Reason for Visit
This 60-year-old patient (assigned male at birth) is already established in your primary care practice. You are seeing them for the first time today on behalf of a colleague who is out on parental leave for the next 3 months. They have been an established patient at the practice for the past 5 years. Last month they came out to their PCP as trans and asked about starting hormone therapy and taking steps to transition. On reviewing your colleague’s note from the last appointment, you read the following description:
AMAB (assigned male at birth)
Gender identity: woman
Preferred name: Blake for now
Pronouns: “I don’t know yet. She/her?”
This patient is well known to me, and shared for the first time today that she is trans and interested in starting hormone therapy. She shares that she has been meeting with a therapist for the past 12 years as she explored her gender. This last birthday felt like a ‘milestone’ and like ‘I’m finally ready to do something about this.’ Her chronic health conditions (HTN, HLD, prediabetes) are well controlled. She wants to start hormone therapy and is ultimately interested in living full-time and presenting as a woman. She is familiar with the effects of feminizing hormone therapy and is hopeful for breast development, fat redistribution to the hips and thighs, reduction in body and facial hair, and an overall more feminine embodiment. She may be interested in gender-affirming surgery in the future, but would like to see what she can achieve with hormones first. She is not interested in future fertility.
She has not discussed gender dysphoria or her gender goals with her wife yet (who is cisgender), and is nervous about doing so. The patient wanted to confirm first if she would be able to access hormone therapy before talking with her partner, so she came in today to ask if this is something I would be willing/able to prescribe.
We reviewed the risks and benefits as well as expected effects of hormone therapy. We reviewed an informed consent for feminizing hormone therapy and a signed copy can be found in the chart. Last bloodwork was over a year ago, so I recommend labs including baseline hormone levels today. Once I see those results, I can write the first prescription. We will plan for estradiol 2 mg once daily and spironolactone 50 mg twice daily to start. Plan for follow-up at 3 months with repeat labs.”
The patients’ baseline labs were normal and your colleague prescribed feminizing hormones 1 month ago as they had planned. The patient presents today sooner than originally planned with symptoms of “heart racing and trouble sleeping.”
Sexual Orientation, Gender Identity and Expression (SOGIE)
- Gender Pronouns: She/Her, Any (left blank to be elicited by participant)
- Sex Assigned at Birth: Male
- Gender Identity: Woman (left blank to be elicited by participant)
- Sexual Orientation: Questioning (left blank to be elicited by participant)
Participants have 25 minutes to conduct this visit.
- Evaluate and treat underlying health concerns which may be contributing to the patient’s symptoms.
- Offer emotional support for a patient grappling with lack of support/acceptance of a loved one. Please review excerpts (will be provided when scheduling) on gender emergence as an adult prior to the patient interview
- Recommend resources such as support groups and databases with affirming healthcare providers of various disciplines (Provided for participants).
There will be verbal feedback with the SP following the visit.
- Practice introducing oneself with pronouns and effectively establishing a respectful and inclusive healthcare environment.
- Demonstrate empathy and provide emotional support to a patient who is going through a challenging life event or experiencing a loss of support from friends or family, adapting communication strategies to address their emotional needs sensitively.
- Utilize knowledge of local or national resources to suggest appropriate community support services and facilitate connections with affirming healthcare providers, assisting patients in accessing additional support outside of the primary care setting.
Who Should Participate?
This scenario provides skills practice for clinicians in all disciplines of medicine.