Hormone therapy in transgender adults is safe with provider supervision; A review of hormone therapy sequelae for transgender individuals

Biochemical liver damage during gender affirming therapy in trans adults assigned female at birth: a meta-analysis

PURPOSE

To assess the effects of testosterone (T)-based gender affirming hormone therapy (GAHT) on liver blood tests (LBTs) in assigned female at birth adults, using a meta-analytic approach.

METHODS

Prospective and retrospective studies were selected that reported the prevalence of biochemical liver damage (BLD) and LBTs changes during T therapy. Data collected included pre-and-during therapy alanine-aminotransferase (ALT), aspartate-aminotransferase (AST), gamma-glutamyl-transferase (GGT), and alkaline phosphatase (ALP) mean concentration values.

RESULTS

The prevalence of BLD in 14 studies on 1698 subjects was 1% (95% CI 0.00-3.00; I2 = 14.1%; p = 0.82). In 17 studies on 2758 subjects, GAHT was associated with a statistically (but not clinically) significant increase in AST, GGT and ALP at 12 months and ALT at 3-7 (MD: 1.19 IU/l; 95% CI 0.31, 2.08; I2: 0%), at 12 (MD: 2.31 IU/l; 95% CI 1.41, 3.21; I2: 29%), but with no more significant increase at 24 months (MD: 1.71 IU/l; 95% CI -0.02, 3.44; I2: 0%).

CONCLUSIONS

Analysis of aggregate estimates confirms a low risk of BLD and abnormalities in LBTs, transient in most cases, during T-based GAHT, thus suggesting a limited need for careful liver monitoring in AFAB people.

Highs, Lows, and Hormones: A Qualitative Metasynthesis of Transgender Individuals' Experiences Undergoing Gender-Affirming Hormone Therapy

Gender Affirming Hormone Therapy (GAHT) is a key therapeutic approach which aims to help trans and gender diverse (or simply "trans") individuals' transition from their sex-presumed-at-birth to their experienced gender identity. Previous reviews have focused on synthesizing quantitative experiences; however, a qualitative lens is important to understand the personal journey of GAHT. This review provides a qualitative meta-synthesis of the experiences of trans people around the world who have undergone GAHT to elicit contextualized understanding of the changes experienced. Systematic searches of eight databases identified an initial 2670 papers, refined to a final 28 papers. Overall, findings suggested that the GAHT journey is unique and elicited a myriad of changes which, whilst challenging at times, were life-changing and brought about positive psychological, physical, and social changes. Other themes explored GAHT not being treated as a fix-all for associated mental health issues, the rules that govern appraisal of physical changes, how privilege and social identity evolve, and the power of affirmation. This work offers important recommendations to improve the care offered to trans people undergoing GAHT. Namely, person-centered support is essential, and peer-navigation may be a useful future direction to explore.

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.

Erythrocytosis in Gender-Affirming Care With Testosterone

PURPOSE

Gender-affirming hormone therapy (GAHT) is safe overall, with few adverse effects. One potential effect from using testosterone for GAHT is an increase in hemoglobin and/or hematocrit, known as secondary erythrocytosis. Current guidelines recommend monitoring hemoglobin or hematocrit routinely in the first year, some as frequently as every 3 months, which can create barriers to care. Our study explored the incidence of erythrocytosis in the first 20 months of testosterone therapy among people receiving gender-affirming care.

METHODS

This is a descriptive fixed cohort study of hematocrit and hemoglobin data from the charts of 282 people taking testosterone for GAHT.

RESULTS

During the first 20 months of testosterone therapy, the cumulative incidence of hematocrit >50.4% was 12.6%, hematocrit >52% was 1.0%, and hematocrit >54% was 0.6%. All people were taking injectable testosterone cypionate, with a median dose of 100 mg weekly.

CONCLUSION

Severe erythrocytosis (hematocrit >54%) is a rare outcome of gender-affirming testosterone therapy. Clinical recommendations should reconsider the need for routine frequent erythrocytosis screening within the first year of testosterone therapy for patients who prefer to minimize laboratory draws.

A Qualitative Examination of Tobacco Use and Smoking Cessation Among Gender Minority Adults

BACKGROUND

Despite the elevated prevalence of smoking among gender minority adults, little is known about the factors that influence their tobacco use and cessation.

PURPOSE

We identified and examined factors that influence tobacco use and cessation for gender minority adults, using a conceptual framework based on the Model of Gender Affirmation and Gender Minority Stress Model.

METHODS

Nineteen qualitative, semi-structured in-depth interviews were conducted with gender minority adults who smoke or no longer smoke and were recruited from the Portland, OR metropolitan area. Interviews were audio-recorded, professionally transcribed, and analyzed utilizing thematic analysis.

RESULTS

Four main themes were generated. Gender minority adults smoke to cope with general and gender minority-specific stressors. Smoking was described as a social behavior that was influenced and sustained by community and interpersonal relationships. Smoking cessation was motivated by health concerns (both general and gender minority-specific) and moderated by conducive life circumstances. Recommendations for tobacco cessation interventions highlighted the importance and role of social support. Participants expressed a strong desire for gender minority-specific tobacco cessation programs. There are unique and complex factors that contribute to the higher prevalence of smoking observed among gender minority adults.

CONCLUSIONS

Tobacco cessation interventions are urgently needed for this population and should be tailored to address the unique factors that impact tobacco use and cessation among gender minority people to increase the likelihood of success.

The metabolic effects of hormonal treatment in transgender males: Safety of the testosterone gender-affirming therapy

BACKGROUND

Gender dysphoria is characterised by a sense of distress because of discordance between the self-perception of gender identity and the assigned sex. Hormonal treatment of transgender males uses testosterone to induce and preserve masculinisation.

