January 25, 2022
By Anna Fuchs, Drexel University College of Medicine

In 2016, the National Institutes of Health officially recognized transgender and gender nonconforming populations as health disparity populations. Gender diverse people experience significant discrimination, stigma and erasure, particularly in medical settings. This issue in part stems from a concept known as cisnormativity, a subconsciously internalized assumption that any given person is cisgender. Cisnormativity is a concept that leads to the “othering” of transgender populations, causing trans people to feel that their experience is different from the majority, and therefore inferior. In the medical setting, trans and nonbinary people are othered for a multitude of reasons, including insufficient research on gender diverse health, and clinician inexperience with health care for trans people. The 2011 National Transgender Discrimination Survey of more than 6,000 transgender people found that 50% of respondents reported having to teach their providers about their own health care. It is imperative that we continue to educate providers and explore the various health issues specific to LGBTQ+ populations, to work toward reducing this health disparity.

Transgender people have a gender identity that differs from their assigned sex at birth, and they may choose to seek medical intervention to reduce the incongruence between their gender identity and their physical appearance. Transmasculine people may seek hormone therapy with testosterone, with the intention of developing masculine features while suppressing feminine features. Some of the desired features that can help to resolve gender dysphoria include deeper tone of voice, redistribution of body fat, amenorrhea, development of body hair and a more muscular body habitus. Adverse effects of these hormones may include volatile mood, acne, body odor and pelvic pain. There are many conditions and adverse effects associated with hormone therapy that are not widely discussed in the medical field; this lack of knowledge contributes to the health disparities experienced by the transgender population. In this blog post, I will focus on vaginal atrophy experienced by trans men on testosterone.

Transmasculine people on testosterone may experience atrophic vaginitis. It is thought to be due to the suppressive effects of testosterone on estrogen, leading to an estrogen-deprived state that appears to be similar to the experience of many post-menopausal cis women. Atrophic vaginitis is a reflection of poor skin barrier function and low tissue resilience, and is associated with bacterial vaginosis (BV). In a study of 28 trans men on testosterone, the vaginal microbiome was found to have fewer lactobacillus and a significantly higher diversity of bacteria compared to 8 cisgender women, likely explaining the predisposition of trans men to BV. Atrophic vaginitis can be quite distressing for patients, as it can also cause dyspareunia and dysuria. The current treatment for vaginal atrophy in transmasculine people is adapted from the recommendation for postmenopausal women: topical estrogen and lubrication.

Though we believe that we understand the mechanism behind vaginal atrophy in trans men, the current treatment for the condition is not evidence-based. While it seems that atrophic vaginitis in trans men and post-menopausal women both stem from an estrogen-deficient state, the physiologic mechanisms behind these depletions are completely distinct. Though topical estrogen may be an effective treatment for the atrophic vaginitis experienced by trans men, it is unclear at this time if this is true. Furthermore, the use of topical estrogen in trans men may lead to systemic absorption and the development of feminizing features, thereby exacerbating gender dysphoria. At this time, there is no research that has been conducted to quantify the prevalence of vaginal atrophy amongst the trans population, to assess for efficacy of estrogen in resolving atrophic vaginitis, or to evaluate for feminizing effects and gender dysphoria. Atrophic vaginitis in trans men is but one example of an LGBTQ+ health issue that is not discussed in medical education, is poorly understood and is unexplored. We must allocate more time, energy and funding into research of transgender health so that we can better serve this growing population and reduce the associated health disparities.

Sources/Resources:

• U.S. Department of Health and Human Services. (n.d.). Director's message for October 6, 2016. National Institute of Minority Health and Health Disparities. Retrieved November 18, 2021, from https://www.nimhd.nih.gov/about/directors-corner/messages/message_10-06-16.html.
• Lampe NM, Carter SK, Sumerau JE. Continuity and change in gender frames: the case of transgender reproduction. Gend Soc. 2019. July;33(6):865–87. 10.1177/0891243219857979
• UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016. Available at transcare.ucsf.edu/guidelines.
• Gabrielle Winston McPherson, Thomas Long, Stephen J Salipante, Jessica A Rongitsch, Noah G Hoffman, Karen Stephens, Kelsi Penewit, Dina N Greene, The Vaginal Microbiome of Transgender Men, Clinical Chemistry, Volume 65, Issue 1, 1 January 2019, Pages 199–207, https://doi.org/10.1373/clinchem.2018.293654