The Amsterdam Cohort of Gender Dysphoria Study (1972–2015): Trends in Prevalence, Treatment, and Regrets

Gender-Related Medical Experiences of Youth Who Have Detranstioned

People whose gender does not align with their sex assigned at birth can undergo a medical transition process, so their body reflects their gender. However, some people interrupt this process temporarily or permanently, which is often referred to as "detransition." Media coverage of detrans experiences tend to attribute this phenomenon to a lack of medical gatekeeping. However, research has shown detransitions are highly unpredictable. The aim of this article is to examine the medical experiences of youth who have detransitioned during various stages of the process from transition to today. Twenty-five interviews with 15-25-year-old youth who detransitioned were conducted. Thematic analysis led to the development of six themes: facing gatekeeping and invalidation during transition, accessing trans care, lacking adequate support during transition, finding support in detransition, lacking support in detransition, leaving the medical system. Our results question the usefulness of gatekeeping to prevent detransition and shows that it tends to erode the trust relationship between youth and practitioners and stifle gender exploration. Validation, support, information giving as well as exploration without constrain, or expectation of outcome seems to be a more helpful way forward to work with gender diverse youth.

Treatment trajectories among children and adolescents referred to the Norwegian National Center for Gender Incongruence

AIM

We aimed to describe treatment trajectories, detransition and mortality rate among children and adolescents referred to the Norwegian National Center for Gender Incongruence (NCGI).

METHODS

The cohort included all 1258 persons under 18 years at referral to the NCGI from 2000 to 2020. Trajectories were registered until end of 2023.

RESULTS

In total, 861/1258 (68.4%) were assigned female gender at birth (AFAB). Mean age at referral was 14.4 years. Puberty suppression with gonadotropin-releasing hormone agonists (GnRHa) was initiated among 135/1258 (10.7%), significantly more persons assigned male gender at birth (AMAB) than AFAB (p < 0.001). Gender-affirming hormonal treatment (GAHT) was initiated in 783/1258 (62.2%). The continuation rate from GnRHa to GAHT was 97%. Discharge rate from NCGI without gender-affirming medical treatment among those who attended at least one appointment, was 264/1198 (22.0%). Eighteen AFAB detransitioned after initiated GAHT, eleven due to a cessation of transgender identity. Mortality rate in the cohort until end of 2023 was 11/1258 (0.9%).

CONCLUSION

Different trajectories including medical pathways and assessments without gender-affirming treatment were observed. GAHT was initiated in 783/1258 (62.2%), including eighteen AFAB detransitioning after testosterone treatment. There was a high continuation rate from GnRHa to GAHT. Various trajectories highlights the need for long-term follow-up in care.

Narratives of Adults Registered Female at Birth Who Started a Medical Transition and Later Detransitioned

The visibility and presence of people who have detransitioned following a gender transition is growing, with an increase in research on the needs and experiences of this group. This study presents a thematic narrative analysis of interviews from six females (M = 25.5 yrs; range = 21-32 yrs). All detransitioned after having at least one gender-affirming medical or surgical treatment as part of a gender transition in the UK. Four narrative themes were developed to capture how they made sense of their detransition: (1) the limits of medical transition, (2) the longer-term health implications, (3) the social limits of transition, and (4) detransition as an ongoing process. Participants discussed a range of emotional, practical, and other support needs, largely unmet by healthcare or other services. These findings highlight the importance of ensuring that people have realistic expectations of transition as part of a holistic assessment process. Long-term health outcome research is also needed, addressing the impact of testosterone on female anatomy and health specifically. Further clinical implications with those considering transition or detransition are discussed.

Reconsidering "inclusive language:" Consequences for healthcare and equitableness of a growing linguistic movement to address gender identity with a path forward

Increasingly, the language of female reproduction is changing, so terms directly referencing people's sex are replaced with terms obscuring sex, a language form commonly called "inclusive language" but more accurately is "desexed language." Desexed language is promoted as assisting individuals experiencing an inner sense of themselves (a gender identity) in conflict with their sex, a state described as being transgender or gender-diverse. It seemingly assumes no harm to the general population. However, the scant existing research suggests it may not be well accepted or understood. There are a variety of types of desexed language, including globalizing language (e.g. replacing "women" with "people"), biology-based language (e.g. "lactating individuals," "menstruators"), neologisms ("chestfeeding"), appropriation of terms with other meanings ("sex assigned at birth"), and additive language (e.g. "women and birthing people"). Second- and third-person language (e.g. "if you are sexually active," "those who are pregnant") can be a type of desexed language depending on context. Desexed language is likely to have an adverse impact on people with low health literacy and language skills, risk alienation, and cause confusion, especially in non-Western countries and cultures. It may even cause harm to transgender and gender-diverse people who also need clear health communications as well as specialized healthcare. Widespread use of desexed language is contrary to the usual practice of implementing targeted tailored communications for those with specialized needs while using the most effective language for most people for general communications. Comprehensive research on the impact of desexed language is urgently needed.

Gender-affirming hormone therapy and impacts on quality of life: a narrative review

Background

Transgender and gender-nonconforming (TGNC) people often face significant disparities in health education and access to quality medical management. This narrative literature review examines the relationship between TGNC patients seeking hormone replacement therapy and resulting improved health outcomes.

Methods

Our search identified papers through the databases PubMed, PsycINFO, CINAHL, Embase, and Web of Science including search terms relating to gender-affirming hormone therapy (GAHT), transgender identities, and patient healthcare experiences and outcomes. Further inclusion criteria required papers published after 1979 with a majority of participants located in the United States. Data extraction and quality assessment of the selected papers were completed using the JBI Manual for Evidence Synthesis, a quality assessment tool created based on the Mixed Methods Appraisal Tool, and Covidence software. Common themes were narratively reviewed.

Results

The search yielded 19,482 results across five databases and 51 papers were included in data extraction and quality assessment. Most papers were published between 2020-2024 and enrolled young adults in cross-sectional studies. Recurrent themes observed from data synthesis include improved mental health and quality of life outcomes associated with GAHT use. Distance to clinics, cost of care, insurance coverage, and governmental policies were commonly identified barriers to obtaining gender-affirming care.

Conclusions

The identified gaps in information reflect the importance of additional research in TGNC health-related disparities including diverse participant populations and rigorous longitudinal methods. With these changes, we expect improved quality of care, patient satisfaction, and health outcomes for these individuals.

HIGHLIGHTS

Gender-affirming hormone therapy is associated with reduced levels of depression, anxiety, and suicidal ideation in transgender and gender-nonconforming individualsSignificant barriers to obtaining GAHT include high costs, lack of insurance coverage, limited access to knowledgeable healthcare providers, geographical distance to clinics, and discriminatory policiesThe number of studies on gender-affirming hormone therapy has increased significantly in recent years, reflecting growing recognition of the importance of transgender healthcareMost existing studies on GAHT and its effects are cross-sectional, limiting the ability to assess long-term outcomesEstablishing standardized assessments for mental health outcomes, quality of life, and long-term effects of gender-affirming hormone therapy would enhance the reliability and comparability of future research.

Topical Tranexamic Acid and Chest Masculinization Surgeries-Impact on Postoperative Hematoma Incidence

Introduction

Postoperative hematoma requiring intervention occurs more frequently in chest masculinization surgeries than in other types of breast surgeries, with incidences ranging from 0.7% to 13.2% per patient. Although there is increasing evidence that topically applied tranexamic acid (TXA) effectively reduces postoperative bleeding in breast surgeries, its impact on masculinization surgeries is understudied.

Aims

Examining the significance of topical TXA in reducing postoperative hematoma in chest masculinization surgeries.

Methods

This retrospective cohort comprises female-to-male transgender and non-binary patients who underwent chest masculinization at Helsinki or Tampere University hospitals between 2018 and 2024. Topical TXA (20 mg/ml, 25 ml per breast) was incorporated into routine use in October 2022, replacing the previous practices; Helsinki mainly operated without TXA, whereas Tampere routinely used intravenous (i.v.) TXA.

Results

A total of 198 patients undergoing chest masculinization surgery were included. Among them, 9 (4.5%) major hematomas occurred. The need for reoperation due to postoperative hematoma was lower in the topical TXA (3.2%, 2 out of 63 patients) and i.v. TXA (3.4%, 2 out of 58 patients) groups compared to the non-TXA group (6.5%, 5 out of 77 patients). Subpectoral incisions (71.2%, 141 patients) resulted in a 5.0% hematoma rate, whereas periareolar incisions (28.8%, 57 cases) had a 3.5% hematoma rate.

