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

Leveraging research into sex differences and steroid hormones to improve brain health

Sex differences, driven in part by steroid hormones, shape the structure and function of the brain throughout the lifespan and manifest across brain health and disease. The influence of steroid hormones on neuroplasticity, particularly in the adult hippocampus, differs between the sexes, which has important implications for disorders and diseases that compromise hippocampus integrity, such as depression and Alzheimer disease. This Review outlines the intricate relationship between steroid hormones and hippocampal neuroplasticity across the adult lifespan and explores how the unique physiology of male and female individuals can affect health and disease. Despite calls to include sex and gender in research, only 5% of neuroscience studies published in 2019 directly investigated the influence of sex. Drawing on insights from depression, Alzheimer disease and relevant hippocampal plasticity, this Review underscores the importance of considering sex and steroid hormones to achieve a comprehensive understanding of disease susceptibility and mechanisms. Such consideration will enable the discovery of personalized treatments, ultimately leading to improved health outcomes for all.

Emerging strategies and clinical recommendations for the management of novel depression subtypes

INTRODUCTION

The phenomenology of depression is characterized by a wide array of emotional, cognitive, and physical symptoms that significantly disrupt an individual's life. Societal changes, driven by technological advancements, economic pressures, environmental concerns including climate change, and shifting cultural norms, have influenced how depression manifests and is understood. These developments have led to the identification of new depression subtypes, highlighting the need for personalized treatment approaches based on individual symptoms and underlying causes.

AREAS COVERED

The authors provide a comprehensive narrative review of the literature on managing novel depression subtypes, focusing on both pharmacological and non-pharmacological treatments. Specifically, scenarios recorded were related to i) depression in adolescents and young adults; ii) depression and social disconnection; iii) depression and alcohol/substance use disorder; iv) depression and gender dysphoria; v) depression, stressful events, and other environmental factors.

EXPERT OPINION

In the novel depression subtypes discussed, individualized treatment approaches tailored to the individual's specific circumstances are necessary. While selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) remain the cornerstone of treatment for many forms of depression, atypical antidepressants such as trazodone, and emerging therapies like ketamine, neuromodulation techniques, and personalized psychotherapy offer hope for those with complex or treatment-resistant presentations.

One person, many changes: a socioecological qualitative analysis of the experiences of transfeminine individuals undergoing feminising gender-affirming hormone therapy

Gender-affirming hormone therapy (GAHT) comes with many physical, psychological, and social changes that are often considered in isolation. This research uses a socioecological lens with a sample of 15 Australian transfeminine individuals to investigate the changes experienced during GAHT. Semi-structured interviews were conducted in 2022, with verbatim transcripts analysed using deductive thematic analysis with Bronfenbrenner's Socioecological Model (SEM) as a framework. Analyses revealed two themes intersecting multiple levels of the SEM. Theme 1 contained two sub-themes and broadly encapsulated how interactions with others influenced GAHT experiences. Sub-theme 1 spoke to how stigma creates positive or negative experiences (through the macrosystem, the exosystem, and proximal processes), while sub-theme 2 described how GAHT causes internal changes that promoted stronger interpersonal relationships (person and proximal processes). Theme 2 described how changes occurred over time, with some changes being temporary, and others being delayed (person and time). These themes highlight the interconnected nature of the physical, psychological, and social changes and experiences that can occur during GAHT. Best-practice care for trans people undergoing GAHT needs to be multi-faceted and holistic in order to embed support across different SEM components.

Hormones, Stress, and Heart Disease in Transgender Women with HIV in LITE Plus

INTRODUCTION

Cardiovascular disease (CVD) is a leading cause of death among transgender women and people with HIV. Exogenous estrogen and psychosocial stressors are known risk factors for CVD. Yet, few studies have used biomarkers to examine the role of stress in CVD risk among transgender women with HIV (TWHIV). This analysis examined whether stress moderates relationships between gender-affirming hormone therapy (GAHT) duration and CVD risk among TWHIV.

METHODS

This cross-sectional analysis of baseline data from an observational cohort of 108 Black and Latina TWHIV in Boston, New York, and Washington, DC, enrolled December 2020 to June 2022, measured sociodemographics, medical diagnoses, medications, smoking history, and perceived stress via interviewer-administered surveys. Physiological stress was measured with 14 biomarkers to calculate allostatic load indices (ALI). Forty participants provided saliva samples used to calculate cortisol awakening response and cortisol daily decline. The 2018 American College of Cardiology Revised Pooled Cohort Equation estimated 10-year CVD risk. Data were analyzed in 2024.

RESULTS

GAHT duration was positively associated with CVD risk scores in bivariate regression. In multivariable linear regression models (adjusting for age, income, education), only age and ALI remained significantly associated with CVD risk scores (β 1.13, CI: 1.05, 1.21). No stress measure significantly interacted with GAHT duration to affect CVD risk scores. In visual plots, GAHT duration increased CVD risk scores only for TWHIV experiencing the highest ALI.

CONCLUSIONS

Stress plays an important role in CVD in TWHIV. More research is needed on non-GAHT factors, which influence CVD health among transgender women.

Gender-affirming care education in pharmacy: a scoping review protocol of practices in Canada and the USA

INTRODUCTION

Gender-affirming care refers to a range of social, psychological, medical and/or surgical interventions provided to affirm one's gender. Pharmacists play a key role in gender-affirming care and are involved with choosing optimal treatments, monitoring progress/side-effects and providing education. However, it is currently unknown what gender-affirming care education is provided to pharmacy students and pharmacists according to information available in published literature. This is important to identify potential education gaps in pharmacy curricula and an understanding of the current state of gender-affirming care education in pharmacy.

METHODS AND ANALYSIS

This scoping review protocol follows guidance from Arksey and O'Malley and Levac and colleagues. The population, concept and context framework are used to specify the research question and subsequently the search strategy. Database searching will occur across four databases: Medline, Embase, APA PsycINFO and Scopus; with the search date ranging from inception to 1 January 2025. Eligible studies will include pharmacy students or pharmacists, and examine the presence of gender-affirming care pharmacy education in Canada and the USA. There are no restrictions to date. Article screening and extraction will occur independently and in duplicate. Educational interventions, gender-affirming care content and recommendations extracted from each article will be narratively synthesised. This work is undertaken with patients and public involvement.

ETHICS AND DISSEMINATION

Ethical approval is not required as this is a review of published studies and does not collect any human data. Results will be disseminated through a peer-reviewed publication and conference presentations.

Musculoskeletal and cardiovascular considerations for transgender athletes

OBJECTIVE

Participation in athletics is essential for the overall well-being of transgender athletes and should be included as part of gender-affirming care. Surveys show physicians and athletic trainers want to provide appropriate care for transgender athletes but lack the proper knowledge and training to do so. Gender Affirming Hormone Therapy (GAHT) is part of gender-affirming care, yet the effects of GAHT on the cardiovascular and musculoskeletal health of transgender athletes is not well-understood. The purpose of this review was to discuss important musculoskeletal and cardiovascular considerations unique to transgender athletes and improve physician understanding in caring for transgender athletes.

METHODS

A representative selection of literature on the effects of GAHT on cardiovascular and musculoskeletal health was included in this review.

RESULTS

Estrogen therapy may increase the risk of venous thromboembolism (VTE) and stroke, and decrease blood pressure levels among transgender women, while studies on lipid profile are inconsistent among both transgender men and women. Transgender women receiving GAHT may also be at greater risk for bone fracture and ligamentous injuries.

CONCLUSION

Exercise is essential for the well-being of transgender individuals and special considerations regarding the cardiovascular and musculoskeletal health of transgender athletes should be incorporated into standard medical education. Educational programs for transgender patients and their support team should focus on preventative measures that can be taken to reduce the risk of adverse musculoskeletal and cardiovascular events. The PPE is an invaluable tool available to physicians to monitor the health and safety of transgender athletes and should be regularly updated as research on the health of transgender individuals continues to grow. Longitudinal and prospective studies should examine the effects of GAHT on the musculoskeletal and cardiovascular health of transgender athletes. Lastly, health care providers play an important role in the advancement of gender-neutral policies.

High Rates of High-risk HPV Anal Infection and Abnormal Cytology in a Cohort of Transgender People Assigned Male at Birth

Background

Transgender people assigned male at birth (TG-AMAB) have higher rates of anal human papillomavirus (HPV) infection and anal cancer compared with cisgender populations. In a cohort of TG-AMAB in Washington DC, we determined the prevalence and epidemiological factors associated with anal high-risk HPV (HR-HPV) infection and cytological abnormalities.

Methods

In an urban academic-community clinic, we recruited adults identifying as a gender different than their sex assigned at birth. Participants provided blood samples, anal swabs for HR-HPV and cytology, and completed surveys on sexual behaviors and use of gender-affirming hormones. Logistic regression was used to identify predictors of HR-HPV and abnormal cytology.

