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Feroe AG, Odum SM, Samora JB. What Is the Representation of Sexual and Gender Minority Identities Among Orthopaedic Professionals in the United States? Clin Orthop Relat Res 2024; 482:1313-1321. [PMID: 39031036 PMCID: PMC11272280 DOI: 10.1097/corr.0000000000003079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 03/18/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND There is substantial corroborating evidence that orthopaedic surgery has historically been the least diverse of all medical and surgical specialties in terms of race, ethnicity, and sex. Growing recognition of this deficit and the benefits of a diverse healthcare workforce has motivated policy changes to improve diversity. To measure progress with these efforts, it is important to understand the existing representation of sexual and gender minorities among orthopaedic professionals. QUESTIONS/PURPOSES (1) What proportion of American Academy of Orthopaedic Surgeons (AAOS) members reported their identity as a sexual or gender minority? (2) What demographic factors are associated with the self-reporting of one's sexual orientation and gender identity? METHODS The AAOS published the updated membership questionnaire in January 2022 to collect information from new and existing society members regarding age and race or ethnicity and newly added categories of gender identity, sexual orientation, and pronouns. The questionnaire was updated with input from a committee of orthopaedic surgeons and researchers to ensure face validity. The AAOS provided a deidentified dataset that included the variables of interest: membership type, gender identity, sexual orientation, pronouns, age, race, and ethnicity. Of 35,427 active AAOS members, 47% (16,652) updated their membership questionnaire. To answer our first study question, we calculated the prevalence of participants who self-reported as lesbian, gay, bisexual, transgender, queer, or another sexual or gender minority identity (LGBTQ+) and other demographic characteristics of the 16,652 respondents. Categorical demographic data are described using frequencies and proportions. Median and IQR were used to describe the central tendency and variability. To answer our second study question, we conducted a stratified analysis to compare demographic characteristics between those who self-reported LGBTQ+ identity and those who did not. Visual methods (quantile-quantile plots) and statistical tests (Kolmogorov-Smirnov and Shapiro Wilk) confirmed that the age of AAOS member was not normally distributed. Therefore, a Kruskal Wallis test was used to determine the statistical associations between age and self-reported LGBTQ+ status. Chi-square tests were used to determine bivariate statistical associations between categorical demographic characteristics and self-reported LGBTQ+ status. A multivariable logistic regression model was developed to identify the independent demographic characteristics associated with respondents who self-reported LGBTQ+ identity. Further stratified analyses were not conducted to protect the anonymity of AAOS members. An alpha level of 5% was established a priori to define statistical significance. RESULTS Overall, 3% (109 of 3679) and fewer than 1% (3 of 16,182) of the AAOS members (surgeons, clinicians, allied healthcare providers, and researchers) who updated their membership profiles reported identifying as a sexual (lesbian, gay, bisexual, queer) or gender minority (nonbinary or transgender), respectively. No individual self-identified as transgender. Five percent (33 of 603) of women and 3% (80 of 3042) of men self-identified as a sexual minority (such as lesbian, gay, bisexual, or queer). AAOS members who self-identified as LGBTQ+ were younger (OR 0.99 [95% confidence interval (CI) 0.98 to 0.99]; p < 0.001), less likely to self-identify as women (OR 0.86 [95% CI 0.767 to 0.954]; p < 0.001), less likely to be underrepresented in medicine (OR 0.49 [95% CI 0.405 to 0.599]; p < 0.001), and less likely to be an emeritus or honorary member (OR 0.75 [95% CI 0.641 to 0.883]; p < 0.003). CONCLUSION The proportion of self-reported LGBTQ+ AAOS members is lower than the 7% of the general US population. The greater proportion of younger AAOS members reporting this information suggests progress in the pursuit of a more-diverse field. CLINICAL RELEVANCE The study findings support standardized collection of sexual orientation and gender identity data to better identify and address diversity gaps. As orthopaedic surgery continues to transform to reflect the diversity of musculoskeletal patients, all orthopaedic professionals (surgeons, clinicians, allied healthcare providers, and researchers), regardless of their identities, are essential in the mission to provide equitable and informed orthopaedic care. Sexual and gender minority individuals may serve as important mentors to the next generations of orthopaedic professionals; individuals from nonminority groups should serve as important allies in achieving this goal.
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Affiliation(s)
- Aliya G. Feroe
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Susan M. Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Julie B. Samora
- Department of Orthopaedic Surgery, Nationwide Children’s Hospital, Columbus, OH, USA
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Rytz CL, Miranda KT, Ronksley PE, Saad N, Raj SR, Somayaji R, Dumanski SM, Ganshorn H, Greene DN, Collister D, Newbert AM, Peace L, Ahmed SB. Association between serum estradiol and cardiovascular health among transgender adults using gender-affirming estrogen therapy. Am J Physiol Heart Circ Physiol 2024; 327:H340-H348. [PMID: 38578239 DOI: 10.1152/ajpheart.00151.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 04/06/2024]
Abstract
Gender-affirming estrogen therapy (GAET) is commonly used for feminization in transgender and nonbinary (TNB) individuals, yet the optimal rate of change (ROC) in estradiol levels for cardiovascular health is unclear. We examined the association between serum estradiol levels and cardiovascular-related mortality, adverse events, and risk factors in TNB adults using GAET. Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, and Web of Science were systematically searched (inception-April 2023) for original articles reporting serum estradiol levels and cardiovascular-related mortality, adverse events, and risk factors in TNB adults using GAET. Data extraction was completed in duplicate following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Stratified random effect meta-analyses using serum estradiol ROC (serum estradiolbaseline - serum estradiolfollow-up/study duration) was used to assess longitudinal studies (low, 0 < ROC ≤ 1 pg/mL/mo; moderate, 1 < ROC ≤ 3 pg/mL/mo; high, ROC ≥ 3 pg/mL/mo). Thirty-five studies (13 cross-sectional, 19 cohort, and 3 trials) were included. Two studies collectively reported 50 cardiovascular-related deaths, and four collectively reported 23 adverse cardiovascular events. Nineteen studies reporting cardiovascular risk factors were meta-analyzed by ROC stratum (low = 5; moderate = 6; high = 8), demonstrating an association between moderate [0.40, 95% confidence interval (CI): 0.22, 0.59 kg/m2, I2 = 28.2%] and high (0.46, 95% CI: 0.15, 0.78 kg/m2; I2 = 0.0%) serum estradiol ROC and increased body mass index. High (-6.67, 95% CI: -10.65, -2.68 mg/dL; I2 = 0.0%) serum estradiol ROC was associated with decreased low-density lipoproteins. Low (-7.05, 95% CI: -10.40, -3.70 mmHg; I2 = 0.0%) and moderate (-3.69, 95% CI: -4.93, -2.45 mmHg; I2 = 0.0%) serum estradiol ROCs were associated with decreases in systolic blood pressure. In TNB adults using GAET, serum estradiol ROC may influence cardiovascular risk factors, which may have implications for clinical cardiovascular outcomes.NEW & NOTEWORTHY In this systematic review and meta-analysis of 35 studies involving 7,745 participants, high rates of serum estradiol change were associated with small increases in body mass index. Moderate to high rates of change were associated with decreases in low-density lipoprotein. Low rates of change were associated with small decreases in systolic blood pressure. Rate of serum estradiol change in adults using gender-affirming estrogen therapy may influence cardiovascular risk factors, though further research is warranted.
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Affiliation(s)
- Chantal L Rytz
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Keila Turino Miranda
- Cardiovascular Health and Autonomic Regulation Laboratory, Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nathalie Saad
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Satish R Raj
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Ranjani Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Microbiology, Immunology and Infectious Disease, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Sandra M Dumanski
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Heather Ganshorn
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Dina N Greene
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, United States
| | - David Collister
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Sofia B Ahmed
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Women and Children's Health Research Institute, University of Alberta, Edmonton, Albert, Canada
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Nolan BJ, Cheung AS. Gender-affirming hormone therapy for transgender and gender-diverse adults in Australia. Intern Med J 2024. [PMID: 39056542 DOI: 10.1111/imj.16413] [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: 04/02/2024] [Accepted: 04/29/2024] [Indexed: 07/28/2024]
Abstract
Gender-affirming hormone therapy (GAHT) is used by many transgender and gender-diverse adults to align physical characteristics with their gender identity, reduce gender incongruence and improve psychological functioning. This narrative review provides an overview of the initiation and monitoring of GAHT in an Australian context. Trans individuals treated with testosterone typically receive standard testosterone doses and formulations recommended for cisgender men, whereas those receiving estradiol GAHT are typically treated with estradiol in combination with an anti-androgen in those without orchidectomy. Proactive monitoring and mitigation of cardiovascular risk factors is pertinent in all transgender and gender-diverse adults and bone health is an important consideration in those using estradiol GAHT.
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Affiliation(s)
- Brendan J Nolan
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia
- Equinox Gender Diverse Clinic, Thorne Harbour Health, Melbourne, Victoria, Australia
| | - Ada S Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia
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Ministrini S, Padro T. MicroRNA in cardiometabolic health and disease: The perspectives of sex, gender and personalised medicine. Eur J Clin Invest 2024; 54:e14223. [PMID: 38623918 DOI: 10.1111/eci.14223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Personalized medicine represents a novel and integrative approach that focuses on an individual's genetics and epigenetics, precision medicine, lifestyle and exposures as key players of health status and disease phenotypes. METHODS In this narrative review, we aim to carefully discuss the current knowledge on gender disparities in cardiometabolic diseases, and we consider the sex- specific expression of miRNAs and their role as promising tool in precision medicine. RESULTS Personalised medicine overcomes the restricted care of patient based on a binomial sex approach, by enriching itself with a holistic and dynamic gender integration. Recognized as a major worldwide health emergency, cardiometabolic disorders continue to rise, impacting on health systems and requiring more effective and targeted strategies. Several sex and gender drivers might affect the onset and progression of cardiometabolic disorders in males and females at multiple levels. In this respect, distinct contribution of genetic and epigenetic mechanisms, molecular and physiological pathways, sex hormones, visceral fat and subcutaneous fat and lifestyle lead to differences in disease burden and outcomes in males and females. CONCLUSIONS Sex and gender play a pivotal role in precision medicine because the influence the physiology of each individual and the way they interact with environment from intrauterine life.
