Taking a Multidisciplinary Approach to Transgender Care

Transgender care is a complex and evolving field. Because so many body systems must be closely monitored throughout the gender-affirming process, patients can often find themselves bouncing from one specialist to another. In order to streamline this, Cleveland Clinic’s Transgender Medicine & Surgery Program takes a multidisciplinary approach to transgender care, and eight specialists — including a primary care specialist, an endocrinologist, surgeons and mental health providers — work collaboratively to ensure patients are on the best and most efficient path towards achieving their gender-affirming goals.

“Our center is filled with providers who are very experienced and have a great wealth of knowledge in gender-affirming care,” says Shirisha Avadhanula, MD (she/her), an endocrinologist involved with Cleveland Clinic’s Transgender Medicine & Surgery Program. “The ease of access for patients going through the system has become increasingly better.”

Throughout the course of the COVID-19 pandemic, the program had to rely heavily on leveraging telehealth systems. Dr. Avadhanula found that this was helpful for some of her patients who were seeking gender-affirming care because gender-affirming care is still unavailable everywhere in the US. Many patients come from out-of-state, so using telehealth has allowed them to seek out care in a more convenient and quicker way.

“One aspect of the program that makes us unique is that we really do base it on a team approach,” says Henry Ng, MD, MPH (he/they), an internal medicine/pediatrics trained primary care physician and the Cleveland Clinic’s Director of the Transgender Surgery & Medicine Program and Head of Lesbian, Gay, Bisexual Medical Care. “Whenever there is a patient that I have a query about or is maybe a unique case, I’ll bring it to our multidisciplinary conference and we’ll all discuss it as a team. This gives us a lot of different perspectives and helps us deliver optimal patient care.”

The care path

When a patient initially seeks gender-affirming care from Cleveland Clinic, they’ll begin with one of the primary care physicians (PCPs). The PCP will discuss their goals with them and will determine where the patient should go next. “Dr. Ng and their highly specialized team, will go through things like objectives of care, contraindications, different hormonal treatments and medical history,” says Dr. Avadhanula. “The multi-disciplinary team-based approach that we have here at Cleveland Clinic is what sets us apart. We’ll quickly triage patients when there is another specialty service that we think will add to the care of the patient. We’re in constant communication with each other so the patient really is allowed to move through the system quite seamlessly.”

Once a patient is referred to Dr. Avadhanula, she will take an extensive medical history. A thorough physical exam is performed to determine which approach is the safest for the patient. While standard treatments and approaches exist, each patient is unique and there are also many different options available, including multiple different formulations of medications.

“In terms of Gender Affirmation Hormonal Therapy (GAHT), we previously worked off more of an algorithmic approach,” says Dr. Avadhanula. “But as we’re evolving throughout this field, we’re trying to tailor care towards what the patient’s goals of care are. There are some patients that come to our clinic and they might just want GAHT, and they don’t want to undergo surgery.”

Helping patients reach their goals

For gender-affirming therapy, Dr. Avadhanula and her team will start patients with the necessary blockers and then proceed to give them hormones in the form of replacement therapy. These labs are monitored through blood tests, and the team also makes sure that patients do not have any contraindications to hormone therapy. If a patient expresses interest in surgery, the transgender surgery team will meet with them to discuss their options. The patient will always meet with a specialty provider if they need to be cleared for treatment prior to surgery. “For example, if a patient needs to see a hematologist or if they need to see a heart specialist before to clear them for treatment, we’ll make sure those consultations are fulfilled prior to treatment. Even physicians who aren’t directly a part of the Transgender Program still play a role in our holistic and multidisciplinary approach to care,” says Dr. Avadhanula.

Patients in the program receive a great deal of attention throughout the entire process, and the team has discussions with the patient plus their own internal discussions, at several points along the care path. Dr. Avadhanula notes that communication is a critical part of the program because there is not a standard path of care for each patient — each treatment plan must be tailored to the individual patient. “We have learned a lot from our European colleagues, who have a lot of data on transgender care. Moving forward we certainly hope to add more to this existing database.”

Once a patient reaches their goal, their medication doses generally do not need to continuously change. But the specialists continue to work very closely together with the patient through blood tests and have regular conversations about how the formulation is going and whether their goals have changed at all.

“There’s a reason that we follow up so closely. And it’s really to help people achieve their goals as efficiently and effectively as possible,” says Cecile Ferrando, MD, MPH (she/her), a urogynecologist and the Director of Surgical Services for the Transgender Medicine & Surgery Program. “We of course want to tailor patient expectations; I tell them not to expect that we’ll be where we want to be within a week. But certainly, we want to get there as efficiently as possible so that our patients are able to feel like themselves.”