Conclusions

Our study suggests that topical and i.v. TXA effectively reduce postoperative bleeding in chest masculinization surgeries, with similar outcomes between the 2 methods. Albeit our results lack statistical significance and they support the potential benefit of prophylactic TXA use in hematoma reduction.

Gender dysphoria in adolescence: examining the rapid-onset hypothesis

The sharp rise in the number of predominantly natal female adolescents experiencing gender dysphoria and seeking treatment in specialized clinics has sparked a contentious and polarized debate among both the scientific community and the public sphere. Few explanations have been offered for these recent developments. One proposal that has generated considerable attention is the notion of "rapid-onset" gender dysphoria, which is assumed to apply to a subset of adolescents and young adults. First introduced by Lisa Littman in a 2018 study of parental reports, it describes a subset of youth, primarily natal females, with no childhood indicators of gender dysphoria but with a sudden emergence of gender dysphoria symptoms during puberty or after its completion. For them, identifying as transgender is assumed to serve as a maladaptive coping mechanism for underlying mental health issues and is linked to social influences from peer groups and through social media. The purpose of this article is to analyze this theory and its associated hypotheses against the existing evidence base and to discuss its potential implications for future research and the advancement of treatment paradigms.

Mental health outcomes and loneliness in older transgender individuals receiving long-term gender-affirming hormone therapy compared with older cisgender individuals

OBJECTIVES

Many older adults experience mental health challenges and loneliness which negatively affect other health aspects. This data is largely lacking in older transgender adults. This study aimed to determine differences in depressive symptoms, anxiety and loneliness between older transgender individuals receiving gender-affirming hormone therapy (GHT), and cisgender (non-transgender) individuals, and to assess the contribution of financial, psychological, somatic, and social-contact related factors.

DESIGN

Cross-sectional.

SETTING

Gender identity clinic; general population.

PARTICIPANTS

Seventy-two transgender women and 39 transgender men (56-84 y) receiving GHT for ≥ 10 y, age-matched 1:3 with cisgender women and men from the general population.

MEASUREMENTS

Depressive symptoms, anxiety and loneliness were assessed with questionnaires. Differences were compared using linear regression analyses with log-transformed variables, and back-transformed for presentation. Additionally, models were adjusted for financial, psychological, somatic and social-contact related factors.

RESULTS

Transgender women scored higher than cisgender women and cisgender men, respectively, on depressive symptoms (1.92, 95 % confidence interval (CI) 1.52-2.42; 2.66, CI 2.11-3.37), anxiety (1.43, CI 1.17-1.75; 1.89, CI 1.54-2.32) and loneliness (2.42, CI 1.96-2.97; 2.32, CI 1.92-2.82). Transgender men scored higher than cisgender men on depressive symptoms (2.10, CI 1.50-2.94), anxiety (1.67, CI 1.27-2.19) and loneliness (1.50, CI 1.16-1.93), and higher than cisgender women on loneliness (1.57, CI 1.20-2.05). These differences were largely explained by differences in financial, psychological, somatic and social-contact related factors.

CONCLUSIONS

Mental health outcomes and loneliness are compromised in older transgender individuals compared to cisgender individuals, particularly in transgender women. The socio-economic, psychological and somatic risk factors identified warrant further research and awareness.

Towards Best-Practice Healthcare for Transgender Patients: Quality Improvement in United Kingdom General Practice

Introduction: The ongoing care of transgender patients in United Kingdom (UK) general practice (GP) is hampered by a lack of UK primary care guidelines regarding the monitoring of treatments, despite the key role that general practice has in holistic lifelong care. This quality improvement project aimed to audit the monitoring of treatments and health screening in a GP practice population, across two large practices in southwest England, in order to drive local improvement and to identify gaps in wider healthcare support for this population. Methods: This project updated a previously published audit instrument, incorporating a novel, pragmatic standard, based on up-to-date UK gender clinic guidelines and the UK population screening programmes. National Health Service (NHS) Health Research Authority and Medical Research Council processes were used to confirm that this quality improvement project did not require formal ethics committee approval. An audit against this standard was performed for 176 transgender and gender-minority patients, to provide data on the consistency of the monitoring of gender hormonal treatments and reminders for appropriate population health screening programmes. Results: A total of 16% of those undergoing hormonal treatments had received optimal monitoring; 20% were missing the most basic hormone level monitoring. Reminders regarding appropriate health screening were rare in patients who had changed the gender markers on their electronic record. Long waiting lists, the use of private clinics, confusion around responsibilities shared between primary and secondary care and growing complex co-morbidity were demonstrated. Conclusions: This project supports previous calls for consistent evidence-based guidelines, improved data systems and adequately resourced primary and secondary care services to support the safe and effective lifelong care of transgender patients.

Hormone therapy and cancer risks in transgender people: a systematic review

OBJECTIVE

To identify the available evidence on the risk of developing cancer in transgender people undergoing hormone therapy.

METHODS

This was a rapid systematic review conducted in the PubMed, Embase, Virtual Health Library, Cochrane Library and Epistemonikos databases. Screening and data extraction were performed by independent reviewers using the Rayyan platform. Data extraction was carried out by 3 independent reviewers. We used the Joanna Briggs Institute checklists specific to cohort and case-control studies to assess the methodological quality of the included studies.

RESULTS

Five studies were included, 4 cohort studies and 1 case-control. The risk of transgender people developing cancer while on hormone therapy was identified by 2 studies and not identified in 3 studies.

CONCLUSION

Despite studies with large sample sizes and rigorous selection criteria, the literature does not present a consensus on the association between hormone therapy and the development of cancer in transgender people.

Prevalence of detransition in persons seeking gender-affirming hormonal treatments: a systematic review

BACKGROUND

Despite recent evidence of the benefits of gender-affirming medical procedures, data in the literature indicate emerging demands of detransition and regrets while suggesting potential sources of bias in different datasets, including a nonconsensual definition of detransition.

AIM

The present systematic review aims to summarize the existing research regarding the prevalence of detransition in transgender persons who requested or started receiving gonadotrophin-releasing hormone analogs (GnRHa) and/or gender-affirming hormonal therapy (GAHT).

METHODS

A systematic literature search (CINAHL Plus, Cochrane Library, Google Scholar, MEDLINE, Web of Science, Sage Journals, Science Direct, Scopus) for quantitative studies was conducted up to May 2024. All eligible studies were assessed using the Strengthening the Reporting of Observational Studies in Epidemiology statement. The risk of bias was assessed using the National Institute of Health quality assessment tool. The present analysis follows the PRISMA statement for systematic review articles and the synthesis without meta-analysis recommendations.

OUTCOMES

The primary outcome was the point-prevalence proportion of detransition events as a percentage in the population of transgender persons who were considered eligible for treatment or had initiated GnRHa and/or GAHT.

RESULTS

Fifteen observational studies involving 3804 children and adolescents and 3270 adult participants were included in the 3212 screened studies. Five studies reported a change in request before starting GnRHa, five studies reported GnRHa discontinuation, and nine studies reported GAHT discontinuation. The point-prevalence proportions of shifts in requests before any treatment ranged from 0.8-7.4%. The point-prevalence proportions of GnRHa discontinuation ranged from 1-7.6%. The point-prevalence proportions of GAHT discontinuation ranged from 1.6-9.8%. All of the included studies were heterogeneous regarding definitions of detransition used and the study design: their numbers were too small to be statistically relevant, their time frame was insufficient, they did not use patient-level data, or they did not consider confounding factors.

CLINICAL IMPLICATIONS

Quality measurement tools are needed, as are monitoring standards, and both are important for health outcomes and guarantee the attention of health care providers and policy-makers.

STRENGTHS AND LIMITATIONS

The unique features of this analysis are its restrictive inclusion criteria compared with those of previous reviews, such as a strict definition of detransition and a focus on empirical studies only. However, most of the studies were retrospective and unblinded, and most were not sufficiently powered to detect detransition rates.

CONCLUSION

Taken together, the results of the present analysis show that detransition in persons undergoing gender-affirming treatment has been insufficiently investigated, highlighting the need for long-term follow-up studies.

Variant genital gender-affirming surgery: a systematic review

OBJECTIVE

To review the available literature on variant genital gender-affirming surgery (GGAS), including the reasons for performing it, the surgeries themselves and their outcomes.

