Care of Transgender Patients: A General Practice Quality Improvement Approach
2. Materials and Methods
2.2. Searching for an Audit Standard
2.3. Instrument Creation
2.4. Patients/Sampling Frame
2.5. Data Extraction
2.6. Strategy for Data and Statistical Analyses
2.7. Ethical Considerations
3.1. Choice of Audit Standard
3.2. Description of the Population Census and Pathways
3.2.2. Clinic Referrals and Pathways
3.2.3. Medical and Surgical Management
3.2.4. Undesired Treatment Outcomes (Stopping Hormones, Abnormal Blood Test Results, Side Effects and Complications)
3.3. Audit of Monitoring against Standards
4.1. Summary of Main Findings
4.2. Strengths and Limitations
4.3. Comparison with Existing Literature
4.4. Implications for Clinicians, Policy Makers, and Patients
4.5. Implications for Research
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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|Hormone Dosing and Routine Long Term Monitoring (once stable/after 12–36 Months)||Maximum Transdermal Testosterone Dose (mg)||Minimum Nebido Injection Frequency (Weeks)||Minimum Sustanon Frequency (Weeks)||ANNUAL MONITORING||Pelvic USS monitoring||Breast Screening (unless Mastectomy)||Cervical Screening (unless Total Hysterectomy)||Bone (DEXA)||AAA Screening|
|Testosterone Level||Target Testosterone Levels (nmol/L)|
TD = Transdermal
N = Nebido
S = Sustanon
Tr = Trough (Day of Injecton)
Pk = Peak (7 Days after Injection)
|Full Blood Count||Haematocrit Levels Specific Advice (L/L)||Liver Function Tests||Lipids||Estradiol||Glucose||HBA1c||Prolactin||FSH&LH||SHBG||Urea and Electrolytes||TSH||Blood Pressure||Weight|
|Guideline or Clinic|
|WPATH ||No specific dosing instructions given. WPATH recommends consulting Feldman and Safer  and Hembree et al.  for hormone regimes and lab monitoring protocols. Testosterone levels should be maintained “within the normal male range while avoiding supraphysiological levels”. WPATH also advises “Follow-up should include careful assessment for signs and symptoms of excessive weight gain, acne, uterine break-through bleeding, and cardiovascular impairment, as well as psychiatric symptoms in at- risk patients. Physical examinations should include measurement of blood pressure, weight, and pulse; and heart, lung, and skin exams”||Y||Y|
|Endocrine Society  A||100||12||Y||11.1–34.7 B||Y||YD||YD||YD||N||Y E||Y||N C|
|Australia ||100||8||3||Y F||Y F||Y F||Y||YF||Y||Y F||Y F||Y G||Y G||Y M|
|San Francisco ||103.25||10||Y||Physiological male range||Y||If above male reference range- check testosterone level, adjust testosterone dose, short term blood donation may be the solution||N||Y||Y||Y H|
|NHS Wales ||80||11||2||Y||TD, N: 15–20|
S: 8–12 Tr, 25–30 Pk
|Y||>0.52 seek GIC advice|
>0.6 stop treatment & seek urgent haematology advice
|NHS Scotland ||100||10||2||Y||S,N; Tr “lower 3rd of normal range”|
TD: “within normal male range”
|Y||“CV risk assess”||Y||Y||N C|
|GP CPD Red Whale ||50||12||2||Y||Y||Y||Y||Y||Y||Y||Y||Y||Y||YQ||Y||N C||Y J|
|London Transgender clinic (private)||10||2||Y||TD: 15–25|
S: 8–12 Tr, 25–30 Pk
0.52–0.55 increase hydration and repeat bloods before next injection or in 8 weeks
0.55–0.6 refer urgently to haematology
|Laurels NHS||80||Y||14–28||Y||>0.56 seek prompt advice from haematologist and The Laurels||Y||Y||Y||YF||YF||N||Y||N|
|Gender GP (private)||100||10||2||Y||9–38 Steady State|
|Y||>0.52 suspend testosterone and refer endocrinology||Y||Y||Y||Y||Biannual||N||N C|
|Sheffield NHS||100||10||2||Y||S, N: 8–12 Tr, 25–30 Pk|
|Y||> 0.52 suspend treatment and refer haematology||Y||Y||Y||Y||Y||Y||Y||N L||N||Y||Y||N||Y|
|Tavistock NHS||100||6||2||Y||S: 10–12 Tr, 25–30 Pk|
N, TD: 15–20
|Y||>0.52 hydration, repeat test in 8 weeks or on day of next injection|
>0.55 seek GIC advice immediately
>0.6 pause treatment, seek urgent GIC and haematology advice
|Nottingham NHS||100||10||2||YR||TD: “upper 1/2 of local ref range”|