OBJECTIVE

The study investigated the safety of testosterone therapy in transgender males.

METHODS

The present study used a retrospective file review of transgender male subjects who were treated with testosterone (initially transdermal testosterone gel and subsequently parenteral testosterone undecanoate) for at least 18 months and had subsequently achieved a serum testosterone level within the normal range of cisgender male counterparts. Changes in somatometric data and blood biomarkers were investigated.

RESULTS

The mean testosterone serum levels after approximately 18 months of treatment were about 545 ng/dL (SD ± 94 ng/dL). There was a statistically significant rise in body mass index (𝜒d = +1.23 kg/m2) with a reduction in blood glucose (𝜒d = -5.33 mg/dL) as well as statistically significant increases in aspartate transaminase (𝜒d = +4.3 U/L), haemoglobin (𝜒d = +1.72 g/dL), and haematocrit (𝜒d = +4.76%). In contrast, there were no significant changes in the lipidaemic profile of the subjects.

CONCLUSIONS

Treatment with testosterone is routinely used for the promotion of virilising physical changes in transgender males. However, the likelihood of adverse effects of continuous treatment is still unclear. This study contributed to the notion that achieving testosterone levels within the target range is a prerequisite for the safety of the gender-affirming treatment.

Liver function in transgender persons: Challenges in the COVID-19 era

Transgender persons constitute a non-negligible percentage of the general population. Physical gender-transitioning in trans persons is mainly achieved with hormonal cross-sex therapy and sex reassignment surgeries that aim to align bodily appearance with gender identity. Hormonal treatment acts via suppressing the secretion of the endogenous sex hormones and replacing them with the hormones of the desired sex. The administration of testosterone is the typical masculinizing treatment in trans men, whilst trans women are routinely treated with estradiol agents in combination with anti-androgens or gonadotrophin-releasing hormone agonists if testes are present. Exogenous androgenic steroids, estradiol agents, and anti-androgens have been implicated in a series of hepatotoxic effects. Thus, liver integrity is a major concern with the long-term administration of cross-sex therapy. Hepatic tissue is susceptible to coronavirus disease 19 (COVID-19) through various pathophysiological mechanisms. Special consideration should be paid to minimize the risk of hepatic damage from the potential cumulative effect of COVID-19 and gender-affirming treatment in transgender patients. Appropriate care is significant, with continuous laboratory monitoring, clinical observation and, if needed, specific treatment, especially in severe cases of infection and in persons with additional liver pathologies. The pandemic can be an opportunity to provide equal access to care for all and increase the resilience of the transgender population.

Incidence, Contributing Factors, and Implications for Clinical Management of Polycythemia in Transmasculine Patients on Testosterone

Purpose: The goal of this study was to evaluate contributing factors and management strategies for polycythemia in transmasculine patients on testosterone therapy. Methods: A retrospective analysis of medical records was performed for transmasculine patients on testosterone for at least 12 months. Data collected from each patient included age, body mass index (BMI), nicotine dependence, pulmonary disease status, obstructive sleep apnea (OSA) status, oophorectomy status, and testosterone route of administration. For patients who developed polycythemia, polycythemia management strategy data were collected. Results: Five-hundred-eleven patients were evaluated and 113 (22%) experienced an episode of polycythemia. Within the polycythemia group, 77% of patients were younger than age 40, 56% had a BMI >30.0, 44% had current or former nicotine dependence, 12% had a pulmonary disease, 12% had OSA, and 47% had received an oophorectomy. The polycythemia group had a significantly higher average age, BMI, and dose of testosterone, and also had a higher proportion of patients with OSA and an oophorectomy. Conclusion: These results revealed that polycythemia is a common side effect for transmasculine patients on testosterone. Importantly, previous oophorectomy may be associated with polycythemia which appears to be a novel finding. This finding requires further research but provides the potential to be an important screening consideration for transmasculine patients after oophorectomy. Polycythemia will continue to be a major concern for patients on testosterone therapy, and this study provided important information for clinical practice and future research that will lead to improved outcomes.

Care of Gender Diverse Youth with Obesity

PURPOSE OF REVIEW

The relationships between gender identity, body image, and gender expression are complex, requiring a gender affirming approach to address weight management. This purpose of this review is to describe the essentials to caring for gender diverse youth, as well as the differences and intersections among those with obesity.

RECENT FINDINGS

Gender-affirming hormone therapy may lead to abnormal weight gain and increased body mass index, or worsen obesity and exacerbate weight-related complications. Moreover, given the high prevalence of victimization, marginalization, and stigmatization among gender diverse people and youth with obesity, care guidelines and treatment goals should also include reducing the negative impact of social-related complications. Despite the overlap in clinical care and lived experiences that impact the health of gender diverse youth with obesity, there is very little research to help guide clinicians. Careful attention to medical and behavioral comorbidities, barriers to care, and health disparities can inform clinical practice. Future research that specifically addresses nuances to care for gender diverse youth with obesity can help to establish standards of care to address their unmet needs and further support clinicians, patients and their families.

Management of acne in transgender and gender diverse youth Part 2: Unique considerations and strategies in medical treatment

Acne vulgaris is among the most common skin disorders afflicting adolescents worldwide, and though well-established guidelines of care exist for acne management, these guidelines do not uniformly consider or address the unique psychosocial and medical needs of transgender and gender diverse (TGD) youth. Part 2 of this two-part review provides guidance on a stepwise approach to the medical treatment of acne in TGD youth, with an emphasis on safety, efficacy, and the delivery of medical care in a culturally humble, thoughtful, and gender-affirming manner.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Use of Hormones Among Trans Women in the West Coast of Peninsular Malaysia: A Mixed Methods Study

Purpose:

There are no national data on hormone use by trans women in Malaysia. The objective of this study was to determine hormone use and the associated factors by trans women in Malaysia.