METHODS

A systematic review on the performance of variant GGAS was conducted (International Prospective Register of Systematic Reviews [PROSPERO] identifier: CRD42022306684) researching PubMed, Embase, Web of Science and Cochrane databases from inception up to 31 December 2023. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and risk of bias was assessed for each study using the five-criteria quality assessment checklist.

RESULTS

In total 23 case series were included, of which 17 on masculinising and six on feminising surgeries. Patients mainly choose these surgical procedures out of personal desire to avoid risk of complication or because they do not have dysphoria about certain parts of their genitalia. Complications in masculinising surgeries primarily arose from the extended urethra, which could be mitigated through primary perineal urethrostomy. Both phalloplasty and metoidioplasty carried a higher risk of urethral complications when the vagina was preserved. In feminising surgeries, risk of visceral damage and requirement for lifelong self-dilation could be avoided when vulvoplasty was performed without vaginal canal creation. All studies had a high risk of bias.

CONCLUSION

This review highlights the importance of variant GGAS and acknowledges the preferences of transgender and gender-diverse individuals. Patients should be informed about the risks and benefits of each step in these procedures.

Evaluating the benefits and risks of puberty blockers and gender-affirming hormones for transgender adolescents

The use of puberty blockers and gender-affirming hormones by transgender adolescents is the subject of an ongoing public debate. In this paper, we address one central ethical aspect of the debate - the question of what sort of benefits these treatments provide and how to evaluate the significance of these benefits in relation to risks. We argue that the intended benefit of these treatments is best understood as appearance congruence, namely, to create or maintain alignment of physical appearance with one's gender identity. The common focus on the mental health benefits associated with these treatments may obscure a range of experiential benefits sought by young people, such as positive gender experiences and being treated by others as one's identified gender. We also address concern about the risk that young people may revert to their assigned gender (de-transition) and experience regret. We distinguish between de-transition and regret, highlighting that regret appears to occur in a minority of instances of de-transition or discontinuation of hormone treatment.

The Importance of Fertility Preservation in the Transgender Population

OBJECTIVE

To call to attention the often-overlooked aspect of pediatric transgender care: the importance of fertility preservation prior to instituting gender-affirming therapy. The transgender population has long been marginalized by society. Societal stigmata, fear to seek care, and dearth of provider knowledge regarding transgender health issues have caused disparities to widen. Gender-affirming procedures and hormone therapy affect the long-term reproductive potential of transgender individuals. While cost concerns and insurance coverage regarding oncofertility is a prominent area of discussion, the transgender community is often excluded.

METHODS

Sixteen genetically XY females, followed by their multidisciplinary transgender care teams, were interested in starting hormone therapy due to impending onset and/or progression of puberty. Their physicians were aware of fertility struggles after undergoing hormone therapy and therefore referred to urology. Sperm cryopreservation via open gonadal biopsy, testicular tissue cryopreservation (TTC), and semen sample (when age/maturity-appropriate) were discussed. Though requiring surgery, biopsy/TTC relieves patients of the psychological impact of semen sample production.

RESULTS

Under IRB approval, 15 patients (median age 12 years, range 10-16 years) underwent TTC (Fig. 1). One patient (aged years) opted for semen sample. All patients had success with spermatogonial stem cells cryopreserved for future patient use.

CONCLUSION

With more individuals beginning medical and surgical therapy at a younger age, fertility preservation discussions are essential but often overlooked, depriving these individuals the joy of becoming a biological parent. TTC can be safely done in pediatric populations, though research is necessary to expand beyond current experimental stage of tissue development.

Gender-affirming medical treatment for adolescents: a critical reflection on "effective" treatment outcomes

BACKGROUND

The scrutiny surrounding gender-affirming medical treatment (GAMT) for youth has increased, particularly concerning the limited evidence on long-term treatment outcomes. The Standards of Care 8 by the World Professional Association for Transgender Health addresses this by outlining research evidence suggesting "effective" outcomes of GAMT for adolescents. However, claims concerning what are considered "effective" outcomes of GAMT for adolescents remain implicit, requiring further reflection.

METHODS

Using trans negativity as a theoretical lens, we conducted a theory-informed reflexive thematic analysis of the literature cited in the "Research Evidence" section of the SOC8 Adolescents chapter. We selected 16 articles that used quantitative measures to assess GAMT outcomes for youth, examining how "effective" outcomes were framed and interpreted to uncover implicit and explicit normative assumptions within the evidence base.

RESULTS

A total of 44 different measures were used to assess GAMT outcomes for youth, covering physical, psychological, and psychosocial constructs. We identified four main themes regarding the normative assumptions of "effective" treatment outcomes: (1) doing bad: experiencing distress before GAMT, (2) moving toward a static gender identity and binary presentation, (3) doing better: overall improvement after GAMT, and (4) the absence of regret. These themes reveal implicit norms about what GAMT for youth should achieve, with improvement being the benchmark for "effectiveness."

DISCUSSION

We critically reflect on these themes through the lens of trans negativity to challenge what constitutes "effective" GAMT outcomes for youth. We explore how improvement justifies GAMT for youth and address the limitations of this notion.

CONCLUSIONS

We emphasize the need for an explicit discussion on the objectives of GAMT for adolescents. The linear narrative of improvement in GAMT for adolescents is limited and fails to capture the complexity of GAMT experiences. With currently no consensus on how the "effectiveness" of GAMT for adolescents is assessed, this article calls for participatory action research that centers the voices of young TGD individuals.

Grappling with the complexities of gender transition interruptions: Toward conceptual clarity on "detransitioning" experiences

Introduction

The existing literature on gender transition interruptions for transgender/nonbinary (TNB) people (what is frequently termed "detransitioning") lacks conceptual clarity and precision, resulting in conflictual findings, misinterpretations, and the weaponization of the literature to support harmful policies aimed at limiting TNB individuals' access to gender-affirming care.

Aims

We conducted a review of the existing literature on gender transition interruptions and propose a conceptual framework to address the current weaknesses in the extant scholarship, provide better conceptual clarity, and offer suggestions for improving future research.

Methods

The paper uses a conceptual review and critique of the extant research including scholarship on transition-related desistence, regret, and gender transition interruptions (i.e. "detransitions").

Main outcome measures

The lay understanding and, at times, the scholarly understanding of gender transition interruptions from the existing literature is most frequently collapsed under the idea of "detransitioning." This is true even though few studies actually examine the experiences of individuals who transition from TNB to the gender associated with the sex they were assigned at birth. There is significant conflation of findings about different types of transition interruption experiences with transition interruption experiences that encapsulate a true identity shift from transgender to cisgender. This conceptual slippage and misinterpretation is used politically to weaponize the existing scholarship.

Results

The paper proposes a conceptual framework of gender transition interruptions that outlines the conceptual nuances including identification of desistance, (6) subcategories of transition-related regret, (2) subcategories of adaptive gender transition interruptions, gender recalibration, embodiment goal attainment, other transition interruption, and gender identity recission.

Conclusion

The proposed conceptual framework details the nuances in the various types of gender transition interruptions suggested, and utilizes the extant scholarship to justify the proposed framework.

Effect of the i2TransHealth e-health intervention on psychological distress among transgender and gender diverse adults from remote areas in Germany: a randomised controlled trial

BACKGROUND

Transgender and gender diverse (TGD) people in remote areas face challenges accessing health-care services, including mental health care and gender-affirming medical treatment, which can be associated with psychological distress. In this study, we aimed to evaluate the effectiveness of a 4-month TGD-informed e-health intervention to improve psychological distress among TGD people from remote areas in northern Germany.

METHODS

In a randomised controlled trial done at a single centre in Germany, adults (aged ≥18 years) who met criteria for gender incongruence or gender dysphoria and who lived at least 50 km outside of Hamburg in one of the northern German federal states were recruited and randomly assigned (1:1) to i2TransHealth intervention or a wait list control group. Randomisation was performed with the use of a computer-based code. Due to the nature of the intervention, study participants and clinical staff were aware of treatment allocation, but researchers responsible for data analysis were masked to allocation groups. Study participants in the intervention group (service users) started the i2TransHealth intervention immediately after completing the baseline survey after enrolment. Participants assigned to the control group waited 4 months before they were able to access i2TransHealth services or regular care. The primary outcome was difference in the Brief Symptom Inventory (BSI)-18 summary score between baseline and 4 months, assessed using a linear model analysis. The primary outcome was assessed in the intention-to-treat (ITT) population, which included all randomly assigned participants. The trial was registered with ClinicalTrials.gov, NCT04290286.