Results

Of 97 TG, 80 were AMAB, of whom 66% were people with HIV (PWH); 73% tested positive for any anal HR-HPV, and 48% had abnormal cytology. Only 24% recalled HPV immunization. While TG-AMAB PWH had increased risk of HPV16 infection (37% vs 8%; P = .014), the prevalence rates of any HR-HPV (80% vs 62%; P = .097) and abnormal cytology (56% vs 32%; P = .085) were similarly elevated regardless of HIV status. Among TG-AMAB, estradiol use was not associated with increased odds of any HR-HPV or abnormal cytology (all P > .05); however, higher testosterone levels were associated with any HR-HPV (P = .014). Age ≥35 years was associated with abnormal cytology in TG-AMAB (59% vs 34%; P = .035).

Conclusions

TG-AMAB have a high prevalence of any HR-HPV and abnormal cytology, regardless of age, HIV status, or hormone use. Given high risk for anal cancer and low rates of HPV vaccination, there is a pressing need for primary and secondary anal cancer prevention strategies targeting this population.

A More Nuanced Story: Pediatric Gender-Affirming Healthcare is Associated With Satisfaction and Confidence

PURPOSE

Pediatric gender-affirming medical care has strong research evidence and support, and transition-related regret is uncommon. Misinformation about regret has nonetheless been used to limit adolescents from accessing this care. This study is the first of a 3-part initiative to clarify long-term satisfaction and regret related to pediatric gender-affirming care (GAC).

METHODS

An anonymous survey was distributed to individuals of age 15 and older who participated in at least one prior appointment at a large pediatric gender clinic. The survey questions included (1) demographics; (2) use of gender-affirming interventions; (3) barriers to accessing medical interventions; (4) reasons for any discontinuation of medical interventions; (5) emotions associated with GAC; and (6) intervention-related regret.

RESULTS

Participants (N = 150; Mage = 18.6) were predominantly transmasculine-identified and/or assigned female at birth (86%). The most common emotions associated with GAC were satisfaction (88.0%) and confidence (86.7%). A total of 141 participants reported taking hormones, 30 of whom reported ever discontinuing (21.3%). Among these, 11 have already resumed hormones, and 16 might resume. Of the three with no plan to resume hormones, one is fully satisfied with the results, and the remaining two no longer identify as transgender. Only one participant (0.7% of those who ever took hormones) wishes they had never started testosterone or had top surgery, both of which occurred in adulthood.

DISCUSSION

Individuals who accessed GAC as adolescents are largely satisfied with this care. Care-related satisfaction and regret are more nuanced than sometimes portrayed and should not be used to limit access.

Exploring Safety in Gender-Affirming Hormonal Treatments: An Observational Study on Adverse Drug Events Using the Food and Drug Administration Adverse Event Reporting System Database

BACKGROUND

People with gender dysphoria are treated with hormone therapy for gender reassignment. The indication of this therapy was initially for the opposite sex, and information on potential adverse drug reaction (ADR) is lacking.

OBJECTIVE

To describe ADR associated with gender transition medication in transgender individuals reported to the US Food and Drug Administration Adverse Event Reporting System (FAERS) database.

METHODS

Data from the FAERS database up to June 2023 were examined, focusing on reports of gender transition medication use in the context of gender dysphoria. The ADRs were categorized using the Medical Dictionary for Regulatory Activities at both Preferred Term and System Organ Class (SOC) levels. Descriptive statistics summarized report counts, medication types, indications, and ADR severity.

RESULTS

For individuals assigned female at birth undergoing gender transition to male (transgender men), 82 reports (230 ADRs) were analyzed, with an average age of 29.5 years. Transgender hormonal therapy was cited in 72% of reports, predominantly from the United States (67.1%). A striking 88% were categorized as serious ADRs, primarily SOC injury, poisoning, and procedural complications (26.5%), followed by psychiatric disorders (14.8%) and nervous system disorders (12.2%). Among those assigned sex male at birth transitioning to female (transgender women) (81 reports, 237 ADRs), mean age was 33.3 years, with 58% indicating use for gender dysphoria. A significant proportion (53.6%) were serious ADRs, primarily SOC: injury, poisoning, and procedural complications (26.6%).

CONCLUSIONS AND RELEVANCE

The FAERS data reveal significant ADRs in transgender individuals using hormone therapy, sometimes unintended for their recipient gender. Population-level studies are crucial to enhance transgender health care. Spontaneous surveillance databases like FAERS illuminate off-label ADRs, urging health care providers to approach hormone therapies with informed caution.

Evaluating the Risk of Venous Thromboembolism in Transfeminine and Gender Diverse People: A Retrospective Analysis

OBJECTIVE

The risk of venous thromboembolism (VTE) with feminizing gender-affirming hormone therapy is an area of concern. This analysis aimed to assess whether gender-affirming hormone therapy and other potential risk factors are associated with VTE in transfeminine and gender diverse individuals.

METHODS

We conducted a chart review of 2126 transfeminine and gender diverse adults receiving care within a large urban health system. The primary outcomes were the prevalence of VTE and odds ratios for the association of VTE with insurer, use of estrogen, and select comorbidities.

RESULTS

A history of VTE was documented in 0.8% of the cohort. Those with a history of VTE were older (P < .001), more often self-identified as Hispanic or Black compared to White or Asian (P < .05) and were more likely to have Medicaid or Medicare (P < .01) when compared to those without a history of VTE. The prevalence of hyperlipidemia (P < .001), diabetes mellitus (P < .05), and hypercoagulable conditions (P < .001) were all greater in the positive VTE group. Hyperlipidemia (P < .001), diabetes mellitus (P < .05), and insurer (P < .05) were associated with increased odds of VTE in univariate analyses. None of the exposure variables analyzed were associated with VTE when controlling for age, race, and the number of comorbidities.

CONCLUSIONS

The prevalence of VTE in our cohort was lower than previously observed. VTE was not associated with any one risk factor, including estrogen use, when controlling for age, race, and the number of comorbidities. Those of advanced age and those with multiple cardiometabolic comorbidities may benefit from increased surveillance and mitigation of modifiable risk factors.

Menstrual management in transgender and gender diverse individuals: psychiatric and psychosocial considerations

Transgender and gender-diverse (TGD) menstruators are individuals assigned female at birth (AFAB)*, who retain the capacity to menstruate and have a gender identity that differs from their natal sex. Reports indicate up to 1.6 million individuals in the US identify as TGD. Until recently, the mainstream menstrual discourse has failed to capture the experience of transmenstruators. However, a better understanding of the menstrual experiences of TGD-AFAB will allow for more individualized patient-centered care. In this review, we provide the relevant data necessary to inform the psychiatric management of menstruation in TGD-AFAB individuals, including experiences of menstruation, preferences for menstrual management, and the impact on mental health. Our review indicates that menstrual care in TGD patients must be tailored to the individual; clinicians should remain open-minded to the unique experience of transmenstruators; gender-affirming menstrual care is necessary to reduce psychological burden. It should not be assumed that TGD-AFAB menstruators are utilizing appropriate contraceptive methods and should receive contraceptive and fertility preservation counseling. We highlight the importance of having these conversations early in the reproductive arch, even before puberty onset. Keeping in mind the gender minority stress model, in the upcoming sections, we discuss the limited body of literature on mood disorders in TGD-AFAB individuals who menstruate, undergo menstrual suppression, or continue to ovulate. The psychological impact of hormonal therapies is also reviewed.

Primary care provider beliefs and knowledge of prescribing gender-affirming hormone therapy to transgender and gender diverse patients

BACKGROUND

Transgender patients often cannot access a provider who is knowledgeable about providing gender-affirming hormone therapy (GAHT). This study evaluated primary care provider (PCP) comfort and experience with, opinions about, and knowledge of prescribing GAHT to adults.

METHODS

An anonymous Qualtrics survey was distributed to PCPs in San Diego County. Fisher's exact test assessed any association between age, years in practice, or practice setting and 1) comfort in prescribing GAHT and 2) favorable statements about learning about, providing, and benefitting from training in GAHT. T-tests determined relationship between age, years in practice, or practice type setting with number of correctly answered multiple choice knowledge-based questions out of 4.

RESULTS

Out of 220 responses, median age was 41, 60% had practiced for ≤ 10 years, and 19% had practiced in an academic setting. Forty-two percent did not receive any education about transgender healthcare during medical training. The most commonly reported barrier to providing GAHT was lack of training (74%). PCPs age ≤ 41 (67% vs 49%, p = 0.009), PCPs practicing for ≤ 10 years (65% vs 51%, p = 0.037), and PCPs in non-academic settings (64% vs. 41%, p = 0.013) were more likely to report being comfortable with prescribing GAHT. PCPs age ≤ 41 (89% vs 62%, p < 0.001) and PCPs practicing for ≤ 10 years (86% vs 66%, p < 0.001) were more likely to show interest in learning about GAHT. PCPs age ≤ 41 (74% vs 46%, p < 0.001) and PCPs practicing for ≤ 10 years (70% vs 50%, p = 0.003) were more likely to show interest in prescribing GAHT. Knowledge scores were higher for PCPs age  ≥42 (mean 1.7 vs 1.4, p = 0.033) and PCPs working in academic centers (mean 2.0 vs 1.4, p = 0.002).

