When it comes to manual therapists, few of us have been trained in the care of transgender individuals. The most frequent result is we may feel a certain level of discomfort addressing transgender population needs for massage or even a degree of confusion when meeting patients whose gender identity or presentation does not correspond with their physiology. And while it's easy to accept that they may suffer from health problems the same as ours, they present some interesting demands.

This is not a comprehensive review, I will only share my personal experience from the last 10 years, knowledge learned from working with seven transgender patients and taking seminars on healthcare for transgender population.

-If you want to be prepared when transgender patients enter your office, consider updating the office intake form, specifically the questions about gender. AMA suggests "the ideal patient intake form has both a "gender question" and an "assigned-sex-at-birth question."  Some may have an optional "preferred pronoun" question. Asking both a gender and a sex question instead of just one, and offering many choices, gives a chance for specific disclosure of a person's history. It also validates their current gender identity.

-It proved to be a good idea—once the patient is in therapy room—to ask about preferred name, pronoun and whether the patient feels comfortable sharing their experiences concerning gender.

-It helps to remember that most transgender patients' health problems are not necessarily due to transgender-related issues or cross-sex hormone use. However, hormone therapy and surgical interventions, with or without sex reassignment surgery, will lead to physiological changes. This is very important when considering giving them a massage.  

-When applying the massage, I provide care for the anatomy that is present, regardless of the patient's self-description or identification. For example, an affirmed male may still have breasts, so I drape accordingly and ask if I shall keep strokes away from certain areas. For example, the uterus - in which case, if performing visceral manipulation (VM) for the bladder, I consider the bladder-uterus relationship.

-An affirmed female most likely still has a penis (so be mindful when draping), a prostate, so again VM or neural manipulations, or massaging the abdomen should be performed with this in mind.

I try to remember the following when treating transgender MaleToFemale(MTF) patients:

- Feminizing hormone therapy usually leads (Within the first 3 months) to fat redistribution, breast growth, voice and skin changes, as well as decreased muscle mass, erections, libido and the spectrum of physical or psychological complaints associated with them.

And the following when treating transgender FTM patients:

-Physiologic changes include fat redistribution, acne, voice deepening, amenorrhea, facial and body hair growth, and increased muscle mass. Risks associated with hormone use include along with many others, also osteoporosis so, I keep my hands light.

- Expect pain, tense tissues, restricted ROM, restlessness, hypersensitivity, inability to relax but also, readiness to engage in Somato-Emotional Release or in other trauma-releasing bodywork methods. 

Specific demands present people who have undergone transgender reassignment surgery. These patients often seek surgical care far from their homes since few surgeons in the U.S. perform these surgeries; and they return home, experience complications, and usually do not see their surgeons for them because of either cost, time or willingness. So, you may see a patient who is seeking pain relief after sex reassignment surgery from you instead of from his distantly located surgeon. In this case, assess mindfully and refer wisely.

-If it's soon after the surgery (two weeks to three months), I have found that Manual Lymph Drainage for the lower body is the best way to start the session.

Assess Social Adjustment

-In general, transgender persons experience more mental stress issues than the general population, so it is important to have a general discussion on mental well-being at every visit. 

Violence should be addressed in the conversation. Transgender people are believed to be victims of violence more frequently than others—from verbal and physical abuse to murder—directly related to their gender identity. Actively ask about a history of verbal, emotional, or physical abuse, about violence, check the available body parts for signs of abuse and be mindful with your hands.

Some of them will share a history of emotional abuse or trauma with you but some will "keep this in the closet" which may manifest as Emotional Cysts or other types of somatized psychological content. Consider this when you stumble on overly tense abdominal muscles, or hypersensitive or ticklish thighs. At this point, I find CST achieving muscle relaxation faster than MFR.

 I try:

• To establish a good rapport with the client

• To be respectful

• To be present

-Take extra care of sanitation. Hepatitis C and HIV are most frequently distributed among transgender population. I use this protective film for my hands before massage and profusely spray with Clean Sweep.

What is your experience? 

Some excellent resources:

American Academy of Family Physicians - LGBT Resources

World Professional Association for Transgender Health - Standards of Care