FINDINGS

Between May 12, 2020, and May 2, 2022, 177 TGD people were assessed for eligibility, of whom 174 were included in the ITT population (n=90 in the intervention group, n=84 in the control group). Six participants did not provide data for the primary outcome at 4 months, and thus 168 people were included in the analysis population (88 participants in the intervention group and 80 participants in the control group). At 4 months, in the intervention group, the adjusted mean change in BSI-18 from baseline was -0·65 (95% CI -2·25 to 0·96; p=0·43) compared with 2·34 (0·65 to 4·02; p=0·0069) in the control group. Linear model analysis identified a significant difference at 4 months between the groups with regard to change in BSI-18 summary scores from baseline (between-group difference -2·98 [95% CI -5·31 to -0·65]; p=0·012). Adverse events were rare: there were two suicide attempts and one participant was admitted to hospital in the intervention group, and in the control group, there was one case of self-harm and one case of self-harm followed by hospital admission.

INTERPRETATION

The intervention was clinically significant in averting worsening psychological distress in service users, outperforming the wait list control group. These findings support the effectiveness of e-health services in TGD health care, specifically for people from remote areas.

FUNDING

Innovation Committee at the Federal Joint Committee.

TRANSLATION

For the German translation of the abstract see Supplementary Materials section.

Transgender and gender diverse individuals embodying endometriosis: a systematic review

Background

Transgender and gender diverse (TGD) people embody social and health inequalities that disproportionately affect this community more than the cisgender population. Endometriosis is a chronic condition of the reproductive tract that affects 5-10% of cisgender women. A recent systematic review with meta-analysis uncovered a pooled prevalence of 25.14% among TGD individuals undergoing gender-affirming surgeries.

Objective

This study aims to investigate the causes of the gap in prevalence of endometriosis between the TGD community and the cisgender population.

Methods

A systematic review with a fit-for-framework analysis was conducted. Results were analysed according to the adjusted developmental framework for embodiment with an intersectional approach. Sources were categorised in multi-levels relating to the framework mechanisms of expression, shaping, interaction, and incorporation.

Results

Four hundred twenty-three (423) studies published between 2001 and 2024 in English and Spanish were identified on the PubMed, Web of Science, Sociological abstracts, and PsycInfo databases. Thirty-two (32) peer-reviewed sources were selected.

Discussion

The higher prevalence of endometriosis among TGD people compared to the cisgender population reflects a complex phenomenon whereby individual biomedical characteristics, and psychological and environmental factors interplay on multiple levels throughout one's lifespan. The prevalence gap is striking in a context where TGD people experience great barriers and delays to access healthcare, and endometriosis is typically understood as a "women's disease." TGD people express lifestyle and environmental factors correlated with endometriosis more often than cisgender women, such as history of trauma, low self-image, obesity. Endometriosis interacts with one's quality of life, and especially with gendered expectations related to menstruations, family planning and sexuality. This interference can result in biographical disruption and gender self-perception changes in both cisgender and TGD people. Exogenous testosterone use as gender-affirming therapy results in amenorrhea in 80% of cases. However, endometrium and follicular activities are still reported upon testosterone use suggesting endometriosis may be active. It is hypothesised that testosterone use could lead to a hyper-estrogenic state that would stimulate endometriosis proliferation.

Endocrine management of transgender adolescents: Expert consensus of the french society of pediatric endocrinology and diabetology working group

INTRODUCTION

Requests for hormonal transition in minors are increasing. To date, there is no national recommendation to guide these practices in France. Therefore, the SFEDP (French Society of Pediatric Endocrinology and Diabetology) has commissioned a group of experts to draft the first national consensus on this topic.

METHOD

Each chapter was prepared by one to three authors who conducted a literature review, and it was then reviewed and revised by the group as many times as necessary to achieve a consensus position. The final document was reviewed by a group of external experts.

RESULTS

A consensus position was reached regarding the multi-professional nature of support for trans youth, the prescription of molecules aimed at inhibiting endogenous hormone secretion, and the use of gender-affirming hormone therapies, as well as the importance of offering gamete preservation. Non-hormonal aspects of support and various considerations, including ethical ones, were also discussed.

CONCLUSION

This work constitutes an initial set of recommendations for professionals involved in the hormonal transition of trans youth. Additional recommendations under the auspices of the French High Authority for Health would be worthy of being drafted, involving all relevant stakeholders to establish comprehensive official national guidelines that would secure the support and rights of these young individuals, especially those under 16 years old, as well as the professionals involved in their care.

Where are the trans masculinities in the SUS? Sociodemographic and access profile of trans men and transmasculine individuals linked to the Transgender Outpatient Clinic in Porto Alegre, Rio Grande do Sul state, Brazil, 2019-2021

OBJECTIVE

To analyze the sociodemographic and access profile of trans men and transmasculine individuals linked to the Transgender Outpatient Clinic in Porto Alegre, capital city of the state of Rio Grande do Sul.

METHODS

This was a descriptive cross-sectional study based on data from users registered with the service between 2019 and 2021.

RESULTS

Of the 418 people included, 384 (91.2%) identified as trans men and 34 (8.8%) as transmasculine individuals. The majority were of White race/skin color (77.9%) and 16.4% had a right to name and gender rectification. Scheduled appointments were the predominant mode of access (84.0%). Among the trans men, 188 (49.0%) had utilized primary healthcare services prior to receiving care at the outpatient clinic.

CONCLUSION

The users were predominantly young, White, with higher levels of education, and were minimally engaged in the formal labor market. The existence of a service staffed with qualified and sensitized professionals can enhance the access of this population to the Brazilian National Health System (Sistema Único de Saúde - SUS).

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.

Retrospective Examination of Peripubertal Return for Patients of Western Australia's Gender Diversity Service

Purpose: Children far in advance of pubertal development may be deferred from further assessment for gender-affirming medical treatment until nearer puberty. It is vital that returning peripubertal patients are seen promptly to ensure time-sensitive assessment and provision of puberty suppression treatment where appropriate. This study investigates (1) how many referrals to the Child and Adolescent Health Service Gender Diversity Service at Perth Children's Hospital are deferred due to prepubertal status; and (2) how many deferred patients return peripubertally. Methods: A retrospective review of all closed referrals to the service was conducted to determine the frequency of prepubertal deferral and peripubertal re-referral. Results: Of 995 referrals received (2014 to 2020), 552 were closed. The reason for closure was determined for 548 referrals (99.3%). Prepubertal status was the second-most frequent reason for closure, and the most frequent for birth-registered males. Twenty-five percent of all deferred prepubertal patients returned peripubertally, before audit closure. A greater return frequency (55.6%) was estimated for those older than 13 years at audit closure. Conclusion: High rates of prepubertal referral indicate the importance of pediatric gender services in providing information, advice, and reassurance to concerned families. With increasing service demand, high rates of return peripubertally have implications for service planning to ensure that returning peripubertal patients are seen promptly for time-sensitive care. Frequency of peripubertal re-referral cannot, however, speak to the stability of trans identity or gender incongruence from childhood to adolescence. Clinics advising prepubertal deferral must proactively plan to ensure that sufficient clinical resources are reserved for this purpose.

Sociodemographic profile, health-related behaviours and experiences of healthcare access in Italian transgender and gender diverse adult population

PURPOSE

Information on the general health of transgender and gender diverse (TGD) individuals continues to be lacking. To bridge this gap, the National Institute of Health in Italy together with the National Office against Racial Discriminations, clinical centres, and TGD organizations carried out a cross-sectional study to define the sociodemographic profile, health-related behaviours, and experiences of healthcare access in Italian TGD adult population.

METHODS

A national survey was conducted by Computer-Assisted Web Interviewing (CAWI) technique. Collected data were compared within the TGD subgroups and between TGD people and the Italian general population (IGP).

RESULTS

TGD respondents were 959: 65% assigned female at birth (AFAB) and 35% assigned male at birth (AMAB). 91.8% and 8.2% were binary and non-binary TGD respondents, respectively. More than 20% of the TGD population reported to be unemployed with the highest rate detectable in AMAB and non-binary people. Cigarette smoking and binge drinking were higher in the TGD population compared with IGP (p < 0.05), affecting TGD subgroups differently. A significant lower percentage of AFAB TGD people reported having had screening for cervical and breast cancer in comparison with AFAB IGP (p < 0.0001, in both cases). Over 40% was the percentage of AFAB and non-binary TGD people accessing healthcare who felt discriminated against because of their gender identity.

CONCLUSIONS

Our results are a first step towards a better understanding of the health needs of TGD people in Italy in order to plan the best policy choices for a more inclusive public health.

