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Baxendale S. The impact of suppressing puberty on neuropsychological function: A review. Acta Paediatr 2024; 113:1156-1167. [PMID: 38334046 DOI: 10.1111/apa.17150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/12/2024] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
AIM Concerns have been raised regarding the impact of medications that interrupt puberty, given the magnitude and complexity of changes that occur in brain function and structure during this sensitive window of neurodevelopment. This review examines the literature on the impact of pubertal suppression on cognitive and behavioural function in animals and humans. METHODS All studies reporting cognitive impacts of treatment with GnRH agonists/antagonists for pubertal suppression in animals or humans were sought via a systematic search strategy across the PubMed, Embase, Web of Science and PsycINFO databases. RESULTS Sixteen studies were identified. In mammals, the neuropsychological impacts of puberty blockers are complex and often sex specific (n = 11 studies). There is no evidence that cognitive effects are fully reversible following discontinuation of treatment. No human studies have systematically explored the impact of these treatments on neuropsychological function with an adequate baseline and follow-up. There is some evidence of a detrimental impact of pubertal suppression on IQ in children. CONCLUSION Critical questions remain unanswered regarding the nature, extent and permanence of any arrested development of cognitive function associated with puberty blockers. The impact of puberal suppression on measures of neuropsychological function is an urgent research priority.
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2
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Singh P, Lopez X. Gender-Affirming Medical Treatments. Child Adolesc Psychiatr Clin N Am 2023; 32:789-802. [PMID: 37739635 DOI: 10.1016/j.chc.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
Individuals with gender dysphoria (as defined by Diagnostic and Statistical Manual of Mental Disorders or DSM-V) experience a marked incongruence between the sex assigned at birth and the experienced gender resulting in significant distress or impairment in social, occupational, or other important areas of functioning. For transgender and gender diverse minors, the Endocrine Society recommends a multidisciplinary approach to gender-affirming medical treatment that involves a physician and a mental health provider, also consistent with the World Professional Association for Transgender Health Standard of Care 8th Edition recommendations. This article will outline the role of medical providers in implementing safe and effective gender-affirming medical treatments in youth.
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Affiliation(s)
- Puja Singh
- Pediatric Endocrinology Division, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
| | - Ximena Lopez
- Pediatric Endocrinology Division, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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3
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Godiwala P, Uliasz TF, Lowther KM, Kaback D, Mehlmann LM. Puberty Suppression Followed by Testosterone Therapy Does Not Impair Reproductive Potential in Female Mice. Endocrinology 2023; 164:bqad145. [PMID: 37768169 DOI: 10.1210/endocr/bqad145] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 08/11/2023] [Accepted: 09/22/2023] [Indexed: 09/29/2023]
Abstract
More adolescents are coming out as transgender each year and are put on puberty blockers to suppress natal puberty, which is then followed by cross-hormone treatment to achieve puberty of the desired gender. Studies to examine the effects of puberty suppression and virilizing therapy on future reproductive potential among transgender males are lacking. This study used a translational murine in vitro fertilization model to examine the effects of female puberty suppression with depot leuprolide acetate (LA), followed by virilizing therapy with testosterone cypionate (T), on embryologic and pregnancy outcomes. LA effectively inhibited puberty when mice were treated beginning at 3 weeks of age. LA treatment was associated with higher mouse weight but lower ovarian weight. LA-treated mice ovulated developmentally competent eggs in response to gonadotropin administration, albeit at a higher dose than controls. Ovaries from mice treated with LA and T produced oocytes that had morphologically normal meiotic spindles after in vitro maturation and responded to gonadotropin stimulation. Eggs from mice treated with LA and T were fertilizable and produced developmentally competent embryos that led to births of fertile pups. These results suggest that fertility may not be impaired after puberty suppression and cross-hormone therapy for transgender males.
