Gender-Affirming Hormone Use in Transgender Individuals: Impact on Behavioral Health and Cognition

SIGIS-SIAMS-SIE position statement of gender affirming hormonal treatment in transgender and non-binary people

PURPOSE

Gender Incongruence (GI) is a marked and persistent incongruence between an individual's experienced and the assigned gender at birth. In the recent years, there has been a considerable evolution and change in attitude as regards to gender nonconforming people.

METHODS

According to the Italian Society of Gender, Identity and Health (SIGIS), the Italian Society of Andrology and Sexual Medicine (SIAMS) and the Italian Society of Endocrinology (SIE) rules, a team of experts on the topic has been nominated by a SIGIS-SIAMS-SIE Guideline Board on the basis of their recognized clinical and research expertise in the field, and coordinated by a senior author, has prepared this Position statement. Later on, the present manuscript has been submitted to the Journal of Endocrinological Investigation for the normal process of international peer reviewing after a first internal revision process made by the SIGIS-SIAMS-SIE Guideline Board.

RESULTS

In the present document by the SIGIS-SIAMS-SIE group, we propose experts opinions concerning the psychological functioning, gender affirming hormonal treatment, safety concerns, emerging issues in transgender healthcare (sexual health, fertility issues, elderly trans people), and an Italian law overview aimed to improve gender non-conforming people care.

CONCLUSION

In this Position statement, we propose experts opinions concerning the psychological functioning of transgender people, the gender-affirming hormonal treatment (full/partial masculinization in assigned female at birth trans people, full/partial feminization and de-masculinization in assigned male at birth trans people), the emerging issues in transgender health care aimed to improve patient care. We have also included an overview of Italian law about gender affirming surgery and registry rectification.

Gender-affirming hormone therapy induces specific DNA methylation changes in blood

Background

DNA methylation is an epigenetic mark that is influenced by underlying genetic profile, environment, and ageing. In addition to X-linked DNA methylation, sex-specific methylation patterns are widespread across autosomal chromosomes and can be present from birth or arise over time. In individuals where gender identity and sex assigned at birth are markedly incongruent, as in the case of transgender people, feminization or masculinization may be sought through gender-affirming hormone therapy (GAHT). GAHT is a cornerstone of transgender care, yet no studies to date have investigated its effect on genome-wide methylation. We profiled genome-wide DNA methylation in blood of transgender women (n = 13) and transgender men (n = 13) before and during GAHT (6 months and 12 months into feminizing or masculinizing hormone therapy).

Results

We identified several thousand differentially methylated CpG sites (DMPs) (Δβ ≥ 0.02, unadjusted p value < 0.05) and several differentially methylated regions (DMRs) in both people undergoing feminizing and masculinizing GAHT, the vast majority of which were progressive changes over time. X chromosome and sex-specific autosomal DNA methylation patterns established in early development are largely refractory to change in association with GAHT, with only 3% affected (Δβ ≥ 0.02, unadjusted p value < 0.05). The small number of sex-specific DMPs that were affected by GAHT were those that become sex-specific during the lifetime, known as sex-and-age DMPs, including DMRs in PRR4 and VMP1 genes. The GAHT-induced changes at these sex-associated probes consistently demonstrated a shift towards the methylation signature of the GAHT-naïve opposite sex, and we observed enrichment of previously reported adolescence-associated methylation changes.

Conclusion

We provide evidence for GAHT inducing a unique blood methylation signature in transgender people. This study advances our understanding of the complex interplay between sex hormones, sex chromosomes, and DNA methylation in the context of immunity. We highlight the need to broaden the field of ‘sex-specific’ immunity beyond cisgender males and cisgender females, as transgender people on GAHT exhibit a unique molecular profile.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13148-022-01236-4.

Epigenetic Effects of Gender-Affirming Hormone Treatment: A Pilot Study of the ESR2 Promoter’s Methylation in AFAB People

Virilization of gender-incongruent subjects to whom were assigned the female gender at birth (AFAB) is achieved through testosterone administration. Inter-individual differences in the timing and acquisition of phenotypic characteristics, even if the same hormone preparations and regimens are used, are frequently observed. Polymorphisms of sex hormone receptors and methylation of their gene promoters, as well of several imprinted genes as H19, may underlie the differential response to treatment. Thus, the aim of this study was to examine the possible relationship between the CpG methylation profile of the estrogen receptor 2 gene (ESR2) and H19 promoters and their influence on phenotype modifications in a cohort of AFAB people at baseline (T0) and after 6 mo (T6) and 12 mo (T12) of testosterone therapy (testosterone enanthate, 250 mg i.m. every 28 d). A total of 13 AFAB subjects (mean age 29.3 ± 12.6) were recruited. The percentage of methylation of the ESR2 promoter significantly increased at T6 (adj. p = 0.001) and T12 (adj. p = 0.05), while no difference was detected for H19 (p = 0.237). Methylation levels were not associated with androgen receptor (AR)/estrogen receptor beta (ERβ) polymorphisms nor hormone levels at baseline and after six months of treatment. On the other hand, total testosterone level and patient age resulted in being significantly associated with ESR2 methylation after twelve months of treatment. Finally, the difference in ESR2 promoter methylation between T6 and baseline was significantly associated with the number of CA repeats of the ERβ receptor, adjusted vs. all considered variables (R2 = 0.62, adj. R2 = 0.35). No associations were found with CAG repeats of the AR, age, and estradiol and testosterone levels. Despite the small sample size, we can hypothesize that treatment with exogenous testosterone can modify the ESR2 methylation pattern. Our data also indicated that epigenetic changes may be regulated, suggesting that the modulation of estrogen signaling is relevant shortly after the beginning of the treatment up to T6, with no further significant modification at T12. Furthermore, estrogen receptor methylation appears to be associated with the age of the subjects and exogenous testosterone administration, representing a marker of androgenic treatment. Nonetheless, it will be necessary to increase the number of subjects to evaluate how epigenetic regulation might play a relevant role in the modulation of phenotypical changes after testosterone treatment.

