Supporting the Transgender Community

Transgender individuals identify their gender, expression, and behavior differently than their biological sex established at birth.^1–3 An estimated 1.4 million Americans identified as transgender in 2014 according to the Williams Institute at the University of California, Los Angeles School of Law.⁴ The number of people in the transgender community has doubled since 2011, and it is suspected this number may be even higher. Transgender people are often underreported due to familial, social, and psychological stressors related to public acceptance. Research has estimated about one in every 250 adults identify with the transgender community, with the majority being young adults.^4,5 Dental hygienists need to understand the complexity of social determinants of health and the impact of hormone replacement therapy during transitioning on oral and systemic health to provide patient-centered care.

DETERMINANTS OF HEALTH

This marginalized community encounters a complex layer of stigmas resulting in inequalities, including rejection of human rights.² Fewer than 18 states prohibit gender identity discrimination regarding employment, housing, education, and public accommodations (eg, restaurants, retail stores, hotels, theaters, medical offices, and pharmacies).⁶ The structural differences experienced by this community result in an increase of barriers to oral and general healthcare. In addition, without legal protection, this community is at higher risk for unemployment, contributing to poverty and homelessness. As a result, some people in the transgender community turn to sex work.⁷ Additionally, transgender individuals may face harassment, violence, and gender crimes.^2,6 Currently, there is no tracking system in the United States to document transgender homicide; however internationally, an estimated one murder of a transgender individual occurs every 3 days.⁸ These factors increase the vulnerability of this community on an individual level, resulting in adverse health outcomes.²

MENTAL HEALTH AND WELL-BEING

The discrimination, social stigma, and harassment faced by transgender individuals increase the risk for mental health disorders and addiction problems.^5,9–12 Stress among people in the transgender community can vary, depending on the transition process, ability to cope, and support systems.⁹ Within the transgender population, 41% reported experiencing discrimination, verbal abuse, and violence, which raise the risk for anxiety and depression.^9,13 Transgender individuals taking hormone replacement therapy (HRT) report  positive effects on quality of life, with reduced anxiety and depression, as HRT changes the physical body characteristics to align with psychological gender.^2,14

The risk of chemical dependency among transgender youth is 2.5 times to 4 times higher than their peers due to trans-related discrimination and mental health disorders. Individuals who were sexually assaulted or verbally threatened within the past year reported greater heavy episodic drinking than those who identified themselves as cisgender (gender corresponds with birth sex).^10,11,15

Additionally, suicide and suicidal behaviors are more prevalent within the transgender community. Environmental factors that contribute to suicidal behaviors include lack of family support, harassment, victimization, and gender violence.^16,17 Interventions to increase social inclusion and reduce transphobic experiences may help to decrease the prevalence of suicidal behaviors, mental health disorders, chemical dependencies, and adverse health outcomes among the transgender community.¹⁷

DENTAL HYGIENE MANAGEMENT

The dental hygiene standard of care is no different for a transgender person than a cisgender person.¹⁸ However, determinants of health, use of HRT during the transition process, risk of oral-systemic conditions, and potential pharmacological interventions need to be considered when developing the dental hygiene care plan. Current dental hygiene risk management assessment models should be used to prevent oral and systemic diseases and promote general health and well-being.

Some transgender people undergo HRT during the transition process, and may choose gender-affirmation surgery to achieve their desired gender identity. However, gender affirmation surgery is not a prerequisite for transitioning. HRT is the primary medical intervention pursued to alter physical characteristics to match gender identity. HRT is a cross-sex hormone therapy consisting of sex hormones and various hormonal medications administered during the transition process.¹ Dental hygienists need to be knowledgeable of the different HRTs when providing individualized patient-centered care.

Transwomen are prescribed estrogens or antiandrogens as feminizing hormone therapy. Estrogen is a hormone responsible for female secondary sex traits such as breast growth, pubic and underarm hair, and the initiation of menstrual cycles.¹⁹ The expected outcomes after 18 months to 24 months of estrogen therapy include breast growth, decrease in body and facial hair growth, decreased testicular size and erectile function, and an increase of body fat.^1,19,20 Antiandrogens are sex hormone antagonists to prevent biological effects in the body, and are often prescribed for transgender girls or adolescents to prevent testosterone production.¹⁹

Transmen are prescribed steroid hormones or androgens (testosterone, dihydrotestosterone, and androstenedione). Testosterone is responsible for physical traits of men, such as muscle mass, deepened voice, and facial and body hair. In transmen, testosterone is responsible for the suppression of the menstrual cycle and decreased production of estrogen from the ovaries. After cross-sex hormone therapy is initiated, physical outcomes can appear within several weeks to months. Physical changes may include oily skin/acne, cessation of menstrual cycle, voice deepening, facial/body hair, body fat distribution, clitoral enlargement, vaginal atrophy, increased muscle mass, and scalpel hair loss.²¹

Transwomen on long-term estrogen replacement have a higher risk profile compared to transmen.¹⁹ Negative systemic effects from estrogen therapy include cardiovascular  and cerebrovascular disease, venous thrombosis, pulmonary embolism, seizures, and breast cancer.^19,22–25 Studies have shown the risk of cardiac events, venous thrombosis, and pulmonary embolism is highest in the first year of estrogen therapy.¹⁹ Individuals undergoing HRT have a two-fold to five-fold increased risk of venous thrombosis and seizures compared to nonusers.¹⁷ Side effects to antiandrogen therapy are sexual dysfunction, infertility, and osteoporosis. Although breast cancer rates in transwomen are comparable to the general population, the risk is heightened by prolonged duration of estrogen therapy.¹⁹