S, N: “lower 1/3 of local reference range” Tr/ steady state
|Y||≥0.52 routine referral to haematology|
≥0.54 urgent referral to haematology
|Gendercare (private)||100||10||2||Y||S, N: 8–12 Tr, 25–30 Pk|
|Leeds NHS||80||8||2||Y||S: “lower 3rd reference range” trough level|
N, TD: “middle third reference range”
|Y||If ≥54% withhold treatment & discuss with specialist||Y||Y||Y||Y||Y||Y||Y|
|Hormone Dosing and Routine Long Term Monitoring (once stable/after 12-36 Months)||Maximum Oral Estradiol Dose (mg)||Maximum Transdermal Estradiol Dose (gel) (mg)||Maximum Transdermal Estradiol Dose (Patch)(mcg Twice Weekly)||ANNUAL MONITORING|
|Estradiol Level||Target Estradiol Level (nmol/L)||Testosterone||Liver Function Tests||Lipids||Glucose||HBA1c||Prolactin||Full Blood Count||FSH&LH||SHBG||Urea and Electrolytes||TSH||Vitamin D and Bone Profile||Blood Pressure||Weight||Breast Screening||Bone (DEXA)||AAA Screening|
|Guideline or Clinic|
|WPATH ||No specific dosing instructions given. WPATH recommends consulting Feldman and Safer  and Hembree et al.  for hormone regimes and lab monitoring protocols. Target estradiol levels “within a premenopausal female range but well below supraphysiologic levels”. Follow- up should also “include careful assessment for signs of cardiovascular impairment and venous thromboembolism through measurement of blood pressure, weight, and pulse; heart and lung exams; and examination of the extremities for peripheral edema, localized swelling, or pain”||Y||Y|
|Endocrine Society  A||6||200||Y||360–735 B||Y||Y D||Y||Y E|
|Australia (children & adolescents) ||4||Y G||Y G||Y G||Y||Y||Y G||Y G||Y G||Y H||Y H||Y J|
|San Francisco ||8||400||Y K||physiological menstruating female range R||Y L||Y D||Y M||Y N|
|NHS Wales ||8||4||200||Y||350–750 S||Y||Y||Y||Y||Y||Y||Y||Y||Y|
|NHS Scotland ||6||3||200||Y||200–600||Y||Y||“If risk factors”||Y|
|GP CPD Red Whale ||4||1.5||100||Y||Y||Y||Y||Y||Y||Y||Y||Y||Y||Y||N F||Y|
|London Transgender clinic (private)||8||3||200||Y||400–700||Y||Y||Y||Y||Y||Y||Y||Y||N F|
|Laurels NHS||12||4||150||Y||200–600||Y||Y||Y||Y||Y||Y||Y||Y||N F|
|Gender GP (private)||6||2||200||Y||300–800||Y||Y||Y||Y||Y||Y||Y||Y P|
|Sheffield NHS||6||3||200||Y||300–600||Y||Y||Y||Y||Y||Y||Y||Y||Y||N F||Y|
|Tavistock NHS||8||5||200||Y||400–600||Y||Y||Y||Y||Y||Y||N F||Y Q|
|Nottingham NHS||8||6||400||Y||400–600||Y||Y||Y||Y||Y||Y Q||Y Q|
|Gendercare (private)||10||100||Y||400–600 R||Y||Y||Y||Y||Y||Y||Y|
|Leeds NHS||8||6||400||Y||350–750 if aged < 40 yrs|
300–600 if aged 40–50 yrs
200–400 if aged > 50 yrs or significant CV risk factors
|Adverse childhood experiences|
|Documented history of childhood abuse, neglect or violence (including “severe bullying” at school, n = 2)||13||19|
|Lifetime history of mental health issue found in notes|
|Deliberate Self Harm||36||54|
|Autistic Spectrum Disorder and/or Asperger’s Syndrome||10||15|
|Attention Deficit Hyperactivity Disorder||4||6|
|Obsessive Compulsive Disorder||3||4|
|Bipolar Type II||1||1|
|None of the above diagnoses||9||13|
|Use of mental health services|
|Child and adolescent mental health service (CAMHS) or child psychiatry involvement for non-gender issues||24||36|
|Secondary psychiatric services’ involvement for non-gender issues (including referrals, assessments or admissions)||20||30|
|Total number of patients||67||100|
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Boyd, I.; Hackett, T.; Bewley, S. Care of Transgender Patients: A General Practice Quality Improvement Approach. Healthcare 2022, 10, 121. https://doi.org/10.3390/healthcare10010121
Boyd I, Hackett T, Bewley S. Care of Transgender Patients: A General Practice Quality Improvement Approach. Healthcare. 2022; 10(1):121. https://doi.org/10.3390/healthcare10010121Chicago/Turabian Style
Boyd, Isabel, Thomas Hackett, and Susan Bewley. 2022. "Care of Transgender Patients: A General Practice Quality Improvement Approach" Healthcare 10, no. 1: 121. https://doi.org/10.3390/healthcare10010121