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Affiliation(s)
- Stefano Ministrini
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Teresa Padro
- Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV) Instituto de Salud Carlos III, Madrid, Spain
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Sánchez Amador L, Becerra Fernández A, Aguilar Vilas MV, Rodríguez Torres R, Alonso Rodríguez MC. Body composition and risk for sarcopenia in transgender women. Nutrition 2024; 123:112398. [PMID: 38521048 DOI: 10.1016/j.nut.2024.112398] [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] [Received: 11/28/2023] [Revised: 01/18/2024] [Accepted: 02/13/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVES Body composition and strength of cisgender (cis) individuals are well established. However, those for transgender women (trans women) undergoing gender-affirming hormone therapy remain unclear. This study aimed to detect possible body composition and strength variations related to sarcopenia. METHODS This was a cross-sectional comparative study of 37 trans women, 34 cis men, and 34 cis women. Body composition was measured in all individuals by bioelectrical impedance analysis; prehensile strength by dynamometry was studied in trans women. RESULTS In this study, trans women had higher body mass index values than cis individuals (P < 0.01). Fat mass was 41% higher for trans women than cis men. Muscle mass (MM) was lower in trans women than cis men (-10%), and higher than cis women (24%). Bone mass was lower in trans women than cis men and higher in cis women (P < 0.01). Trans women's prehensile strengths were 25.26 kg for the right hand and 24.8 kg for the left. Appendicular skeletal muscle mass was 23.63 kg, and appendicular skeletal muscle mass index was 8.14 kg. CONCLUSION Trans women undergoing gender-affirming hormone therapy show a tendency to adapt body compartments to those of cis women with increased fat mass and reduced muscle mass. Prehensile strength in trans women was close to the cutoff points for sarcopenia risk. Nutrition, physical activity, strength, and body composition are important to avoid the possible risk for sarcopenia. More studies along these lines are necessary, especially in older adults.
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Affiliation(s)
- Laura Sánchez Amador
- Food, Nutrition and Public Health Strategies Research Group, University of Alcala, Alcalá de Henares, Madrid, Spain.
| | - Antonio Becerra Fernández
- Food, Nutrition and Public Health Strategies Research Group, University of Alcala, Alcalá de Henares, Madrid, Spain; Department of Biomedical Sciences, Faculty of Pharmacy, University of Alcala, Alcalá de Henares, Madrid, Spain
| | - María Victorina Aguilar Vilas
- Food, Nutrition and Public Health Strategies Research Group, University of Alcala, Alcalá de Henares, Madrid, Spain; Department of Biomedical Sciences, Faculty of Pharmacy, University of Alcala, Alcalá de Henares, Madrid, Spain
| | - Rosa Rodríguez Torres
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcala, Alcalá de Henares, Madrid, Spain
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Krasowski MD, Hines NG, Imborek KL, Greene DN. Impact of sex used for assignment of reference intervals in a population of patients taking gender-affirming hormones. J Clin Transl Endocrinol 2024; 36:100350. [PMID: 38737625 PMCID: PMC11087993 DOI: 10.1016/j.jcte.2024.100350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/19/2024] [Accepted: 04/29/2024] [Indexed: 05/14/2024] Open
Abstract
Background Gender-affirming hormone therapy with either estradiol or testosterone for transgender persons can significantly impact chemistry and hematology laboratory tests. The sex used for assignment of reference intervals (RIs) in the electronic health record (EHR) will influence normal/abnormal flagging of test results. Objective To analyze common non-hormonal laboratory tests with sex-specific RIs ordered in patients with sexual orientation/gender identify (SOGI) field differences (one or more differences between legal sex, sex assigned at birth, and gender identity) in the EHR at an academic medical center in midwestern United States. Methods We utilized a previously characterized data set of patients at our institution that included chart review information on gender identity and gender-affirming therapy. We focused on the subset of these patients that had orders for 18 common laboratory tests in calendar year 2021. Results A total of 1336 patients with SOGI field differences (1218 or 91.2% identifying as gender-expansive; 892 or 66.8% receiving estradiol or testosterone as gender-affirming therapy) had a total of 9374 orders for 18 laboratory tests with sex-specific RIs. Hemoglobin, creatinine, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and high-density lipoprotein were the most frequently ordered tests. For patients taking estradiol, 128 of 970 (13.2%) creatinine and 39 of 193 (20.2%) hemoglobin measurements were within the RI for one sex but not the other. For those taking testosterone, 119 of 531 (22.4%) creatinine and 49 of 120 (40.8%) hemoglobin measurements were within the RI for one sex but not the other. Values above the cisgender female RI but within the cisgender male RI were common for hemoglobin, alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase in patients taking testosterone. Conclusions Clinicians should be aware of the potential impact of gender-affirming therapy on laboratory tests and what sex/gender is being used in the EHR to assign RIs.
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Affiliation(s)
- Matthew D. Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Nicole G. Hines
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
- Carver College of Medicine, University of Iowa, Iowa City, IA, 52242, USA
| | | | - Dina N. Greene
- Department of Laboratory Medicine, University of Washington, Seattle, WA, 98195, USA
- LetsGetChecked Laboratories, Monrovia, CA, 91016, USA
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Pei Q, Song Y, Huang Z, Yu H, Xu H, Ye X, Gao L, Gong J, Tian X. Effects of gender-affirming hormone therapy on body fat: a retrospective case‒control study in Chinese transwomen. Lipids Health Dis 2024; 23:146. [PMID: 38760846 PMCID: PMC11100057 DOI: 10.1186/s12944-024-02131-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND There is insufficient research on how gender-affirming hormone therapy (GAHT) affects body fat modifications in transwomen from China. It is unclear whether hormone therapy affects the prevalence of obesity and blood lipid levels within this population. The current research aimed to assess how GAHT and treatment duration had an impact on the change in and redistribution of body fat in Chinese transwomen. METHODS This study included 40 transwomen who had not received GAHT and 59 who had. Body fat, blood lipid, and blood glucose levels were measured. GAHT is mainly a pharmacologic (estrogen and anti-androgen) treatment. The study also stratified participants based on the duration of GAHT to assess its impact on body fat distribution. The duration of GAHT was within one year, one to two years, two to three years, or more than three years. RESULTS After receiving GAHT, total body fat increased by 19.65%, and the percentage of body fat increased by 17.63%. The arm, corrected leg, and leg regions showed significant increases in fat content (+ 24.02%, + 50.69%, and + 41.47%, respectively) and percentage (+ 25.19%, + 34.90%, and + 30.39%, respectively). The total visceral fat content decreased (-37.49%). Based on the diagnostic standards for a body mass index ≥ 28 or total body fat percentage ≥ 25% or 30%, the chance of developing obesity did not change significantly. Blood glucose levels significantly increased (+ 12.31%). Total cholesterol levels (-10.45%) decreased significantly. Fat changes in those who received GAHT for one to two years were significantly different from those who did not receive GAHT. CONCLUSION After receiving GAHT, total body fat and regional fat increased in Chinese transwomen, and the body fat distribution changed from masculine to feminine, especially during the first two years. However, neither the increase in total body fat percentage nor the decrease in visceral fat content didn't bring about significant changes in the incidence of obesity, nor did triglycerides or low-density lipoprotein-cholesterol.
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Affiliation(s)
- Qin Pei
- School of Nursing, Jinan University, No. 601, West Huangpu Avenue, Guangzhou, Guangdong, 510632, China
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, No. 613, West Huangpu Avenue, Guangzhou, Guangdong, 510630, China
| | - Yuwei Song
- Central Laboratory, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhongwei Huang
- Department of Obstetrics and Gynaecology, National University Health Systems, Singapore, Singapore
| | - Hongkun Yu
- Department of Nuclear Medicine, The First Affiliated Hospital of Jinan University, No. 613, West Huangpu Avenue, Guangzhou, Guangdong, 510630, China
| | - Hao Xu
- Department of Nuclear Medicine, The First Affiliated Hospital of Jinan University, No. 613, West Huangpu Avenue, Guangzhou, Guangdong, 510630, China
| | - Xunda Ye
- Central Laboratory, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Lvfen Gao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Jinan University, No. 613, West Huangpu Avenue, Guangzhou, Guangdong, 510630, China.
| | - Jian Gong
- Department of Nuclear Medicine, The First Affiliated Hospital of Jinan University, No. 613, West Huangpu Avenue, Guangzhou, Guangdong, 510630, China.
| | - Xiaoying Tian
- School of Nursing, Jinan University, No. 601, West Huangpu Avenue, Guangzhou, Guangdong, 510632, China.
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Jasuja GK, Wolfe HL, Reisman JI, Vimalananda VG, Rao SR, Blosnich JR, Livingston NA, Shipherd JC. Clinicians in the Veterans Health Administration initiate gender-affirming hormone therapy in concordance with clinical guideline recommendations. Front Endocrinol (Lausanne) 2024; 15:1086158. [PMID: 38800485 PMCID: PMC11116601 DOI: 10.3389/fendo.2024.1086158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/22/2024] [Indexed: 05/29/2024] Open
Abstract
Background Gender-affirming hormone therapy (GAHT) is a common medical intervention sought by transgender and gender diverse (TGD) individuals. Initiating GAHT in accordance with clinical guideline recommendations ensures delivery of high-quality care. However, no prior studies have examined how current GAHT initiation compares to recommended GAHT initiation. Objective This study assessed guideline concordance around feminizing and masculinizing GAHT initiation in the Veterans Health Administration (VHA). Methods The sample included 4,676 veterans with a gender identity disorder diagnosis who initiated feminizing (n=3,547) and masculinizing (n=1,129) GAHT between 2007 and 2018 in VHA. Demographics and health conditions on veterans receiving feminizing and masculinizing GAHT were assessed. Proportion of guideline concordant veterans on six VHA guidelines on feminizing and masculinizing GAHT initiation were determined. Results Compared to veterans receiving masculinizing GAHT, a higher proportion of veterans receiving feminizing GAHT were older (≥60 years: 23.7% vs. 6.3%), White non-Hispanic (83.5% vs. 57.6%), and had a higher number of comorbidities (≥7: 14.0% vs. 10.6%). A higher proportion of veterans receiving masculinizing GAHT were Black non-Hispanic (21.5% vs. 3.5%), had posttraumatic stress disorder (43.0% vs. 33.9%) and positive military sexual trauma (33.5% vs.16.8%; all p-values<0.001) than veterans receiving feminizing GAHT. Among veterans who started feminizing GAHT with estrogen, 97.0% were guideline concordant due to no documentation of contraindication, including venous thromboembolism, breast cancer, stroke, or myocardial infarction. Among veterans who started spironolactone as part of feminizing GAHT, 98.1% were guideline concordant as they had no documentation of contraindication, including hyperkalemia or acute renal failure. Among veterans starting masculinizing GAHT, 90.1% were guideline concordant due to no documentation of contraindications, such as breast or prostate cancer. Hematocrit had been measured in 91.8% of veterans before initiating masculinizing GAHT, with 96.5% not having an elevated hematocrit (>50%) prior to starting masculinizing GAHT. Among veterans initiating feminizing and masculinizing GAHT, 91.2% had documentation of a gender identity disorder diagnosis prior to GAHT initiation. Conclusion We observed high concordance between current GAHT initiation practices in VHA and guidelines, particularly for feminizing GAHT. Findings suggest that VHA clinicians are initiating feminizing GAHT in concordance with clinical guidelines. Future work should assess guideline concordance on monitoring and management of GAHT in VHA.
