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Mehta JM, Kanell S, Borowicz CEA, Fisher MA. Transgender patients and gender-affirming hormone therapy through the mid-life. Maturitas 2024; 189:108093. [PMID: 39178607 DOI: 10.1016/j.maturitas.2024.108093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 08/07/2024] [Accepted: 08/17/2024] [Indexed: 08/26/2024]
Abstract
The menopause transition and post-menopause period marks a time of dynamic physiological and hormonal change. Cisgender women commonly experience vasomotor symptoms, genitourinary symptoms, and changes in bone health. The transgender population, including those assigned female at birth (AFAB) and those assigned male at birth (AMAB), has been understudied in terms of experiences through the menopause transition and midlife. Additionally, there is no formal recommendation or guidance on continuation of gender-affirming hormone therapy (GAHT) through midlife. While gender-affirming therapies for transgender patients are well defined and supported by organizational guidelines, including from the World Professional Association for TGD Health (WPATH) (Standards of Care 8, SOC8) and from the Endocrine Society (2017), evidence on continuation of therapy and dose adjustments into mid-life are lacking. Data from a few large cohort studies and small cross-sectional studies suggest increased risk of venous thromboembolism (VTE), stroke and myocardial infarction in those AMAB on GAHT. For those AFAB on testosterone therapy, risks of cardiovascular disease and stroke and to bone health are not well defined, given inconsistent findings from large cohort studies. Currently, the decision to continue GAHT for transgender patients is guided by patient preference along with clinician guidance. Further research is warranted regarding risks of continuing GAHT into mid-life for both AMAB and AFAB patients. Given the significant benefit of GAHT in this population, however, this data would be most helpful for counseling on risks along with appropriate monitoring and prevention for related morbidities during mid-life in the setting of GAHT use.
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Affiliation(s)
- Jaya M Mehta
- Primary Care Institute, Allegheny Health Network, Pittsburgh, PA, United States of America; Allegheny General Hospital Internal Medicine, Allegheny Health Network, Pittsburgh, PA, United States of America.
| | - Sarah Kanell
- Allegheny General Hospital Internal Medicine, Allegheny Health Network, Pittsburgh, PA, United States of America
| | - Charlie E A Borowicz
- Center for Inclusion Health, Allegheny Health Network, Pittsburgh, PA, United States of America
| | - Molly Ainsman Fisher
- Primary Care Institute, Allegheny Health Network, Pittsburgh, PA, United States of America; Allegheny General Hospital Internal Medicine, Allegheny Health Network, Pittsburgh, PA, United States of America
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Fowler JA, Warzywoda S, Franks N, Mendis M, Lazarou M, Bisshop F, Wood P, Dean JA. Highs, Lows, and Hormones: A Qualitative Metasynthesis of Transgender Individuals' Experiences Undergoing Gender-Affirming Hormone Therapy. JOURNAL OF HOMOSEXUALITY 2024; 71:1652-1683. [PMID: 36884002 DOI: 10.1080/00918369.2023.2186759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
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.
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Affiliation(s)
- James A Fowler
- Faculty of Medicine, School of Public Health, The University of Queensland, Herston, Queensland, Australia
| | - Sarah Warzywoda
- Faculty of Medicine, School of Public Health, The University of Queensland, Herston, Queensland, Australia
| | - Nia Franks
- School of Psychology and Counselling, Faculty of Health, Engineering and Sciences, Centre for Health Research, Institute for Resilient Regions, University of Southern Queensland, Ipswich, Queensland, Australia
| | - Marini Mendis
- Faculty of Medicine, School of Public Health, The University of Queensland, Herston, Queensland, Australia
| | - Mattea Lazarou
- Faculty of Medicine, School of Public Health, The University of Queensland, Herston, Queensland, Australia
| | - Fiona Bisshop
- Holdsworth House Medical Practice, Brisbane, Queensland, Australia
| | - Penny Wood
- Alexander Heights Family Practice, Perth, Western Australia, Australia
| | - Judith A Dean
- Faculty of Medicine, School of Public Health, The University of Queensland, Herston, Queensland, Australia
- Poche Centre for Indigenous Health, The University of Queensland, Brisbane, Queensland, Australia
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Crossway AK, Rogers SM, Hansen A, Sturtevant J, Moffit DM, Lopez RM. The Role of the Athletic Trainer in Providing Care to Transgender and Gender-Diverse Patients: Considerations for Medical Affirmation-Part II. J Athl Train 2024; 59:345-353. [PMID: 36735628 PMCID: PMC11064118 DOI: 10.4085/1062-6050-0313.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Recently, with discriminatory legislation efforts and changing participation policies in organized sports, media attention surrounding transgender and gender-diverse (TGD) individuals has increased. These changes and the historical lack of competence and education regarding the transgender patient population have resulted in subpar patient care and a misunderstanding of the athletic trainer's (AT's) role within the health care and compliance systems. This literature review is the second part of a 2-paper series, and our objective was to educate ATs on the processes relevant to medical affirmation, including compliance considerations regarding medical eligibility, and to establish the AT's role. The gender affirmation framework includes social and legal components, which are discussed in part 1 of this literature, and the medical component is thoroughly discussed in part 2. All health care providers involved in the care of TGD individuals should work collaboratively on an interprofessional care team and have a general knowledge of the gender-affirmation process, including gender-affirming hormone therapy, surgical options, known risks and complications, and the general health needs of TGD patients. With this knowledge, ATs, as point-of-care providers and members of the interprofessional care team, are uniquely positioned to help reduce health and health care disparities. Furthermore, ATs can use their knowledge to facilitate medical compliance and eligibility in the evolving policies of sporting organizations.