Care pathways of children and adolescents referred to specialist gender services: a systematic review

BACKGROUND

Increasing numbers of children and adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services. However, little is currently known about the proportions accessing different types of care and treatment following referral.

AIM

This systematic review examines the range of care pathways of children/adolescents (under 18) referred to specialist gender or endocrinology services.

METHODS

Database searches were performed (April 2022), with results assessed independently by two reviewers. Peer-reviewed articles providing data for numbers of children and/or adolescents at referral/assessment and their treatment pathways were included. A narrative approach to synthesis was used and where appropriate proportions were combined in a random-effects meta-analysis.

RESULTS

23 studies across nine countries were included, representing 6133 children and/or adolescents with a median age at assessment of 14-16 and overall a higher percentage of birth-registered females. Of those assessed, 36% (95% CI 27% to 45%) received puberty suppression, 51% (95% CI 40% to 62%) received masculinising or feminising hormones, 68% (95% CI 57% to 77%) received puberty suppression and/or hormones and 16% (95% CI 10% to 24%) received surgery. No study systematically reported information about the full pathway or psychological care received by children/adolescents. Follow-up in many studies was insufficient or unclear. Reasons for discontinuation were rarely provided.

CONCLUSIONS

Prospective studies with long-term follow-up reporting information about the full range of pathways are needed to understand what happens to children and adolescents referred to specialist gender services. Information about provision of psychological care is needed considering high rates of psychosocial difficulties in this population. PROSPERO registration number CRD42021289659.

Characteristics of children and adolescents referred to specialist gender services: a systematic review

BACKGROUND

Increasing numbers of children/adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services. Services and practice guidelines are responding to these changes.

AIM

This systematic review examines the numbers and characteristics of children/adolescents (under 18) referred to specialist gender or endocrinology services.

METHODS

Database searches were performed (April 2022), with results assessed independently by two reviewers. Peer-reviewed articles providing at least birth-registered sex or age at referral were included. Demographic, gender-related, mental health, neurodevelopmental conditions and adverse childhood experience data were extracted. A narrative approach to synthesis was used and where appropriate proportions were combined in a meta-analysis.

RESULTS

143 studies from 131 articles across 17 countries were included. There was a twofold to threefold increase in the number of referrals and a steady increase in birth-registered females being referred. There is inconsistent collection and reporting of key data across many of the studies. Approximately 60% of children/adolescents referred to services had made steps to present themselves in their preferred gender. Just under 50% of studies reported data on depression and/or anxiety and under 20% reported data on other mental health issues and neurodevelopmental conditions. Changes in the characteristics of referrals over time were generally not reported.

CONCLUSIONS

Services need to capture, assess and respond to the potentially co-occurring complexities of children/adolescents being referred to specialist gender and endocrine services. Agreement on the core characteristics for collection at referral/assessment would help to ensure services are capturing data as well as developing pathways to meet the needs of these children. PROSPERO registration number CRD42021289659.

Does every transgender person want gender affirming surgery? A survey of transgender individuals in the Midwestern United States

Gender-affirming surgery (GAS) is a highly personalized decision for transgender and gender diverse (TGD) individuals. However, the proportion of TGD individuals who desire GAS is unknown. A questionnaire was created after identifying themes surrounding experiences with gender-affirming medical care by community focus groups. Respondents who reported medically transitioning and who had undergone GAS were compared to those without prior GAS. From 88 completed surveys, 18 (20.5%) individuals did not wish to undergo GAS. Of those medically transitioning and desiring GAS, 15.2% (9/59) desired GAS but had not received it yet, with 6.7% (6/9) identifying as non-binary. Individuals who had not had GAS were more likely to earn under $15,000 annually, compared to $25,000-49,000 in the GAS group (p = 0.01). There was no significant difference in educational level (p = 0.32) or insurance status (p = 0.33). Of TGD individuals who desire GAS, out-of-pocket expenses such as hair removal, opaque insurance policies, lack of social support, and access to gender-affirming providers can hinder the transition process. Understanding barriers and rationales for pursuing GAS can provide targets for improving healthcare delivery to this diverse population.

Clinical pharmacology in adolescent transgender medicine

Adolescent transgender medicine is a growing clinical field. Gender-affirming medications for transgender youth may include gonadotropin-releasing hormone (GnRH) agonists, gender-affirming hormones or both. To evaluate the potential effects of GnRH agonists (puberty suppression) on pharmacokinetic processes for transgender youth, we searched PubMed from inception to May 2024 for publications on the effects of GnRH agonists on drug absorption, distribution, metabolism or excretion for transgender adolescents or effects on hormones (including gonadotropins, adrenal androgens, sex steroids) that are associated with changes in drug metabolism during puberty in the general adolescent population. No publications discussed the effects of GnRH agonist treatment on pharmacokinetic processes for adolescent transgender people. Sixteen publications observed marked decreases in gonadotropins and sex steroids for both adolescent transgender men and adolescent transgender women and slight effects on adrenal androgens. During GnRH agonist treatment, changes in body composition and body shape were greater for adolescent transgender people than for cisgender adolescent people. Further research is needed to better understand the effects of GnRH agonists on drug metabolism and other pharmacokinetic processes for transgender adolescents receiving GnRH agonists and other gender-affirming medications.

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.

The natural course of bone mineral density in transgender youth before medical treatment; a cross sectional study

OBJECTIVE

Bone mineral density (BMD) Z-scores decrease during puberty suppression in transgender youth. Assessment of treatment impact has been based on the assumption that without intervention, BMD Z-scores remain stable. However, the natural course of BMD in this population is unknown.

DESIGN

Retrospective cross-sectional study.

METHODS

Dual-energy X-ray absorptiometry scans prior to medical intervention were included from 333 individuals assigned male at birth (AMAB) and 556 individuals assigned female at birth (AFAB) aged 12-25 years. The relationship between age and BMD Z-scores of sex assigned at birth was analysed for the lumbar spine (LS), total hip (TH), femoral neck (FN), and total-body-less-head (TBLH), adjusted for height SDS, height-adjusted lean mass Z-score, and whole body percentage fat Z-score.

RESULTS

In individuals AMAB, the BMD Z-score was negatively associated with age between 12 and 22 years: LS -0.13/year (95% confidence interval, CI -0.17; -0.10); TH -0.05/year (95% CI -0.08; -0.02); FN -0.06/year (95% CI -0.10; -0.03); and TBLH -0.12/year (95% CI -0.15; -0.09). Adjusting for height-adjusted lean mass Z-score attenuated the association at the LS and TBLH and eliminated the association at the TH and FN. BMD Z-scores and age were not associated between 22 and 25 years. In individuals AFAB, BMD Z-scores were only associated with age at the TBLH (-0.08/year, 95% CI -0.12; -0.04) between age 12 and 20 years.

CONCLUSION

In individuals AMAB aged 12-22 years prior to any treatment, BMD Z-scores were inversely correlated with age. This could imply that BMD increases less in individuals AMAB than in the general population, and that changes in Z-score during puberty suppression and subsequent hormone supplementation are not necessarily due to treatment, but possibly related to lifestyle factors.

Depathologization of trans* experience in ICD-11: Suggestions for context-sensitive psychotherapeutic work

The current changes to the treatment recommendations and the diagnostic categorization of trans* identities in the ICD-11 require a new consideration of past therapeutic methods and approaches. The depathologization of trans* lives in the ICD-11 finally enables trans* people to access psychotherapeutic services more freely, as the compulsory therapy that has thus far been required for access to transition-related treatments, as well as the so-called "diagnosis" and "treatment" of "transsexuality", have been removed. Trans* people will nevertheless be interested in qualified psychotherapeutic treatment options. Due to the decades-long discrimination and treatment in the health system that has disregarded the human rights of trans* people, a trans*-affirmative approach is necessary, one that takes into account the context of the treatment and critically reflects upon one's own position as a health professional. This affirmative and self-reflective approach provides the basis upon which therapeutic concerns and topics related to a life lived in accordance with a self-determined (gender) identity, related needs, and the fulfillment of those needs, can be discussed. The consequences of experiences of discrimination, violence and exclusion are, moreover, important elements of therapy that require a structural and social contextualization in order to address internalized trans*-negativity and to empower trans* people in their self-assertion.

"I'm not getting paid to give you a TED talk on how my trans body works". Experiences of hysterectomy gender affirming surgery: A qualitative study

OBJECTIVE

To explore the experiences of care surrounding hysterectomy as part of gender affirming surgery.