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Affiliation(s)
- Guneet K. Jasuja
- Center for Healthcare Organization & Implementation Research, Veteran Affairs (VA) Bedford Healthcare System, Bedford, MA, United States
- Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States
| | - Hill L. Wolfe
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
- Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT, United States
| | - Joel I. Reisman
- Center for Healthcare Organization & Implementation Research, Veteran Affairs (VA) Bedford Healthcare System, Bedford, MA, United States
| | - Varsha G. Vimalananda
- Center for Healthcare Organization & Implementation Research, Veteran Affairs (VA) Bedford Healthcare System, Bedford, MA, United States
- Section of Endocrinology, Diabetes, Nutrition and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Sowmya R. Rao
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States
| | - John R. Blosnich
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, United States
| | - Nicholas A. Livingston
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, United States
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Jillian C. Shipherd
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, United States
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
- LGBTQ+ Health Program, Office of Patient Care Services, Department of Veterans Affairs, Washington, DC, United States
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Dix C, Moloney M, Tran HA, McFadyen JD. Venous Thromboembolism and Estrogen-Containing Gender-Affirming Hormone Therapy. Thromb Haemost 2024; 124:387-398. [PMID: 37816389 DOI: 10.1055/a-2188-8898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
Gender-affirming therapy involves the use of hormones to develop the physical characteristics of the identified gender and suppressing endogenous sex hormone production. Venous thromboembolism (VTE) is a known risk of exogenous estrogen therapy, and while evidence of VTE risk among transgender women using modern gender-affirming hormone therapy (GAHT) is still emerging, it is thought to affect up to 5% of transgender women. Historically, GAHT was associated with a high risk of VTE; however, modern preparations are less thrombogenic mainly due to significantly lower doses used as well as different preparations. This review presents the available literature regarding the following four topics: (1) risk of VTE among transgender women receiving estradiol GAHT, (2) how the route of administration of estradiol affects the VTE risk, (3) perioperative management of GAHT, (4) VTE risk among adolescents on GAHT. There is a need for large, longitudinal studies of transgender women using GAHT to further characterize VTE risk and how this is affected by factors such as patient age, duration of GAHT use, tobacco use, body mass index, and comorbidities. Future studies in these areas could inform the development of clinical guidelines to improve the care of transgender people.
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Affiliation(s)
- Caroline Dix
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
| | - Mollie Moloney
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
| | - Huyen A Tran
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
| | - James D McFadyen
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
- Atherothrombosis and Vascular Biology Program, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
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10
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de Barros VIPVL, de Oliveira ALML, do Nascimento DJ, Zlotnik E, Teruchkin MM, Marques MA, Margarido PFR. Use of hormones and risk of venous thromboembolism. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2024; 46:e-FPS02. [PMID: 38765519 PMCID: PMC11075397 DOI: 10.61622/rbgo/2024fps02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
•The risk of venous thromboembolism (VTE) is not increased in women using long-acting reversible contraceptive methods (LARCs) with progestogens. •Oral contraceptives with levonorgestrel or norgestimate confer half the risk of VTE compared to oral contraceptives containing desogestrel, gestodene or drospirenone. •Progestogen-only pills do not confer an increased risk of VTE. •Women using transdermal contraceptive patches and combined oral contraceptives (COCs) are at an approximately eight times greater risk of VTE than non-users of hormonal contraceptives (HCs), corresponding to 9.7 events per 10,000 women/years. •Vaginal rings increase the risk of VTE by 6.5 times compared to not using HC, corresponding to 7.8 events per 10,000 women/years. •Several studies have demonstrated an increased risk of VTE in transgender individuals receiving hormone therapy (HT). •Hormone therapy during menopause increases the risk of VTE by approximately two times, and this risk is increased by obesity, thrombophilia, age over 60 years, surgery and immobilization. •The route of estrogen administration, the dosage and type of progestogen associated with estrogen may affect the risk of VTE in the climacteric. •Combined estrogen-progesterone therapy increases the risk of VTE compared to estrogen monotherapy. •Postmenopausal HT increases the risk of thrombosis at atypical sites.
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Affiliation(s)
- Venina Isabel Poço Viana Leme de Barros
- Clínica Obstétrica Hospital das Clínicas Universidade de São Paulo São PauloSP Brasil Clínica Obstétrica, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - André Luiz Malavasi Longo de Oliveira
- Clínica Obstétrica Hospital das Clínicas Universidade de São Paulo São PauloSP Brasil Clínica Obstétrica, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Denis Jose do Nascimento
- Departamento de Obstetrícia e Ginecologia Faculdade de Medicina Universidade Federal do Paraná CuritibaPR Brasil Departamento de Obstetrícia e Ginecologia, Faculdade de Medicina, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Eduardo Zlotnik
- Hospital Israelita Albert Einstein São PauloSP Brasil Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
| | - Marcelo Melzer Teruchkin
- Hospital Moinhos de Vento Porto AlegreRS Brasil Hospital Moinhos de Vento, Porto Alegre, RS, Brasil
| | - Marcos Arêas Marques
- Universidade do Estado do Rio de Janeiro Rio de JaneiroRJ Brasil Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
- Universidade Federal do Estado do Rio de Janeiro Rio de JaneiroRJ Brasil Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Paulo Francisco Ramos Margarido
- Hospital Universitário Universidade de São Paulo São PauloSP Brasil Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brasil
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11
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Pal S, Morgan X, Dar HY, Gacasan CA, Patil S, Stoica A, Hu YJ, Weitzmann MN, Jones RM, Pacifici R. Gender-affirming hormone therapy preserves skeletal maturation in young mice via the gut microbiome. J Clin Invest 2024; 134:e175410. [PMID: 38530358 DOI: 10.1172/jci175410] [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] [Received: 09/01/2023] [Accepted: 03/20/2024] [Indexed: 03/27/2024] Open
Abstract
Gender-affirming hormone therapy (GAHT) is often prescribed to transgender (TG) adolescents to alleviate gender dysphoria, but the effect of GAHT on the growing skeleton is unclear. We found GAHT to improve trabecular bone structure via increased bone formation in young male mice and not to affect trabecular structure in female mice. GAHT modified gut microbiome composition in both male and female mice. However, fecal microbiota transfers (FMTs) revealed that GAHT-shaped gut microbiome was a communicable regulator of bone structure and turnover in male, but not in female mice. Mediation analysis identified 2 species of Bacteroides as significant contributors to the skeletal effects of GAHT in male mice, with Bacteroides supplementation phenocopying the effects of GAHT on bone. Bacteroides have the capacity to expand Treg populations in the gut. Accordingly, GAHT expanded intestinal Tregs and stimulated their migration to the bone marrow (BM) in male but not in female mice. Attesting to the functional relevance of Tregs, pharmacological blockade of Treg expansion prevented GAHT-induced bone anabolism. In summary, in male mice GAHT stimulated bone formation and improved trabecular structure by promoting Treg expansion via a microbiome-mediated effect, while in female mice, GAHT neither improved nor impaired trabecular structure.
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Affiliation(s)
- Subhashis Pal
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine and
- Emory Microbiome Research Center, Emory University, Atlanta, Georgia, USA
| | - Xochitl Morgan
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Hamid Y Dar
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine and
- Emory Microbiome Research Center, Emory University, Atlanta, Georgia, USA
| | - Camilo Anthony Gacasan
- Emory Microbiome Research Center, Emory University, Atlanta, Georgia, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics and
| | - Sanchiti Patil
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine and
- Emory Microbiome Research Center, Emory University, Atlanta, Georgia, USA
| | - Andreea Stoica
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine and
- Emory Microbiome Research Center, Emory University, Atlanta, Georgia, USA
| | - Yi-Juan Hu
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia, USA
| | - M Neale Weitzmann
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine and
- Emory Microbiome Research Center, Emory University, Atlanta, Georgia, USA
- Atlanta VA Healthcare System, Atlanta, Georgia, USA
| | - Rheinallt M Jones
- Emory Microbiome Research Center, Emory University, Atlanta, Georgia, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics and
| | - Roberto Pacifici
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine and
- Emory Microbiome Research Center, Emory University, Atlanta, Georgia, USA
- Immunology and Molecular Pathogenesis Program, Emory University, Atlanta, Georgia, USA
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12
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Lad SU, Sinopoli J, Khong B, Conroy B, Perzynski AT, Del Rincon JP. Clinical and sociodemographic characteristics as predictors for quality of life in transmasculine and transfeminine individuals receiving gender-affirming hormone therapy. Soc Sci Med 2024:116734. [PMID: 38490912 DOI: 10.1016/j.socscimed.2024.116734] [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: 05/25/2023] [Revised: 02/14/2024] [Accepted: 02/26/2024] [Indexed: 03/17/2024]
Abstract
Healthcare systems and providers have increasingly acknowledged the role and impact of social determinants in overall health. However, gender-diverse individuals face persistent health disparities due to their identities. There is limited research on the impact of clinical and sociodemographic characteristics on mood and quality of life (QoL) for transgender (TG) individuals. Our study aims to understand and better elucidate social and clinical characteristics of transmasculine (TM) and transfeminine (TF) individuals and their impact on quality of life and depressive symptoms. In this cross-sectional study, 298 TF and TM individuals on gender-affirming hormone therapy (GAHT) were surveyed about their demographic characteristics (age, gender identity, body mass index (BMI), and education), social needs, mood, and quality of life. Multivariable regression modelling was performed to assess the effect of each variable listed above on three domains of QoL (psychological, environmental, and physical) as well as depressive symptoms. We find that QoL scores are similar between TM and TF individuals, with scores in the psychological domain particularly low in both cohorts. TM individuals report higher rates of stress and restroom avoidance than TF individuals. In particular, psychological well-being (measured by the psychological domain of QoL and depressive symptoms) is significantly associated with increased BMI, financial instability, and stress in TM individuals while for TF individuals, psychological well-being is associated with stress and social integration. These data suggest that social circumstances are key drivers of QoL and psychological well-being among gender-diverse individuals receiving GAHT with specific differences between TF and TM individuals. This information may be utilized by healthcare providers and policymakers to address and improve clinical care and social policies to improve health equity for gender-diverse individuals.