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Affiliation(s)
- Prachi Godiwala
- Department of Cell Biology, UConn Health, Farmington, CT 06030, USA
- Center for Advanced Reproductive Services, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, UConn Health, Farmington, CT 06030, USA
| | - Tracy F Uliasz
- Department of Cell Biology, UConn Health, Farmington, CT 06030, USA
| | - Katie M Lowther
- Department of Cell Biology, UConn Health, Farmington, CT 06030, USA
| | - Deborah Kaback
- Department of Cell Biology, UConn Health, Farmington, CT 06030, USA
| | - Lisa M Mehlmann
- Department of Cell Biology, UConn Health, Farmington, CT 06030, USA
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4
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Cohen A, Gomez-Lobo V, Willing L, Call D, Damle LF, D'Angelo LJ, Song A, Strang JF. Shifts in Gender-Related Medical Requests by Transgender and Gender-Diverse Adolescents. J Adolesc Health 2023; 72:428-436. [PMID: 36529618 PMCID: PMC9974924 DOI: 10.1016/j.jadohealth.2022.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 09/12/2022] [Accepted: 10/13/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Gender-affirming hormones and/or surgeries seeking to change the body can have potentially lasting effects. Changes in requests for these therapies among gender-diverse youth are not well-understood. The study aim is to characterize factors associated with shifts in gender-related medical requests. METHODS This mixed-methods study used retrospective chart review and qualitative interviews with clinicians. Of 130 youth receiving clinical gender care at Children's National Hospital, 68 met inclusion criteria. Qualitative interview analysis was performed to identify patterns and themes around shifts in gender-related medical requests over time. Statistical analysis employed chi-square and t-tests to compare characteristics in the shift versus no-shift groups and kappa statistics to calculate qualitative coding agreement. RESULTS Of the 68 youth followed over time (mean age 15.11 years, 47% autistic, 22% nonbinary), 20 (29%) reported a shift in request. No significant differences were found by age, autism status, or designated sex at birth. More youth with shifts were nonbinary (p = .012). Six shift profiles were identified from qualitative interviews with excellent reliability (κ = 0.865). Four of the profiles reflect shifts in request prior to starting treatment (85% sample); two involved shifts after commencing treatment (15%). The most common profile reflected a medical request that was made, withdrawn, and re-requested (45%). DISCUSSION Shifts in gender-affirming medical requests by gender-diverse youth may not be uncommon during the adolescent's gender discernment process, and may more likely occur among nonbinary youth. Many individuals who experience shifts away from medical treatment may later resume the request.
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Affiliation(s)
- Ariel Cohen
- Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland; Department of Surgery, Children's National Hospital, Washington, DC; Department of Pediatric and Adolescent Gynecology, Kaiser Permanente Mid-Atlantic Permanente Medical Group, Washington, DC.
| | - Veronica Gomez-Lobo
- Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, Maryland; Department of Surgery, Children's National Hospital, Washington, DC
| | - Laura Willing
- Gender Development Program, Children's National Hospital, Washington, DC; Department of Pediatrics, George Washington University School of Medicine, Washington, DC; Departments of Psychiatry, and Behavioral Sciences, George Washington University School of Medicine, Washington, DC
| | - David Call
- Gender Development Program, Children's National Hospital, Washington, DC; Department of Pediatrics, George Washington University School of Medicine, Washington, DC; Departments of Psychiatry, and Behavioral Sciences, George Washington University School of Medicine, Washington, DC
| | - Lauren F Damle
- Department of Surgery, Children's National Hospital, Washington, DC; Department of Women and Infant Services, MedStar Washington Hospital Center, Washington, DC
| | - Lawrence J D'Angelo
- Department of Pediatrics, George Washington University School of Medicine, Washington, DC; Divisions of Adolescent and Young Adult Medicine, George Washington University School of Medicine, Washington, DC
| | - Amber Song
- Gender Development Program, Children's National Hospital, Washington, DC; Division of Neuropsychology, Center for Autism Spectrum Disorders, Children's National Hospital, Washington, DC; Center for Neuroscience, Children's National Research Institute, Children's National Hospital, Washington, DC
| | - John F Strang