Recommendations to Address the Unique Clinical and Psychological Needs of Transgender Persons Living With Multiple Sclerosis

BACKGROUND

People living with multiple sclerosis (MS) face challenges coping with chronic illnesses, and transgender (TGD) persons living with MS may experience additional unique challenges and barriers to care. Medical biases toward TGD people are widely reported, and best practices in TGD MS care have not been identified.

METHODS

A case report of a TGD person living with MS is reviewed that helped to identify and inform us regarding the unique aspects of their clinical and psychological care needs. We conducted a systematic review of the literature according to the standard methods in PubMed. The literature was reviewed and summarized for relevant topics related to the unique care needs of TGD persons living with MS, and proposed care recommendations were created.

RESULTS

We used the aforementioned case to identify and inform the special care needs and subsequently describe proposed recommendations to achieve inclusive comprehensive care of TGD persons with MS. The importance of providing an inclusive environment, comprehensive care, mental health screening, domestic violence screening, and case coordination are highlighted with the goal of providing best practice recommendations for the comprehensive inclusive care of TGD persons living with MS.

CONCLUSIONS

The lack of published guidance on the care of TGD persons living with MS and our informative case have led to the proposed recommendations for the care of TGD persons living with MS.

Task-domain and hemisphere-asymmetry effects in cisgender and transmale individuals

The present research examined the extent to which transmale individuals’ functional brain organization resembles that of their assigned sex or gender identity. Cisgender-female, cisgender-male, and transmale participants, who were assigned female sex but did not have a female gender identity, were compared in terms of effects that have been observed in cisgender individuals: task-domain effects, in which males perform better than females on spatial tasks and females perform better than males on verbal tasks; and hemisphere-asymmetry effects, in which males show larger differences between the left and right hemispheres than females. In addition, the present research measured participants’ intelligence in order to control for potential moderating effects. Participants performed spatial (mental rotation) and verbal (lexical decision) tasks presented to each hemisphere using a divided-visual field paradigm, and then completed an intelligence assessment. In the mental-rotation task, cismale and transmale participants performed better than cisfemale participants, however this group difference was explained by intelligence scores, with higher scores predicting better performance. In the lexical-decision task, cismale and transmale participants exhibited a greater left-hemisphere advantage than cisfemales, and this difference was not affected by intelligence scores. Taken together, results do not support task-domain effects when intelligence is accounted for; however, they do demonstrate a hemisphere-asymmetry effect in the verbal domain that is moderated by gender identity and not assigned sex.

Investigating the impacts of COVID-19 among LGBTQ2S youth experiencing homelessness

BACKGROUND

LGBTQ2S youth are overrepresented among youth experiencing homelessness and experience significantly higher rates of mental health issues compared to heterosexual and cisgender youth. COVID-19 related challenges for LGBTQ2S youth experiencing homelessness remain unknown. To address this gap, this study aimed to understand the impacts of the COVID-19 pandemic on LGBTQ2S youth at risk of, and experiencing, homelessness in the Greater Toronto Area, Ontario, Canada and surrounding areas.

METHODS

Utilizing a mixed-methods convergent parallel design, LGBTQ2S youth experiencing homelessness were recruited to participate in virtual surveys and in-depth one-on-one interviews. Surveys included standardized measures and were administered to measure mental health outcomes and collect information on demographic characteristics, and health service use. Survey data were analyzed with descriptive statistics and statistical tests for difference of proportions. Interviews were analyzed using an iterative thematic content approach.

RESULTS

Sixty-one youth completed surveys and 20 youth participated in one-on-one interviews. Quantitative and qualitative data showed that youth have been significantly impacted by the COVID-19 pandemic in various ways, including experiencing poor mental health, such as suicidality, depression, anxiety, and increased substance use, and lack of access to health and social support services.

CONCLUSION

Our study highlights the need for LGBTQ2S inclusive and affirming health care and support services for precariously housed adolescents to address the pre-existing social and health issues that have been exacerbated by the pandemic.

Defensive Functioning of Individuals Diagnosed With Gender Dysphoria at the Beginning of Their Hormonal Treatment

Defense mechanisms are relevant indicators of psychological functioning and vulnerability to psychopathology. Their evaluation can unveil individuals' unconscious strategies for mediating reactions to emotional conflict and external stressors. At the beginning of their journey toward gender reassignment, individuals diagnosed with gender dysphoria (GD) may experience conflict and stressful experiences that trigger a wide range of defense mechanisms. Mature defenses may strengthen these individuals as they travel along this important path, while neurotic and immature defenses may exacerbate their body dissatisfaction (BD) and hinder their processing of change. Only a few studies have investigated self-reported defensive functioning in transgender people, finding a higher frequency of maladaptive defense mechanisms relative to controls. The present study was the first to apply an in-depth clinician-rated tool to assess the entire hierarchy of defense mechanisms within a sample of transgender people. Defensive functioning and personality organization were assessed in 36 individuals diagnosed with GD (14 trans women, 22 trans men, mean age 23.47 years), using the Defense Mechanisms Rating Scales (Perry, 1990) and the Shedler-Westen Assessment Procedure-200 (Shedler et al., 2014). Body uneasiness was assessed using the Body Uneasiness Test (BUT; Cuzzolaro et al., 2006). The findings showed that defensive functioning correlated positively with healthy personality functioning and negatively with BD. Compared to cisgender controls, participants with GD who presented greater defensive functioning were found to be more immature and to demonstrate significant differences in many levels of functioning. The clinical implications of the results suggest that psychological interventions aimed at improving defensive functioning in individuals with GD will be important in helping them manage the challenges posed by their gender transition.