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Affiliation(s)
- Saloni U Lad
- Cleveland Clinic Lerner College of Medicine, 9501 Euclid Ave., Cleveland, OH, 44195, USA.
| | - Jacob Sinopoli
- The Chester Summer Scholars Program, MetroHealth Medical System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA; Case Western Reserve University, Cleveland, OH, USA.
| | - Brian Khong
- Department of Medicine, MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
| | - Britt Conroy
- Case Western Reserve University, Cleveland, OH, USA; Department of Urology and Family Medicine & Community Health, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH, 44106, USA.
| | - Adam T Perzynski
- Center for Healthcare Research and Policy, Case Western Reserve University at MetroHealth, 10900 Euclid Ave., Cleveland, OH, 44106, USA.
| | - Juan P Del Rincon
- Case Western Reserve University, Cleveland, OH, USA; Department of Medicine, MetroHealth System, Cleveland, OH, USA; Endocrinology and Metabolism Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA.
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13
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Morssinkhof MWL, Wiepjes CM, van den Heuvel OA, Kreukels BPC, van der Tuuk K, T'Sjoen G, den Heijer M, Broekman BFP. Changes in depression symptom profile with gender-affirming hormone use in transgender persons. J Affect Disord 2024; 348:323-332. [PMID: 38154588 DOI: 10.1016/j.jad.2023.12.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/10/2023] [Accepted: 12/23/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Women show higher prevalence of depression and different symptomatology than men, possibly influenced by sex hormones. Many transgender persons, who face a high risk of depression, use Gender-Affirming Hormone Therapy (GAHT), but the impact of GAHT on depressive symptom profiles is unknown. METHODS This study examined depressive symptoms in transgender persons before GAHT and after 3- and 12 months of GAHT. We used the Inventory of Depressive Symptomatology-Self Report to assess depressive symptoms, exploratory factor analysis (EFA) to assess symptom clusters, and linear mixed models to assess changes in symptom clusters. RESULTS This study included 110 transmasculine (TM) and 89 transfeminine (TF) participants. EFA revealed four symptom clusters: mood, anxiety, lethargy, and somatic symptoms. Changes in total depressive symptoms significantly differed between TM and TF groups. After 3 months of GAHT, TM participants reported improvement in lethargy (-16 %; 95%CI: -29 %; -2 %), and after 12 months TF participants reported worsening in low mood (24 %; 95%CI: 3 %; 51 %), but absolute score changes were modest. Neither group showed changes in anxiety or somatic symptoms. LIMITATIONS This study had limited sample sizes at 12 months follow-up and did not include relevant biological or psychosocial covariates. DISCUSSION Changes in depressive symptoms after GAHT use differ in TM and TF persons: TM persons report slight improvements in lethargy, whereas TF persons report a slight increase in low mood. Starting GAHT represents a significant life event with profound social and physical effects, and further research should assess social and biological effects of GAHT on mood-related symptoms.
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Affiliation(s)
- Margot W L Morssinkhof
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Department of Endocrinology and Metabolism, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Department of Psychiatry and Medical Psychology, OLVG, Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands.
| | - Chantal M Wiepjes
- Department of Endocrinology and Metabolism, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - Odile A van den Heuvel
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Department of Anatomy and Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Amsterdam Neurosciences, Compulsivity Impulsivity and Attention, Amsterdam, the Netherlands
| | - Baudewijntje P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Department of Medical Psychology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - Karin van der Tuuk
- Department of Obstetrics and Gynecology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Guy T'Sjoen
- Dept. of Endocrinology and Centre for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - Martin den Heijer
- Department of Endocrinology and Metabolism, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - Birit F P Broekman
- Department of Psychiatry, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands; Department of Psychiatry and Medical Psychology, OLVG, Amsterdam, the Netherlands; Amsterdam Public Health, Mental Health Program, Amsterdam, the Netherlands
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14
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Antunes Junior N, Galuppo AG, Soares JB, Glina S. Restructuring healthcare services, routines and procedures on reproductive medicine based on respect for differences. JBRA Assist Reprod 2024; 28:96-102. [PMID: 38224575 PMCID: PMC10936915 DOI: 10.5935/1518-0557.20230061] [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] [Received: 02/23/2023] [Accepted: 08/31/2023] [Indexed: 01/17/2024] Open
Abstract
Although the term homosexuality was removed from the International Classification of Diseases and trans identities from mental disorders, these classifications promote the pathologizing of homosexuality. The direct consequence is discrimination, which adds to the difficulty in carrying out accurate information related to the LGBT population and makes it very difficult to organize public policies suited to their needs. An important issue is related to the limited access of that population to assisted reproduction techniques, when compared to traditional families. The desire for same sex couples and transgender persons to have biological children is reportedly the same as for cisgender persons, but parenthood can be a much greater endeavor both medically and psychologically for them. The right to health includes freedom to control one's health and body, including sexual and reproductive issues. Despite these difficulties, we are living in a period of great social progress that increases access to assisted reproduction among novel patient populations. With legalization of gay marriage, individuals and couples who identify as lesbian, gay, bisexual and transgender, may seek to begin or expand their families with assisted reproduction technologies. Therefore, the aim of this review was to assist in the restructuring of healthcare services, routines and procedures, mainly related to reproductive medicine, in order to promote changes in values based on respect for differences. In conclusion, the healthcare personnel of fertility centers should undergo specific training and preparations to meet the specific demands of the LGBT patient population and to overcome communication barriers.
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Affiliation(s)
- Nelson Antunes Junior
- Clinica Pluris, Director - São Paulo, SP, Brazil
- ALFA Project, Director - São Paulo, SP, Brazil
| | | | - Jonathas Borges Soares
- Clinica Pluris, Director - São Paulo, SP, Brazil
- ALFA Project, Director - São Paulo, SP, Brazil
| | - Sidney Glina
- Clinica Pluris, Director - São Paulo, SP, Brazil
- Clinica Pluris, Researcher - São Paulo, SP, Brazil
- Discipline of Urology at Centro Universitário - FMABC -
Santo André, SP, Brazil
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15
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Kielb J, Saffak S, Weber J, Baensch L, Shahjerdi K, Celik A, Farahat N, Riek S, Chavez-Talavera O, Grandoch M, Polzin A, Kelm M, Dannenberg L. Transformation or replacement - Effects of hormone therapy on cardiovascular risk. Pharmacol Ther 2024; 254:108592. [PMID: 38286163 DOI: 10.1016/j.pharmthera.2024.108592] [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] [Received: 11/30/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 01/31/2024]
Abstract
Hormone therapy (HT) is important and frequently used both regarding replacement therapy (HRT) and gender affirming therapy (GAHT). While HRT has been effective in addressing symptoms related to hormone shortage, several side effects have been described. In this context, there are some studies that show increased cardiovascular risk. However, there are also studies reporting protective aspects of HT. Nevertheless, the exact impact of HT on cardiovascular risk and the underlying mechanisms remain poorly understood. This article explores the relationship between diverse types of HT and cardiovascular risk, focusing on mechanistic insights of the underlying hormones on platelet and leukocyte function as well as on effects on endothelial and adipose tissue cells.
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Affiliation(s)
- Julia Kielb
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Germany
| | - Süreyya Saffak
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Germany
| | - Jessica Weber
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Germany
| | - Leonard Baensch
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Germany
| | - Khatereh Shahjerdi
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Germany
| | - Aylin Celik
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Germany
| | - Nora Farahat
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Germany
| | - Sally Riek
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Germany
| | - Oscar Chavez-Talavera
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Germany
| | - Maria Grandoch
- Institute for Translational Pharmacology, Medical Faculty and University Hospital of Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Amin Polzin
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Germany
| | - Lisa Dannenberg
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Cardiovascular Research Institute Düsseldorf (CARID), Germany.
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16
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van Zijverden LM, Wiepjes CM, van Diemen JJK, Thijs A, den Heijer M. Cardiovascular disease in transgender people: a systematic review and meta-analysis. Eur J Endocrinol 2024; 190:S13-S24. [PMID: 38302717 DOI: 10.1093/ejendo/lvad170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Hormone therapy in transgender people might be associated with an increased risk of cardiovascular disease (CVD). We aimed to investigate whether the risk of CVD is increased in transgender people compared with people of the same birth sex. DESIGN AND METHODS PubMed, Cochrane, Embase, and Google Scholar were searched until July 2022. Studies evaluating cardiovascular events in transgender women or men were included. Primary outcomes were stroke, myocardial infarction (MI), and venous thromboembolism (VTE). The risk for transgender women versus cisgender men and for transgender men versus cisgender women was analysed through random-effects meta-analysis. RESULTS Twenty-two studies involving 19 893 transgender women, 14 840 transgender men, 371 547 cisgender men, and 434 700 cisgender women were included. The meta-analysis included 10 studies (79% of transgender women and 76% of transgender men). In transgender women, incidence of stroke was 1.8%, which is 1.3 (95% confidence interval [CI], 1.0-1.8) times higher than in cisgender men. Incidence of MI was 1.2%, with a pooled relative risk of 1.0 (95% CI, 0.8-1.2). Venous thromboembolism incidence was 1.6%, which is 2.2 (95% CI, 1.1-4.5) times higher. Stroke occurred in 0.8% of transgender men, which is 1.3 (95% CI, 1.0-1.6) times higher compared with cisgender women. Incidence of MI was 0.6%, with a pooled relative risk of 1.7 (95% CI, 0.8-3.6). For VTE, this was 0.7%, being 1.4 (95% CI, 1.0-2.0) times higher. CONCLUSIONS Transgender people have a 40% higher risk of CVD compared with cisgender people of the same birth sex. This emphasizes the importance of cardiovascular risk management. Future studies should assess the potential influence of socio-economic and lifestyle factors.