- Gender Development Program, Children's National Hospital, Washington, DC; Department of Pediatrics, George Washington University School of Medicine, Washington, DC; Departments of Psychiatry, and Behavioral Sciences, George Washington University School of Medicine, Washington, DC; Division of Neuropsychology, Center for Autism Spectrum Disorders, Children's National Hospital, Washington, DC; Center for Neuroscience, Children's National Research Institute, Children's National Hospital, Washington, DC
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5
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Huang C, Gold S, Radi R, Amos S, Yeung H. Managing Dermatologic Effects of Gender-Affirming Therapy in Transgender Adolescents. Adolesc Health Med Ther 2022; 13:93-106. [PMID: 36237602 PMCID: PMC9552673 DOI: 10.2147/ahmt.s344078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 09/14/2022] [Indexed: 11/05/2022] Open
Abstract
Transgender adolescents seek gender-affirming medical care to address gender identity and incongruence. Improved understanding of the dermatologic impact of gender-affirming medical care such as pubertal suppression, hormone therapy, and surgeries can enhance patient outcome. Pubertal suppression treats dysphoria associated with development of secondary sex characteristics, including androgen-driven acne. Gender-affirming hormone therapy influences acne and hair development in transgender adolescents. Dermatologists can help manage skin effects associated with chest binding and gender-affirming hormone therapy and surgery. Provision of patient-centered gender-affirming care in dermatologic and multidisciplinary settings is essential to improve skin and overall outcomes of gender-affirming therapy.
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Affiliation(s)
- Christina Huang
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Sarah Gold
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Rakan Radi
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Seth Amos
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Howa Yeung
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
- Clinical Resource Hub, Veterans Affairs Southeast Network Veterans Integrated Service Network 7, Decatur, GA, USA
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Moreno-Bencardino C, Zuluaga L, Perez J, Cespedes C, Forero C, Fernandez N. Gender Dysphoria in the Pediatric Population: Initial Experience of a Transdisciplinary Group. Rev Urol 2021. [DOI: 10.1055/s-0041-1730327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Introduction Although there is an increasing experience in the management of transgender individuals, this has not been thoroughly explored in children. The need to establish a comprehensive and transdisciplinary management is of critical importance. In order to solve this issue, we want to report the results of a cohort of individuals with gender dysphoria (GD) seen by our transdisciplinary group from a social and clinical and health access perspective.
Methods A 10-year retrospective case series of all patients that had been seen by our transdisciplinary team was reviewed. The main demographic characteristics were described, as well as impact variables in terms of diagnosis and treatment of these individuals. A social description of each individual was described. Frequency, distribution, and central tendency measures were evaluated for data presentation. IBM SPSS Statistics for Windows, version 24.0 (IBM Corp, Armonk, NY) software was used.
Results Four cases of GD were included. Three had male to female dysphoria and one female to male. The median reported age of GD awareness was 6 years old (between 4 and 8 years old), and the median time between GD awareness and the 1st medical evaluation was 7 years for all individuals. The median age at gender role expression was 12 years old (between 10 and 14 years old). All patients had already assumed their experienced gender role before the 1st evaluation by our group. The median age at the 1st evaluation by our group was 13 years old (between 10 and 16 years old); three of the patients were evaluated after initiation of puberty. In the present study, individuals with GD demonstrated having health care access barriers for their transition process. Referral times are high, and individuals with GD are cared after pubertal development, which is related to suboptimal outcomes. The spectrum of GD is broad, and management must be individualized according to expectations.
Conclusion Individuals with GD face multiple access barriers that limit their possibility of being seen by a transdisciplinary team. This reflects in longer waiting times that negatively impact medical management. Gender dysphoria is a wide spectrum, and individuals should be evaluated individually by a transdisciplinary team.