Testosterone, identity and the body: Exploring cultural definitions of disorder

Medically-sanctioned testosterone administration has seen increasingly widespread application in the treatment of gender dysphoria (GD). Yet, by comparison, this approach is not medically accepted for those who are experiencing muscle dysmorphia (MD), a specifier of body dysmorphic disorder (BDD), despite both conditions reflecting incongruences between self-perception, identity and phenotype, and both currently being classified as mental health disorders. Rather, by stark contrast, those with MD are largely treated with psychological intervention to accept themselves as they physically are and the illicit use of testosterone for muscle-related body perception purposes is generally subject to criminal justice enforcement actions. In this commentary, we examine attempts to distinguish between the use of testosterone for gender-affirming hormone therapy in the case of GD and for aesthetic (muscle enhancement) use in the case of MD, as well as explore the implications of this disparity. Moreover, we consider how such disparity in policy and practice may be understood, in part, as an example of a bias reflecting the selective pathologizing of anabolic-androgenic steroid (AAS) use, socio-cultural evolutions in gender identity and expression and, more broadly, the manner in which culture defines disorder and its appropriate response.

Differences in Patient and Parent Informant Reports of Depression and Anxiety Symptoms in a Clinical Sample of Transgender and Gender Diverse Youth

Purpose: We assessed characteristics of patients at a pediatric gender clinic and investigated if reports of mental health concerns provided by transgender and gender diverse (TGD) youth patients differed from reports provided by a parent informant on their behalf. Methods: This cross-sectional study included 259 TGD patients 8 to 22 years of age attending a pediatric gender clinic in the southeast United States from 2015 to 2020. Pearson correlations and paired sample t-tests compared patient-reported mental health concerns at patient intake with those provided by a parent informant. Clinical symptom severity was assessed with standardized T-scores. Level 2 Patient-Reported Outcomes Measurement Information System (PROMIS) Emotional Distress-Depression Scale and Level 2 PROMIS Emotional Distress-Anxiety Scale assessed depression and anxiety symptoms of patients. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Parent/Guardian-Rated Level 1 Cross-Cutting Symptom Measure was used with parents. Results: Patients had a mean age of 14.9 at first visit, with most identifying as White (85.5%), non-Hispanic (91.1%), and as a boy or man (63.6%). Half had moderate-to-severe depression (51.2%) or anxiety (47.9%) symptoms. There was a moderate, positive correlation between patient-reported and parent-reported depression symptoms, with no correlation for anxiety symptoms. Informant type differences were statistically significant (patients reporting greater depression and anxiety symptoms). Conclusions: TGD youth patients reported more severe depression and anxiety symptoms compared with parent informants. Despite moderate agreement on depression symptoms, parents did not accurately detect their child's anxiety symptoms. These discrepancies highlight a need for interventions which increase parental recognition of child mental health status.

Gender-affirming care, mental health, and economic stability in the time of COVID-19: A multi-national, cross-sectional study of transgender and nonbinary people

BACKGROUND

Transgender and nonbinary people are disproportionately affected by structural barriers to quality healthcare, mental health challenges, and economic hardship. This study examined the impact of the novel coronavirus disease (COVID-19) crisis and subsequent control measures on gender-affirming care, mental health, and economic stability among transgender and nonbinary people in multiple countries.

METHODS

We collected multi-national, cross-sectional data from 964 transgender and nonbinary adult users of the Hornet and Her apps from April to August 2020 to characterize changes in gender-affirming care, mental health, and economic stability as a result of COVID-19. We conducted Poisson regression models to assess if access to gender-affirming care and ability to live according to one's gender were related to depressive symptoms, anxiety, and changes in suicidal ideation.

RESULTS

Individuals resided in 76 countries, including Turkey (27.4%, n = 264) and Thailand (20.6%, n = 205). A majority were nonbinary (66.8%, n = 644) or transfeminine (29.4%, n = 283). Due to COVID-19, 55.0% (n = 320/582) reported reduced access to gender-affirming resources, and 38.0% (n = 327/860) reported reduced time lived according to their gender. About half screened positive for depression (50.4%,442/877) and anxiety (45.8%, n = 392/856). One in six (17.0%, n = 112/659) expected losses of health insurance, and 77.0% (n = 724/940) expected income reductions. The prevalence of depressive symptoms, anxiety, and increased suicidal ideation were 1.63 (95% CI: 1.36-1.97), 1.61 (95% CI: 1.31-1.97), and 1.74 (95% CI: 1.07-2.82) times higher for individuals whose access to gender-affirming resources was reduced versus not.

DISCUSSION

The COVID-19 crisis is associated with reduced access to gender-affirming resources and the ability of transgender and nonbinary people to live according to their gender worldwide. These reductions may drive the increased depressive symptoms, anxiety, and suicidal ideation reported in this sample. To improve health of transgender and nonbinary communities, increased access to gender-affirming resources should be prioritized through policies (e.g., digital prescriptions), flexible interventions (e.g., telehealth), and support for existing transgender health initiatives.

Estrogen-induced gallstone pancreatitis in a transgender female

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

The case of a transgender female who developed gallstone pancreatitis in the context of estrogen use for gender-affirming hormone therapy is reported.