Methods:

This mixed method (quantitative and qualitative) study (JPEC 03-18-0021) was conducted using a self-administered questionnaire among trans women who used hormones and recruited using snow ball sampling method. All participants had undergone a blood test in an assigned laboratory. Besides total testosterone and total estradiol blood levels, renal and liver function tests and lipid profile were done.

Results:

A total of 111 out of the 141 respondents who participated were taking hormones. The main reason for not taking hormones was the concern for side effects. The main source of information concerning hormones was friends, and most procured the hormones from pharmacy without prescription and without first undergoing a physical or blood examination. All were on estrogens and only about half were on progesterone. The common mode of intake was oral and by injection. Most were on <4 mg of estrogens and did not report any major complication. Most rated the hormone affordability and satisfaction as good. Most had inadequate testosterone and estradiol blood levels. Except for total cholesterol and low-density lipoproteins, all other blood tests were normal. Correlation between serum testosterone and estradiol (R² 0.012. B−9.273 (95% confidence interval −16.44 to −2.11). p=0.012) was statistically significant.

Conclusion:

The prevalence of hormone use was high, mostly nonprescription use and with no medical supervision.

Gender-affirming hormone therapy: An updated literature review with an eye on the future

In line with increasing numbers of transgender (trans) and gender nonbinary people requesting hormone treatment, the body of available research is expanding. More clinical research groups are presenting data, and the numbers of participants in these studies are rising. Many previous review papers have focused on all available data, as these were scarce, but a more recent literature review is timely. Hormonal regimens have changed over time, and older data may be less relevant for today's practice. In recent literature, we have found that even though mental health problems are more prevalent in trans people compared to cisgender people, less psychological difficulties occur, and life satisfaction increases with gender-affirming hormone treatment (GAHT) for those who feel this is a necessity. With GAHT, body composition and contours change towards the affirmed sex. Studies in bone health are reassuring, but special attention is needed for adolescent and adult trans women, aiming at adequate dosage of hormonal supplementation and stimulating therapy compliance. Existing epidemiological data suggest that the use of (certain) estrogens in trans women induces an increased risk of myocardial infarction and stroke, the reason that lifestyle management can be an integral part of trans health care. The observed cancer risk in trans people does not exceed the known cancer-risk differences between men and women. Now it is time to integrate the mostly reassuring data, to leave the overly cautious approach behind, to not copy the same research questions repeatedly, and to focus on longer follow-up data with larger cohorts.

[Transgender health and healthcare during the COVID‑19 pandemic: a cross-sectional online survey in German-speaking countries]

BACKGROUND AND OBJECTIVE

Since spring of 2020, the COVID‑19 pandemic has disrupted our day-to-day lives and led to negative consequences in various areas of life, including mental and physical wellbeing. In this article, we take a closer look at the situation of trans people, who - due to experiences with discrimination and marginalization as well as their specific health-related interests - could be characterized by a particular vulnerability.

METHODS

Using an online cross-sectional survey, which we designed collaboratively with experts from the trans community, we investigated the mental and physical health of trans people from German-speaking countries and their access to trans-related healthcare during the COVID‑19 pandemic in the period from 1 May 2020 to 31 January 2021.

RESULTS

Since the beginning of the COVID‑19 pandemic, trans people have experienced barriers in access to gender-affirming treatments, mental health services, and COVID‑19-related medical care. At the same time, trans people reported being affected by chronic diseases disproportionately more often than the general population, including those leading to a higher risk for poorer outcomes of a COVID‑19 infection. Moreover, the participants reported being exposed to many risk factors associated with higher mental distress (e.g., having a chronic illness, belonging to a minority based on a non-heterosexual orientation, or having a low income).

DISCUSSION

The results of this survey indicate that prior vulnerabilities with regards to health problems and the restricted access to an informed and qualified transgender healthcare were exacerbated by the COVID‑19 pandemic.

Southern African HIV Clinicians' Society gender-affirming healthcare guideline for South Africa

No abstract available.

Effects of testosterone treatment on transgender males: A single-institution study

Objectives:

Data regarding gender-affirming hormone therapy in the Asian population are sparse. We aimed to evaluate the efficacy and safety of testosterone therapy in transgender men.

Methods:

A retrospective study chart review was conducted in a single university-based transgender clinic. Transgender men aged >18 years who newly started testosterone therapy during January 2015 to October 2019 were recruited. Physical changes, laboratory results, and adverse events, including cancer, thromboembolism, cardiovascular events, and death after masculinizing hormone therapy, were evaluated.

Results:

A total of 39 transgender men (mean age: 27.8 ± 6.0 years) were included. All individuals were treated with intramuscular testosterone injection with a mean follow-up of 25.2 ± 12.9 months. The most common maintenance regimen was testosterone enanthate 250 mg every 4 weeks. Masculinizing effects developed in all transgender men. There were no changes in body weight, and systolic and diastolic blood pressure. Hematocrit levels were 12% significantly increased from 39.9 ± 3.3% to 48.9 ± 2% (p < 0.001). Ten individuals (25.6%) had hematocrit >50%. Significant changes were found in decreased fasting plasma glucose, increased creatinine, and increased uric acid levels. A non-significantly increased alanine aminotransferase, increased low-density lipoprotein cholesterol, and decreased high-density lipoprotein cholesterol were observed. No thromboembolism, cancer, stroke, or coronary artery disease occurred.