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Affiliation(s)
- Camila Moreno-Bencardino
- Division of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, D.C, Colombia
| | - Laura Zuluaga
- Urology Department, Fundación Santa Fe de Bogotá, Universidad de los Andes, Bogotá, D.C, Colombia
| | - Jaime Perez
- Division of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, D.C, Colombia
- Urology Department, Fundación Santa Fe de Bogotá, Universidad de los Andes, Bogotá, D.C, Colombia
| | - Camila Cespedes
- Pediatric Endocrinology Division, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, D.C, Colombia
| | - Catalina Forero
- Pediatric Endocrinology Division, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana. Bogotá, D.C, Colombia
| | - Nicolas Fernandez
- Division of Urology, Seattle Children's Hospital, University of Washington, Seattle, WA, United States
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Kimberly L, Folkers KM, Karrington B, Wernick J, Busa S, Salas-Humara C. Navigating Evolving Ethical Questions in Decision Making for Gender-Affirming Medical Care for Adolescents. THE JOURNAL OF CLINICAL ETHICS 2021. [DOI: 10.1086/jce2021324307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Routine Screening for Transgender and Gender Diverse Adults Taking Gender-Affirming Hormone Therapy: a Narrative Review. J Gen Intern Med 2021; 36:1380-1389. [PMID: 33547576 PMCID: PMC8131455 DOI: 10.1007/s11606-021-06634-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
Despite the growing number of adult transgender and gender diverse (TGD) patients seeking health services, there are many unknowns regarding how routine screening recommendations should be applied to TGD persons receiving gender-affirming hormone therapy (GAHT). Patients taking GAHT may have disease risks that differ from what is expected based on their sex assigned at birth or affirmed gender identity. We discuss two patient cases, one transgender man and one transgender woman who present for routine medical care, to review several conditions that may be impacted by the hormones utilized in masculinizing and feminizing GAHT and for which screening recommendations are available for TGD adults: cardiovascular risk factors, osteoporosis, breast cancer, cervical cancer, and prostate cancer. We reviewed the TGD-specific screening recommendations from several major medical organizations and programs and found them to be largely based upon expert opinion due to a lack of evidence. The goal of this narrative review is to assist healthcare professionals in counseling and screening their TGD patients when and where appropriate. Not all TGD adults have the ability or need to receive routine medical care from a specialized TGD health clinic; therefore, it is essential for all healthcare professionals involved in routine and gender-affirming care to have knowledge about these conditions and screenings.
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Claahsen - van der Grinten H, Verhaak C, Steensma T, Middelberg T, Roeffen J, Klink D. Gender incongruence and gender dysphoria in childhood and adolescence-current insights in diagnostics, management, and follow-up. Eur J Pediatr 2021; 180:1349-1357. [PMID: 33337526 PMCID: PMC8032627 DOI: 10.1007/s00431-020-03906-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/04/2020] [Accepted: 12/10/2020] [Indexed: 12/03/2022]
Abstract
Gender incongruence (GI) is defined as a condition in which the gender identity of a person does not align with the gender assigned at birth. Awareness and more social acceptance have paved the way for early medical intervention about two decades ago and are now part of good clinical practice although much robust data is lacking. Medical and mental treatment in adolescents with GI is complex and is recommended to take place within a team of mental health professionals, psychiatrists, endocrinologists, and other healthcare providers. The somatic treatment generally consists of the use of GnRH analogues to prevent the progression of biological puberty and subsequently gender-affirming hormonal treatment to develop sex characteristics of the self-identified gender and surgical procedures. However to optimize treatment regimens, long-term follow-up and additional studies are still needed. What is known • The prevalence of gender dysphoria increased significantly in the past years and can lead to significant complaints and burdens especially during puberty. • Pubertal suppression and gender-affirmed treatment can be effectively used in adolescence with gender dysphoria. What is new • Transgender mental and medical healthcare is a long-lasting process during which not only the child/adolescent with GI but also their parents/family have to be counseled in making choices about their social, medical, and legal transitions. • There are an increasing number of transgender persons defining as nonbinary. Therefore, an individualized approach by an experienced team is necessary.