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Affiliation(s)
- Lieve Mees van Zijverden
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam,De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
| | - Chantal Maria Wiepjes
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam,De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
| | - Jeske Joanna Katarina van Diemen
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
| | - Abel Thijs
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
| | - Martin den Heijer
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam,De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
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17
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Cheung AS, Zwickl S, Miller K, Nolan BJ, Wong AFQ, Jones P, Eynon N. The Impact of Gender-Affirming Hormone Therapy on Physical Performance. J Clin Endocrinol Metab 2024; 109:e455-e465. [PMID: 37437247 PMCID: PMC10795902 DOI: 10.1210/clinem/dgad414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/14/2023]
Abstract
CONTEXT The inclusion of transgender people in elite sport has been a topic of debate. This narrative review examines the impact of gender-affirming hormone therapy (GAHT) on physical performance, muscle strength, and markers of endurance. EVIDENCE ACQUISITION MEDLINE and Embase were searched using terms to define the population (transgender), intervention (GAHT), and physical performance outcomes. EVIDENCE SYNTHESIS Existing literature comprises cross-sectional or small uncontrolled longitudinal studies of short duration. In nonathletic trans men starting testosterone therapy, within 1 year, muscle mass and strength increased and, by 3 years, physical performance (push-ups, sit-ups, run time) improved to the level of cisgender men. In nonathletic trans women, feminizing hormone therapy increased fat mass by approximately 30% and decreased muscle mass by approximately 5% after 12 months, and steadily declined beyond 3 years. While absolute lean mass remains higher in trans women, relative percentage lean mass and fat mass (and muscle strength corrected for lean mass), hemoglobin, and VO2 peak corrected for weight was no different to cisgender women. After 2 years of GAHT, no advantage was observed for physical performance measured by running time or in trans women. By 4 years, there was no advantage in sit-ups. While push-up performance declined in trans women, a statistical advantage remained relative to cisgender women. CONCLUSION Limited evidence suggests that physical performance of nonathletic trans people who have undergone GAHT for at least 2 years approaches that of cisgender controls. Further controlled longitudinal research is needed in trans athletes and nonathletes.
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Affiliation(s)
- Ada S Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg 3084, Australia
| | - Sav Zwickl
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
| | | | - Brendan J Nolan
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg 3084, Australia
| | - Alex Fang Qi Wong
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
| | - Patrice Jones
- Institute for Health and Sport (IHeS), Victoria University, Footscray 3011, Australia
| | - Nir Eynon
- Institute for Health and Sport (IHeS), Victoria University, Footscray 3011, Australia
- Australian Regenerative Medicine Institute, Monash University, Clayton 3800, Australia
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18
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Kim E, Park H, Cho Y, Jeon K, An H. Invisibility and Stigma: Experiences of Transgender and Gender Non-Conforming Individuals in South Korea. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:77-90. [PMID: 37950133 DOI: 10.1007/s10508-023-02730-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 09/26/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023]
Abstract
In this qualitative study, we explored the challenges that transgender and gender non-confirming (TGNC) individuals face in South Korea. For this, we conducted in-depth interviews with 14 South Korean TGNC younger adults attending colleges or graduate schools and analyzed their data through consensus qualitative research. Analyses revealed that issues related to interpersonal relationships and medical transiting were major challenges perceived by participants. Four categories emerged in the domain of challenges in interpersonal relationships, including issues associated with family, romantic partner, coming out and outing, and transphobia and cisnormativity. In addition, two categories (i.e., medical difficulties and physical appearance-related distress) were included in the domain of challenges related to medical transition. Unique sources of stress for South Korean TGNC younger adults included high risk of being outed due to Korean resident registration numbers, dissatisfaction with bodily changes when transitioning, and misgendering caused by Korean's different honorific titles depending on gender.
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Affiliation(s)
- Eunha Kim
- Department of Psychology, Ajou University, 206 Worldcupro, Suwon, 16499, South Korea.
| | - Hyun Park
- Department of Psychology, Ajou University, 206 Worldcupro, Suwon, 16499, South Korea
| | - YeJi Cho
- Department of Psychology, Ajou University, 206 Worldcupro, Suwon, 16499, South Korea
| | - KyungAh Jeon
- Department of Psychology, Ajou University, 206 Worldcupro, Suwon, 16499, South Korea
| | - Hyunju An
- Department of Psychology, Ajou University, 206 Worldcupro, Suwon, 16499, South Korea
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Snyder L, Hebert KJ, Horns JJ, Schardein J, McCormick BJ, Downing J, Dy GW, Goodwin I, Agarwal C, Hotaling JM, Myers JB. Incidence and Risk Factors for Postoperative Venous Thromboembolism After Gender Affirming Vaginoplasty: A Retrospective Analysis of a Large Insurance Claims Database. Urology 2023; 182:95-100. [PMID: 37774849 DOI: 10.1016/j.urology.2023.08.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/20/2023] [Accepted: 08/14/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVES To investigate the incidence and associated risk factors of venous thromboembolism (VTE) after gender affirming vaginoplasty. METHODS We searched International Business Machines Corporation (IBM) Marketscan, a commercial claims database, for Current Procedural Terminology and International Classification of Diseases (ICD) procedure codes to identify patients who underwent gender affirming vaginoplasty from 2011-2020. We quantified deep venous thrombosis and pulmonary embolism using ICD-9 and ICD-10 codes found within 90 days after surgery. Univariate and multivariate analyses were performed to establish association between VTE events and age, residency location, and comorbidities. RESULTS We identified 1588 patients who underwent gender affirming vaginoplasty. Overall, 1.1% of patients experienced a VTE within 90 days following surgery. Patients who experienced postoperative VTE were older, more likely to have had a prior VTE, less likely to be from an urban area, and more likely to have a higher Charlson Comorbidity Index score. Among patients with postoperative VTE, 47.1% had previous VTE. Among patients without a postoperative VTE, 1.3% had previous VTE. CONCLUSION In patients undergoing gender affirming vaginoplasty, the incidence of postoperative VTE was 1.1%. Older age, rurality, increased comorbidities, and prior VTE were associated with increased risk of postoperative VTE. Current guidelines do not recommend cessation of gender affirming hormone therapy (GAHT) prior to vaginoplasty. Further research is needed to evaluate if certain high-risk patients would benefit from perioperative adjustment of GAHT or perioperative VTE prophylaxis.
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Affiliation(s)
- Liem Snyder
- Division of Urology, University of Utah, Salt Lake City, UT.
| | - Kevin J Hebert
- Division of Urology, University of Utah, Salt Lake City, UT.
| | - Joshua J Horns
- Division of Urology, University of Utah, Salt Lake City, UT.
| | | | | | - Jae Downing
- Oregon Health and Science University, Portland, OR.
| | - Geolani W Dy
- Oregon Health and Science University, Portland, OR.
| | - Isak Goodwin
- Division of Plastic Surgery, University of Utah, Salt Lake City, UT.
| | - Cori Agarwal
- Division of Plastic Surgery, University of Utah, Salt Lake City, UT.
| | | | - Jeremy B Myers
- Division of Urology, University of Utah, Salt Lake City, UT.
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Lopez DS, Mulla JS, El Haddad D, Tahashilder MI, Polychronopolou E, Baillargeon J, Kuo YF, Gilani S, Khalife WI. Testosterone Replacement Therapy in Relation With Cardiovascular Disease in Cisgender Women and Transgender People. J Clin Endocrinol Metab 2023; 108:e1515-e1523. [PMID: 37392459 PMCID: PMC10655536 DOI: 10.1210/clinem/dgad388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 07/03/2023]
Abstract
AIMS This study aimed to investigate the association of testosterone replacement therapy (TTh) with risk of cardiovascular disease (CVD), and CVD-specific outcomes, in cisgender women and transgender population, and to determine whether this association varies by menopausal status. METHODS In 25 796 cisgender women and 1580 transgender people (≥30 years old) who were enrolled in the Optum's deidentified Clinformatics Data Mart Database (2007-2021), we identified 6288 pre- and postmenopausal cisgender women and 262 transgender people diagnosed with incident composite of CVD (coronary artery disease [CAD], congestive heart failure, stroke, and myocardial infarction). Prediagnostic prescription of TTh was ascertained for this analysis. Multivariable adjusted Cox proportional hazards models were used to examine the independent association of TTh with incident CVD. RESULTS We found a 24% increased risk of CVD (hazard ratio [HR] = 1.24; 95% CI, 1.15-1.34), 26% risk of CAD (HR = 1.26; 95% CI, 1.14-1.39), and a 29% risk of stroke (HR = 1.29; 95% CI, 1.14-1.45) after comparing cisgender women who used TTh with nonusers. Stratification by age group showed similar effects of TTh on CVD, CAD, and stroke. Among transgender people, TTh did not increase the risk of composite CVD, including by age stratification. CONCLUSION Use of TTh increased the risk of CVD, CAD, and stroke among cisgender women but not among transgender people. TTh is becoming more widely accepted in women, and it is the main medical treatment for transgender males. Therefore, use of TTh should be further investigated for the prevention of CVD.
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Affiliation(s)
- David S Lopez
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX 77555-0553, USA
| | - Juwairia S Mulla
- Division of Cardiology, Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555-0553, USA
| | - Danielle El Haddad
- Division of Cardiology, Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555-0553, USA
| | - Md Ibrahim Tahashilder
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX 77555-0553, USA
| | - Efstathia Polychronopolou
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX 77555-0553, USA
| | - Jacques Baillargeon
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX 77555-0553, USA
| | - Yong-Fang Kuo
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX 77555-0553, USA
| | - Syed Gilani
- Division of Cardiology, Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555-0553, USA
| | - Wissam I Khalife
- Division of Cardiology, Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555-0553, USA
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21
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Bobba R, Kalra P, Dharmalingam M. Study of Effects of Gender-Affirming Hormone Therapy on Bone Mineral Density in Individuals with Gender Dysphoria. Indian J Endocrinol Metab 2023; 27:486-491. [PMID: 38371188 PMCID: PMC10871006 DOI: 10.4103/ijem.ijem_265_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 09/24/2023] [Indexed: 02/20/2024] Open
Abstract
Introduction Gender affirming hormone therapy (GAHT) is the mainstay treatment in transitioning individuals and has positive physical and psychological effects. Among the things to monitor in transgender patients on long-term hormones, bone health is an essential consideration. As the calcium intake in the Indian population is less, and many gender-incongruent individuals may not take adequate calcium in their diet, we needed data on the bone health of Indians with gender dysphoria as the information available globally may not apply to our population. Materials and Methods The study was performed to assess bone mineral density in individuals with gender dysphoria who were on gender-affirming hormonal therapy for at least 6 months. It was a hospital-based cross-sectional study of bone mineral density measured at two sites - hip and spine in individuals with gender dysphoria on GAHT for at least six months. Results A total of 30 individuals were included in this study. The mean age of individuals with Gender dysphoria was found to be 28.17 ± 6.15 years, and the age range was 19-42 years. Out of the 30 individuals, 14 were transgender males, and the remaining 16 were transgender females. Bone mineral density at the hip and spine in transgender males was 1.047 ± 0.124 g/cm2 and 1.065 ± 0.115 g/cm2, which was better compared to transgender females in whom the bone mineral density at hip and spine was 0.899 ± 0.873 g/cm2 and 0.854 ± 0.099 g/cm2 (P = 0.001 for hip; P = 0.000 for spine). The Z score at hip and spine were better in transgender males as compared to transgender females (P < 0.001 for hip; P < 0.001 for spine) when compared to genetic sex and at the spine (P = 0.001) when compared to affirmed sex. In this study, we observed that the transgender females who underwent orchidectomy had a lower mean Z score at spine compared to individuals who did not undergo the procedure. Conclusions The current study results indicate that GAHT does have positive effects on bone health in transmen.