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Affiliation(s)
| | | | | | | | - Dani M Moffit
- Physical Therapy & Athletic Training Department, Idaho State University, Pocatello
| | - Rebecca M Lopez
- Department of Orthopaedics & Sports Medicine, School of Physical Therapy & Rehabilitation Sciences, University of South Florida, Tampa
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Wright ME, Murphy K. A mini-review of the evidence for cerebrovascular changes following gender-affirming hormone replacement therapy and a call for increased focus on cerebrovascular transgender health. Front Hum Neurosci 2023; 17:1303871. [PMID: 38077183 PMCID: PMC10702528 DOI: 10.3389/fnhum.2023.1303871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 10/31/2023] [Indexed: 02/12/2024] Open
Abstract
Gender-affirming hormone replacement therapy (gaHRT) is an important step for many in the gender diverse community, associated with increased quality-of-life and lower self-reported scores of depression and anxiety. However, considering the interactions that the involved sex hormones have on vasculature (with oestrogen and testosterone demonstrating vasodilatory and vasoconstricting properties, respectively), it is important for transgender healthcare research to examine how the manipulation of these hormones interact with cerebrovascular structure and functioning. There is a stark lack of research in this area. This mini-review outlines the research suggesting a vascular impact of these sex hormones using evidence from a range of cohorts (e.g., menopause, polycystic ovary syndrome) and discusses the work that has been done into cerebrovascular changes following gaHRT. Finally, recommendations for future research into cerebrovascular health in transgender cohorts following gaHRT are outlined.
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Affiliation(s)
- Melissa Emily Wright
- Cardiff University Brain Research Imaging Centre (CUBRIC), School of Psychology, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
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Doyle DM, Lewis TOG, Barreto M. A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people. Nat Hum Behav 2023; 7:1320-1331. [PMID: 37217739 PMCID: PMC10444622 DOI: 10.1038/s41562-023-01605-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/12/2023] [Indexed: 05/24/2023]
Abstract
This systematic review assessed the state and quality of evidence for effects of gender-affirming hormone therapy on psychosocial functioning. Forty-six relevant journal articles (six qualitative, 21 cross-sectional, 19 prospective cohort) were identified. Gender-affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress. Evidence for quality of life was inconsistent, with some trends suggesting improvements. There was some evidence of affective changes differing for those on masculinizing versus feminizing hormone therapy. Results for self-mastery effects were ambiguous, with some studies suggesting greater anger expression, particularly among those on masculinizing hormone therapy, but no increase in anger intensity. There were some trends toward positive change in interpersonal functioning. Overall, risk of bias was highly variable between studies. Small samples and lack of adjustment for key confounders limited causal inferences. More high-quality evidence for psychosocial effects of gender-affirming hormone therapy is vital for ensuring health equity for transgender people.