SUMMARY

A 24-year-old Caucasian transgender female presented to the emergency department for abdominal pain and vomiting after referral from urgent care for suspected pancreatitis. Her home medications included estradiol, medroxyprogesterone, and spironolactone for gender-affirming hormone therapy and omeprazole for reflux. The patient reported minimal alcohol intake, presented with mildly elevated triglyceride levels, and did not have a family history of pancreatitis or gallstone disease. She underwent a laparoscopic cholecystectomy on hospital day 4 and was given a postoperative diagnosis of chronic cholecystitis, cholelithiasis, and pancreatitis. Given her history and the present illness, the use of estrogen therapy is a likely risk factor for the development of gallstone pancreatitis.

CONCLUSION

Estrogen is a cornerstone of gender-affirming hormone therapy used by transgender women; however, in addition to its role in gender identity confirmation, estrogen can result in drug-induced pancreatitis.

Psychoneuroendocrine protocol to comprehensively study sexually dimorphic cognition

Background

A large body of research provides evidence for sex differences in cognitive abilities. These sex differences stem from the interplay between biological sex (e.g., birth-assigned sex, sex hormones) and psychosocial gender (e.g., gender identity, gender-roles, sexual orientation). Literature remains rather mixed with regards to the magnitude of sex and gender effects on cognitive abilities and mental health. Growing evidence shows that sex hormone assessment combined with measures of psychosocial gender may be fundamental to comprehensively understand individual differences in sexually dimorphic cognitive abilities.

Objectives

This study protocol describes a sexually dimorphic cognitive battery to assess the influence of sex hormones on performance. In parallel, we aim to assess the inter-related effects that biological sex and psychosocial gender-based factors exert on cognition and mental health.

Methods

Our projected sample includes 180 adult participants who are at least 18 years old. Sub-groups will be recruited based on birth-assigned sex, gender identity, and sexual orientation. Biological measures will be collected via salivary samples throughout testing to include sex hormones (testosterone, estradiol and progesterone) and stress hormones (cortisol). Demographic and psychosocial variables will be measured through self-report questionnaires. Participants will be required to complete eight classic cognitive tasks that assess a variety of cognitive domains in a 2-h testing session.

Results and future directions

Results from this study provides unique insights into the correlates of cognitive sex differences and gender diversity. This will give us solid ground to further investigate these influences in clinical populations in which sex hormones and cognitive functioning are often altered.

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Cognition is modulated by multiple sex and gender factors.

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Cognitive abilities will be assessed among 180 adults representing diverse sexual orientations and gender identities.

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This protocol aims to nuance the effects of sex hormones in contrast to those of socio-cultural gender.

Neuroimaging gender dysphoria: a novel psychobiological model

Gender identity development is complex and involves several key processes. Transgender people experience incongruence between their biological and identified gender. This incongruence can cause significant impairment in overall functioning and lead to gender dysphoria (GD). The pathophysiology of GD is complex and is poorly understood. A PubMed search based on predetermined eligibility criteria was conducted to review neuropsychiatric articles focused on neurological, biological and neuroimaging aspects of gender development, transgender identity and GD. The information obtained from the literature was then used to formulize a GD model. Distinct gray matter volume and brain activation and connectivity differences were found in individuals with GD compared to controls, suggesting a neurobiological basis of GD; which leads to the concept of brain gender. Individuals with GD encounter a recurrent conflict between their brain gender and the societal feedback; which causes recurrent and ongoing cognitive dissonance, finally leading to GD and functional connectivity and activation changes in the transgender brain. GD has neurobiological basis, but it is closely associated with the individuals' interaction with the external world, their self-perception and the feedback received in return. We propose a novel model where the development of GD includes cognitive dissonance, involving anterior cingulate cortex and ventral striatum as the key brain structures. This model can be used to generate testable hypotheses using behavioral and neuroimaging techniques to understand the neuropsychobiology of GD.

Supporting the Health of Transgender and Gender-Diverse Youth in Primary Care Settings

Transgender and gender-diverse youth represent approximately 2% of all youth in the United States. Given that gender diversity usually develops during childhood and adolescence, primary care providers must be equipped to recognize and support youth exploring gender identity or experiencing gender dysphoria. This article provides an overview of gender diversity and reviews strategies for creating a welcoming clinical space, discussing gender during the office visit, providing affirming primary care, and supporting youth and their families during gender identity exploration and gender transition.

Providing Affirmative Care to Transgender and Gender Diverse Youth: Disparities, Interventions, and Outcomes

PURPOSE OF REVIEW

This paper reviews the evolving body of research on the mental health of transgender and gender diverse (TGD) youth. Minority stress experiences in families, schools, and the community impact the health and well-being of this population due to experiences of stigma, discrimination, and rejection. Poor healthcare access and outcomes may be compounded in youth with intersectional identities.

RECENT FINDINGS

There is increasing evidence that gender-affirming interventions improve mental health outcomes for TGD youth. TGD youth report worse mental health outcomes in invalidating school and family environments and improved outcomes in affirming climates. TGD youth experience significant healthcare disparities, and intersectional clinical approaches are needed to increase access to affirmative care. Providers can best support TGD youth by considering ways they can affirm these youth in their healthcare settings, and helping them access support in schools, family systems, and communities. Understanding the intersection of multiple minority identities can help providers address potential barriers to care to mitigate the health disparities seen in this population.

Implications for management of ovarian cancer in a transgender man: Impact of androgens and androgen receptor status

A 36-year-old transgender man (assigned female at birth) on exogenous testosterone therapy was found to have stage IIA ovarian endometrioid carcinoma, and underwent adjuvant chemotherapy. Diffuse androgen receptor expression in the tumor initiated a multidisciplinary discussion regarding the safety of continuing exogenous testosterone as gender-affirming hormone therapy.