Conclusions:

Gender-affirming hormone therapy is an effective and safe short-term treatment in Thai transgender men. Apart from the standard recommendation, uric acid, plasma glucose, and creatinine level evaluation before and during masculinizing hormone therapy are rational practices. An intramuscular testosterone enanthate 250 mg every 4 weeks is an alternative masculinizing regimen with decent efficacy and safety profile.

How does hormone transition in transgender women change body composition, muscle strength and haemoglobin? Systematic review with a focus on the implications for sport participation

Objectives

We systemically reviewed the literature to assess how long-term testosterone suppressing gender-affirming hormone therapy influenced lean body mass (LBM), muscular area, muscular strength and haemoglobin (Hgb)/haematocrit (HCT).

Design

Systematic review.

Data sources

Four databases (BioMed Central, PubMed, Scopus and Web of Science) were searched in April 2020 for papers from 1999 to 2020.

Eligibility criteria for selecting studies

Eligible studies were those that measured at least one of the variables of interest, included transwomen and were written in English.

Results

Twenty-four studies were identified and reviewed. Transwomen experienced significant decreases in all parameters measured, with different time courses noted. After 4 months of hormone therapy, transwomen have Hgb/HCT levels equivalent to those of cisgender women. After 12 months of hormone therapy, significant decreases in measures of strength, LBM and muscle area are observed. The effects of longer duration therapy (36 months) in eliciting further decrements in these measures are unclear due to paucity of data. Notwithstanding, values for strength, LBM and muscle area in transwomen remain above those of cisgender women, even after 36 months of hormone therapy.

Conclusion

In transwomen, hormone therapy rapidly reduces Hgb to levels seen in cisgender women. In contrast, hormone therapy decreases strength, LBM and muscle area, yet values remain above that observed in cisgender women, even after 36 months. These findings suggest that strength may be well preserved in transwomen during the first 3 years of hormone therapy.

Research gaps in medical treatment of transgender/nonbinary people

With the growing number of transgender and gender-nonbinary individuals who are becoming visible, it is clear that there is a need to develop a rigorous evidence base to inform care practice. Transgender health research is often limited to HIV/AIDS or mental health research and is typically subsumed in larger studies with general LGBTQ focus. Although the number of knowledgeable health care providers remains modest, the model for the medical approach to transgender health is shifting owing to growing social awareness and an appreciation of a biological component. Gender-affirming medicine facilitates aligning the body of the transgender person with the gender identity; typical treatment regimens include hormone therapy and/or surgical interventions. While broadly safe, hormone treatments require some monitoring for safety. Exogenous estrogens are associated with a dose-dependent increase in venous thromboembolic risk, and androgens stimulate erythropoiesis. The degree to which progressing gender-affirming hormone treatment changes cancer risk, cardiac heart disease risk, and/or bone health remains unknown. Guidelines referencing the potential exacerbation of cancer, heart disease, or other disease risk often rely on physiology models, because conclusive clinical data do not exist. Dedicated research infrastructure and funding are needed to address the knowledge gap in the field.

Medicare Prescription Drug Plan Coverage of Hormone Therapies Used by Transgender Individuals

Purpose: Although pharmacologic hormone therapy represents one of the mainstays of gender-affirming therapy for transgender individuals, there are many access barriers for these therapies, including insurance coverage of these drugs. The purpose of this study was to examine Medicare coverage of hormone therapies used by transgender individuals. Methods: Using Centers for Medicare and Medicaid Services prescription drug plan formulary files, we determined plan coverage, coverage restrictions, and out-of-pocket (OOP) costs for all 10 drugs recommended in the 2009 and 2017 Endocrine Society treatment guidelines for transgender patients. Results: For masculinizing therapies, the proportion of plans providing unrestricted coverage ranged from 22% to 79% in 2010 and from 5% to 75% in 2018. For feminizing therapies, the proportion providing unrestricted coverage ranged from 24% to 100% in 2010 and from 13% to 100% in 2018. Median annual OOP costs for masculinizing therapies ranged from $232 to $1112 in 2010 and from $180 to $2176 in 2018. For feminizing therapies, OOP costs ranged from $84 to $2716 in 2010 and from $72 to $3792 in 2018. Conclusion: Our findings highlight the variability in access to guideline-recommended hormone therapies for individuals insured through Medicare.

Cardiovascular Risk Associated With Gender Affirming Hormone Therapy in Transgender Population

Transgender men and women represent about 0.6 -1.1%% of the general population. Gender affirming hormone therapy (GAHT) helps ameliorate gender dysphoria and promote well-being. However, these treatments' cardiovascular (CV) effects are difficult to evaluate due to the limited number of extensive longitudinal studies focused on CV outcomes in this population. Furthermore, these studies are mainly observational and difficult to interpret due to a variety of hormone regimens and observation periods, together with possible bias by confounding factors (comorbidities, estrogen types, smoking, alcohol abuse, HIV infection). In addition, the introduction of GAHT at increasingly earlier ages, even before the full development of the secondary sexual characteristics, could lead to long-term changes in CV risk compared to current data. This review examines the impact of GAHT in the transgender population on CV outcomes and surrogate markers of CV health. Furthermore, we review available data on changes in DNA methylation or RNA transcription induced by GAHT that may translate into changes in metabolic parameters that could increase CV risk.