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Affiliation(s)
| | - Chris Verhaak
- Department of Medical Psychology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Thomas Steensma
- Center of Expertise on Gender Dysphoria and Department of Medical Psychology, Amsterdam UMC, location VUmc, Amsterdam, Netherlands
| | - Tim Middelberg
- Department of plastic surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Joep Roeffen
- Genderteam South Netherlands, Mutsaersstichting, Venlo/Eindhoven, Netherlands
| | - Daniel Klink
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children’s Hospital, Antwerp, Belgium and Division of Pediatric Endocrinology, Department of Internal Medicine and Pediatrics, Ghent University Hospital and Ghent University, Ghent, Belgium
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Carmichael P, Butler G, Masic U, Cole TJ, De Stavola BL, Davidson S, Skageberg EM, Khadr S, Viner RM. Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLoS One 2021; 16:e0243894. [PMID: 33529227 PMCID: PMC7853497 DOI: 10.1371/journal.pone.0243894] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 11/29/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In adolescents with severe and persistent gender dysphoria (GD), gonadotropin releasing hormone analogues (GnRHa) are used from early/middle puberty with the aim of delaying irreversible and unwanted pubertal body changes. Evidence of outcomes of pubertal suppression in GD is limited. METHODS We undertook an uncontrolled prospective observational study of GnRHa as monotherapy in 44 12-15 year olds with persistent and severe GD. Prespecified analyses were limited to key outcomes: bone mineral content (BMC) and bone mineral density (BMD); Child Behaviour CheckList (CBCL) total t-score; Youth Self-Report (YSR) total t-score; CBCL and YSR self-harm indices; at 12, 24 and 36 months. Semistructured interviews were conducted on GnRHa. RESULTS 44 patients had data at 12 months follow-up, 24 at 24 months and 14 at 36 months. All had normal karyotype and endocrinology consistent with birth-registered sex. All achieved suppression of gonadotropins by 6 months. At the end of the study one ceased GnRHa and 43 (98%) elected to start cross-sex hormones. There was no change from baseline in spine BMD at 12 months nor in hip BMD at 24 and 36 months, but at 24 months lumbar spine BMC and BMD were higher than at baseline (BMC +6.0 (95% CI: 4.0, 7.9); BMD +0.05 (0.03, 0.07)). There were no changes from baseline to 12 or 24 months in CBCL or YSR total t-scores or for CBCL or YSR self-harm indices, nor for CBCL total t-score or self-harm index at 36 months. Most participants reported positive or a mixture of positive and negative life changes on GnRHa. Anticipated adverse events were common. CONCLUSIONS Overall patient experience of changes on GnRHa treatment was positive. We identified no changes in psychological function. Changes in BMD were consistent with suppression of growth. Larger and longer-term prospective studies using a range of designs are needed to more fully quantify the benefits and harms of pubertal suppression in GD.
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Affiliation(s)
- Polly Carmichael
- Gender Identity Development Service (GIDS), Tavistock and Portman NHS Foundation Trust, London, United Kingdom
| | - Gary Butler
- Gender Identity Development Service (GIDS), Tavistock and Portman NHS Foundation Trust, London, United Kingdom
- Paediatric Endocrine Service, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Una Masic
- Gender Identity Development Service (GIDS), Tavistock and Portman NHS Foundation Trust, London, United Kingdom
| | - Tim J. Cole
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Bianca L. De Stavola
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Sarah Davidson
- Gender Identity Development Service (GIDS), Tavistock and Portman NHS Foundation Trust, London, United Kingdom
| | - Elin M. Skageberg
- Gender Identity Development Service (GIDS), Tavistock and Portman NHS Foundation Trust, London, United Kingdom
| | - Sophie Khadr
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Russell M. Viner
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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von Vaupel-Klein AM, Walsh RJ. Considerations in genetic counseling of transgender patients: Cultural competencies and altered disease risk profiles. J Genet Couns 2020; 30:98-109. [PMID: 33368789 PMCID: PMC7898523 DOI: 10.1002/jgc4.1372] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 12/29/2022]
Abstract
Transgender people are a growing population with specific healthcare needs, barriers to care, and disease risk factors. Cultural competencies for working with transgender people in healthcare settings are essential to reduce barriers to care and combat the associated health disparities. Genetic counselors support their patients to understand and manage medically and personally complex life events and decisions. A genetic counselor caring for a transgender patient or a patient with a transgender relative will therefore require specific cultural competencies and medical knowledge that may not have been covered in their training. Transgender health is also a relatively young field in which new insights may quickly become fundamental. The present paper therefore provides an overview of current best practices for culturally sensitive working with transgender patients, and an introduction to the additional considerations for assessment of disease risk in transgender people. Guidance on how to ensure communication with patients and other stakeholders is inclusive and affirming of transgender identities, is offered. Medical interventions used for gender transitions are described, and their (potential) effects on cancer and cardiovascular disease risk are discussed. Furthermore, the effects of sociocultural risk factors such as minority stress are outlined. In sum, we invite the reader to consider the specific biological, psychological, and social context of the consultation. Finally, we explore culturally competent approaches to pedigree charting and physical examinations with transgender people and provide recommendations for practice.