Factors associated with suicide attempts among Australian transgender adults

BACKGROUND

Transgender, including gender diverse and non-binary people, henceforth referred to collectively as trans people, are a highly marginalised population with alarming rates of suicidal ideation, attempted suicide and self-harm. We aimed to understand the risk and protective factors of a lifetime history of attempted suicide in a community sample of Australian trans adults to guide better mental health support and suicide prevention strategies.

METHODS

Using a non-probability snowball sampling approach, a total of 928 trans adults completed a cross-sectional online survey between September 2017 and January 2018. The survey assessed demographic data, mental health morbidity, a lifetime history of intentional self-harm and attempted suicide, experiences of discrimination, experiences of assault, access to gender affirming healthcare and access to trans peer support groups. Logistic regression was used to examine the risk or protective effect of participant characteristics on the odds of suicide.

RESULTS

Of 928 participants, 85% self-reported a lifetime diagnosis of depression, 63% reported previous self-harm, and 43% had attempted suicide. Higher odds of reporting a lifetime history of suicide attempts were found in people who were; unemployed (adjusted odds ratio (aOR) 1.55 (1.05, 2.29), p = 0.03), had a diagnosis of depression (aOR 3.70 (2.51, 5.45), p < 0.001), desired gender affirming surgery in the future (aOR 1.73 (1.14, 2.61), p = 0.01), had experienced physical assault (aOR 2.01 (1.37, 2.95), p < 0.001) or experienced institutional discrimination related to their trans status (aOR 1.59 (1.14, 2.23), p = 0.007).

CONCLUSION

Suicidality is associated with barriers to gender affirming care, gender based victimisation and institutionalised cissexism. Interventions to increase social inclusion, reduce transphobia and enable timely access to gender affirming care, particularly surgical interventions, are potential areas of intervention.

Endocrine Management of Transgender Adults: A Clinical Approach

The attention to transgender medicine has changed over the last decade and the interest is most likely going to increase in the future due to the fact that gender-affirming treatments are now being requested by an increasing number of transgender people. Even if gender-affirming hormone therapy (GAHT) is based on a multidisciplinary approach, this review is going to focus on the procedures adopted by the endocrinologist in an out-clinic setting once an adult patient is referred by another specialist for ‘gender affirming’ therapy. Before commencing this latter treatment, several background information on unmet needs regarding medical and surgical outcomes should be investigated. We summarized our endocrinological clinical and therapeutic approaches to adult transgender individuals before and during GAHT based on a non-systematic review. Moreover, the possible relationships between GAHT, gender-related pharmacology, and COVID-19 are also reported.

Predicting outcomes of cross-sex hormone therapy in transgender individuals with gender incongruence based on pre-therapy resting-state brain connectivity

Individuals with gender incongruence (GI) experience serious distress due to incongruence between their gender identity and birth-assigned sex. Sociological, cultural, interpersonal, and biological factors are likely contributory, and for some individuals medical treatment such as cross-sex hormone therapy and gender-affirming surgery can be helpful. Cross-sex hormone therapy can be effective for reducing body incongruence, but responses vary, and there is no reliable way to predict therapeutic outcomes. We used clinical and MRI data before cross-sex hormone therapy as features to train a machine learning model to predict individuals' post-therapy body congruence (the degree to which photos of their bodies match their self-identities). Twenty-five trans women and trans men with gender incongruence participated. The model significantly predicted post-therapy body congruence, with the highest predictive features coming from the cingulo-opercular (R² = 0.41) and fronto-parietal (R² = 0.30) networks. This study provides evidence that hormone therapy efficacy can be predicted from information collected before therapy, and that patterns of functional brain connectivity may provide insights into body-brain effects of hormones, affecting one's sense of body congruence. Results could help identify the need for personalized therapies in individuals predicted to have low body-self congruence after standard therapy.

The Prevalence of Frascati-Criteria-Based HIV-Associated Neurocognitive Disorder (HAND) in HIV-Infected Adults: A Systematic Review and Meta-Analysis

Background: The HIV associated mortality is decreasing in most countries due to the widespread use of antiretroviral therapy. However, HIV-associated neurocognitive disorder (HAND) remains a problematic issue that lowers the quality of life and increases the public health burden among people living with HIV. The prevalence of HAND varies across studies and selected samples. Therefore, we aimed to quantitatively summarize the pooled prevalence of Frascati-criteria-based HAND and to explore the potential demographic, clinical, and immunological factors. Methods: A comprehensive literature search in PubMed/Medline, Web of Science, Embase, and PsycINFO was performed. A random-effects meta-analysis was conducted using the event rate (ER) for the estimation of the incidence of HAND. Subgroup meta-analyses were used to evaluate between-group differences in categorical variables. Meta-regression with the unrestricted maximum likelihood (ML) method was used to evaluate associations of continuous variables. Results: Eighteen studies whose sample sizes ranged from 206 to 1555 were included in the final analyses. The estimated prevalence of HAND, ANI, MND and HAD were 44.9% (95% CI 37.4-52.7%), 26.2% (95% CI 20.7-32.7%), 8.5% (95% CI 5.6-12.7%), 2.1% (95% CI 1.2-3.7%), respectively. Factors associated with HAND were percent female, current CD4 count, education level and country development level (all ps < 0.05). Conclusion: Longitudinal cohort and multimodal neuroimaging studies are needed to verify the clinical prognosis and the underlying neurocognitive mechanism of HAND. In addition, it is urgently necessary to establish a standardized HAND diagnostic process.