The expectations of transgender people in the face of their health-care access difficulties and how they can be overcome. A qualitative study in France

AIM

Our objective was to explore the difficulties experienced by transgender people in accessing primary health-care services and their expectations towards primary care providers to improve their health-care access.

BACKGROUND

Because transgender people are exposed to many discriminations, their health-care access is particularly poor. Guidelines recommend greater involvement of primary care providers in the processes because of the accessibility feature of primary care services.

METHODS

A qualitative study using semi-directed interviews was conducted among 27 transgender people (February 2018 - August 2018). These voluntary participants were recruited through different means: local trans or LGBTI (lesbian, gay, bisexual, trans, and/or intersex) associations, primary care providers, and social networks. The data analysis was based on reflexive thematic analysis in an inductive approach.

FINDINGS

Difficulties in accessing health-care occurred at all the levels of the primary health-care system: primary care providers - transgender people interaction, access to the primary care team facility (starting with the secretariat), access to secondary care specialists, and continuity of care. Transgender people report ill-adapted health-care services as a result of gender-based identification in health-care settings. Their main expectation was depsychiatrization and self-determination. They supported mixed health network comprising primary care providers and transgender people with a coordinating role for the general practitioner. These expectations should be priorities to consider in our primary health-care system to improve access to health-care for transgender people.

Hormone Therapy and Discrimination in the Labor Market: Emerging Experimental Evidence on the Economics of Endocrinology

BACKGROUND

Gender transitioning is increasingly common, but little is known about the extent to which individuals in transition and fully transitioned suffer from wage discrimination. Methods: Managers in the United States (n=204) were shown photos of white and Asian male and female "employees" at different stages of simulated hormone therapy and were asked to estimate their actual hourly wages based on appearance.

RESULTS

The results suggest that Asian men and women "in transition" and fully transitioned do not suffer from significant wage discrimination. However, among the white stimuli, gender atypical ("in transition" and fully transitioned) men and women are estimated to earn significantly less than their gender typical (sexually dimorphic) counterparts, with some gender-specific nuances.

CONCLUSIONS

The effects of hormone therapy may have a deleterious impact on the wages of white transgender individuals.

Endocrine treatment of transgender individuals: current guidelines and strategies

INTRODUCTION

This review summarizes gender affirming medical and surgical care available to transgender individuals, along with proposals to improve medically and culturally appropriate care.

AREAS COVERED

Transgender individuals are those whose gender identity differs from that recorded at birth (usually based on visualization of external sexual anatomy). In order to align the body with the patient's gender identity, clinicians can provide hormone therapy (HT) to bring sex hormone levels to the range associated with the patient's gender identity. At steady state, monitoring for maintenance of levels, as well as for known risks and complications, is required. Treating clinicians should have knowledge of trans assessment criteria, hormone therapy, surgical options, primary care, and mental health needs of transgender patients. A narrative literature review was conducted using Pubmed and EMBASE with articles then selected for relevance. The initial search terms were: androgen suppression, antiandrogen, breast development, chest reconstruction, cisgender, estrogen, fertility preservation, gender-affirming surgery, gender identity, gender incongruence, genital reconstruction, hormone replacement, hyperlipidemia, orchiectomy, prolactin, prostate atrophy, spermatogenesis, spironolactone, testosterone, thrombogenesis, transgender, and virilization.

EXPERT OPINION

Although guidelines exist and examples of training are available, systematic formal training must be implemented to truly mainstream high-quality gender-affirming health care .

Impact of Exogenous Testosterone on Reproduction in Transgender Men

Studies show that a subset of transgender men desire children; however, there is a paucity of literature on the effect of gender-affirming testosterone therapy on reproductive function. In this manuscript, we will review the process of gender-affirming hormone therapy for transgender men and what is known about ovarian and uterine consequences of testosterone exposure in transgender men; draw parallels with existing animal models of androgen exposure; summarize the existing literature on parenting experiences and desires in transgender people; discuss considerations for assisted reproductive technologies and fertility preservation; and identify gaps in the literature and opportunities for further research.

HYPERPROLACTINEMIA IN A TRANSGENDER MALE

OBJECTIVE

We present a case of hyperprolactinemia in a transgender male. We discuss the various etiologies for hyperprolactinemia in this population of patients and discuss management options.

METHODS

We present a case report and review of the literature. A 29-year-old transgender male treated with gender-affirming hormone therapy with testosterone presented with hyperprolactinemia.

RESULTS

Labs revealed an elevated prolactin level. The patient completed further laboratory evaluation as well as imaging with a pituitary magnetic resonance imaging which all revealed normal results. He was wearing a tightly fitted breast binder while awaiting bilateral mastectomy. After bilateral mastectomy prolactin normalized, suggesting breast binding as the cause of the elevated prolactin.

CONCLUSION

This is the only case in the literature which highlights breast binding as a possible cause of an elevated prolactin level. Our case report illustrates the various etiologies associated with an elevated prolactin level and highlights the importance of considering unique etiologies in populations such as transgender males.