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Affiliation(s)
| | - Reubs J Walsh
- Department of Clinical, Neuro- and Developmental Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,Gender Identity Research and Education Society (GIRES), Ashtead, UK
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12
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Panagiotakopoulos L, Chulani V, Koyama A, Childress K, Forcier M, Grimsby G, Greenberg K. The effect of early puberty suppression on treatment options and outcomes in transgender patients. Nat Rev Urol 2020; 17:626-636. [PMID: 32968238 DOI: 10.1038/s41585-020-0372-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/17/2022]
Abstract
In the past 10-15 years, paediatric transgender care has emerged at the forefront of several general practice and subspecialty guidelines and is the topic of continuing medical education for various medical disciplines. Providers in specialties ranging from family medicine, paediatrics and adolescent medicine to endocrinology, gynaecology and urology are caring for transgender patients in increasing numbers. Current and evolving national and international best practice guidelines recommend offering a halt of endogenous puberty for patients with early gender dysphoria, in whom impending puberty is unacceptable for their psychosocial health and wellness. Pubertal blockade has implications for fertility preservation, transgender surgical care and psychosocial health, all of which must be considered and discussed with the patient and their family and/or legal guardian before initiation.
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Affiliation(s)
| | - Veenod Chulani
- Department of Paediatrics, Chief of Adolescent Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Atsuko Koyama
- Department of Paediatrics, Emory University, Atlanta, GA, USA
| | | | - Michelle Forcier
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Division of Adolescent Medicine, Hasbro Children's Hospital, Providence, RI, USA
| | - Gwen Grimsby
- Division of Adolescent Medicine, Departments of Paediatrics and Obstetrics/Gynecology, University of Rochester Medical Center, Rochester, NY, USA
| | - Katherine Greenberg
- Division of Paediatric Urology, Phoenix Children's Hospital, Phoenix, AZ, USA
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13
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Skordis N, Kyriakou A, Dror S, Mushailov A, Nicolaides NC. Gender dysphoria in children and adolescents: an overview. Hormones (Athens) 2020; 19:267-276. [PMID: 32020566 DOI: 10.1007/s42000-020-00174-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/22/2020] [Indexed: 02/07/2023]
Abstract
Over the last decade, we have witnessed considerable progress in gender dysphoria (GD) terminology in an attempt to better describe the condition based on certain criteria. The ever-increasing social acceptance and destigmatization of children and adolescents with GD have resulted in an increased number of transgender individuals seeking endocrine care. In addition to terminology and diagnostic criteria, the tremendous progress of genetics and neuroimaging has enabled us to have a deeper understanding of the complex pathogenesis of GD. Although helpful guidelines for treatment with GnRH analogs and gender-affirming hormones have been proposed, several challenges and controversies still exist. In this article, the current knowledge about GD in adolescents is reviewed, with particular emphasis on terminology, clinical manifestations, and epidemiologic data. The neurobiological basis of the condition is presented, and both hormonal treatment and mental issues of transgender individuals are discussed. Undoubtedly, further research will optimize the diagnostic and therapeutic approach of children and adolescents with GD.
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Affiliation(s)
- Nicos Skordis
- Division of Pediatric Endocrinology, Paedi Center for Specialized Pediatrics, Nicosia, Cyprus.