The Body I Live in. Perceptions and Meanings of Body Dissatisfaction in Young Transgender Adults: A Qualitative Study

Body dissatisfaction in individuals with Gender Incongruence (GI) represents a primary source of suffering. Several studies have highlighted how this suffering has psychological, physical, and biological implications. This work aims to explore experiences related to body dissatisfaction and investigate the issues associated with living in a body perceived as incongruent for individuals with GI. Thirty-six individuals, aged between 18 and 30 years old and at stage T0 of hormone treatment, participated in the study. Body dissatisfaction and experiences related to it were investigated using the Clinical Diagnostic Interview. The Consensual Qualitative Research methodology was applied to the transcripts of the interviews. Several themes emerged: experiences with GI development, experiences with puberty and bodily changes, perception of one’s body, psychological problems and complex behavioral patterns related to body dissatisfaction. Results pointed out the complexity implied in the relationship with one’s body for individuals with GI, highlighting specific aspects of body dissatisfaction among these individuals (e.g., eating disorders, sexual difficulties, social withdrawal). This study underlines the need for a deeper understanding of some aspects of GI to better define guidelines for a correct assessment of it. In this way it will be easier to avoid negative outcomes for the psychological and general health of transgender people.

Gender-affirming care, mental health, and economic stability in the time of COVID-19: a global cross-sectional study of transgender and non-binary people

BACKGROUND

Transgender and non-binary people are disproportionately burdened by barriers to quality healthcare, mental health challenges, and economic hardship. This study examined the impact of the novel coronavirus disease (COVID-19) pandemic and subsequent control measures on gender-affirming care, mental health, and economic stability among transgender and non-binary people globally.

METHODS

We collected global cross-sectional data from 964 transgender and non-binary adult users of the Hornet and Her apps from April to August 2020 to characterize changes in gender-affirming care, mental health, and economic stability as a result of the COVID-19 pandemic. We conducted Poisson regression models to assess if access to gender-affirming care and ability to live according to one's gender were related to depressive symptoms, anxiety, and changes in suicidal ideation.

RESULTS

Individuals resided in 76 countries, including Turkey (27.4%,n=264/964) and Thailand (20.6%,n=205). A majority were non-binary (66.8%,n=644) or transfeminine (29.4%,n=283). Due to the COVID-19 pandemic, 55.0% (n=320/582) reported reduced access to gender- affirming resources, and 38.0% (n=327/860) reported reduced time lived according to their gender. About half screened positive for depression (50.4%,442/877) and anxiety (45.8%,n=392/856). One in six (17.0%,n=112/659) expected losses of health insurance, and 77.0% (n=724/940) expected income reductions. The prevalence of depressive symptoms, anxiety, and increased suicidal ideation were 1.63 (95% CI: 1.36-1.97), 1.61 (95% CI: 1.31-1.97), and 1.74 (95% CI: 1.07-2.82) times higher for individuals whose access to gender- affirming resources was reduced versus not.

DISCUSSION

The COVID-19 pandemic has reduced access to gender-affirming resources and the ability of transgender and non-binary people to live according to their gender worldwide. These reductions may drive the increased depressive symptoms, anxiety, and suicidal ideation reported in this sample. To improve transgender and non-binary health globally, increased access to gender-affirming resources should be achieved through policies (e.g., digital prescriptions), flexible interventions (e.g., telehealth), and support for existing transgender health initiatives.

Changes in Anxiety and Depression from Intake to First Follow-Up Among Transgender Youth in a Pediatric Endocrinology Clinic

Monitoring acute distress in transgender youth initiating gender-affirming care is important given their increased risk for significant mental health symptoms. The current study examined changes in anxiety, depression, and suicidality from initial appointment to first follow-up in 80 youth, ages 11-18. Average time between visits was ∼4 months but varied across participants. Results revealed no change in acute distress from intake to follow-up. Neither distance from medical center nor initiation of hormone therapy was associated with symptom changes. While research shows decreased distress with initiation of hormones, study findings suggest changes may actually take longer to occur.

A Descriptive Study of Transgender Active Duty Service Members in the U.S. Military

Purpose: Department of Defense policy prohibits, with limited exceptions, transgender individuals from serving in their affirmed gender in the U.S. Military, citing potential impact on unit cohesion and military readiness. To date, however, little is known about the sociodemographic profile and health of transgender military personnel. Methods: U.S. Military personnel who self-identified as transgender completed anonymous online measures of demographics and military service. Participants also completed measures of health, mood, eating pathology, and risk behaviors. Results: One hundred ninety-five service members (mean age: 28.9±7.2 years, 48.7% transmale, 70.3% non-Hispanic White, 7.83±5.9 years in service) completed the survey. The majority of respondents first identified as transgender before military accession. Most had disclosed their gender identity to their command and providers, and had undertaken steps toward gender affirmation. The sample as a whole reported above average physical health, with mood symptoms within normal ranges and few reported risk behaviors. Analyses of covariance indicated that transmales reported significantly better mental health and psychosocial functioning compared with transfemales. Conclusion: In light of current policy that precludes, with limited exceptions, transgender individuals from serving in the U.S. Military in their affirmed gender, the current study provides an initial sociodemographic profile of this understudied population and indicates that transgender service members report above average physical health and few risk behaviors. Preliminary analyses indicated that transfemales in the military may be at higher risk for mental health concerns, compared with transmales. Additional research is needed to elucidate risk and protective factors among transgender service members.

Association of Nondiscrimination Policies With Mental Health Among Gender Minority Individuals

IMPORTANCE

In the past decade, many states have implemented policies prohibiting private health insurers from discriminating based on gender identity. Policies banning discrimination have the potential to improve access to care and health outcomes among gender minority (ie, transgender and gender diverse) populations.