Creating the Trans Youth Research Network: A Collaborative Research Endeavor

Purpose: This article outlines the process of establishing the Trans Youth Care Research Network, composed of four academic clinics providing care for transgender and gender-diverse (TGD) youth. The Network was formed to design and implement research studies to better understand physiologic and psychosocial outcomes of gender-affirming medical care among TGD youth. Methods: Formed in response to both the Institute of Medicine's report recommendation for an increase of data concerning sexual and gender minority populations and a transgender-specific NIH program announcement, The Center for Transyouth Health and Development at Children's Hospital Los Angeles, the Gender Management Service at Boston Children's Hospital, the Child and Adolescent Gender Center Clinic at Benioff Children's Hospital in San Francisco, and the Gender and Sex Development Program at Lurie Children's Hospital of Chicago established a collaborative research network that subsequently designed a longitudinal observational study of TGD youth undergoing medical interventions to address gender dysphoria. Results: Two cohorts, youth starting puberty blockers and youth starting gender-affirming hormones, are participating. Psychosocial measures that span multiple domains of mental and behavioral health are collected from youth and parents. Physiologic data are abstracted from patient's charts. Baseline and follow-up data of this large cohort will be disseminated through conferences, abstracts, posters, and articles. Conclusion: Since initiation of funding in 2015, a total of 497 participants have been enrolled in TYC across the four sites; gonadotropin releasing hormone analogs (GnRHa) cohort youth (n=93), GnRHa cohort parents (n=93), and gender affirming hormone cohort youth (n=311). As the network moves toward data dissemination, its lessons learned have helped strengthen the current study, as well as inform future endeavors in this field.

Effects of resistance training on depression and cardiovascular disease risk in Black men: Protocol for a randomized controlled trial

BACKGROUND

Depression is severely undertreated in Black men. This is primarily because Black men are less likely to seek traditional psychiatric treatment, have less access and more barriers to treatment, and perceive more stigma associated with treatment. Depression contributes to cardiovascular disease (CVD), and Black men have the highest rate of mortality from CVD. Resistance training (RT) can have beneficial effects on both depression and CVD. This study will be the first randomized controlled trial to test the effects of RT on depression and cardiovascular health in a sample of depressed Black men.

METHOD/DESIGN

Fifty Black men with clinically significant symptoms of depression will be randomized to either (a) a 12-week RT or (b) an attention-control group. Behavioral Activation techniques will be used to support adherence to home-based RT goals. Both groups will meet on-site twice/week during the 12-week program, and follow-up assessments will occur at the end-of-treatment and 3 months post-treatment. Qualitative interviews will be conducted after the 3-month follow-up. The objectives of this study are (1) to assess the feasibility and acceptability of recruitment, retention, and intervention procedures, (2) to obtain preliminary evidence of efficacy, and (3) to explore potential mediators of the effects of RT on depression.

DISCUSSION

This study will advance the field of minority men's health by producing new data on the effects of RT for depression, the potential mechanisms of action that may support its use, and its effects on markers of CVD risk in Black men.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03107039).

The Perioperative Care of the Transgender Patient

An estimated 25 million people identify as transgender worldwide, approximately 1 million of whom reside in the United States. The increasing visibility and acceptance of transgender people makes it likely that they will present in general surgical settings; therefore, perioperative health care providers must develop the knowledge and skills requisite for the safe management of transgender patients in the perioperative setting. Extant guidelines, such as those published by the World Professional Association for Transgender Health and the University of California San Francisco Center of Excellence for Transgender Health, serve as critical resources to those caring for transgender patients; however, they do not address their unique perioperative needs. It is essential that anesthesia providers develop the knowledge and skills necessary for safely managing transgender patients in the perioperative setting. This review provides an overview of relevant terminology, the imperative for the provision of culturally sensitive care, and guidelines for preoperative, intraoperative, and postoperative management of the transgender patient.

MANAGEMENT OF ENDOCRINE DISEASE: Approach to the management of children and adolescents with Gender Dysphoria

Over the past 20 years, the care for transgender adolescents has developed throughout many countries following the "Dutch Approach" initiated in the 90's in pioneer countries as the Netherlands, United States and Canada, with increasing numbers of children and adolescents seeking care in transgender clinics. This medical approach has considerable positive impacts on the psychological outcomes of these adolescents and several studies have been recently published underlining the relative safety of such treatments. This paper reviews the current standards of care for transgender children and adolescents with particular emphasis on disparities among countries and short to medium-term outcomes. Finally it highlights ethical considerations regarding categorization of gender dysphoria, timing of treatment initiation, infertility, and how to deal with the long-term consequences.

Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study

BACKGROUND

Venous thromboembolism (VTE), ischemic stroke, and myocardial infarction in transgender persons may be related to hormone use.

OBJECTIVE

To examine the incidence of these events in a cohort of transgender persons.

DESIGN

Electronic medical record-based cohort study of transgender members of integrated health care systems who had an index date (first evidence of transgender status) from 2006 through 2014. Ten male and 10 female cisgender enrollees were matched to each transgender participant by year of birth, race/ethnicity, study site, and index date enrollment.

SETTING

Kaiser Permanente in Georgia and northern and southern California.

PATIENTS

2842 transfeminine and 2118 transmasculine members with a mean follow-up of 4.0 and 3.6 years, respectively, matched to 48 686 cisgender men and 48 775 cisgender women.

MEASUREMENTS

VTE, ischemic stroke, and myocardial infarction events ascertained from diagnostic codes through the end of 2016 in transgender and reference cohorts.

RESULTS

Transfeminine participants had a higher incidence of VTE, with 2- and 8-year risk differences of 4.1 (95% CI, 1.6 to 6.7) and 16.7 (CI, 6.4 to 27.5) per 1000 persons relative to cisgender men and 3.4 (CI, 1.1 to 5.6) and 13.7 (CI, 4.1 to 22.7) relative to cisgender women. The overall analyses for ischemic stroke and myocardial infarction demonstrated similar incidence across groups. More pronounced differences for VTE and ischemic stroke were observed among transfeminine participants who initiated hormone therapy during follow-up. The evidence was insufficient to allow conclusions regarding risk among transmasculine participants.

LIMITATION

Inability to determine which transgender members received hormones elsewhere.