CONCLUSION

Younger (age ≤ 41) and early career (practicing for ≤ 10 years) PCPs reported being more comfortable with prescribing GAHT and had more favorable opinions in learning about, providing, and benefitting from training in GAHT. They are interested in providing GAHT; however, few prescribe GAHT with most reporting lack of training as a major barrier. This was evident with overall low knowledge scores regardless of age, experience, or clinical setting and underscores the need for increased educational efforts in transgender care throughout medical training.

Adaptive transition decisions and identity exploration among transgender and nonbinary persons exposed to gender identity conversion efforts

Introduction

Transgender and nonbinary (TNB) persons' healthcare experiences and related transition decisions have received increasing attention in recent years. Growing literature indicates gender non-affirming practices, such as gender identity conversion efforts (GICE), are harmful for the wellbeing of TNB persons. Yet, how exposure to GICE is linked to transition related decisions among TNB persons remains unexplored. This study examines links between GICE and TNB persons' transition decisions and identity exploration, using a conceptual framework that distinguishes adaptive transition decisions (e.g. transition interruptions due to interpersonal coercion) from identity-related transition decisions.

Methods

This study is a secondary data analysis of the 2015 U.S. Transgender Survey (N = 27,630). Multinomial logistic regression was conducted to examine the relationship between GICE and transition decisions among TNB persons while controlling for demographic covariates.

Results

Overall, 13.5% of TNB participants experienced GICE. Participants interrupted their transition due to interpersonal coercion (4.9%), structural factors (2.0%), and identity-related factors (0.4%). Participants with GICE exposure were more likely to report interrupting their transition due to interpersonal coercion than not interrupting their transition. However, GICE-exposed participants did not have a higher chance of identity-related transition interruptions than no interruptions.

Conclusions

These findings point to a potentially harmful role GICE may play in the transition decisions of TNB persons. Our analysis adds to evidence indicating the need for banning GICE and calls for a more nuanced understanding, recognition, and respect for TNB persons' non-linear transitioning trajectories. Otherwise, we risk vilifying gender-affirming practices and pathologizing adaptive transitioning decisions of TNB persons.

Transgender Latinas' Perspectives on HIV PrEP Uptake, Condom Use, and Medically Supervised Gender-Affirming Hormone Therapy: Insights From ChiCAS Qualitative Interviews

There is a dearth of HIV prevention behavioral interventions for transgender Latinas, despite this population's HIV risk. ChiCAS (Chicas Creando Acceso a la Salud) is an intervention to increase PrEP, condom, and gender-affirming hormone therapy (GAHT) use among transgender Latinas. To inform future work, semistructured interviews were conducted postintervention with 28 ChiCAS participants. Thematic analysis with inductive coding was used. Six themes emerged: (1) health-related priorities include sexual health and avoiding discrimination; (2) safe and collaborative community is of high importance; (3) interactive education with time for sharing stories and discussion was valued; (4) PrEP uptake was facilitated through awareness and health care navigation; (5) accessing GAHT depends on cost, clinic location, and individual goals; (6) ChiCAS could be improved with more PrEP/GAHT details and social connection. Interventions with goals similar to those of ChiCAS should prioritize building community, PrEP and GAHT education tailored to participants' needs, and emphasize health care options available locally.

Time to Gender-Affirming Hormone Therapy Among US Military-Affiliated Adolescents and Young Adults

Importance

Use of exogenous sex steroid hormones, when indicated, may improve outcomes in adolescents and young adults with gender incongruence. Little is known about factors associated with the time from diagnosis of gender dysphoria to initiation of gender-affirming hormone therapy. Identification of inequities in time to treatment may have clinical, policy, and research implications.

Objective

To evaluate factors associated with time to initiation of gender-affirming hormone therapy after a diagnosis of gender dysphoria in adolescents and young adults receiving care within the US Military Health System.

Design, Setting, and Participants

This retrospective cohort study used TRICARE Prime billing and pharmacy data contained in the Military Health System Data Repository. Patients aged 14 to 22 years, excluding service members and their spouses, who received a diagnosis of gender dysphoria between September 1, 2016, and December 31, 2021, were included. The data were analyzed between August 30 and October 12, 2023.

Exposures

Included patient characteristics were race and ethnicity, age group, first sex assigned in the medical record, and TRICARE Prime sponsor military rank and service at the time of diagnosis. Health care and contextual characteristics included the year of diagnosis and the primary system in which the patient received health care.

Main Outcomes and Measures

The primary outcome was the time between initial diagnosis of gender dysphoria to the first prescription for gender-affirming hormone medication within a 2-year period. A Poisson generalized additive model was used to evaluate this primary outcome. Adjusted probability estimates were calculated per specified reference categories.

Results

Of the 3066 patients included (median [IQR] age, 17 [15-19] years; 2259 with first assigned gender marker of female [74%]), an unadjusted survival model accounting for censoring indicated that 37% (95% CI, 35%-39%) initiated therapy by 2 years. Age-adjusted curves indicated that the proportion initiating therapy by 2 years increased by age category (aged 14-16 years, 25%; aged 17-18 years, 39%; aged 19-22 years, 55%). Incidence rate ratios (IRRs) and 2-year adjusted probabilities indicated that longer times to hormone initiation were experienced by adolescents aged 14 to 16 years (IRR, 0.36; 95% CI, 0.30-0.44) and 17 to 18 years (IRR, 0.66; 95% CI, 0.54-0.79) compared with young adults aged 19 to 22 years and Black compared with White adolescents (IRR, 0.73; 95% CI, 0.54-0.99). Senior officer compared with junior enlisted insurance sponsor rank (IRR, 1.93; 95% CI, 1.04-3.55) and civilian compared with military health care setting (IRR, 1.21; 95% CI, 1.02-1.43) was associated with shorter time to hormone initiation.

Conclusions and Relevance

In this cohort study, most adolescents and young adults with a diagnosis of gender dysphoria receiving health care through the US military did not initiate exogenous sex steroid hormone therapy within 2 years of diagnosis. Inequities in time to treatment indicate the need to identify and reduce barriers to care.

Culturally Sensitive and Inclusive IBD Care

As the prevalence of inflammatory bowel disease (IBD) increases within historically disadvantaged communities, it is imperative to better understand how intersectionality-defined as the complex, cumulative way in which the effects of multiple forms of discrimination (such as racism, sexism, and classism)-intersects and social determinants of health influence the patient's experiences within the medical system when navigating their disease. Culturally sensitive care is characterized by the ability to deliver patient-centered care that recognizes how the intersectionality of an individual's identities impacts their disease journey. An intentional consideration and sensitivity to this impact play important roles in providing an inclusive and welcoming space for historically disadvantaged individuals living with IBD and will help address health inequity in IBD. Cultural competence implies mastery of care that understands and respects values and beliefs across cultures, while cultural humility involves recognizing the complexity of cultural identity and engaging in an ongoing learning process from individual patient experiences. Heightening our patient care goals from cultural competence to cultural sensitivity allows healthcare professionals and the systems in which they practice to lead with cultural humility as they adopt a more inclusive and humble perspective when caring for patient groups with a diverse array of identities and cultures and to avoid maintaining the status quo of implicit and explicit biases that impede the delivery of quality IBD care. In this article, we review the literature on IBD care in historically disadvantaged communities, address culturally sensitive care, and propose a framework to incorporating cultural humility in IBD practices and research.

Assessment of sociodemographic and psychiatric characteristics of transgender adults seen at a Midwest tertiary medical center

Background

The National Academy of Medicine has formally identified transgender adults as an understudied population in critical need of health research. While national surveys, like the US Transgender survey, have characterized higher rates of depression, anxiety, suicidality and socioeconomic need in the transgender community, studies have not examined the impact of sociodemographic and clinical characteristics on mental health related outcomes.

Objective

To describe the sociodemographic and mental health characteristics of transgender adults seen at a large Midwest transgender clinic and to determine factors associated with self-reported mental health conditions.

Methods

Descriptive, retrospective, cross-sectional study of new transgender patients 18 years and older seen at a large Midwest transgender clinic between December 2019 and June 2022.