OBJECTIVE

To evaluate whether state-level nondiscrimination policies are associated with suicidality and inpatient mental health hospitalizations among privately insured gender minority individuals.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, difference-in-differences analysis comparing changes in mental health outcomes among gender minority enrollees before and after states implemented nondiscrimination policies in 2009-2017 was conducted. A sample of gender minority children and adults was identified using gender minority-related diagnosis codes obtained from private health insurance claims. The present study was conducted from August 1, 2018, to September 1, 2019.

EXPOSURE

Living in states that implemented policies banning discrimination based on gender identity in 2013, 2014, 2015, and 2016.

MAIN OUTCOMES AND MEASURES

The primary outcome was suicidality. The secondary outcome was inpatient mental health hospitalization.

RESULTS

The study population included 28 980 unique gender minority enrollees (mean [SD] age, 26.5 [15] years) from 2009 to 2017. Relative to comparison states, suicidality decreased in the first year after policy implementation in the 2014 policy cohort (odds ratio [OR], 0.72; 95% CI, 0.58-0.90; P = .005), the 2015 policy cohort (OR, 0.50; 95% CI, 0.39-0.64; P < .001), and the 2016 policy cohort (OR, 0.61; 95% CI, 0.44-0.85; P = .004). This decrease persisted to the second postimplementation year for the 2014 policy cohort (OR, 0.48; 95% CI, 0.41-0.57; P < .001) but not for the 2015 policy cohort (OR, 0.81; 95% CI, 0.47-1.38; P = .43). The 2013 policy cohort experienced no significant change in suicidality after policy implementation in all 4 postimplementation years (2014: OR, 1.19; 95% CI, 0.85-1.67; P = .31; 2015: OR, 0.94; 95% CI, 0.73-1.20; P = .61; 2016: OR, 0.82; 95% CI, 0.65-1.03; P = .10; and 2017: OR, 1.29; 95% CI, 0.90-1.88; P = .18). Mental health hospitalization rates generally decreased or stayed the same for individuals living in policy states vs the comparison group.

CONCLUSIONS AND RELEVANCE

Implementation of a state-level nondiscrimination policy appears to be associated with decreased or no changes in suicidality among gender minority individuals living in states that implemented these policies from 2013 to 2016. Given high rates of suicidality among gender minority individuals in the US, health insurance nondiscrimination policies may offer a mechanism for reducing barriers to care and mitigating discrimination.

Gender-affirming hormone treatment and cognitive function in transgender young adults: a systematic review and meta-analysis

BACKGROUND

Previous studies have examined whether steroid hormone treatment in transgender individuals may affect cognitive function; yet, their limited power does not allow firm conclusions to be drawn. We leveraged data from to-date literature aiming to explore the effect of gender-affirming hormone administration on cognitive function in transgender individuals.

METHODS

A search strategy of MEDLINE was developed (through June 1, 2019) using the key terms transgender, hormone therapy and cognitive function. Eligible were (i) cohort studies examining the longitudinal effect of hormone therapy on cognition, and (ii) cross-sectional studies comparing the cognitive function between treated and non-treated individuals. Standardized mean differences (Hedges' g) were pooled using random-effects models. Study quality was evaluated using the Newcastle-Ottawa Scale.

OUTCOMES

Ten studies (seven cohort and three cross-sectional) were eligible representing 234 birth-assigned males (aM) and 150 birth-assigned females (aF). The synthesis of cohort studies (n = 5) for visuospatial ability following hormone treatment showed a statistically significant enhancement among aF (g = 0.55, 95% confidence intervals [CI]: 0.29, 0.82) and an improvement with a trend towards statistical significance among aM (g = 0.28, 95%CI: -0.01, 0.58). By contrast, no adverse effects of hormone administration were shown. No heterogeneity was evident in most meta-analyses.

INTERPRETATION

Current evidence does not support an adverse impact of hormone therapy on cognitive function, whereas a statistically significant enhancing effect on visuospatial ability was shown in aF. New longitudinal studies with longer follow-up should explore the long-term effects of hormone therapy, especially the effects on younger individuals, where there is greater scarcity of data.

Biological sex classification with structural MRI data shows increased misclassification in transgender women

Transgender individuals (TIs) show brain-structural alterations that differ from their biological sex as well as their perceived gender. To substantiate evidence that the brain structure of TIs differs from male and female, we use a combined multivariate and univariate approach. Gray matter segments resulting from voxel-based morphometry preprocessing of N = 1753 cisgender (CG) healthy participants were used to train (N = 1402) and validate (20% holdout N = 351) a support-vector machine classifying the biological sex. As a second validation, we classified N = 1104 patients with depression. A third validation was performed using the matched CG sample of the transgender women (TW) application sample. Subsequently, the classifier was applied to N = 26 TW. Finally, we compared brain volumes of CG-men, women, and TW-pre/post treatment cross-sex hormone treatment (CHT) in a univariate analysis controlling for sexual orientation, age, and total brain volume. The application of our biological sex classifier to the transgender sample resulted in a significantly lower true positive rate (TPR-male = 56.0%). The TPR did not differ between CG-individuals with (TPR-male = 86.9%) and without depression (TPR-male = 88.5%). The univariate analysis of the transgender application-sample revealed that TW-pre/post treatment show brain-structural differences from CG-women and CG-men in the putamen and insula, as well as the whole-brain analysis. Our results support the hypothesis that brain structure in TW differs from brain structure of their biological sex (male) as well as their perceived gender (female). This finding substantiates evidence that TIs show specific brain-structural alterations leading to a different pattern of brain structure than CG-individuals.