CONCLUSION

The patterns of increases in VTE and ischemic stroke rates among transfeminine persons are not consistent with those observed in cisgender women. These results may indicate the need for long-term vigilance in identifying vascular side effects of cross-sex estrogen.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute and Eunice Kennedy Shriver National Institute of Child Health and Human Development.

The Boston Medical Center Experience: An Achievable Model for the Delivery of Transgender Medical Care at an Academic Medical Center

Despite increasing appreciation for the medical needs of transgender individuals, the organization of transgender medical care remains suboptimal. Transgender individuals report difficulty in finding providers who have adequate expertise in caring for transgender patients, a lack of provider cultural competence, health system barriers, and discrimination in healthcare settings. At Boston Medical Center (BMC), we sought to address these gaps within an existing academic medical center. In February 2016, BMC established a Center for Transgender Medicine and Surgery (CTMS) to provide a single address for patients to obtain transgender-specific services across a spectrum of healthcare needs. With the establishment of a CTMS at BMC, we were able to leverage broad transgender medical coverage across multiple specialties within an existing academic medical framework. Furthermore, the development of the CTMS resulted in our identification of multiple gaps in transgender healthcare which we could target. Large gaps in care for our institution included genital surgery, perisurgical support, adolescent care, and care coordination. Notably, most of our interventions used existing resources. We propose that this is a replicable model that should be adopted by other academic medical institutions.

Gender Dysphoria: Bioethical Aspects of Medical Treatment

Gender affirmation surgery remains one of the greatest challenges in transgender medicine. In recent years, there have been continuous discussions on bioethical aspects in the treatment of persons with gender dysphoria. Gender reassignment is a difficult process, including not only hormonal treatment with possible surgery but also social discrimination and stigma. There is a great variety between countries in specified tasks involved in gender reassignment, and a complex combination of medical treatment and legal paperwork is required in most cases. The most frequent bioethical questions in transgender medicine pertain to the optimal treatment of adolescents, sterilization as a requirement for legal recognition, role of fertility and parenthood, and regret after gender reassignment. We review the recent literature with respect to any new information on bioethical aspects related to medical treatment of people with gender dysphoria.

Physiologic Response to Gender-Affirming Hormones Among Transgender Youth

PURPOSE

The purpose of this study was to examine the physiologic impact of hormones on youth with gender dysphoria. These data represent follow-up data in youth ages 12-23 years over a two-year time period of hormone administration.

METHODS

This prospective, longitudinal study initially enrolled 101 youth with gender dysphoria at baseline from those presenting consecutively for care between February 2011 and June 2013. Physiologic data at baseline and follow-up were abstracted from medical charts. Data were analyzed by descriptive statistics.

RESULTS

Of the initial 101 participants, 59 youth had follow-up physiologic data collected between 21 and 31 months after initiation of hormones available for analysis. Metabolic parameters changes were not clinically significant, with the exception of sex steroid levels, intended to be the target of intervention.

CONCLUSIONS

Although the impact of hormones on some historically concerning physiologic parameters, including lipids, potassium, hemoglobin, and prolactin, were statistically significant, clinical significance was not observed. Hormone levels physiologically concordant with gender of identity were achieved with feminizing and masculinizing medication regimens. Extensive and frequent laboratory examination in transgender adolescents may be unnecessary. The use of hormones in transgender youth appears to be safe over a treatment course of approximately two years.

Clinical pearls of gender-affirming hormone therapy in transgender patients

Despite the growing visibility of transgender individuals in the mainstream media, this population still encounters discrimination as well as many barriers to receiving appropriate care. Of note, not all medical providers are familiar with gender-affirming hormone treatment for transgender patients. Gender-affirming hormone treatment is used in transgender patients to reduce characteristics of their natal sex and induce those of their desired sex. Pharmacists have a potential role to make a positive impact by providing information regarding gender-affirming hormone treatment. This article aims to give an overview of the medications used in gender-affirming hormone treatment, the desired effects caused by these medications, the expected timeline to achieving these effects, and to provide information as to where these treatment guidelines can be found.

Effect of Sex Steroids on the Bone Health of Transgender Individuals: A Systematic Review and Meta-Analysis

BACKGROUND

The impact of sex steroids on bone health in transgender individuals is unclear.

METHODS

A comprehensive search of several databases to 7 April 2015 was conducted for studies evaluating bone health in transgender individuals receiving sex steroids. Pairs of reviewers selected and appraised studies. A random effects model was used to pool weighted mean differences and 95% confidence intervals (CIs).

RESULTS

Thirteen studies evaluating 639 transgender individuals were identified [392 male-to-female (MTF), 247 female-to-male (FTM)]. In FTM individuals and compared with baseline values before initiation of masculinizing hormone therapy, there was no statistically significant difference in the lumbar spine, femoral neck, or total hip bone mineral density (BMD) when assessed at 12 and 24 months. In MTF individuals and compared with baseline values before initiation of feminizing hormone therapy, there was a statistically significant increase in lumbar spine BMD at 12 months (0.04 g/cm2; 95% CI, 0.03 to 0.06 g/cm2) and 24 months (0.06 g/cm2; 95% CI, 0.04 to 0.08 g/cm2). Fracture rates were evaluated in a single cohort of 53 MTF and 53 FTM individuals, with no events at 12 months. The body of evidence is derived mostly from observational studies at moderate risk of bias.

CONCLUSION

In FTM individuals, masculinizing hormone therapy was not associated with significant changes in BMD, whereas in MTF individuals feminizing hormone therapy was associated with an increase in BMD at the lumbar spine. The impact of these BMD changes on patient-important outcomes such as fracture risk is uncertain.