Results

A total of 482 charts were reviewed. During their initial evaluation, 11.6% (56/482) reported having a history of suicide attempt and 81.3% (392/482) reported a mental health diagnosis with the most common being depression, anxiety, attention deficit disorder, and post-traumatic stress disorder. Multivariable logistic regression results show no single factor was significantly associated with mental health diagnosis after adjusting for the effect of age and race. Patients who were new to gender affirming hormone therapy (54%, 254/468) are 2.0 (95% CI 1.4-2.9) times more likely to report having a mental health care provider than patients who were seen for continuation of therapy (46%, 214/468). Ten records with race not disclosed, 3 records with gender identity "other" and 2 records with gender identity not disclosed were excluded from analysis.

Conclusion

This study reinforces the finding that transgender adults have an increased lifetime prevalence of mental health conditions. The higher prevalence of mental health conditions in our clinic was not associated with sociodemographic factors included in the study. Furthermore, transgender patients are less likely to have seen mental healthcare providers after initiation of gender affirming hormone therapy.

A Narrative Synthesis Review of Legislation Banning Gender-Affirming Care

Purpose of Review

In recent years, there has been a drastic increase in legislation across US states that aims to ban gender-affirming care (GAC) for transgender and nonbinary (trans) youth. We synthesized the literature on bans on GAC, its impacts on medical and mental health providers, trans communities, particularly trans youth and their caregivers (e.g., parents/families), and provided recommendations for future research and advocacy.

Recent Findings

We highlight several adverse impacts of legislation banning GAC, including: an increase in professional tensions for medical and mental health providers that work with trans youth and worse mental health outcomes for trans youth and their caregivers due to loss of autonomy in accessing evidence-based GAC.

Summary

Bans on GAC undermine evidenced-based practices and are resulting in negative health effects for trans communities and youth. Research evidence highlights the need to examine effects of bans at the intersections of gender identity, socioeconomic status, race, and ethnicity.

A comparative study of 3D measuring methods for monitoring breast volume changes

Three-dimensional (3D) imaging techniques are promising new tools for measuring breast volume, for example in gender-affirming therapy. Transgender individuals can be treated with gender-affirming hormone therapy (GAHT). A robust method for monitoring breast volume changes is critical to be able to study the effects of feminizing GAHT. The primary aim of this study was to compare the accuracy of three 3D devices (Vectra XT, Artec LEO and iPhone XR) for measuring modest breast volume differences using a mannequin. The secondary aim of this study was to evaluate these methods in several performance domains. We used reference prostheses of increasing volumes and compared the volumes using GOM-inspect software. For Vectra XT 3D images, manufacturer-provided software was used to calculate volumes as well. The scanning methods were ranked based on their performance in a total of five categories: volume estimations, costs, user-friendliness, test subject-friendliness and technical aspects. The 3D models analyzed with GOM-inspect showed relative mean estimate differences from the actual volumes of 9.1% for the Vectra XT, 7.3% for the Artec LEO and 14% for the iPhone XR. For the Vectra XT models analyzed with the built-in software this was 6.2%. Root mean squared errors (RMSE) calculated based on the GOM-inspect volume analyses showed mean RMSEs of 2.27, 2.54 and 8.93 for the Vectra XT, Artec LEO and iPhone XR, respectively. The Vectra software had a mean RMSE of 3.00. In the combined performance ranking, the Vectra XT had the most favorable ranking, followed by the Artec LEO and the iPhone XR. The Vectra XT and Artec LEO are the preferred scanners to monitor breast development due to the combination of higher accuracy and overall performance. The current study shows that 3D techniques can be used to adequately measure modest breast volume differences and therefore will be useful to study for example breast changes in transgender individuals using feminizing GAHT. These observations may also be relevant in other fields of 3D imaging research.

Caring for the Older Transgender Adults: Social, Nursing, and Medical Challenges

Aging is a challenging process for people with gender nonconformity. Indeed, the older transgender population faces several disparities in accessing and using health care and social support services. Furthermore, the clinical management of gender transition in later life is empirical since clear research evidence is lacking. This paper aimed to present the problems encountered by older transgender adults in their access to social support and health care and to propose insightful solutions to address them both from a social and medical/nursing perspective. Trans elders face profound disparities in health and social care due to factors associated with limited accessibility to health services, social restrictions, administrative failures, and physical vulnerabilities. The medical treatment of older transgender adults also needs a careful approach to achieve satisfying gender affirmation without clinically significant risks. The potential induction of hormone-sensitive malignancies and the provocation of major adverse vascular events are the main concerns. Gender transition in older adults without a prior history of following gender-affirming therapy is challenging due to biological factors related to advanced age. Caring for elderly trans people unfolds at multiple levels. International organizations and governmental bodies should address the underprivileged status of elderly transgender people by creating and implementing inclusive policies. Safe and respectful clinical and residential environments and the formation of clearer medical guidelines could meet the unique needs of older trans adults. Care providers must advocate for their patients and be equipped to provide safe and effective services.

Clinicians in the Veterans Health Administration initiate gender-affirming hormone therapy in concordance with clinical guideline recommendations

Background

Gender-affirming hormone therapy (GAHT) is a common medical intervention sought by transgender and gender diverse (TGD) individuals. Initiating GAHT in accordance with clinical guideline recommendations ensures delivery of high-quality care. However, no prior studies have examined how current GAHT initiation compares to recommended GAHT initiation.

Objective

This study assessed guideline concordance around feminizing and masculinizing GAHT initiation in the Veterans Health Administration (VHA).

Methods

The sample included 4,676 veterans with a gender identity disorder diagnosis who initiated feminizing (n=3,547) and masculinizing (n=1,129) GAHT between 2007 and 2018 in VHA. Demographics and health conditions on veterans receiving feminizing and masculinizing GAHT were assessed. Proportion of guideline concordant veterans on six VHA guidelines on feminizing and masculinizing GAHT initiation were determined.

Results

Compared to veterans receiving masculinizing GAHT, a higher proportion of veterans receiving feminizing GAHT were older (≥60 years: 23.7% vs. 6.3%), White non-Hispanic (83.5% vs. 57.6%), and had a higher number of comorbidities (≥7: 14.0% vs. 10.6%). A higher proportion of veterans receiving masculinizing GAHT were Black non-Hispanic (21.5% vs. 3.5%), had posttraumatic stress disorder (43.0% vs. 33.9%) and positive military sexual trauma (33.5% vs.16.8%; all p-values<0.001) than veterans receiving feminizing GAHT. Among veterans who started feminizing GAHT with estrogen, 97.0% were guideline concordant due to no documentation of contraindication, including venous thromboembolism, breast cancer, stroke, or myocardial infarction. Among veterans who started spironolactone as part of feminizing GAHT, 98.1% were guideline concordant as they had no documentation of contraindication, including hyperkalemia or acute renal failure. Among veterans starting masculinizing GAHT, 90.1% were guideline concordant due to no documentation of contraindications, such as breast or prostate cancer. Hematocrit had been measured in 91.8% of veterans before initiating masculinizing GAHT, with 96.5% not having an elevated hematocrit (>50%) prior to starting masculinizing GAHT. Among veterans initiating feminizing and masculinizing GAHT, 91.2% had documentation of a gender identity disorder diagnosis prior to GAHT initiation.

Conclusion

We observed high concordance between current GAHT initiation practices in VHA and guidelines, particularly for feminizing GAHT. Findings suggest that VHA clinicians are initiating feminizing GAHT in concordance with clinical guidelines. Future work should assess guideline concordance on monitoring and management of GAHT in VHA.

Electroconvulsive Therapy in Transgender and Gender Diverse Population: A Case Report and Review of Literature

Objective

Present a case of a transgender and gender diverse (TGD) individual receiving gender affirming hormone therapy (GAHT) who presented with first episode bipolar mania and received electroconvulsive therapy (ECT). To understand the safety and efficacy of ECT in the TGD population including those receiving GAHT through literature review.

Materials and Methods

Case report using informed consent from an individual TGD patient who received ECT. A review of the literature was conducted using PubMed, Embase, and Medline.

Results

The case illustrated safe and effective ECT use in a TGD individual receiving GAHT. Eight studies were reviewed. GAHT has been reported to interfere with certain anaesthetic agents used in ECT. ECT appeared to be a safe and effective treatment in the TGD samples in those studies.

Conclusion

There is limited literature on the safety and efficacy of ECT for TGD individuals receiving GAHT. More research is required to address mental health inequalities in this population and to support safe and effective gender affirming treatment modalities.