METHODS

An in-depth reflexive thematic analysis from accounts by 10 out of 12 people was undertaken. Experiences were then mapped to the surgery journey as a template for developing system responsiveness.

RESULTS

No one person's experience of the procedure was affirmed across the entire surgery journey. Transgender health literacy was central to inclusive practice as it mediated bodily autonomy being upheld. The physical care environment influenced the experience, for example, the waiting room was marginalizing (intimidating), with a gendered clinic name and toilets. Some participants took a female support person/partner so that "people looking would assume that I was there supporting her, not the other way around." Communication misalignments were evident around information provided/understood about fertility and ovarian preservation. Participants were also placed in the position of both receiving care and providing education: "I also shouldn't have to be going in there for treatment, and then being expected to educate the medical professional that's meant to be helping me… I'm not getting paid to give you a TED talk on how my trans body works." The experiences mapped across the surgery journey highlighted multiple levels of service provision development needed to foster inclusive practice, for example, from workforce education to healthcare policy.

CONCLUSION

Healthcare for transgender people can be unsafe and inequitable. Increasing transgender health responsiveness across the surgery journey will facilitate better alignments in communication and uphold bodily autonomy, leading to safer and inclusive practice.

Discontinuing hormonal gender reassignment: a nationwide register study

BACKGROUND

With increasing numbers of people seeking medical gender reassignment, the scientific community has become increasingly aware of the issue of detransitioning from social, hormonal or even surgical gender reassignment (GR). This study aimed to assess the proportion of patients who discontinued their established hormonal gender transition and the risk factors for discontinuation.

METHODS

A nationwide register-based follow-up was conducted. Data were analysed via cross-tabulations with chi-square statistics and t tests/ANOVAs. Multivariate analyses were performed via Cox regression, which accounts for differences in follow-up times.

RESULTS

Of the 1,359 subjects who had undergone hormonal GR in Finland from 1996 to 2019, 7.9% discontinued their established hormonal treatment during an average follow-up of 8.5 years. The risk for discontinuing hormonal GR was greater among later cohorts. The hazard ratio was 2.7 (95% confidence interval 1.1-6.1) among those who had accessed gender identity services from 2013 to 2019 compared with those who had come to contact from 1996 to 2005. Discontinuing also appeared to be emerging earlier among those who had entered the process in later years.

CONCLUSIONS

The risk of discontinuing established medical GR has increased alongside the increase in the number of patients seeking and proceeding to medical GR. The threshold to initiate medical GR may have lowered, resulting in a greater risk of unbalanced treatment decisions.

TRIAL REGISTRATION NUMBER (TRN)

Not applicable (the paper does not present a clinical trial).

Psychosexual Health and Well-Being of Trans and Gender-Diverse Individuals in Portugal

This study aimed to explore and describe the perceptions of trans and gender-diverse individuals (TGD) in Portugal regarding the implications on their psychological, social, and psychosexual health. A qualitative investigation was conducted using an electronic interview answered by 32 participants. The data were examined through a thematic analysis, and the following themes were identified: experiences with healthcare services, social interaction, discrimination experiences, mental health, social support systems, self-esteem, social identity, sex and sexual health, quality of life, and sociopolitical enhancement strategy proposals. The analysis of these themes provides information on the perceptions and experiences of the participants and suggests factors that impact the well-being and quality of life of the individuals in the current sample.

Neurobiological characteristics associated with gender identity: Findings from neuroimaging studies in the Amsterdam cohort of children and adolescents experiencing gender incongruence

This review has been based on my invited lecture at the annual meeting of the Society for Behavioral Neuroendocrinology in 2023. Gender incongruence is defined as a marked and persistent incongruence between an individual's experienced gender and the sex assigned at birth. A prominent hypothesis on the etiology of gender incongruence proposes that it is related to an altered or less pronounced sexual differentiation of the brain. This hypothesis has primarily been based on postmortem studies of the hypothalamus in transgender individuals. To further address this hypothesis, a series of structural and functional neuroimaging studies were conducted in the Amsterdam cohort of children and adolescents experiencing gender incongruence. Additional research objectives were to determine whether any sex and gender differences are established before or after puberty, as well as whether gender affirming hormone treatment would affect brain development and function. We found some evidence in favor of the sexual differentiation hypothesis at the functional level, but this was less evident at the structural level. We also observed some specific transgender neural signatures, suggesting that they might present a unique brain phenotype rather than being shifted towards either end of the male-female spectrum. Our results further suggest that the years between childhood and mid-adolescence represent an important period in which puberty-related factors influence several neural characteristics, such as white matter development and functional connectivity patterns, in both a sex and gender identity specific way. These latter observations thus lead to the important question about the possible negative consequences of delaying puberty on neurodevelopment. To further address this question, larger-scale, longitudinal studies are required to increase our understanding of the possible neurodevelopmental impacts of delaying puberty in transgender youth.

Expectations and Experienced Outcomes Regarding Gender-Affirming Surgeries: A Pilot Study

Purpose

This study aimed to explore in what ways the preoperative expectations of transgender individuals regarding gender-affirming surgery (GAS) align with experienced postoperative outcomes and, subsequently, how these expectations can best be managed to support optimal outcomes.

Methods

In the parent study, interviews were conducted to understand the health care experiences of a group of trans individuals that had or wanted to have gender-affirming surgical care. In this secondary analysis, we focused specifically on the individuals' expectations and experiences about the gender-affirming procedures they desired or underwent. Recruitment occurred from August 2018 to October 2018 at the Amsterdam University Medical Center (VUmc) in the Netherlands. Axial coding and theory-informed thematic analysis were used to assess preoperative expectations and postoperative.

Results

The data regarding expectations related to GAS (ncodes=273) and postoperative experienced outcomes (ncodes=292) yielded a total of four themes-(1) Procedure, recovery, and functional results; (2) Esthetic outcomes of GAS; (3) Improved body image in relation to one's gender role; and (4) Increased psychosocial and sexual wellbeing at large in relation to one's gender role. Each of the four themes were divided into two subthemes: (1) expectations, and (2) experienced outcomes.

Conclusion

Better understanding, education, and support in the decision-making process of trans individuals seeking gender-affirming surgical care is needed to manage expectations and overall outcomes of GAS procedures.

Time Course of Body Composition Changes in Transgender Adolescents During Puberty Suppression and Sex Hormone Treatment

CONTEXT

Transgender adolescents can undergo puberty suppression (PS) and subsequent gender-affirming hormone therapy (GAHT) but little information is available on the expected rate of physical changes.

OBJECTIVE

To investigate the time course of body composition changes during PS and GAHT.

METHODS

In this study, retrospective data of 380 trans boys and 168 trans girls treated with PS prior to GAHT from a gender identity clinic were included. Total lean and fat mass Z-scores using birth-assigned sex as reference were determined using dual-energy X-ray absorptiometry.

RESULTS

In trans boys, lean mass Z-scores decreased (-0.32, 95% CI -0.41; -0.23) and fat mass Z-scores increased (0.31, 95% CI 0.21; 0.41) in the first year of PS and remained stable thereafter. Lean mass Z-scores increased (0.92, 95% CI 0.81; 1.04) and fat mass Z-scores decreased (-0.43, 95% CI -0.57; -0.29) only during the first year of testosterone,. In trans girls, both lean and fat mass Z-scores gradually changed over 3 years of PS (respectively -1.13, 95% CI -1.29; -0.98 and 1.06, 95% CI 0.90; 1.23). In the first year of GAHT, lean mass Z-scores decreased (-0.19, 95% CI -0.36; -0.03) while fat mass Z-scores remained unchanged after 3 years (-0.02, 95% CI -0.20; 0.16).

CONCLUSION

Compared with peers, trans girls experienced ongoing lean mass decrease and fat mass increase during 3 years of PS while in trans boys smaller changes were observed that stabilized after 1 year. A large increase in lean mass Z-scores occurred only during the first year of testosterone treatment. In trans girls, body composition changed only slightly during GAHT. This information can improve counseling about treatment effects.

Chest Feminization in Transwomen with Subfascial Breast Augmentation-Our Technique and Results

BACKGROUND

The increasing population of this minority community is approaching plastic surgeons more frequently to achieve their dream of becoming a phenotypic female, the breast being the single sure identity. After undergoing the bottom surgery (SRS) which is essential for them to gain entry into the transgender community, very few take up hormone therapy; the rest approach plastic surgeons for chest feminization which includes breast augmentation.