- St George's, University London Medical Program at the University of Nicosia Medical School, Nicosia, Cyprus.
| | - Andreas Kyriakou
- Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, Glasgow, UK
| | - Shai Dror
- St George's, University London Medical Program at the University of Nicosia Medical School, Nicosia, Cyprus
| | - Avital Mushailov
- St George's, University London Medical Program at the University of Nicosia Medical School, Nicosia, Cyprus
| | - Nicolas C Nicolaides
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, National and Kapodistrian University of Athens Medical School, "Aghia Sophia" Children's Hospital, Athens, Greece
- Division of Endocrinology and Metabolism, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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Grin L, Girsh E, Harlev A. Male fertility preservation-Methods, indications and challenges. Andrologia 2020; 53:e13635. [PMID: 32390180 DOI: 10.1111/and.13635] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/13/2020] [Accepted: 04/16/2020] [Indexed: 12/23/2022] Open
Abstract
Male fertility preservation has been steadily increasing over the past two decades. Significant improvements have been achieved in the treatment modalities of cancer and other severe chronic medical conditions, leading to an increase in patient survivorship and the resulting demand for future parenthood. Recognition and proper patient counselling before commencing therapies with a potential gonadotoxic effect are of paramount importance. Similarly, nonmedically indicated fertility preservation is on the rise. Social sperm banking, gender dysphoria prior to affirmation procedures and posthumous reproduction preservation are becoming more common. When timing and logistics are appropriate, sperm cryopreservation is considered the gold standard for fertility preservation. Testicular tissue and spermatogonial stem cell autotransplantation is considered experimental and represents a promising alternative for pre-pubertal patients. The current paper aims to review the recent trends in male fertility preservation, the common indications for sperm cryopreservation, techniques for sperm retrieval and experimental frontiers.
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Affiliation(s)
- Leonti Grin
- Fertility and IVF Unit, Department of Obstetrics and Gynecology, Barzilai University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Eliezer Girsh
- Fertility and IVF Unit, Department of Obstetrics and Gynecology, Barzilai University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Avi Harlev
- Fertility and IVF Unit, Department of Obstetrics and Gynecology, Barzilai University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
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15
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Kyriakou A, Nicolaides NC, Skordis N. Current approach to the clinical care of adolescents with gender dysphoria. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:165-175. [PMID: 32191677 PMCID: PMC7569586 DOI: 10.23750/abm.v91i1.9244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/12/2020] [Indexed: 01/29/2023]
Abstract
Over the last decade, we have witnessed a significant rise in the number of transgender young people seeking endocrine treatment, of which clinical service and gender dysphoria terminology have attempted to keep pace both in matching demand and better describing the condition. Although helpful guidelines for pubertal suppression and gender affirming hormones have been developed, uncertainties remain regarding treatment and monitoring during treatment, often because the clinical needs of the transgender population have outpaced medical expertise and training. Recently, multidisciplinary team work has evolved due to the increasing complexity of diagnostic and treatment decision-making and has been instrumental in creating a unique service with input from a range of specialists. In this article, the current approach in clinical management of adolescents with gender dysphoria is reviewed, with focus on the endocrine aspect of care in children and adolescents. Questions on what defines optimal clinical care of children and adolescents with gender dysphoria remain and should be the focus of future research. (www.actabiomedica.it)
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Affiliation(s)
- Andreas Kyriakou
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, UK.
| | - Nicolas C Nicolaides
- Division of Endocrinology and Metabolism, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Greece; Division of Endocrinology, Metabolism and Diabetes, First Department of Paediatrics, National and Kapodistrian University of Athens Medical School, "Aghia Sophia" Children's Hospital, Athens, Greece.
| | - Nicos Skordis
- Division of Paediatric Endocrinology, Paedi Center for Specialized Pediatrics, Nicosia, Cyprus; School of Medicine, University of Nicosia, Nicosia, Cyprus .