Subjective Experiences of Pregnancy, Delivery, and Nursing in Transgender Men and Non-Binary Individuals: A Qualitative Analysis of Gender and Mental Health Concerns

Studies of how gender-diverse individuals experience pregnancy, childbirth, and nursing remain few, mainly focus on the US and contain scarce information about mental health concerns peri-partum. This hinders informed reproductive health decisions and counseling. We used in-depth interviews to examine how gestational gender-diverse individuals in Sweden experience the process of planning and undergoing pregnancy, delivery, and nursing. In total, 12 participants, identifying on the masculine side of the gender spectrum or as non-binary, who had attended Swedish antenatal care and delivered a live birth, were included in the study. Data were analyzed using qualitative thematic content analysis. The analysis resulted in one overarching theme: sustaining gender congruence during pregnancy and three main categories: (1) considering pregnancy; (2) undergoing pregnancy and childbirth; and (3) postnatal reflections. The association between childbearing and being regarded as female permeated narratives. Participants renegotiated the feminine connotations of pregnancy, accessed gender-affirming treatment, and concealed their pregnancy to safeguard their gender congruence. Mis-gendering and breast enlargement triggered gender dysphoria. Social judgment, loneliness, information shortages, hormonal influence and cessation of testosterone increased gender dysphoria and strained their mental health. Depression exacerbated gender dysphoria and made it harder to claim one's gender identity. Dissociation was used to handle a feminized body, vaginal delivery, and nursing. Pregnancy was easier to envision and handle after masculinizing gender-affirming treatments. The results deepen the understanding of gender dysphoria and may be used to inform reproductive counseling and healthcare development. Research outcomes on mental health concerns provide a basis for further research.

Patient Characteristics Associated with Receiving Gender-Affirming Hormone Therapy in the Veterans Health Administration

Purpose

This study aimed to examine patient characteristics associated with receipt of gender-affirming hormone therapy in the Veterans Health Administration (VHA).

Methods

This cross-sectional study included a national cohort of 9555 transgender and gender diverse (TGD) patients with TGD-related diagnosis codes who received care in the VHA from 2006 to 2018. Logistic regression models were used to determine the association of health conditions and documented social stressors with receipt of gender affirming hormone therapy.

Results

Of the 9555 TGD patients, 57.4% received gender-affirming hormone therapy in the VHA. In fully adjusted models, patients who had following characteristics were less likely to obtain gender-affirming hormones in the VHA: Black, non-Hispanic versus white (adjusted odds ratio [aOR]: 0.61; 95% confidence interval [CI]: 0.52-0.72), living in the Northeast versus the West (aOR: 0.72; 95% CI: 0.62-0.84), a documented drug use disorder (aOR: 0.56; 95% CI: 0.47-0.68), ≥3 versus no comorbidities (aOR: 0.44; 95% CI: 0.34-0.57), and ≥3 versus no social stressors (aOR: 0.42; 95% CI: 0.30-0.58; all p<0.001). Younger patients aged 21-29 years were almost 3 times more likely to receive gender affirming hormone therapy in the VHA than those aged ≥60 (aOR: 2.98; 95% CI: 2.55-3.47; p<0.001).

Conclusion

TGD individuals who were older, Black, non-Hispanic, and had more comorbidities and documented social stressors were less likely to receive gender-affirming hormone therapy in the VHA. Further understanding of patient preferences in addition to clinician- and site-level determinants that may impact access to gender-affirming hormone therapy for TGD individuals in the VHA is needed.

Gender Identity and Mental Health Symptom Severity Among Adolescents Admitted to an Inpatient Psychiatric Hospital

Transgender youth are at an increased risk of suicide, substance use, experiencing violent assaults, and reporting major depressive episodes and greater psychological distress compared to their cisgender counterparts. This study examined mental health symptom severity in adolescents admitted to an inpatient psychiatric hospital who wished they were of a different gender compared to those who did not. A group of 180 adolescents admitted to an inpatient psychiatric hospital completed assessments to measure mental health symptom severity at admission. Gender diverse (n = 90) and cisgender (n = 90) groups were established. Analyses of variance (ANOVA) were used to examine between group (gender diverse vs. cisgender) difference on depression, anxiety, suicide risk, nighttime sleep quality, and emotion regulation problems. Results revealed significant differences in emotion regulation difficulties at admission, specifically in nonacceptance and awareness. There were no significant differences on measures of depression, anxiety, suicide risk, and nighttime sleep quality at admission. This study is one of the first to measure mental health symptom severity in gender diverse adolescents while admitted to an inpatient psychiatric setting. Adolescents in the gender diverse group had significantly higher level of difficulty with emotion regulation, which may indicate an increased risk of developing psychiatric symptoms such as depression and anxiety. This paper demonstrates the importance of using targeted interventions to address difficulties with emotion regulation in at-risk adolescents.

Androgen treatment effects on neurocognition in female-to-male transgender adolescents

INTRODUCTION

It has been hypothesized that cognitive and memory-related brain function in transgender during cross-sex hormonal treatment might be activated towards that of the subjective gender. However, research on this topic has produced inconsistent results, and to the best of our knowledge no studies have investigated neurocognitive changes in androgen-treated female-to-male (FM) transgender adolescents.

SUBJECTS AND METHODS

A total of 15 FM transgender adolescents (14-17 years) underwent neuropsychological testing in order to examine the effects of androgen on visuo-spacial abilities, verbal memory language, processing speed and executive functions. We used a longitudinal design in which 10 participants were tested twice, before and after receiving 12 months of testosterone treatment. This group was also compared with 5 FM transgender adolescents off-androgen treatment.

RESULTS

Participants tested before and after 12 months of androgen treatment improved significantly on processing speed in a visuo-spatial (Rey-Osterrieth complex figure test) and in a visuo-oral task (Stroop), their performance on a verbal memory task (TAVEC) and on interference (Stroop) and they exhibited lower impulsivity control (CARAS-R). On-androgen treatment adolescents exhibited worse cognitive impulsivity control than off-androgen treatment adolescents.

CONCLUSIONS

The results indicate that androgen has an influence on immediate verbal memory, cognitive interference, impulsivity control and processing speed.

Sex and gender correlates of sexually polymorphic cognition

BACKGROUND

Sexually polymorphic cognition (SPC) results from the interaction between biological (birth-assigned sex (BAS), sex hormones) and socio-cultural (gender identity, gender roles, sexual orientation) factors. The literature remains quite mixed regarding the magnitude of the effects of these variables. This project used a battery of classic cognitive tests designed to assess the influence of sex hormones on cognitive performance. At the same time, we aimed to assess the inter-related and respective effects that BAS, sex hormones, and gender-related factors have on SPC.

METHODS

We recruited 222 adults who completed eight cognitive tasks that assessed a variety of cognitive domains during a 150-min session. Subgroups were separated based on gender identity and sexual orientation and recruited as follows: cisgender heterosexual men (n = 46), cisgender non-heterosexual men (n = 36), cisgender heterosexual women (n = 36), cisgender non-heterosexual women (n = 38), gender diverse (n = 66). Saliva samples were collected before, during, and after the test to assess testosterone, estradiol, progesterone, cortisol, and dehydroepiandrosterone. Psychosocial variables were derived from self-report questionnaires.

RESULTS

Cognitive performance reflects sex and gender differences that are partially consistent with the literature. Interestingly, biological factors seem to better explain differences in male-typed cognitive tasks (i.e., spatial), while psychosocial factors seem to better explain differences in female-typed cognitive tasks (i.e., verbal).

CONCLUSION

Our results establish a better comprehension of SPC over and above the effects of BAS as a binary variable. We highlight the importance of treating sex as a biological factor and gender as a socio-cultural factor together since they collectively influence SPC.

Cognitive functioning in older transgender individuals receiving long-term gender-affirming hormone therapy

Background

Cognitive functioning can be negatively influenced by age, cardiovascular risk (CVR) and mental health challenges, and sex-hormones can have neuroprotective effects. Little is known about cognitive functioning in older transgender individuals receiving long-term gender-affirming hormone therapy (GHT). In a previous, smaller study, cognitive differences between transgender women and cisgender groups were minimal yet statistically significant.

Aims

This study assessed cognitive differences between larger samples of older transgender and cisgender individuals, and the contribution of CVR and mental/social health to these differences.

Methods

This cross-sectional study compared 73 transgender women and 39 transgender men (56-84 y) receiving long-term GHT (10-47 y) with matched (age; education level) cisgender women and men from the Longitudinal Aging Study Amsterdam on cognitive functioning assessed with neuropsychological tests. Mean z-scores per cognitive domain were calculated and analyzed using linear regression. Models were subsequently adjusted for CVR ((history of) cardiovascular disease; smoking) and mental/social health (anxiety; loneliness) factors.

Results

Transgender women had lower scores than cisgender women and men, respectively, on information-processing speed (b = -0.62, 95% CI -0.90 to -0.35; b = -0.33, 95%CI -0.60 to -0.05), episodic memory (b = -1.28, 95%CI -1.53 to -1.04; b = -0.77, 95%CI -1.01 to -0.52), and crystallized intelligence (b = -0.42, 95%CI -0.75 to -0.10; b = -0.41, 95%CI -0.75 to -0.08). Transgender men scored lower on episodic memory than cisgender women but scored equal to cisgender men (b = -0.43, 95%CI -0.79 to -0.08; b = -0.01, 95%CI -0.36 to 0.35). Mental/social health factors (particularly depressive symptoms) largely, and CVR factors slightly, explained cognitive differences between the trans- and cisgender groups.