METHODS

A total of 177 transgenders underwent subfascial breast augmentation between 2014 and 2023. They were followed up for 10 years. Their demographics were documented. Operative details and postoperative complications were analyzed. Patient-related outcome measures were performed for size, appearance and cleavage.

RESULTS

A well-performed surgery in our cohort had a good aesthetic outcome even after many years. Only three patients were dissatisfied with the size; revision surgeries of 12 patients done elsewhere had many complications like wound dehiscence and exposure, scar hypertrophy, low placed axillary scars, capsular contracture, asymmetry, and nonspecific pain. All of them had submuscular placement.

CONCLUSIONS

The subfascial placement of implants in transwomen had good aesthetic outcomes with fewer complications and good acceptance.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Adolescent neurocognitive development and decision-making abilities regarding gender-affirming care

Recently, politicians and legislative bodies have cited neurodevelopmental literature to argue that brain immaturity undermines decision-making regarding gender-affirming care (GAC) in youth. Here, we review this literature as it applies to adolescents' ability to make decisions regarding GAC. The research shows that while adolescence is a time of peak risk-taking behavior that may lead to impulsive decisions, neurocognitive systems supporting adult-level decisions are available given deliberative processes that minimize influence of short-term rewards and peers. Since GAC decisions occur over an extended period and with support from adult caregivers and clinicians, adolescents can engage adult-level decision-making in this context. We also weigh the benefits of providing GAC access during adolescence and consider the significant costs of blocking or delaying GAC. Transgender and non-binary (TNB) adolescents face significant mental health challenges, many of which are mitigated by GAC access. Further, initiating the GAC process during adolescence, which we define as beginning at pubertal onset, leads to better long-term mental health outcomes than waiting until adulthood. Taken together, existing research indicates that many adolescents can make informed decisions regarding gender-affirming care, and that this care is critical for the well-being of TNB youth. We highlight relevant considerations for policy makers, researchers, and clinicians.

Referrals For Gender-Affirming Hormone Treatment in Croatia's National Network for Transgender Healthcare

A network of healthcare professionals specializing in transgender care was established in Croatia in 2011, and legal advancements were subsequently made in 2014. Both achievements made gender transition more transparent and thus more attainable in Croatia. This observational study was conducted to assess the number of transgender individuals initiating gender-affirming hormone treatment (GAHT) in Croatia and describes trends in age and sex assigned at birth. Between 2011 and 2022, a total of 111 transgender individuals initiated GAHT. Within the cohort, 52 were assigned male at birth (AMAB) and 59 were assigned female at birth (AFAB). The overall annual incidence rate of transgender individuals initiating GAHT was 0.52 per 100,000 age-adjusted individuals. There was a statistically significant increase (p < 0.01) in transgender individuals commencing GAHT before the COVID-19 pandemic. Furthermore, a rising trend toward masculinizing rather than feminizing treatment was identified (p < 0.05), particularly among younger transgender individuals. The COVID-19 pandemic disrupted these trends in 2020, except for the trend of initiating therapy at a younger age (p < 0.01). The annual incidence and age distribution trends of transgender individuals initiating GAHT in Croatia closely mirrored those in other European countries, with a higher prevalence of individuals assigned female at birth. The study underscores a significant rise in the number of individuals initiating gender-affirming hormone treatment, emphasizing the need for proper legal regulation and healthcare system response.

Gender-affirming hormone therapy and cardiovascular health in transgender adults

A growing number of people identify as transgender and gender non-binary in the USA and worldwide. Concomitantly, an increasing number of patients are receiving gender-affirming hormone therapy (GAHT) to achieve gender congruence. GAHT has far-ranging effects on clinical and subclinical markers of cardiovascular risk. Transgender patients also appear to be at higher risk for cardiovascular diseases compared to their cisgender peers and the impact of gender-affirming therapy on cardiovascular health is unclear. Studies on the effect of GAHT on cardiovascular outcomes are confounded by differences in GAHT regimens and methodological challenges in a diverse and historically hard-to-reach population. Current cardiovascular guidelines do not incorporate gender identity and hormone status into risk stratification and clinical decision-making. In this review, we provide an overview on the cardiometabolic impact and clinical considerations of GAHT for cardiovascular risk in transgender patients.

Detransition Narratives Trouble the Simple Attribution of Madness in Transantagonistic Contexts: A Qualitative Analysis of 16 Canadians' Experiences

Emerging evidence suggests that transgender individuals are more likely than cisgender peers to receive a diagnosis with a primary mental disorder. Attributions of madness, though, may serve the social function of dismissing and discrediting transgender individual's self-perceptions. The narratives of individuals who stop or reverse an initial gender transition who also identify as living with mental health conditions can sometimes amplify these socio-political discourses about transgender people. Through a critical mental health lens, this article presents a qualitative analysis of 16 individuals who stopped or reversed a gender transition and who also reported a primary mental health condition. Semi-structured, virtual interviews were conducted with people living in Canada. Applying constructivist grounded theory methodology, and following an iterative, inductive approach to analysis, we used the constant comparative method to analyse these 16 in-depth interviews. Results show rich complexity such that participants narrated madness in nuanced and complex ways while disrupting biased attitudes that madness discredited their thoughts and feelings, including prior gender dysphoria. Instead, participants incorporated madness into expanding self-awareness and narrated their thoughts and feelings as valid and worthy. Future research must consider provider's perspectives, though, in treating mad individuals who detransitioned, since alternate gender-affirming care models may better support the identification and wellness of care-seeking individuals who may be identified (in the past, present, or future) as mad.

The association of gender-affirming hormone therapy duration and body mass index on bone mineral density in gender diverse adults

Introduction

Feminizing and masculinizing gender-affirming hormone therapy (fGAHT, mGAHT) results in bone mineral density (BMD) maintenance or improvement over time in transgender and gender diverse (TGD) adults. Mostly European TGD studies have explored GAHT's impact on BMD, but the association of BMI and BMD in TGD adults deserves further study.

Objective

To determine whether GAHT duration or BMI are associated with BMD and Z-scores among TGD young adults.

Methods

Cross-sectional study of nonsmoking TGD adults aged 18-40 years without prior gonadectomy or gonadotropin-releasing hormone agonist (GnRHa) therapy taking GAHT for > 1 year. BMD and Z-scores were collected from dual-energy x-ray absorptiometry. Associations between femoral neck, total hip, and lumbar spine BMDs and Z-scores and the predictors, GAHT duration and BMI, were estimated using linear regression.

Results

Among 15 fGAHT and 15 mGAHT, mean BMIs were 27.6 +/- standard deviation (SD) 6.4 kg/m2 and 25.3 +/- 5.9 kg/m2, respectively. Both groups had mean BMDs and Z-scores within expected male and female reference ranges at all three sites. Higher BMI among mGAHT was associated with higher femoral neck and total hip BMDs (femoral neck: β = 0.019 +/- standard error [SE] 0.007 g/cm2, total hip: β = 0.017 +/- 0.006 g/cm2; both p < 0.05) and Z-scores using male and female references. GAHT duration was not associated with BMDs or Z-scores for either group.

Conclusions

Z-scores in young, nonsmoking TGD adults taking GAHT for > 1 year, without prior gonadectomy or GnRHa, and with mean BMIs in the overweight range, were reassuringly within the expected ranges for age based on male and female references. Higher BMI, but not longer GAHT duration, was associated with higher femoral neck and total hip BMDs and Z-scores among mGAHT. Larger, prospective studies are needed to understand how body composition changes, normal or low BMIs, and gonadectomy affect bone density in TGD adults.

Adult outcomes of urinary, sexual functions and fertility after pediatric management of differences in sex development: Who should be followed and how?

The management of Differences of Sex Development (DSD) has evolved considerably in recent years. The questioning of systematic early childhood treatment of DSD requires a better understanding of the outcomes of such treatments and long-term studies are therefore essential to better evaluate the prognosis of DSD. Unfortunately, limitations are numerous including the limited size of the series, the absence of standardized methodology, the evaluation of managements that no longer take place today and the absence of prospective and comparative studies. Despite these difficulties, the purpose of this paper is to present the current data on the long-term follow-up of patients with DSD from the urological, sexual and fertility points of view. Even if it remains difficult at present to establish precise recommendations, we recapitulate the most important points that should drive follow-up of these patients especially the constitution of a multidisciplinary team with a holistic approach, the organization of the transition between adolescence and adulthood, a particular attention to psychological care, a careful communication with the patients and his/her family and the use of standardized data collection systems.