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Affiliation(s)
- Rakesh Bobba
- Department of Endocrinology, M S Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Pramila Kalra
- Department of Endocrinology, M S Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Mala Dharmalingam
- Department of Endocrinology, M S Ramaiah Medical College, Bengaluru, Karnataka, India
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22
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Gilles de la Londe J, Aïm-Eusébi A, Cadwallader D, Rincon Murillo G, Cadwallader JS, Aubert JP. The Experience of HIV-Positive Transgender Women Engaging in Physical Activity: An Interpretative Phenomenological Analysis. ARCHIVES OF SEXUAL BEHAVIOR 2023; 52:3541-3552. [PMID: 37452265 DOI: 10.1007/s10508-023-02655-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
Regular physical activity should benefit HIV-positive transgender women because they are a particularly vulnerable population. However, engaging in physical activity seems particularly difficult among this population. To inform the development of interventions to increase adherence to physical activity, we explored perceptions of physical activity in 10 semi-structured interviews with HIV-positive transgender women. Interviews were subjected to a qualitative approach named interpretative phenomenological analysis (IPA). Inspired by Cooley's theory, we chose to illustrate the results according to a three-level structure, i.e., confronting oneself to oneself with a specific identity, then confronting oneself with others on an interpersonal level, and eventually confronting oneself with society as a normative frame through the specific prism of physical activity, and thus relationship to one's body. The idea of practicing physical activity meant for them: having to face what they tried to be kept hidden, being ostracized by the cis population, and facing social heteronormativity. The fears about health were mostly about HIV and the transitioning process side effects. The psychological issues were mostly about the fear of developing male shaped bodies and worsened by traumatic life stories. External factors were often related to the passing concept and violence caused by stigma and discrimination. The group appeared as a strong motivation factor, facilitating self-acceptance and socialization.
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Affiliation(s)
| | - Amélie Aïm-Eusébi
- Département de Médecine Générale, Université Paris Cité, Paris, France
| | | | | | - Jean Sébastien Cadwallader
- Department of General Practice, Sorbonne University, Paris, France.
- Institut Pierre Louis d'Épidémiologie Et de Santé Publique, INSERM, Sorbonne University, 75012, Paris, France.
| | - Jean Pierre Aubert
- Département de Médecine Générale, Université Paris Diderot, Paris, France
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23
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Sanchez KJ, Sanchez RA, Ben Khallouq B, Ellis DB. Perioperative Care of Transgender and Gender-Diverse Patients: A Biopsychosocial Approach. Anesth Analg 2023; 137:234-246. [PMID: 37010957 DOI: 10.1213/ane.0000000000006480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
Transgender and gender-diverse (TGD) people endure numerous physical and mental health disparities secondary to lifelong stigma and marginalization, which are often perpetuated in medical spaces. Despite such barriers, TGD people are seeking gender-affirming care (GAC) with increased frequency. GAC facilitates the transition from the sex assigned at birth to the affirmed gender identity and is comprised of hormone therapy (HT) and gender-affirming surgery (GAS). The anesthesia professional is uniquely poised to serve as an integral support for TGD patients within the perioperative space. To provide affirmative perioperative care to TGD patients, anesthesia professionals should understand and attend to the biological, psychological, and social dimensions of health that are relevant to this population. This review outlines the biological factors that impact the perioperative care of TGD patients, such as the management of estrogen and testosterone HT, safe use of sugammadex, interpretation of laboratory values in the context of HT, pregnancy testing, drug dosing, breast binding, altered airway and urethral anatomy after prior GAS, pain management, and other GAS considerations. Psychosocial factors are reviewed, including mental health disparities, health care provider mistrust, effective patient communication, and the interplay of these factors in the postanesthesia care unit. Finally, recommendations to improve TGD perioperative care are reviewed through an organizational approach with an emphasis on TGD-focused medical education. These factors are discussed through the lens of patient affirmation and advocacy with the intent to educate the anesthesia professional on the perioperative management of TGD patients.
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Affiliation(s)
- Kyle J Sanchez
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Bertha Ben Khallouq
- Orlando Health Winnie Palmer Hospital for Women and Babies, Orlando, Florida
- University of Central Florida, Orlando, Florida
| | - Dan B Ellis
- Jacksonville University, Jacksonville, Florida
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24
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Moreland E, Cheung AS, Hiam D, Nolan BJ, Landen S, Jacques M, Eynon N, Jones P. Implications of gender-affirming endocrine care for sports participation. Ther Adv Endocrinol Metab 2023; 14:20420188231178373. [PMID: 37323162 PMCID: PMC10262668 DOI: 10.1177/20420188231178373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 05/09/2023] [Indexed: 06/17/2023] Open
Abstract
Many transgender (trans) individuals utilize gender-affirming hormone therapy (GAHT) to promote changes in secondary sex characteristics to affirm their gender. Participation rates of trans people in sport are exceedingly low, yet given high rates of depression and increased cardiovascular risk, the potential benefits of sports participation are great. In this review, we provide an overview of the evidence surrounding the effects of GAHT on multiple performance-related phenotypes, as well as current limitations. Whilst data is clear that there are differences between males and females, there is a lack of quality evidence assessing the impact of GAHT on athletic performance. Twelve months of GAHT leads to testosterone concentrations that align with reference ranges of the affirmed gender. Feminizing GAHT in trans women increases fat mass and decreases lean mass, with opposite effects observed in trans men with masculinizing GAHT. In trans men, an increase in muscle strength and athletic performance is observed. In trans women, muscle strength is shown to decrease or not change following 12 months of GAHT. Haemoglobin, a measure of oxygen transport, changes to that of the affirmed gender within 6 months of GAHT, with very limited data to suggest possible reductions in maximal oxygen uptake as a result of feminizing GAHT. Current limitations of this field include a lack of long-term studies, adequate group comparisons and adjustment for confounding factors (e.g. height and lean body mass), and small sample sizes. There also remains limited data on endurance, cardiac or respiratory function, with further longitudinal studies on GAHT needed to address current limitations and provide more robust data to inform inclusive and fair sporting programmes, policies and guidelines.
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Affiliation(s)
- Ethan Moreland
- Institute for Health and Sport (IHeS), Victoria University, Footscray, VIC, Australia
| | - Ada S. Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, VIC, Australia
- Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
| | - Danielle Hiam
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Deakin University, Burwood, VIC, Australia
| | - Brendan J. Nolan
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, VIC, Australia
- Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
| | - Shanie Landen
- Institute for Health and Sport (IHeS), Victoria University, Footscray, VIC, Australia
| | - Macsue Jacques
- Institute for Health and Sport (IHeS), Victoria University, Footscray, VIC, Australia
| | - Nir Eynon
- Institute for Health and Sport (IHeS), Victoria University, Footscray, VIC, Australia
| | - Patrice Jones
- Institute for Health and Sport (IHeS), Victoria University, Ballarat Road, Footscray, VIC 3011, Australia
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25
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Buonaiuto K, Dodge E, Aboul-Enein BH. Registered Dietitian Nutritionists' Knowledge, Attitudes, and Beliefs Regarding Nutrition for the Transgender Population in Three New England States: A Cross-Sectional Study. J Immigr Minor Health 2023:10.1007/s10903-023-01484-3. [PMID: 37084019 DOI: 10.1007/s10903-023-01484-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2023] [Indexed: 04/22/2023]
Abstract
This Study examined the knowledge, attitudes, and beliefs of Registered Dietitian Nutritionists (RDN's) practicing in Maine, New Hampshire, and Vermont, regarding the transgender population. 196 RDN's from the Commission of Dietetics Registration registry located in the tri-state area responded to an anonymous online survey. The survey used the Transgender Knowledge, Attitudes and Beliefs (T-KAB) Scale and nine true/false clinically-focused questions. Descriptive statistics and chi-square analysis were used to identify trends and associations in RDN's knowledge, attitudes, and beliefs regarding the transgender population. Political views (p < 0.0001), years practicing (p = 0.0454), and religious commitment (p = 0.0429) were negatively associated, and health disparities awareness (p < 0.0002) was positively associated, with total T-KAB Score. RDN's surveyed had positive attitudes and beliefs, but a low level of knowledge. Future research should focus on training and education of RDN's, and use of the T-KAB scale to evaluate pre/post-education modules regarding nutrition care for transgender patients.
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Affiliation(s)
- Kimberly Buonaiuto
- College of Graduate & Professional Studies, University of New England, 716 Stevens Ave, Portland, ME, 04103, USA
| | - Elizabeth Dodge
- College of Graduate & Professional Studies, University of New England, 716 Stevens Ave, Portland, ME, 04103, USA
| | - Basil H Aboul-Enein
- College of Health & Wellness, Department of Health Science, Johnson & Wales University, 8 Abbott Park Place, Providence, RI, 02903, USA.
- London School of Hygiene & Tropical Medicine, Faculty of Public Health and Policy, 15-17 Tavistock Place, London, WC1H 9SH, UK.