Discussion

Small cognitive differences between transgender men and cisgender groups do not suggest adverse or beneficial long-term testosterone effects on cognitive functioning. However, transgender women had lower cognitive functioning than cisgender groups, which was largely explained by mental/social health. This warrants further research and clinical awareness of mental and cognitive health in older transgender individuals.

Mental Health of Transmasculine Adults Receiving Gender-Affirming Hormone Therapy in Thailand

Purpose

Many studies have shown conflicting results regarding mental health among transmasculine adults or transgender men (TM). This study aimed to identify the prevalence of depression among Thai TM receiving gender-affirming hormone therapy (GAHT).

Methods

All TM, over 18 years of age, who received GAHT for at least three consecutive months were invited to complete a self-report questionnaire that covered participants' demographic and clinical data. Mental health, including depression, anxiety, and quality of life (QoL), was assessed. We reported the prevalence of mental illnesses and examined the correlations between mental health scores and other associated data.

Results

A total of 84 TM were included in the analysis. Major depression and generalized anxiety disorder were detected in 14.3% and 3.6%, respectively. Depression severity was negatively associated with age and QoL. Depression and anxiety severity were found to be positively associated.

Conclusions

Compared with the general Thai population, the prevalence of mental health problems among Thai TM receiving GAHT was higher. Age of maturity may be a potential mental health protective factor, and assessment in younger individuals may benefit mental health.

Testosterone use and sexual function among transgender men and gender diverse people assigned female at birth

BACKGROUND

Testosterone use among transgender people likely impacts their experience of sexual function and vulvovaginal pain via several complex pathways. Testosterone use is associated with decreased estrogen in the vagina and atrophic vaginal tissue, which may be associated with decreased vaginal lubrication and/or discomfort during sexual activity. At the same time, increased gender affirmation through testosterone use may be associated with improved sexual function. However, data on pelvic and vulvovaginal pain among transgender men and nonbinary people assigned female at birth are scarce.

OBJECTIVE

This study aimed to assess the association between testosterone and sexual function with a focus on symptoms that are commonly associated with vaginal atrophy.

STUDY DESIGN

We conducted a cross-sectional analysis of 1219 participants aged 18 to 72 years using data collected from 2019 to 2021 from an online, prospective, longitudinal cohort study of sexual and/or gender minority people in the United States (The Population Research in Identity and Disparities for Equality Study). Our analysis included adult transgender men and gender diverse participants assigned female at birth who were categorized as never, current, and former testosterone users. Sexual function was measured across 8 Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction domains.

RESULTS

Overall, 516 (42.3%) participants had never used testosterone, and 602 (49.4%) currently used testosterone. The median duration of use was 37.7 months (range, 7 days to >27 years). Most participants (64.6%) reported genital pain or discomfort during sexual activity in the past 30 days, most commonly in the vagina or frontal genital opening (52.2%), followed by around the clitoris (29.1%) and labia (24.5%). Current testosterone use was associated with a greater interest in sexual activity (β=6.32; 95% confidence interval, 4.91-7.74), higher ability to orgasm (β=1.50; 95% confidence interval, 0.19-2.81), and more vaginal pain or discomfort during sexual activity (β=1.80; 95% confidence interval, 0.61-3.00). No associations were observed between current testosterone use and satisfaction with sex life, lubrication, labial pain or discomfort, or orgasm pleasure.

CONCLUSION

Testosterone use among transgender men and gender diverse people was associated with an increased interest in sexual activity and the ability to orgasm, as well as with vaginal pain or discomfort during sexual activity. Notably, the available evidence demonstrates that >60% of transgender men experience vulvovaginal pain during sexual activity. The causes of pelvic and vulvovaginal pain are poorly understood but are likely multifactorial and include physiological (eg, testosterone-associated vaginal atrophy) and psychological factors (eg, gender affirmation). Given this high burden, there is an urgent need to identify effective and acceptable interventions for this population.

Sublingual Estradiol Offers No Apparent Advantage Over Combined Oral Estradiol and Cyproterone Acetate for Gender-Affirming Hormone Therapy of Treatment-Naive Trans Women: Results of a Prospective Pilot Study

Purpose

Chronic gender-affirming hormone therapy (GAHT) with sublingual estradiol (SLE) has not been studied. We aimed to compare GAHT with SLE only, to combined oral (CO) estradiol and cyproterone acetate, in treatment-naive trans women.

Methods

Twenty-two trans women enrolled into either the CO arm or the SLE-only arm (0.5 mg four times daily) in this 6-month prospective study. Anthropometric and laboratory variables were collected at baseline and 3 and 6 months. At the study beginning and end, body composition was measured by dual-energy X-ray absorptiometry and bioelectrical impedance, and gender dysphoria, sexual desire, and function were assessed by validated questionnaires.

Results

Subjects in the SLE were older, 26.3±5.8 years versus 20.1±2.3 years, p=0.006. All anthropometric, body composition, and laboratory variables were identical at baseline. Although dysphoria appeared greater, and sexual function lower at baseline in the CO group, this canceled out after age adjustment. Both treatments induced similar biochemical and hormonal changes. Creatinine, hemoglobin and cholesterol decreased significantly, while testosterone was suppressed to the same level in both groups: 3.22 [1.47-5.0] nmol/L in the SLE group and 2.41 [0.55-8.5] nmol/L in the CO, p=0.65. Significant changes in body composition toward a more feminine body were noted in both groups. Dysphoria did not significantly improve in either group, while sexual desire and function decreased at six months in both, p<0.001.

Conclusions

Both treatments achieved similar clinical changes. At this stage, SLE, which repeatedly induces alarming excursions of serum estradiol throughout the day, appears to offer no advantage over the CO approach.

Exploring Hormone Therapy Effects on Reproduction and Health in Transgender Individuals

Transgender individuals often face elevated mental health challenges due to gender dysphoria, but gender-affirming treatments such as surgery and hormone therapy have been linked to significant improvements in mental well-being. The potential influence of time and circadian rhythms on these treatments is prevalent. The intricate interplay between hormones, clock genes, and fertility is profound, acknowledging the complexity of reproductive health in transgender individuals. Furthermore, risks associated with gender-affirming hormonal therapy and potential complications of puberty suppression emphasize the importance of ongoing surveillance for these patients and the need of fertility preservation and family-building options for transgender individuals. This narrative review delves into the intricate landscape of hormone therapy for transgender individuals, shedding light on its impact on bone, cardiovascular, and overall health. It explores how hormone therapy affects bone maintenance and cardiovascular risk factors, outlining the complex interplay of testosterone and estrogen. It also underscores the necessity for further research, especially regarding the long-term effects of transgender hormones. This project emphasizes the critical role of healthcare providers, particularly obstetricians and gynecologists, in providing affirming care, calling for comprehensive understanding and integration of transgender treatments. This review will contribute to a better understanding of the impact of hormone therapy on reproductive health and overall well-being in transgender individuals. It will provide valuable insights for healthcare providers, policymakers, and transgender individuals themselves, informing decision-making regarding hormone therapy and fertility preservation options. Additionally, by identifying research gaps, this review will guide future studies to address the evolving healthcare needs of transgender individuals. This project represents a critical step toward addressing the complex healthcare needs of this population. By synthesizing existing knowledge and highlighting areas for further investigation, this review aims to improve the quality of care and support provided to transgender individuals, ultimately enhancing their reproductive health and overall well-being.

Expanding upon the relationship between gender-affirming hormone therapy, neural connectivity, mental health, and body image dissatisfaction

OBJECTIVE

Transgender/non-binary (TNB) youth are at increased risk for anxiety, depression, and suicidality compared to cisgender youth. Gender affirming hormone therapy (GAHT, i.e., testosterone or estrogen) is a standard of care option for TNB youth, and we have recently shown that GAHT (testosterone) in transgender youth assigned a female sex at birth is associated with reductions in internalizing symptomatology. The current analysis explores: 1) whether these benefits are observed in both TNB youth assigned female at birth (TNBAFAB) and TNB youth assigned male at birth (TNBAMAB) and 2) the extent to which body image dissatisfaction and alteration in neural circuitry relate to internalizing symptoms.

METHOD

The current study is an expansion of a previous publication from our lab that explored the association between gender-affirming testosterone and internalizing symptomatology. While participants in our previous study consisted of 42 TNBAFAB youth, participants in the current study included adolescent TNBAFAB receiving GAHT (n = 21; GAHT+) and not receiving GAHT (n = 29; GAHT-) as well as adolescent GAHT+ TNBAMAB (n = 15) and GAHT- TNBAMAB (n = 17). Participants reported symptoms of trait and social anxiety, depression, suicidality in the past year, and body image dissatisfaction. Brain activation was measured during a face processing task designed to elicit amygdala activation during functional MRI.