Transmen face a higher risk of metabolic disease due to an increase in abdominal fat caused by the use of steroid hormones or androgens. Some may also undergo unexplained menses and experience increased risks of polycystic ovarian disease due to high levels of androgens and endometrial cancer.¹⁹ The impact of testosterone on cardiovascular health and hypertension is conflicting; however transmen with underlying risk factors may be prone to these systemic diseases.^19,22,23 Sleep apnea in transmen may become worse with testosterone therapy, thus increasing risk factors for cardiovascular disease.^19,26 Additionally, testosterone increases hemoglobin by 5% to 7%, therefore posing a greater risk for polycythemia in this patient group. Complications associated with polycythemia include stroke, myocardial infarction, and deep vein thrombosis.²⁶ Additionally, studies have indicated a correlation between testosterone and psychiatric effects, including mania and aggression.¹⁹

Osteoporosis/osteopenia is a risk factor for people in the transgender community due to the effects of sex hormones on bone mineral density. Both transwomen and transmen should take daily supplements of vitamin D and calcium in addition to regular weight-bearing exercises to maintain muscle mass. Although there is conflicting evidence regarding the effect of testosterone on bone mineral density, transmen are at elevated risk for osteoporosis/osteopenia due to decreased estrogen.²⁰ As such, this patient group should undergo frequent bone mineral density screenings.²⁷ Furthermore, people in this community may have altered liver function and increased liver enzymes from either estrogen or testosterone therapy.¹⁹

As transgender individuals may be at increased risk for cardiovascular and metabolic disease and cardiovascular disase and diabetes are associated with periodontal disease risk, this patient population should be assessed regularly for any changes in periodontal status.^28–31 Dental hygienists may implement dietary counseling to reduce cardiovascular, cerebrovascular, and metabolic disease risk.¹⁸

ADDITIONAL RISK FACTORS

Dental hygienists should be mindful of the complex determinants of health that impact this community. Transgender people may have an increased risk of dental caries as a result of reduced salivary flow from HRT, sex hormones, prescribed medications, or depression-related lack of daily self-care. Caries risk assessment and management should be incorporated into the treatment plan with recommendations for oral hygiene instruction, fluoride use, dental dietary counseling, and 3-month to 6-month recare intervals.¹⁸

Transgender patients with xerostomia may benefit from over-the-counter or prescription medications to alleviate dry mouth symptoms and promote caries prevention. Reduced salivary flow increases the risk for periodontal inflammation due to the plaque buildup around oral soft and hard tissues. Due to complex risk factors, early intervention may be suggested to prevent periodontal and caries disease progression.

Evidence indicates the transgender community is at increased risk for human immunodeficiency virus (HIV) and other sexually transmitted diseases, such as human papillomavirus (HPV).^5,7,12 In 2015, the rate of new diagnoses for HIV among transgender individual was three times higher than the national average.¹¹ Additionally, transgender women are at risk for HPV, which causes oral and pharyngeal cancers.^5,12 Dental hygienists may want to recommend the HPV vaccination to this population.^32,33 Additionally, completing a comprehensive oral cancer screening at each visit is key to identify early lesions.³³

PROVIDER ACCEPTANCE

Transgender individuals may encounter discrimination and hostility from healthcare providers when disclosing their status upon medical history review.¹³ In addition, this community has reported “trans broken arm syndrome” during patient-provider experiences. This term is used to describe healthcare providers associating medical issues solely based on being transgender.³⁴ To prevent trans broken arm syndrome during patient care, dental hygienists need to be competent and ethical providers who demonstrate respect and inclusive patient-centered care for the transgender community. In a dental setting, providing a nonjudgmental, supportive, and safe environment may enhance provider acceptance by developing trust during patient care.

PHARMACOLOGICAL CONSIDERATIONS

Transgender people may also be prescribed medications in addition to HRT to treat symptoms related to mental health disorders and/or chemical dependencies. The increased incidence of depression and anxiety among the transgender community is usually managed by prescribing antidepressants and/or antianxiety medications.

Social history may include tobacco (smoke, smokeless, or vape), prescription medications or substance/alcohol abuse resulting in a higher risk profile for oral-systemic conditions.¹⁸ Dental hygienists delivering motivational interviewing strategies to support positive behavior change during patient care may reduce these social habits.³⁵ In addition, social history may include gender violence, physical and emotional abuse, and psychiatric conditions.^5,9,11,12,18 Dental hygienists should be prepared to provide referrals to a physician, social worker, and/or a therapist/counselor.

CONCLUSION

Dental hygienists can play a unique role in supporting the transgender community and are instrumental in the prevention of oral-systemic diseases. Dental hygienists have the opportunity to initiate change by reducing determinants of health, increasing healthcare equality, and providing nonjudgmental patient-centered care and referrals for trans people. The lack of longitudinal evidence on the impact of long-term sex hormone therapy on mental health, well-being, and systemic health supports the need for continued training and education for dental hygienists to provide quality care for this patient group.

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From Dimensions of Dental Hygiene. September 2020;18(8):40-43.