient's wishes and needs.

Possible surgical procedures tend to be split into two categories - those which are meant to feminize and those that are meant to masculinize. Note - despite these gendered terms, non-binary and gender-nonconforming individuals may also wish to pursue any of these surgical procedures in order to address their gender dysphoria. See below for a list of common procedures related to affirming gender for trans individuals.


Feminizing Surgeries

Procedure Description
Feminizing Mammaplasty (Opens New Window) Augmentation of breast tissue using implants or fat grafting.
Facial Feminization Surgery (Opens New Window) A category of surgeries that may be conducted to alter the facial structure. Depending on an individual's needs, areas including the hairline, jaw, chin, cheekbones, forehead, and lips can be reshaped.
Orchiectomy (Opens New Window) Removal of the testicles.
Vaginoplasty (Opens New Window) Surgical creation of a vagina using existing genital tissue.
Vulvoplasty (Opens New Window) Surgical creation of a vulva using tissues from the penis, scrotum, testes, and urethra.


Masculinizing Surgeries

Procedure Description
Masculinizing Chest Reconstruction/Mastectomy (Opens New Window) Reduction of breast tissue. Depending on the individual, this procedure may also require reconstruction of the nipple and areola.
Hysterectomy (Opens New Window) Removal of the uterus.
Oophorectomy (Opens New Window) Removal of the ovaries.
Metoidioplasty (Opens New Window) Surgical creation of a penis using the tissues surrounding the clitoris. Requires reworking of the urethra.
Phalloplasty (Opens New Window) Surgical creation of a penis using donor skin from other parts of the body (typically the forearm or thigh).

Hormone Replacement Therapy

Some trans and gender non-conforming people may choose to receive hormone replacement therapy (HRT) as part of their medical transition. HRT is not a requirement to be trans or gender non-conforming, but for some people it can help alleviate their gender dysphoria by altering their physical appearance. There are different dosages and types of treatment, and the amount of changes a person might like to see in their body will vary. 

Possible HRTs tend to be split into two categories - those which are meant to feminize and those that are meant to masculinize. Note - despite these gendered terms, non-binary and gender-nonconforming individuals may also wish to pursue any of these surgical procedures in order to address their gender dysphoria.


Feminizing Hormones

Hormone Description
Estrogens A class of hormones that stimulate primary and secondary sex characteristics in female bodies. Can include natural, synthetic, steroidal, and non-steroidal compounds. Method of administration varies depending on the drug and the patient's preferences (pills, injections, dermatological gels, nasal sprays, and patches). Most often administered orally as a pill.

A class of hormones that block the action or downregulate the production of androgens. Generally prescribed as a pill or as an oral suspension.

See "Androgens" under Masculinizing Hormones for more info.

Progesterone In female bodies, a hormone that supports pregnancy (embryo implantation, mammary gland milk production) and the uterine lining. Sometimes used in HRT, but used with caution as it can impact mood and cholesterol levels. Typically administered as a pill.


Effects of Feminizing Hormones

The human body with colors highlighted on it in the various areas of the body that feminizing hormones impact. This includes skin, voice, body fat redistribution, thinned body hair, breast growth, and decreased testicular volume.Chart of the physical effects, reversibility, and timeline of feminizing hormone therapy effects

Trans Primary Care

Click on the images or link to be taken to the full interactive chart in a new tab.


Masculinizing Hormones

Hormone Description
Androgens A class of hormones that stimulate primary and secondary sex characteristics in male bodies. Impacts libido, development of muscle mass, development of reproductive organs, and spermatogenesis.
Dihydrotestosterone (DHT) A metabolite derived from testosterone. Stimulates primary sex characteristics in male bodies. Can be prescribed as a topical cream for transmasc individuals.
Testosterone The primary hormone that regulates sex differentiation in utero and that stimulates primary and secondary sex characteristics in male bodies. Frequently prescribed for transmasc individuals. Can take the form of an injection, topical gel, dermal patch, or pellet placed under the skin (depending on patient preference).


Effects of Masculinizing Hormones

The human body with areas that are impacted by masculinizing hormones highlighted. This includes: skin, voice, body fat redistribution, facial hair growth, body hair growth, scalp hair loss, clitoral enlargement, and vaginal atrophy

Trans Primary Care

Click on the images or link to be taken to the full interactive chart in a new tab.

Puberty Blockers

If a person still experiencing puberty is questioning their gender or identifies as trans or gender non-conforming, they may want to take puberty blockers.

Puberty blockers are used to delay the development of both primary and secondary sex characteristics. Typical changes for individuals with ovaries include growth of pubic and axillary hair, increased breast size, increase in hip width, and beginning menstruation. Changes for individuals with testes include growth of the testicles and penis, growth of pubic, axillary, and facial hair, height increases, deepening of vocal pitch, and development of an "Adam's apple".

The effects of taking puberty blockers is reversible - if a child experiences a change in their gender identity and no longer wish to deter the effects of puberty, they can stop taking blockers and experience puberty. Having access to puberty blockers provides young people with agency over their gender expression as enduring puberty can be incredibly harmful to a child's mental health if they are trans or GNC.

Providing youth with the opportunity to prevent their body from changing in ways they are not comfortable with has proven to decrease depression and anxiety, decrease rates of self harm and suicide attempts, and lower the need for future surgeries and treatments. 


Drugs Used to Block Puberty

Hormone Blocker Description
Gonadotropin-Releasing Hormone Agonists (GnRHas) A class of drugs that will temporarily block the body's production of sex hormones.
Histrelin Acetate A GnRHa in the form of an annual subcutaneous implant placed in the upper arm used to reduce testosterone levels.
Leuprolide Acetate Can be administered as a subcutaneous implant OR as an injection (if injected, can last for several months depending on dosage). Also used to reduce testosterone levels.
Nafarelin Acetate A GnRHa in the form of a nasal spray used to reduce estrogen levels for individuals experiencing endometriosis, precocious puberty, or who want to prevent puberty.

Hormone blockers can only be prescribed once puberty has begun (generally around ages 10-12) and while puberty is still occurring (Delemarre-van de Waal & Cohen-Kettenis, 2006). In addition to being used for treating gender dysphoria, these drugs can be used for helping delay precocious puberty, endometriosis, and in the treatment of prostate and breast cancers.


Safety Concerns

GnRHas have been used to delay puberty symptoms in cisgender and transgender youth since the 1980s. While they have not yet received FDA approval in treating gender dysphoria, they are approved by the FDA to treat conditions such as precocious puberty and endometriosis (Nevada Department of Health and Human Services, 2018). In addition to this, the Endocrine Society (Opens New Window) as well as the World Professional Assocation for Transgender Health encourage the use of puberty blockers to treat trans and gender non-conforming youth who are experiencing gender dysphoria.

Individuals who are interested in puberty blockers or who have children who wish to delay puberty should consult with their healthcare professional for more information.