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16
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Iwamoto SJ, Defreyne J, Rothman MS, Van Schuylenbergh J, Van de Bruaene L, Motmans J, T’Sjoen G. Health considerations for transgender women and remaining unknowns: a narrative review. Ther Adv Endocrinol Metab 2019; 10:2042018819871166. [PMID: 31516689 PMCID: PMC6719479 DOI: 10.1177/2042018819871166] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 07/31/2019] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Sean J. Iwamoto
- University of Colorado School of Medicine, Division of Endocrinology, Metabolism and Diabetes, 12801 East 17th Avenue, Mail Stop: 8106, Aurora, CO 80045, USA
- UCHealth Integrated Transgender Program, Anschutz Medical Campus, Aurora, CO, USA
- Division of Endocrinology, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Justine Defreyne
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Micol S. Rothman
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
- UCHealth Integrated Transgender Program, Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Joz Motmans
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
- Center for Research on Culture and Gender, Ghent University, Ghent, Belgium
| | - Guy T’Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
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17
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Liu W, Schulster ML, Alukal JP, Najari BB. Fertility Preservation in Male to Female Transgender Patients. Urol Clin North Am 2019; 46:487-493. [PMID: 31582023 DOI: 10.1016/j.ucl.2019.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Gender dysphoria, or the incongruence between gender identification and sex assigned at birth with associated discomfort or distress, manifests in transgender patients, whose multifaceted care includes puberty suppression, cross-sex hormonal therapy, and gender-affirming surgery. Discussion of fertility preservation (FP) is paramount because many treatments compromise future fertility, and although transgender patients demonstrate desire for children, use of FP remains low for a plethora of reasons. In transgender women, established FP options include ejaculated sperm cryopreservation, electroejaculation, or testicular sperm extraction. Further research is needed regarding reproductive health and FP in transgender patients.
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Affiliation(s)
- Wen Liu
- Department of Urology, NYU Langone Medical Center, New York University School of Medicine, 222 East 41st Street, New York, NY 10017, USA
| | - Michael L Schulster
- Department of Urology, NYU Langone Medical Center, New York University School of Medicine, 222 East 41st Street, New York, NY 10017, USA
| | - Joseph P Alukal
- Department of Urology, New York Presbyterian Hospital, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - Bobby B Najari
- Department of Urology, NYU Langone Medical Center, New York University School of Medicine, 222 East 41st Street, New York, NY 10017, USA; Department of Population Health, NYU Langone Medical Center, New York University School of Medicine, 227 East 30th Street, New York, NY 10016, USA.
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18
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Abstract
It is well known that sex steroids, particularly estrogen, play a crucial role in the attainment and maintenance of peak bone density in all people. Transgender (trans) women have been frequently observed to have low bone density prior to initiation of gender-affirming hormone therapy, while trans men generally do not. With pharmacologic estrogen, many studies show improving bone density in trans women. With pharmacologic testosterone, bone density in trans men remains largely unchanged although androgens have indirect effects on bone health via changes in fat and lean mass. Much remains unknown about best practices to optimize bone health, interpret DXA scans and assess fracture risk in trans adults.
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Affiliation(s)
- Micol S Rothman
- Division of Endocrinology, Metabolism & Diabetes, University of Colorado School of Medicine, Anschutz Medical Campus, 12801 East 17th Avenue, Mail Stop: 8106, Aurora, CO 80045, USA
| | - Sean J Iwamoto
- Division of Endocrinology, Metabolism & Diabetes, University of Colorado School of Medicine, Anschutz Medical Campus, 12801 East 17th Avenue, Mail Stop: 8106, Aurora, CO 80045, USA
- Division of Endocrinology, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
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19
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Affiliation(s)
- Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine and the Atlanta VA Medical Center, Atlanta, GA, USA.
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20
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Koch CA, Tangpricha V. Gender dysphoria and transgender medicine in the year 2018. Rev Endocr Metab Disord 2018; 19:193-195. [PMID: 30382492 DOI: 10.1007/s11154-018-9471-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Christian A Koch
- Medicover GmbH Germany, Berlin / Hannover, Germany.
- Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
- Technical University of Dresden, Dresden, Germany.
- University of Louisville, Louisville, KY, USA.
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids at Emory University School of Medicine and the Atlanta VA Medical Center, Atlanta, GA, USA
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