RESULTS

GAHT+ TNBAFAB had significantly lower rates of social anxiety, depression, and suicidality compared to GAHT- TNBAFAB. While there were no significant relationships between estrogen and depression and anxiety symptoms, longer duration of estrogen was related to less suicidality. Both testosterone and estrogen administration were related to significantly lower rates of body image dissatisfaction compared to GAHT- youth. No significant differences emerged for BOLD response in the left or right amygdala during the face processing task, however, there was a significant main effect of GAHT on functional connectivity between the right amygdala and the ventromedial prefrontal cortex, such that GAHT+ youth had stronger co-activation between the two regions during the task. Body image dissatisfaction, greater functional connectivity, their interaction effect, and age predicted depression symptomatology and body image dissatisfaction additionally predicted suicidality in the past year.

CONCLUSION

The current study suggests that GAHT is associated with fewer short-term internalizing symptoms in TNBAFAB than in TNBAMAB, although internalizing symptoms among TNBAMAB may diminish with longer durations of estrogen treatment. Controlling for age and sex assigned at birth, our findings indicate that less body image dissatisfaction and greater functional connectivity between the amygdala and ventromedial prefrontal cortex were both predictors of fewer levels of internalizing symptoms following GAHT.

Caring for Sexual and Gender Minority Adults with Cardiovascular Disease

This article summarizes existing evidence on cardiovascular disease (CVD) risk and CVD diagnoses among sexual and gender minority adults and provides recommendations for providing nursing care to sexual and gender minority adults with CVD. More research is needed to develop evidence-based strategies to care for sexual and gender minority adults with CVD.

Exploring the Impact of Legislation Aiming to Ban Gender-Affirming Care on Pediatric Endocrine Providers: A Mixed-Methods Analysis

Context

Access to gender-affirming medical care is associated with better mental health outcomes in transgender and gender diverse youth. In 2021 and 2022, legislation aiming to ban gender-affirming medical care for youth was proposed in 24 states.

Objective

This study aimed to (1) assess the impact of this legislation on pediatric providers based on legislative status of their state of practice and (2) identify the themes of concerns reported by them.

Methods

A mixed-methods study was conducted via an anonymous survey distributed to pediatric endocrinology providers. Survey responses were stratified based on US state of practice, with attention to whether legislation aiming to ban gender-affirming care had been considered. Data were analyzed both quantitatively and qualitatively.

Results

Of 223 respondents, 125 (56.0%) were currently providing gender-affirming medical care. A total of 103 (45.7%) respondents practiced in a state where legislation aiming to ban gender-affirming care had been proposed and/or passed between January 2021 to June 2022. Practicing in legislation-affected states was associated with negative experiences for providers including (1) institutional pressure that would limit the ability to provide care, (2) threats to personal safety, (3) concerns about legal action being taken against them, (4) concerns about their career, and (5) institutional concerns about engagement with media. Major qualitative themes emerging for providers in legislation-affected states included safety concerns and the impact of laws on medical practice.

Conclusion

This study suggests that legislation aiming to ban health care for transgender youth may decrease access to qualified providers in affected states.

A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people

This systematic review assessed the state and quality of evidence for effects of gender-affirming hormone therapy on psychosocial functioning. Forty-six relevant journal articles (six qualitative, 21 cross-sectional, 19 prospective cohort) were identified. Gender-affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress. Evidence for quality of life was inconsistent, with some trends suggesting improvements. There was some evidence of affective changes differing for those on masculinizing versus feminizing hormone therapy. Results for self-mastery effects were ambiguous, with some studies suggesting greater anger expression, particularly among those on masculinizing hormone therapy, but no increase in anger intensity. There were some trends toward positive change in interpersonal functioning. Overall, risk of bias was highly variable between studies. Small samples and lack of adjustment for key confounders limited causal inferences. More high-quality evidence for psychosocial effects of gender-affirming hormone therapy is vital for ensuring health equity for transgender people.

Psychopharmacological Considerations for Gender-Affirming Hormone Therapy

ABSTRACT

The field of transgender health has grown exponentially since the early 2010s. While this increased visibility has not been without controversy, there is growing acknowledgement of the needs of transgender, nonbinary, and gender expansive (TNG) patients and the health disparities they experience compared to the cisgender population. There is also increased interest among clinicians and trainees in providing gender-affirming care in all medical specialties. This is particularly relevant in psychiatry as mental health disparities in TNG patients have been well-documented. TNG patients experience significant minority stress and higher rates of psychiatric illness, self-harm, suicidality, and psychiatric hospitalization compared to their cisgender peers. In this review, we will cover potential interactions and side effects relevant to psychiatric medication management for the three most common medication classes prescribed as part of gender-affirming hormone therapy (GAHT): gonadotropin-releasing hormone receptor agonists, estradiol, and testosterone. Although no studies directly examining the efficacy of psychiatric medications or their interactions with GAHT for TNG patients have been published yet, we have synthesized the existing literature from both cisgender and TNG patients to shed light on health care disparities seen in TNG patients. Since clinicians' lack of comfort and familiarity with gender-affirming care contributes significantly to these disparities, we hope this narrative review will help psychiatric prescribers provide TNG patients with the same quality of care that cisgender patients receive.

Gender-affirming hormone therapy, mental health, and surgical considerations for aging transgender and gender diverse adults

As the transgender and gender diverse (TGD) population ages, more transfeminine and transmasculine individuals present to clinic to initiate or continue their gender-affirming care at older ages. Currently available guidelines on gender-affirming care are excellent resources for the provision of gender-affirming hormone therapy (GAHT), primary care, surgery, and mental health care but are limited in their scope as to whether recommendations require tailoring to older TGD adults. Data that inform guideline-recommended management considerations, while informative and increasingly evidence-based, mainly come from studies of younger TGD populations. Whether results from these studies, and therefore recommendations, can or should be extrapolated to aging TGD adults remains to be determined. In this perspective review, we acknowledge the lack of data in older TGD adults and discuss considerations for evaluating cardiovascular disease, hormone-sensitive cancers, bone health and cognitive health, gender-affirming surgery, and mental health in the older TGD population on GAHT.

Application of single-cell RNA sequencing on human testicular samples: a comprehensive review

So far there has been no comprehensive review using systematic literature search strategies to show the application of single-cell RNA sequencing (scRNA-seq) in the human testis of the whole life cycle (from embryos to aging males). Here, we summarized the application of scRNA-seq analyses on various human testicular biological samples. A systematic search was conducted in PubMed and Gene Expression Omnibus (GEO), focusing on English researches published after 2009. Articles related to GEO data-series were also retrieved in PubMed or BioRxiv. 81 full-length studies were finally included in the review. ScRNA-seq has been widely used on different human testicular samples with various library strategies, and new cell subtypes such as State 0 spermatogonial stem cells (SSC) and stage_a/b/c Sertoli cells (SC) were identified. For the development of normal testes, scRNA-seq-based evidence showed dynamic transcriptional changes of both germ cells and somatic cells from embryos to adults. And dysregulated metabolic signaling or hedgehog signaling were revealed by scRNA-seq in aged SC or Leydig cells (LC), respectively. For infertile males, scRNA-seq studies revealed profound changes of testes, such as the increased proportion of immature SC/LC of Klinefelter syndrome, the somatic immaturity and altered germline autophagy of patients with non-obstructive azoospermia, and the repressed differentiation of SSC in trans-females receiving testosterone inhibition therapy. Besides, the re-analyzing of public scRNA-seq data made further discoveries such as the potential vulnerability of testicular SARS-CoV-2 infection, and both evolutionary conservatism and divergence among species. ScRNA-seq analyses would unveil mechanisms of testes' development and changes so as to help developing novel treatments for male infertility.

Assessing and Addressing the Risk of Venous Thromboembolism Across the Spectrum of Gender Affirming Care: A Review

OBJECTIVE

Accumulating evidence demonstrates that gender affirming hormone therapy (GAHT) improves mental health outcomes in transgender persons. Data specific to the risks associated with GAHT for transgender persons continue to emerge, allowing for improvements in understanding, predicting, and mitigating adverse outcomes while informing discussion about desired effects. Of particular concern is the risk of venous thromboembolism (VTE) in the context of both longitudinal GAHT and the perioperative setting. Combining what is known about the risk of VTE in cisgender individuals on hormone therapy (HT) with the evidence for transgender persons receiving HT allows for an informed approach to assess underlying risk and improve care in the transgender community.