Effects of hormones and hormone therapy on breast tissue in transgender patients: a concise review

PURPOSE

Hormone replacement therapy (HRT) has become a mainstay medical treatment option for management of gender dysphoria in transgender patients of both biologic sexes. Very little is known about the long-term effects of steroid hormone modulation on breast tissue in this population. Most of the data available on the effects of HRT on breast and reproductive tissues come from studies of postmenopausal cisgender women. Therapeutic regimens are often provider-dependent, and there, are no uniform guidelines in place for cancer surveillance in transgender patients. In this review, we present what forms of hormone therapy and hormone modulation are available to transgender patients, what is known about their effects on male and female breast tissue, and what other endogenous and exogenous factors contribute to the macroscopic and cellular changes observed.

METHODS

A search for the existing literature focusing on therapeutic regimens and the effects of HRT on breast tissue provided the most current information available for this review. Recent evidence-based reports (since the year 2000) and reviews were given priority over anecdotal evidence and expert opinions when conflicting information was encountered. Older resources were considered when primary sources were needed. Given the paucity of available articles on this subject, all resources were given careful consideration.

RESULTS

Information about the risks associated with HRT in the current literature and in this setting is limited and often conflicting, due to a scarcity of long-term studies tracking breast pathology among transgender men and women.

CONCLUSIONS

We conclude that the long-term effects of off-label pharmaceutical use for modulation of hormone levels and sexual characteristics in transgender patients have not been well studied. The tendency of steroid hormones to promote the growth of certain cancers also raises questions about the safety of differing doses and drug combinations. Further clinical and laboratory study is needed to better establish safety and dosing guidelines in transgender patients.

Trans-specific Geriatric Health Assessment (TGHA): An inclusive clinical guideline for the geriatric transgender patient in a primary care setting

There is a growing concern in the field of geriatric medicine that transgender health is often overlooked and under-reported. Not only does this impact the health and safety of the aging transgender community, but it also often influences the ability of physicians to provide high-quality evidence-based care. This article reviews the current knowledge base for geriatric transgender health and aims to organize evidence-based clinical recommendations for the primary care provider. Our proposed guideline, the Trans-specific Geriatric Health Assessment (TGHA), highlights areas of current clinical practice that do not address the geriatric transgender experience and modifies them to include trans-specific clinical recommendations found in the literature. The TGHA emphasizes topics such as cognitive function, vision and hearing, gait and stability, nutrition, sleep, functional/social status, urogenital health, psychiatric health, hormone replacement therapy, cancer screening, disease prevention and advanced care planning. Our review also addresses the limitations of certain clinical topics and where there is significant need for supportive research.

Gender affirming medical care of transgender youth

The number of gender diverse and transgender youth presenting for treatment are increasing. This is a vulnerable population with unique medical needs; it is essential that all pediatricians attain an adequate level of knowledge and comfort caring for these youth so that their health outcomes may be improved. There are several organizations which provide clinical practice guidelines for the treatment of transgender youth including the WPATH and the Endocrine Society and they recommend that certain eligibility criteria should be met prior to initiation of gender affirming hormones. Medical intervention for transgender youth can be broken down into stages based on pubertal development: pre-pubertal, pubertal and post-pubertal. Pre-pubertally no medical intervention is recommended. Once puberty has commenced, youth are eligible for puberty blockers; and post-pubertally, youth are eligible for feminizing and masculinizing hormone regimens. Treatment with gonadotropin releasing hormone agonists are used to block puberty. Their function is many-fold: to pause puberty so that the youth may explore their gender identity, to delay the development of (irreversible) secondary sex characteristics, and to obviate the need for future gender affirmation surgeries. Masculinizing hormone regimens consists of testosterone and feminizing hormone regimens consist of both estradiol as well as spironolactone. In short term studies gender affirming hormone treatment with both estradiol and testosterone has been found to be safe and improve mental health and quality of life outcomes; additional long term studies are needed to further elucidate the implications of gender affirming hormones on physical and mental health in transgender patients. There are a variety of surgeries that transgender individuals may desire in order to affirm their gender identity; it is important for providers to understand that desire for medical interventions is variable among persons and that a discussion about individual desires for surgical options is recommended.

Health considerations for transgender women and remaining unknowns: a narrative review

Transgender (trans) women (TW) were assigned male at birth but have a female gender identity or gender expression. The literature on management and health outcomes of TW has grown recently with more publication of research. This has coincided with increasing awareness of gender diversity as communities around the world identify and address health disparities among trans people. In this narrative review, we aim to comprehensively summarize health considerations for TW and identify TW-related research areas that will provide answers to remaining unknowns surrounding TW's health. We cover up-to-date information on: (1) feminizing gender-affirming hormone therapy (GAHT); (2) benefits associated with GAHT, particularly quality of life, mental health, breast development and bone health; (3) potential risks associated with GAHT, including cardiovascular disease and infertility; and (4) other health considerations like HIV/AIDS, breast cancer, other tumours, voice therapy, dermatology, the brain and cognition, and aging. Although equally deserving of mention, feminizing gender-affirming surgery, paediatric and adolescent populations, and gender nonbinary individuals are beyond the scope of this review. While much of the data we discuss come from Europe, the creation of a United States transgender cohort has already contributed important retrospective data that are also summarized here. Much remains to be determined regarding health considerations for TW. Patients and providers will benefit from larger and longer prospective studies involving TW, particularly regarding the effects of aging, race and ethnicity, type of hormonal treatment (e.g. different oestrogens, anti-androgens) and routes of administration (e.g. oral, parenteral, transdermal) on all the topics we address.