Laboratory Changes During Gender-Affirming Hormone Therapy in Transgender Adolescents

OBJECTIVES

Guidelines for monitoring of medications frequently used in the gender-affirming care of transgender and gender-diverse (TGD) adolescents are based on studies in adults or other medical conditions. In this study, we aimed to investigate commonly screened laboratory measurements in TGD adolescents receiving gender-affirming hormone therapy (GAHT).

METHODS

TGD adolescents were recruited from 4 study sites in the United States before beginning GAHT. Hemoglobin, hematocrit, hemoglobin A1c, alanine transaminase, aspartate aminotransferase, prolactin, and potassium were abstracted from the medical record at baseline and at 6, 12, and 24 months after starting GAHT.

RESULTS

Two-hundred and ninety-three participants (68% designated female at birth) with no previous history of gonadotropin-releasing hormone analog use were included in the analysis. Hemoglobin and hematocrit decreased in adolescents prescribed estradiol (-1.4 mg/dL and -3.6%, respectively) and increased in adolescents prescribed testosterone (+1.0 mg/dL and +3.9%) by 6 months after GAHT initiation. Thirteen (6.5%) participants prescribed testosterone had hematocrit > 50% during GAHT. There were no differences in hemoglobin A1c, alanine transaminase, or aspartate aminotransferase. There was a small increase in prolactin after 6 months of estradiol therapy in transfeminine adolescents. Hyperkalemia in transfeminine adolescents taking spironolactone was infrequent and transient if present.

CONCLUSIONS

Abnormal laboratory results are rare in TGD adolescents prescribed GAHT and, if present, occur within 6 months of GAHT initiation. Future guidelines may not require routine screening of these laboratory parameters beyond 6 months of GAHT in otherwise healthy TGD adolescents.

Prevalence of Regret in Gender-Affirming Surgery: A Systematic Review

INTRODUCTION

Gender-affirmation surgeries are a rapidly growing set of procedures in the field of plastic surgery. This study is novel in that a thorough analysis has not been performed quantifying, identifying, and recognizing the reasons and factors associated with regret in a largely US population.

METHODS

A systematic review of several databases was conducted. After compiling the articles, we extracted study characteristics. From the data set, weighted proportions were generated and analyzed.

RESULTS

A total of 24 articles were included in this study, with a population size of 3662 patients. A total of 3673 procedures were conducted in the United States, 514 in European nations, 97 in Asian nations, which included only Thailand, and 19 in South American nations, which included only Brazil. The pooled prevalence of regret was 1.94%. The prevalence of transfeminine regret was 4.0% while the prevalence of transmasculine regret was 0.8%.

CONCLUSIONS

Both transfeminine and transmasculine patients had significantly lower rates of regret in the United States when compared with the rest of the world. Our study largely excluded facial gender-affirming surgeries as most of its articles did not fall into our inclusion search criteria. To our knowledge, this is the most recent review performed on the topic of regret among gender-affirming surgery patients with an emphasis on a US cohort. This analysis can help shed light on better ways to enhance patient selection and surgical experience.

Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future

In this essay, we consider the clinical and ethical implications of puberty blockers for pediatric gender dysphoria through the lens of "the child's right to an open future," which refers to rights that children do not have the capacity to exercise as minors, but that must be protected, so they can exercise them in the future as autonomous adults. We contrast the open future principle with the beliefs underpinning the gender affirming care model and discuss implications for consent. We evaluate claims that puberty blockers are reversible, discuss the scientific uncertainty about long-term benefits and harms, summarize international developments, and examine how suicide has been used to frame puberty suppression as a medically necessary, lifesaving treatment. In discussing these issues, we include relevant empirical evidence and raise questions for clinicians and researchers. We conclude that treatment pathways that delay decisions about medical transition until the child has had the chance to grow and mature into an autonomous adulthood would be most consistent with the open future principle.

Reidentification With Birth-Registered Sex in a Western Australian Pediatric Gender Clinic Cohort

Importance

Some young people who identify as transgender and seek gender-affirming medical care subsequently reidentify with their sex registered at birth. Evidence regarding the frequency and characteristics of this experience is lacking.

Objective

To determine the frequency of reidentification and explore associated characteristics in a pediatric gender clinic setting.

Design, Setting, and Participants

This retrospective cohort study examined all referrals to the Child and Adolescent Health Service Gender Diversity Service at Perth Children's Hospital between January 1, 2014, and December 31, 2020. The Gender Diversity Service is the sole statewide specialist service in Western Australia that provides children and adolescents up to age 18 years with multidisciplinary assessment, information, support, and gender-affirming medical care. All closed referrals for this study were audited between May 1, 2021, and August 8, 2022.

Exposure

Reidentification with birth-registered sex.

Main Outcomes and Measures

The number of referrals closed due to reported reidentification with birth-registered sex was determined, as well as descriptives and frequencies of patient demographics (age, birth-registered sex), informant source, International Statistical Classification of Diseases, Tenth Revision gender-related diagnoses, pubertal status, any gender-affirming medical treatment received, and whether subsequent re-referrals were received.

Results

Of 552 closed referrals during the study period, a reason for closure could be determined for 548 patients, including 211 birth-registered males (mean [SD] age, 13.88 [2.00] years) and 337 birth-registered females (mean [SD] age, 15.81 [2.22] years). Patients who reidentified with their birth-registered sex comprised 5.3% (29 of 548; 95% CI, 3.6%-7.5%) of all referral closures. Except for 2 patients, reidentification occurred before or during early stages of assessment (93.1%; 95% CI, 77.2%-99.2%). Two patients who reidentified with their birth-registered sex did so following initiation of puberty suppression or gender-affirming hormone treatment (1.0% of 196 patients who initiated any gender-affirming medical treatment; 95% CI, 0.1%-3.6%).

Conclusions and Relevance

These findings from a pediatric gender clinic audit indicate that a small proportion of patients, and a very small proportion of those who initiated medical gender-affirming treatment, reidentified with their birth-registered sex during the study period. Longitudinal follow-up studies, including qualitative self-report, are required to understand different pathways of gender identity experience.

Trajectories of Gender Identity and Depressive Symptoms in Youths

Importance

Concerns about the mental health of youths going through gender identity transitions have received increased attention. There is a need for empirical evidence to understand how transitions in self-reported gender identity are associated with mental health.

Objective

To examine whether and how often youths changed self-reported gender identities in a longitudinal sample of sexual and gender minority (SGM) youths, and whether trajectories of gender identity were associated with depressive symptoms.

Design, Setting, and Participants

This cohort study used data from 4 waves (every 9 months) of a longitudinal community-based study collected in 2 large cities in the US (1 in the Northeast and 1 in the Southwest) between November 2011 and June 2015. Eligible participants included youths who self-identified as SGM from community-based agencies and college groups for SGM youths. Data analysis occurred from September 2022 to June 2023.

Exposure

Gender identity trajectories and gender identity variability.

Main Outcomes and Measures

The Beck Depression Inventory for Youth (BDI-Y) assessed depressive symptoms. Gender identity variability was measured as the number of times participants' gender identity changed. Hierarchical linear models investigated gender identity trajectories and whether gender identity variability was associated with depressive symptoms over time.

Results

Among the 366 SGM youths included in the study (mean [SD] age, 18.61 [1.71] years; 181 [49.4%] assigned male at birth and 185 [50.6%] assigned female at birth), 4 gender identity trajectory groups were identified: (1) cisgender across all waves (274 participants ), (2) transgender or gender diverse (TGD) across all waves (32 participants), (3) initially cisgender but TGD by wave 4 (ie, cisgender to TGD [28 participants]), and (4) initially TGD but cisgender by wave 4 (ie, TGD to cisgender [32 participants]). One in 5 youths (18.3%) reported a different gender identity over a period of approximately 3.5 years; 28 youths varied gender identity more than twice. The cisgender to TGD group reported higher levels of depression compared with the cisgender group at baseline (Β = 4.66; SE = 2.10; P = .03), but there was no statistical difference once exposure to lesbian, gay, bisexual, and transgender violence was taken into account (Β = 3.31; SE = 2.36; P = .16). Gender identity variability was not associated with within-person change in depressive symptoms (Β = 0.23; SE = 0.74; P = .75) or the level of depressive symptoms (Β = 2.43; SE = 2.51; P = .33).

Conclusions

These findings suggest that gender identity can evolve among SGM youths across time and that changes in gender identity are not associated with changes in depressive symptoms. Further longitudinal work should explore gender identity variability and adolescent and adult health.