Ten Most Important Things to Know About Caring for Transgender Patients

Transgender people have a gender that is not in agreement with their birth sex. Previous barriers, including lack of provider knowledge, have created significant healthcare disparities for this population. Recent societal changes are increasing the numbers of transgender people seen by primary care practitioners. Ten key principles are provided to help primary care practitioners create more welcoming environments and provide quality care to transgender patients. Overall, all members of the healthcare team (primary and specialty) need to become aware of the transition process and maintain communication regarding risks, benefits, and goals. Transwomen (aka male to female) can be treated with estrogens, antiandrogens, or a combination. Benefits include change in fat distribution, skin softening, and breast development. Significant risks for thrombosis from estrogens have been linked to genetic mutations, smoking, prolonged inactivity, and hormone formulation. Oral administration may provide increased risk over peripheral administration. Transmen (aka female to male) can be treated with peripheral testosterone preparations. Benefits include deepening of voice and development of facial and body hair with variable changes in muscle mass. Risks from testosterone appear to be less common than from estrogen. Laboratory monitoring can guide treatment decisions and provide early detection of some complications. Monitoring of "existing" anatomy (either hormonally or surgically created or removed) is an important component of healthcare for transgender patients. Primary care providers also should be aware of resources in their community and online, which can help patients optimize their transition.

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline

OBJECTIVE

To update the "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline," published by the Endocrine Society in 2009.

PARTICIPANTS

The participants include an Endocrine Society-appointed task force of nine experts, a methodologist, and a medical writer.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.

CONSENSUS PROCESS

Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines.

CONCLUSION

Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person's genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person's affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments-appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)-should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.

Transgender Individuals and Osteoporosis Prevention

BACKGROUND

Risk behaviors and hormone use place transgender individuals (TIs) in jeopardy for osteoporosis.

PURPOSE

The purpose of this study was to expand the science about the knowledge, health beliefs, and osteoporosis (OP) preventing behaviors of TIs.

METHODS

This was a mixed-methods pilot study of a convenience sample of 31 TIs 30 years and older. Participants completed an online Osteoporosis Bone Health Survey. Fifteen participants were randomly selected for an interview to describe their perceptions of bone health.

RESULTS

Transgender individuals performed poorly on the knowledge measure. There were no significant findings for osteoporosis health beliefs. Participants' daily dietary dairy calcium intake was 800 mg and daily walking activity was 17 minutes. Perceptions of bone health revealed two essential elements, knowing and doing.

CONCLUSION

Determining TIs' bone health perception is important because of their unique healthcare issues. Healthcare providers need to be aware of TIs' bone health needs to help enhance TIs' OP knowledge, health beliefs, and preventing behaviors.

Gender-Affirming Pharmacological Interventions for Youth With Gender Dysphoria: When Treatment Guidelines Are Not Enough

Youth with gender dysphoria, also known as transgender youth, are increasingly presenting to multidisciplinary clinics within academic pediatric centers across the United States. Gender-affirming pharmacological interventions for adolescents with gender dysphoria may be used to promote positive psychological well-being and mental health outcomes. Interventions range from completely reversible to partially irreversible, based on the age and sexual maturity of the adolescent. For each intervention, dilemmas and controversies exist regarding age at treatment initiation, treatment duration, safety, and cost. Pharmacists' awareness of these considerations and interventions is important when providing evidence-based gender-affirming care to this underserved population.

Oestrogen and anti-androgen therapy for transgender women

Transgender women experience lifelong gender dysphoria due to a gender assignment at birth that is incongruent with their gender identity. They often seek hormone therapy, with or without surgery, to improve their gender dysphoria and to better align their physical and psychological features with a more feminine gender role. Some of the desired physical changes from oestrogen and anti-androgen therapy include decreased body and facial hair, decreased muscle mass, breast growth, and redistribution of fat. Overall the risks of treatment are low, but include thromboembolism, the risk of which depends on the dose and route of oestrogen administration. Other associated conditions commonly seen in transgender women include increased risks of depression and osteoporosis. The risk of hormone-sensitive cancer seems to be low in transgender women, with no increased risk of breast cancer compared with women and no increase in prostate cancer when compared with men. The evidence base for the care of transgender women is limited by the paucity of high-quality research, and long-term longitudinal studies are needed to inform future guidelines.

Gender identity and the management of the transgender patient: a guide for non-specialists

In this review, we introduce the topic of transgender medicine, aimed at the non-specialist clinician working in the UK. Appropriate terminology is provided alongside practical advice on how to appropriately care for transgender people. We offer a brief theoretical discussion on transgenderism and consider how it relates to broader understandings of both gender and disease. In respect to epidemiology, while it is difficult to assess the exact size of the transgender population in the UK, population surveys suggest a prevalence of between 0.2 and 0.6% in adults, with rates of referrals to gender identity clinics in the UK increasing yearly. We outline the legal framework that protects the rights of transgender people, showing that is not legal for physicians to deny transgender people access to services based on their personal beliefs. Being transgender is often, although not always, associated with gender dysphoria, a potentially disabling condition in which the discordance between a person's natal sex (that assigned to them at birth) and gender identity results in distress, with high associated rates of self-harm, suicidality and functional impairment. We show that gender reassignment can be a safe and effective treatment for gender dysphoria with counselling, exogenous hormones and surgery being the mainstay of treatment. The role of the general practitioner in the management of transgender patients is discussed and we consider whether hormone therapy should be initiated in primary care in the absence of specialist advice, as is suggested by recent General Medical Council guidance.