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26
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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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27
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Santos RB, Lemos C, Saraiva M. Gender-Affirming Hormone Therapy: Physical and Sociopsychological Effects, Impact and Satisfaction. Cureus 2023; 15:e36484. [PMID: 37090416 PMCID: PMC10118284 DOI: 10.7759/cureus.36484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/25/2023] Open
Abstract
Background Gender dysphoria treatment includes gender-affirming hormone therapy (GAHT). Studies are still lacking on how to characterize its effects and impact on transgender people's lives more effectively. Aim To study the physical and psychological effects of GAHT on transgender individuals, assess its impact on their lives, and rate their overall satisfaction. Methods Participants (n = 114; ages 18-62 years; median age 24.0 (21.0 - 33.0) years) included transgender adults residing in Portugal who were undergoing or had undergone hormonal therapy for at least one uninterrupted year. Participants completed an original questionnaire. For most items, an ordinal Likert-style scale ranging from 0 (worst result) to 6 (best result) was used. Descriptive statistics and non-parametric tests, including Pearson's chi-squared test, Wilcoxon signed-rank test, and Mann-Whitney U test were used to analyze categorical and continuous variables, with a significance level set at 0.05. Outcomes The outcomes included desired physical changes rating (perception and satisfaction with changes); side effects of GAHT; the sociopsychological impact of GAHT (on self-esteem, body image, psychological wellbeing, social and family relations); overall satisfaction (with treatment results and medical follow-up). Results The changes classified as the most perceptible in those undergoing masculinizing treatment (Group M) were amenorrhea (6 (5.0-6.0) points) and clitoris enlargement (6 (5.0-6.0) points). These were also the ones rated as the most satisfactory (6 (6.0-6.0) points for amenorrhea and 6 (4.0-6.0) points for clitoris enlargement). On those undergoing feminizing therapy (Group F), the alteration voted as the most perceptible was sperm production decrease (6 (2.0-6.0) points), and the ones classified as the most satisfactory were sperm production decrease (6 (4.0-6.0) points) and spontaneous erections decrease (6 (5.0-6.0) points). Side effects were reported by 89.7% of Group M (mood swings were the most common) and 96.3% of Group F (decreased libido was the most frequent). The sociopsychological impact of hormonal treatment was significantly positive in all analyzed variables (p<0.001). Overall satisfaction with treatment results and medical follow-up were rated with 5 points and 4.5 points, respectively. Clinical implications This study provides clinicians with more evidence that GAHT may improve the physical, psychological and social health of transgender people seeking medical transition. Strengths and limitations The strengths of the current study include a high participant count relative to the target population, the acquisition of data on previously unexplored variables, and the significance of being one of the few investigations of its kind conducted in Portugal. However, the study has limitations, including differences in participant characteristics, a small sample size for some variables, potential bias due to the retrospective nature of the study, individualized treatment regimens, and the inclusion of participants from different countries, which limit the generalization of the results. Conclusions This study provides further evidence that GAHT is effective, and that its physical effects are satisfactory while resulting in mostly non-severe nor life-threatening side effects. GAHT is an important therapy in gender dysphoria and has consistent results in improving numerous sociopsychological variables.
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Affiliation(s)
- Rafael B Santos
- Endocrinology Department, Centro Hospitalar Universitário do Porto, Porto, PRT
| | - Carolina Lemos
- Population Studies, Instituto de Ciências Biomédicas Abel Salazar, Porto, PRT
| | - Miguel Saraiva
- Endocrinology Department, Centro Hospitalar Universitário do Porto, Porto, PRT
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28
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Leone AG, Trapani D, Schabath MB, Safer JD, Scout NFN, Lambertini M, Berardi R, Marsoni S, Perrone F, Cinieri S, Miceli R, Morano F, Pietrantonio F. Cancer in Transgender and Gender-Diverse Persons: A Review. JAMA Oncol 2023; 9:556-563. [PMID: 36757703 DOI: 10.1001/jamaoncol.2022.7173] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Importance Transgender and gender-diverse individuals face unique challenges, including barriers to health care access and inequities in treatment, that may influence cancer risk and outcomes. Observations In this narrative review, a scoping review was conducted focusing on primary and secondary prevention and epidemiology of cancer, barriers to health care services, and health care practitioners' knowledge about specific issues pertaining to transgender and gender-diverse individuals. PubMed, the Cochrane Library, and Embase, were reviewed for citations from their inception to December 31, 2021. This review revealed that transgender and gender-diverse people had a high prevalence of tobacco consumption and alcohol use and high rates of infection with human papillomavirus (HPV) and HIV. Transgender and gender-diverse individuals were less likely to adhere to cancer screening programs and had a higher incidence of HIV- and HPV-associated cancers. Social and economic determinants seemed to drive these disparities in risk factors and outcomes. A lack of knowledge about gender minorities' health needs among health care practitioners was evidenced, and it represented a major hurdle to cancer prevention, care, and survivorship for transgender and gender-diverse individuals. Discrimination, discomfort caused by gender-labeled oncological services, stigma, and lack of cultural sensitivity of health care practitioners were other barriers met by transgender and gender-diverse persons in the oncology setting. Conclusions and Relevance The findings suggest that transgender and gender-diverse peoples' needs in the cancer care continuum are not optimally addressed. Effective solutions are needed to offer the best care to every patient in a person-centric and gender diversity-sensitive environment.
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Affiliation(s)
| | - Dario Trapani
- European Institute of Oncology, IRCCS, Milan, Italy.,Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | | - Joshua D Safer
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York, New York.,Mount Sinai Center for Transgender Medicine and Surgery, New York, New York
| | - N F N Scout
- National LGBT Cancer Network, Providence, Rhode Island
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties, School of Medicine, University of Genova, Genova, Italy.,Department of Medical Oncology, Unità Operativa Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Rossana Berardi
- Oncology Clinic, Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Silvia Marsoni
- IFOM, FIRC Institute of Molecular Oncology, Milan, Italy
| | - Francesco Perrone
- Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Saverio Cinieri
- Medical Oncology Unit, Ospedale di Summa A. Perrino, Brindisi, Italy
| | - Rosalba Miceli
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Federica Morano
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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29
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Defreyne J, Vander Stichele C, Iwamoto SJ, T'Sjoen G. Gender-affirming hormonal therapy for transgender and gender-diverse people-A narrative review. Best Pract Res Clin Obstet Gynaecol 2023; 86:102296. [PMID: 36596713 PMCID: PMC11197232 DOI: 10.1016/j.bpobgyn.2022.102296] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/07/2022] [Indexed: 12/23/2022]
Abstract
As the number of transgender and gender-diverse (TGD) people accessing gender-affirming care increases, the need for healthcare professionals (HCPs) providing gender-affirming hormonal therapy (GAHT) also increases. This chapter provides an overview of the HCPs interested in getting involved in providing GAHT.
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Affiliation(s)
- J Defreyne
- Department of Endocrinology and Center for Sexology, Ghent University Hospital, Ghent, Belgium.
| | - Clara Vander Stichele
- Department of Endocrinology and Center for Sexology, Ghent University Hospital, Ghent, Belgium.
| | - Sean J Iwamoto
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, and Rocky Mountain Regional VA Medical Center, Aurora, CO, USA.
| | - G T'Sjoen
- Department of Endocrinology and Center for Sexology, Ghent University Hospital, Ghent, Belgium.
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Dela Cruz C, Kinnear HM, Hashim PH, Wandoff A, Nimmagadda L, Chang FL, Padmanabhan V, Shikanov A, Moravek MB. A mouse model mimicking gender-affirming treatment with pubertal suppression followed by testosterone in transmasculine youth. Hum Reprod 2023; 38:256-265. [PMID: 36484619 PMCID: PMC10167862 DOI: 10.1093/humrep/deac257] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 11/04/2022] [Indexed: 12/13/2022] Open
Abstract
STUDY QUESTION Can mice serve as a translational model to examine the reproductive consequences of pubertal suppression with GnRH agonist (GnRHa) followed by testosterone (T) administration, a typical therapy in peripubertal transmasculine youth? SUMMARY ANSWER An implanted depot with 3.6 mg of GnRHa followed by T enanthate at 0.45 mg weekly can be used in peripubertal female mice for investigating the impact of gender-affirming hormone therapy in transmasculine youth. WHAT IS KNOWN ALREADY There is limited knowledge available in transgender medicine to provide evidence-based fertility care, with the current guidelines being based on the assumption of fertility loss. We recently successfully developed a mouse model to investigate the reproductive consequences of T therapy given to transgender men. On the other hand, to our knowledge, there is no mouse model to assess the reproductive outcomes in peripubertal transmasculine youth. STUDY DESIGN, SIZE, DURATION A total of 80 C57BL/6N female mice were used in this study, with n = 7 mice in each experimental group. PARTICIPANTS/MATERIALS, SETTING, METHODS We first assessed the effectiveness of GnRHa in arresting pubertal development in the female mice. In this experiment, 26-day-old female mice were subcutaneously implanted with a GnRHa (3.6 mg) depot. Controls underwent a sham surgery. Animals were euthanized at 3, 9, 21 and 28 days after the day of surgery. In the second experiment, we induced a transmasculine youth mouse model. C57BL/6N female mice were subcutaneously implanted with a 3.6 mg GnRHa depot on postnatal day 26 for 21 days and this was followed by weekly injections of 0.45 mg T enanthate for 6 weeks. The control for the GnRH treatment was sham surgery and the control for T treatment was sesame oil vehicle injections. Animals were sacrificed 0.5 weeks after the last injection. The data collected included the day of the vaginal opening and first estrus, daily vaginal cytology, weekly and terminal reproductive hormones levels, body/organ weights, ovarian follicular distribution and corpora lutea (CL) counts. MAIN RESULTS AND THE ROLE OF CHANCE GnRHa implanted animals remained in persistent diestrus and had reduced levels of FSH (P = 0.0013), LH (P = 0.0082) and estradiol (P = 0.0155), decreased uterine (P < 0.0001) and ovarian weights (P = 0.0002), and a lack of CL at 21 days after GnRHa implantation. T-only and GnRHa+T-treated animals were acyclic throughout the treatment period, had sustained elevated levels of T, suppressed LH levels (P < 0.0001), and an absence of CL compared to controls (P < 0.0001). Paired ovarian weights were reduced in the T-only and GnRHa+T groups compared with the control and GnRHa-only groups. LARGE SCALE DATA N/A. LIMITATIONS, REASONS FOR CAUTION Although it is an appropriate tool to provide relevant findings, precaution is needed to extrapolate mouse model results to mirror human reproductive physiology. WIDER IMPLICATIONS OF THE FINDINGS To our knowledge, this study describes the first mouse model mimicking gender-affirming hormone therapy in peripubertal transmasculine youth. This model provides a tool for researchers studying the effects of GnRHa-T therapy on other aspects of reproduction, other organ systems and transgenerational effects. The model is supported by GnRHa suppressing puberty and maintaining acyclicity during T treatment, lower LH levels and absence of CL. The results also suggest GnRHa+T therapy in peripubertal female mice does not affect ovarian reserve, since the number of primordial follicles was not affected by treatment. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by the Michigan Institute for Clinical and Health Research grants KL2 TR 002241 and UL1 TR 002240 (C.D.C.); National Institutes of Health grants F30-HD100163 and T32-HD079342 (H.M.K.); University of Michigan Office of Research funding U058227 (A.S.); American Society for Reproductive Medicine/Society for Reproductive Endocrinology and Infertility grant (M.B.M.); and National Institutes of Health R01-HD098233 (M.B.M.). The University of Virginia Center for Research in Reproduction Ligand Assay and Analysis Core Facility was supported by the Eunice Kennedy Shriver NICHD/NIH grants P50-HD028934 and R24-HD102061. The authors declare that they have no competing interests.
