Intended for healthcare professionals


Sex specific reference ranges and transgender care

BMJ 2022; 376 doi: (Published 16 February 2022) Cite this as: BMJ 2022;376:e069874
  1. Ada S Cheung, associate professor12,
  2. Teddy Cook, acting director, community health and wellbeing3,
  3. Ariel Ginger, researcher1 2,
  4. Sav Zwickl, researcher1
  1. 1Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Victoria, Australia
  2. 2Gender Clinic, Department of Endocrinology, Austin Health, Victoria, Australia
  3. 3ACON, Surry Hills, New South Wales, Australia
  1. Correspondence to: A Cheung adac{at}

Both male and female ranges should be given on all relevant test results

The correct interpretation of laboratory test results is an integral part of daily clinical care. Many clinicians scan for “red flags” without always examining reference ranges closely. However, reporting of reference ranges, particularly sex specific ranges, can lead to substantial distress and potentially incorrect care for people who are transgender, which includes people with a binary (man or woman) or non-binary gender identity.1 For example, how should clinicians interpret a haemoglobin concentration of 168 g/L (female reference range 115-155, male 120-170) and a packed cell volume of 0.5% (female 0.33-0.45, male 0.36-0.50), both flagged as high in a trans man after 12 months of testosterone therapy?

For many trans people, gender affirming hormone therapy reduces gender dysphoria and improves quality of life.2345 Physiological effects also occur. Masculinising testosterone therapy increases red cell production, suppresses menstruation, increases muscle mass, and reduces fat mass.67 Feminising hormone therapy, typically with oestradiol and anti-androgen therapy, reduces red cell production and muscle mass and …

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