OBSERVATIONS

Hormone formulation, dosing, route, and duration of therapy can impact thromboembolic risk, with transdermal estrogen formulations having the lowest risk. There are no existing risk scores for VTE that consider HT as a possible risk factor. Risk assessment for recurrent VTE and bleeding tendencies using current scores may be helpful when assessing individual risk. Gender affirming surgeries present unique perioperative concerns, and certain procedures include a high likelihood that patients will be on exogenous estrogens at the time of surgery, potentially increasing thromboembolic risk.

CONCLUSIONS AND RELEVANCE

Withholding GAHT due to potential adverse events may cause negative impacts for individual patients. Providers should be knowledgeable about the management of HT in transgender individuals of all ages, as well as in the perioperative setting, to avoid periods in which transgender individuals are off GAHT. Treatment decisions for both anticoagulation and HT should be individualized and tailored to patients' overall goals and desired outcomes, given that the physical and mental health benefits of gender affirming care may outweigh the risk of VTE.

Exposomics as a tool to investigate differences in health and disease by sex and gender

The health and disease of an individual is mediated by their genetics, a lifetime of environmental exposures, and interactions between the two. Genetic or biological sex, including chromosome composition and hormone expression, may influence both the types and frequency of environmental exposures an individual experiences, as well as the biological responses an individual has to those exposures. Gender identity, which can be associated with social behaviors such as expressions of self, may also mediate the types and frequency of exposures an individual experiences. Recent advances in exposome-level analysis have progressed our understanding of how environmental factors affect health outcomes; however, the relationship between environmental exposures and sex- and gender-specific health remains underexplored. The comprehensive, non-targeted, and unbiased nature of exposomic research provides a unique opportunity to systematically evaluate how environmental exposures interact with biological sex and gender identity to influence health. In this forward-looking narrative review, we provide examples of how biological sex and gender identity influence environmental exposures, discuss how environmental factors may interact with biological processes, and highlight how an intersectional approach to exposomics can provide critical insights for sex- and gender-specific health sciences.

Delays in gender affirming healthcare due to COVID-19 are mitigated by expansion of telemedicine

BACKGROUND

Gender-affirming healthcare is vital for transgender and gender diverse (TGD) patients, and during the pandemic, accessing healthcare became challenging. Hypothesizing that many had procedures postponed, we sought to characterize the impact of the pandemic on TGD patients.

METHODS

A mixed-methods approach was employed, combining surveys and interviews; Duke patients were identified by ICD-10 codes, while non-Duke (national) patients were recruited through online social media.

RESULTS

All specialties increased telemedicine usage during the pandemic. Duke surgical patients reported a nearly three-fold increase in telemedicine access. COVID-19 symptoms were reported by 24% of Duke and 20% of national patients; barriers to urgent care included the fear of discrimination (27%).

CONCLUSION

Delays were experienced in all domains of care, mitigated in part by telemedicine. Nearly one-third of patients cite discrimination as a barrier to care. Though pandemic-related expansion of telemedicine may be a marker of success, significant barriers still complicate delivery of healthcare.

Hormone Prescription and HIV Screening/Preventive Practices Among Clinicians Providing Care for Transgender Individuals

Purpose

Through a survey-based approach, we sought to investigate regional differences in gender-affirming hormone therapy (GAHT) prescribing practices, as well as HIV screening and prevention practices among clinicians providing care to transgender individuals.

Methods

Our survey was disseminated between December 2019 and January 2021 to clinicians who prescribe GAHT within New England (United States). Between-group differences in GAHT prescribing and HIV screening/prevention practices were evaluated by practice setting and subspecialty.

Results

Of the 20 survey respondents, 55% practiced in health care settings affiliated with an academic institution, 45% practiced in a community-based health care setting, and 30% were Endocrinologists. Clinicians in community-based health care settings reported more frequently prescribing oral 17β-estradiol (p=0.02) and spironolactone (p=0.007) for feminizing GAHT compared with clinicians in health care settings affiliated with an academic institution, who reported more frequently prescribing leuprolide (p=0.03). For masculinizing GAHT, clinicians from health care settings affiliated with an academic institution reported more frequently prescribing topical testosterone (p=0.03). There were no significant between-group differences in reported barriers to initiation or reasons for stopping GAHT. While non-Endocrinologists reported "often" or "always" offering HIV screening, most Endocrinologists reported "rarely" or "never" offering HIV screening and "rarely" or "never" offering pre-exposure or postexposure prophylaxis to their transgender patients.

Conclusions

Regional GAHT prescribing practices varied by setting. Additional research is needed to better understand whether these differences translate to differences in GAHT efficacy and side-effects. Further, HIV screening/prevention practices varied by subspecialty. Integrated GAHT and HIV screening/prevention across subspecialties could help reduce the disproportionate burden of HIV faced by the transgender community.

Effects of Hormones on Breast Development and Breast Cancer Risk in Transgender Women

Transgender women experience gender dysphoria due to a gender assignment at birth that is incongruent with their gender identity. Transgender people undergo different surgical procedures and receive sex steroids hormones to reduce psychological distress and to induce and maintain desired physical changes. These persons on feminizing hormones represent a unique population to study the hormonal effects on breast development, to evaluate the risk of breast cancer and perhaps to better understand the precise role played by different hormonal components. In MTF (male to female) patients, hormonal treatment usually consists of antiandrogens and estrogens. Exogenous hormones induce breast development with the formation of ducts and lobules and an increase in the deposition of fat. A search of the existing literature dedicated to hormone regimens for MTF patients, their impact on breast tissue (incidence and type of breast lesions) and breast cancer risk provided the available information for this review. The evaluation of breast cancer risk is currently complicated by the heterogeneity of administered treatments and a lack of long-term follow-up in the great majority of studies. Large studies with longer follow-up are required to better evaluate the breast cancer risk and to understand the precise mechanisms on breast development of each exogenous hormone.

A pilot study of the metabolic profiles of apheresis platelets modified by donor age and sex and in vitro short-term incubation with sex hormones

BACKGROUND

Platelets are part of innate immunity and comprise the cellular portion of hemostasis. Platelets express sex hormone receptors on their plasma membrane and sex hormones can alter their function in vitro. Little is known about how age and sex may affect platelet biology; thus, we hypothesized that platelets from males and females have different metabolomic profiles, which may be altered by age and in vitro treatment with sex hormones.

METHODS

Day 1 apheresis platelets were drawn from five 18-53-year-old, premenopausal younger females (YF), five ≥54-year-old, postmenopausal, older females (OF), five 18-44-year-old younger males (YM), and four ≥45-year-old older males (OM). Platelets were normalized to a standard concentration and metabolomics analyses were completed. Unsupervised statistical analyses and hierarchical clustering with principal component analyses were completed.

RESULTS

Platelets from OM had (1) elevated mono-, di- and tri-carboxylates, (2) increased levels of free fatty acids, acyl-carnitines, and free amino acids, and (3) increased purine breakdown and deamination products. In vitro incubation with sex hormones only affected platelets from OM donors with trends towards increased ATP and other high-energy purines and decreases in L-proline and other amino acids.

CONCLUSION

Platelets from OM's versus YF, OF, and YM have a different metabolome implying increased energy metabolism, more free fatty acids, acylcarnitines, and amino acids, and increased breakdown of purines and deamination products. However, only platelets from OM were affected by sex hormones in vitro. Platelets from OM are metabolically distinct, which may impart functional differences when transfused.

The Comparison of Gender Dysphoria, Body Image Satisfaction and Quality of Life Between Treatment-Naive Transgender Males With and Without Polycystic Ovary Syndrome

The prevalence of polycystic ovary syndrome (PCOS) among trans men has been reported as higher than among the cisgender population, which varies between 14.4% and 58%. In this cross-sectional study, we aimed to evaluate the association of oligo-anovulation and/or features of hyperandrogenism with the scores on the Utrecht Gender Dysphoria Scale (UGDS), the Body Image Scale (BIS), and the Short Form-36 Health Survey (SF-36) in treatment-naive trans men with PCOS seeking help for gender transition. The study sample consisted of trans men who were diagnosed with gender dysphoria (GD) between December 2019 and November 2020. To assess body dissatisfaction and psychological functioning, the UGDS, BIS, and SF-36 were administered to all transgender individuals as part of the routine assessment procedure. A total of 49 treatment-naive trans men were included in our study; 38.8% (n=19) of the participants were diagnosed with PCOS using the Rotterdam 2003 criteria. The scores of UGDS and BIS were significantly lower in the PCOS group compared with the non-PCOS group (p<0.001 and p=0.003, respectively). Among the eight parameters within SF-36, general health, emotional role, and vitality scores were significantly higher in the PCOS group (p=0.031, p=0.015, and p=0.006, respectively). Our study is the first study that demonstrates significantly lower GD, higher body image satisfaction and quality of life in trans men with PCOS compared with those without PCOS. Our findings are promising for larger prospective cohort studies to develop a consensus on the management of PCOS in trans men.