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Affiliation(s)
- David Matthew Doyle
- Department of Medical Psychology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands.
| | - Tom O G Lewis
- Department of Psychology, University of Exeter, Exeter, UK
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Cheung AS, Nolan BJ, Zwickl S. Transgender health and the impact of aging and menopause. Climacteric 2023; 26:256-262. [PMID: 37011669 DOI: 10.1080/13697137.2023.2176217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Gender affirming hormone therapy (GAHT) is used by many transgender people to reduce gender incongruence and improve psychological functioning. As GAHT shares many similarities with menopausal hormone therapy, clinicians supporting people through menopause are ideally placed to manage GAHT. This narrative review provides an overview of transgender health and discusses long-term effects of GAHT to consider when managing transgender individuals across the lifespan. Menopause is less relevant for transgender individuals who take GAHT (often given lifelong) to achieve sex steroid concentrations generally in the range of the affirmed gender. For people using feminizing hormone therapy, there is an elevated risk of venous thromboembolism, myocardial infarction, stroke and osteoporosis relative to cisgender individuals. For trans people using masculinizing hormone therapy, there is an increased risk of polycythemia, probable higher risk of myocardial infarction and pelvic pain which is poorly understood. Proactive mitigation of cardiovascular risk factors is important for all transgender people and optimization of bone health is important for those using feminizing hormones. With a lack of research to guide GAHT in older age, a shared decision-making approach is recommended for the provision of GAHT to achieve individual goals whilst minimizing potential adverse effects.
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Affiliation(s)
- A S Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Australia
| | - B J Nolan
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Australia
| | - S Zwickl
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Australia
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Howell JD, Maguire R. Factors Associated with Experiences of Gender-Affirming Health Care: A Systematic Review. Transgend Health 2023; 8:22-44. [PMID: 36895311 PMCID: PMC9991448 DOI: 10.1089/trgh.2021.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose Transgender people often pursue gender-affirming health care (GAH), such as hormone therapy and/or surgeries. While research has begun to explore influences on general health care for transgender individuals, less is known about the experiences of GAH specifically. We aimed to systematically review the factors associated with experiences of GAH. Methods PubMed, EMBASE, PsycInfo, and Web of Science were systematically searched for relevant literature using a predetermined search strategy. Studies were screened by two researchers to determine whether they fit the inclusion criteria. Following quality appraisal and data extraction, results were thematically analyzed. Results Thirty-eight studies were included in the review. Factors associated with experiences of GAH were broadly categorized as follows: (i) sociodemographic factors, (ii) treatment-related factors, (iii) psychosocial factors, and (iv) health care interactions, with health care interactions, in particular, being strong determinants of experience. Conclusion Findings suggest that experiences of GAH may be determined by a number of diverse factors, which have implications for understanding how to better support those undergoing transition. In particular, health care professionals play a key role in determining how transgender people experience treatment, which should be considered when providing care for this population.
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Affiliation(s)
- Jamie D. Howell
- Department of Psychology, Maynooth University, Maynooth, Ireland
| | - Rebecca Maguire
- Department of Psychology, Maynooth University, Maynooth, Ireland
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Henry RS, Perrin PB, Coston BM, Witten TM. Transgender and gender non-conforming adult preparedness for aging: Concerns for aging, and familiarity with and engagement in planning behaviors. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2020; 21:58-69. [PMID: 33015659 PMCID: PMC7430476 DOI: 10.1080/15532739.2019.1690612] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background: Research on transgender and gender-nonconforming (TGNC) aging is limited. To date, most of the literature about TGNC aging has focused on discrimination (particularly in healthcare), violence and abuse, caregiving and family relations, and religiosity. Aims: The purposes of this study were to: (a) document concerns about aging among TGNC adults, including concerns that are identity-specific; (b) examine preparation for aging and end of life (i.e., familiarity and planning) among TGNC adults; and (c) examine potential differences in familiarity and planning based on gender identity. Methods: One hundred fifty-four individuals who currently or have ever identified as TGNC completed a national online survey assessing these constructs. Results: TGNC individuals reported many concerns about aging, both gender identity-specific and not. The most common aging concern was losing the ability to care for themselves followed by having to go into a nursing home or assisted living facility. The age preparatory behaviors individuals were most commonly aware of included: life insurance, wills, organ donation, regular medical checkups, living wills, durable power of attorney for healthcare, and trusts. Gender-nonconforming individuals had significantly more familiarity with age preparatory behaviors than trans feminine individuals, but had lower levels of planning to engage in age preparatory behaviors than both trans masculine and trans feminine individuals. Conclusion: The current findings highlight the need for providers to address age preparatory behaviors with TGNC individuals or provide referrals to support individuals in this planning.
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Affiliation(s)
- Richard S. Henry
- College of Humanities & Sciences, Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Paul B. Perrin
- College of Humanities & Sciences, Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
- CONTACT Paul B. Perrin College of Humanities & Sciences, Psychology Department, Virginia Commonwealth University, Box 842018, Richmond, VA 23284-2018, USA.
| | - Bethany M. Coston
- Department of Gender, Sexuality and Women's Studies, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Tarynn M. Witten
- Department of Computer Science, Virginia Commonwealth University, Richmond, Virginia, USA
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