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Affiliation(s)
- Cynthia Dela Cruz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Postdoctoral Translational Scholar Program, Michigan Institute for Clinical & Health Research, University of Michigan, Ann Arbor, MI, USA
| | - Hadrian M Kinnear
- Program in Cellular and Molecular Biology, University of Michigan, Ann Arbor, MI, USA
- Medical Scientist Training Program, University of Michigan, Ann Arbor, MI, USA
| | - Prianka H Hashim
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Abigail Wandoff
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Likitha Nimmagadda
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Faith L Chang
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Vasantha Padmanabhan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Ariella Shikanov
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Program in Cellular and Molecular Biology, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Molly B Moravek
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Division of Reproductive Endocrinology and Infertility, University of Michigan, Ann Arbor, MI, USA
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
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Marques MA, Teruchkin MM, de Oliveira ALML. Venous thromboembolism in transgender women. J Vasc Bras 2023; 21:e20220120. [PMID: 36660102 PMCID: PMC9844815 DOI: 10.1590/1677-5449.202201201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 11/18/2022] [Indexed: 01/15/2023] Open
Affiliation(s)
- Marcos Arêas Marques
- Universidade Federal do Estado do Rio de Janeiro - UNIRIO, Rio de Janeiro, RJ, Brasil.,Universidade do Estado do Rio de Janeiro - UERJ, Rio de Janeiro, RJ, Brasil.
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Iwamoto SJ, Defreyne J, Kaoutzanis C, Davies RD, Moreau KL, Rothman MS. Gender-affirming hormone therapy, mental health, and surgical considerations for aging transgender and gender diverse adults. Ther Adv Endocrinol Metab 2023; 14:20420188231166494. [PMID: 37113210 PMCID: PMC10126651 DOI: 10.1177/20420188231166494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 03/13/2023] [Indexed: 04/29/2023] Open
Abstract
As the transgender and gender diverse (TGD) population ages, more transfeminine and transmasculine individuals present to clinic to initiate or continue their gender-affirming care at older ages. Currently available guidelines on gender-affirming care are excellent resources for the provision of gender-affirming hormone therapy (GAHT), primary care, surgery, and mental health care but are limited in their scope as to whether recommendations require tailoring to older TGD adults. Data that inform guideline-recommended management considerations, while informative and increasingly evidence-based, mainly come from studies of younger TGD populations. Whether results from these studies, and therefore recommendations, can or should be extrapolated to aging TGD adults remains to be determined. In this perspective review, we acknowledge the lack of data in older TGD adults and discuss considerations for evaluating cardiovascular disease, hormone-sensitive cancers, bone health and cognitive health, gender-affirming surgery, and mental health in the older TGD population on GAHT.
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Affiliation(s)
| | - Justine Defreyne
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Christodoulos Kaoutzanis
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
| | - Robert D. Davies
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- CUMedicine LGBTQ Mental Health Clinic, University of Colorado Hospital, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
| | - Kerrie L. Moreau
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Eastern Colorado Geriatric Research Education and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Micol S. Rothman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
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OH JW, Yun Y, Lee ES. A Review of Gender-Affirming Hormone Therapy for Transgender and Gender Diverse Adults in South Korea. J Menopausal Med 2022; 28:92-102. [PMID: 36647272 PMCID: PMC9843037 DOI: 10.6118/jmm.22039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/21/2022] [Accepted: 12/21/2022] [Indexed: 01/14/2023] Open
Abstract
Recently, gender-affirming hormone therapy for gender incongruence has become an issue in various countries and organizations with various guidelines. In South Korea, several clinical treatments are also used with many possible options. These treatments include masculinizing (female-to-male [FTM]) or feminizing (male-to-female [MTF]) hormone therapies, with regimens usually driven by standards of hormonal replacement therapy for hypogonadism (i.e., hypogonadal natal men and postmenopausal women). This cross-sex hormone therapy can change patients' physical appearance to better match their gender identity and expression. Regarding masculinizing therapy, injection and transdermal gel types of testosterone are used according to international guidelines. Progesterone is utilized in the form of oral pills, injections, or intrauterine devices to suppress menstruation and avoid pregnancy. Essentially, feminizing therapy uses androgen blockers along with estrogen. This is because estrogen alone cannot exert sufficient androgen-suppressing effects. In South Korea, the most commonly used androgen blockers are spironolactone and cyproterone acetate. Gonadotropin-releasing hormone (GnRH) agonist is also available. Regarding estrogen, oral pills, injections, and transdermal gels are utilized. This review introduces these gender-affirming hormone therapies in South Korea and discusses the side effects of each regimen.
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Affiliation(s)
- Jeong-Won OH
- Department of Obstetrics and Gynecology, Soon Chun Hyang University Seoul Hospital, Soon Chun Hyang University College of Medicine, Seoul, Korea
| | - Yeoul Yun
- Department of Obstetrics and Gynecology, Soon Chun Hyang University Seoul Hospital, Soon Chun Hyang University College of Medicine, Seoul, Korea
| | - Eun Sil Lee
- Department of Obstetrics and Gynecology, Soon Chun Hyang University Seoul Hospital, Soon Chun Hyang University College of Medicine, Seoul, Korea
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Bunderen CCV, Leentjens J, Middeldorp S. Transgender Medicine and Risk of Venous Thromboembolism. Hamostaseologie 2022; 42:301-307. [PMID: 36323277 DOI: 10.1055/a-1891-8158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
Gender dysphoria refers to psychological distress that results from an incongruence between gender identity and sex assigned at birth. Administration of sex hormones is most often used as a first step to develop and maintain physical characteristics consistent with gender identity. Gender-affirming hormone treatment is considered beneficial for the quality of life and reduction of depression. However, estrogen and androgen-lowering hormone therapies used in transwomen are in particular associated with increased risk of venous thromboembolism. In this review, introduced by a clinical case, we provide an overview of the currently available medical therapies in transgender medicine, and put the associated increased risk of venous thromboembolism into perspective.
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Affiliation(s)
- C C Van Bunderen
- Division of Endocrinology, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Leentjens
- Division of Vascular Medicine, Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - S Middeldorp
- Division of Vascular Medicine, Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
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Gusmão-Silva JV, Lichtenecker DCK, Ferreira LGA, Gois Í, Argeri R, Gomes GN, Dias-da-Silva MR. Body, metabolic and renal changes following cross-sex estrogen/progestogen therapy in a rodent model simulating its use by transwomen. J Endocrinol Invest 2022; 45:1875-1885. [PMID: 35689728 DOI: 10.1007/s40618-022-01817-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/02/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The use of sex steroids by trans people has been of paramount importance regarding body changes during gender transition. The objective of this study was to assess the effects of an injectable steroid combination frequently used by transwomen, namely estradiol enanthate with dihydroxyprogesterone acetophenide (E2EN/DHPA), on blood pressure and metabolic outcomes using an animal model. METHODS Two-month-old male Wistar rats were orchiectomized or sham-operated and divided into groups: (1) Sham treated with sesame oil vehicle (SG), (2) sham treated with E2EN/DHPA (SP), (3) orchiectomized rats treated with vehicle (OG), and (4) orchiectomized rats treated with E2EN/DHPA (OP), with all groups treated every 10 days for 5 months. We evaluated systolic blood pressure (SBP), body weight (BW), abdominal circumference, nasoanal length (NAL), food and water intake (FI, WI), lipid profile (triglycerides, LDL, and HDL), serum C-reactive protein (CRP), plasma concentrations of urea (URpl) and creatinine (CRpl), 24 h urinary volume (V24 h), sodium and potassium excretion (UNa+, UK+), and proteinuria. RESULTS E2EN/DHPA administration reduced BW (SP 324.5 ± 31.1; OP 291.7 ± 41.3 g) and NAL (SP 24.5 ± 0.4; OP 24.6 ± 1.0 cm), without changing blood pressure, but increased URpl concentration (SP 55.0 ± 4.8; OP 42.5 ± 8.8 mg/dL) and CRpl (SP 0.47 ± 0.05; OP 0.46 ± 0.04 mg/dL), sodium (SP 3.1 ± 0.8; OP 3.3 ± 0.4 µEq/min/kg), potassium (SP 0.91 ± 0.22; OP 0.94 ± 0.22 µEq/min/kg) excretions and urinary volume (SP 15.5 ± 2.1; OP 16.4 ± 2.9 mL/24 h). CONCLUSION Cross-sex hormone therapy with E2EN/DHPA significantly modified body characteristics in male rats, producing a feminizing change without altering blood pressure or generating harmful metabolic parameters, but larger translational studies are still needed.
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Affiliation(s)
- J V Gusmão-Silva
- Laboratory of Renal Physiology, Department of Physiology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (EPM/Unifesp), Rua Botucatu nº 862, Sao Paulo, 04023-900, Brazil
| | - D C K Lichtenecker
- Laboratory of Renal Physiology, Department of Physiology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (EPM/Unifesp), Rua Botucatu nº 862, Sao Paulo, 04023-900, Brazil
| | - L G A Ferreira
- Laboratory of Molecular and Translational Endocrinology (LEMT), Endocrinology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (EPM/Unifesp), Rua Pedro de Toledo, nº 699, Sao Paulo, 04039-032, Brazil
| | - Í Gois
- Laboratory of Molecular and Translational Endocrinology (LEMT), Endocrinology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (EPM/Unifesp), Rua Pedro de Toledo, nº 699, Sao Paulo, 04039-032, Brazil
- Trans Care Outpatient Clinics; Núcleo de Estudos, Pesquisa, Extensão e Assitência à Pessoa Trans Professor Roberto Farina, Universidade Federal de Sao Paulo (Núcleo TransUnifesp), Rua Napoleão de Barros nº 859, Sao Paulo, 04024-002, Brazil
| | - R Argeri
- Laboratory of Renal Physiology, Department of Physiology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (EPM/Unifesp), Rua Botucatu nº 862, Sao Paulo, 04023-900, Brazil
| | - G N Gomes
- Laboratory of Renal Physiology, Department of Physiology, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (EPM/Unifesp), Rua Botucatu nº 862, Sao Paulo, 04023-900, Brazil.
| | - M R Dias-da-Silva
- Laboratory of Molecular and Translational Endocrinology (LEMT), Endocrinology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de Sao Paulo (EPM/Unifesp), Rua Pedro de Toledo, nº 699, Sao Paulo, 04039-032, Brazil
- Trans Care Outpatient Clinics; Núcleo de Estudos, Pesquisa, Extensão e Assitência à Pessoa Trans Professor Roberto Farina, Universidade Federal de Sao Paulo (Núcleo TransUnifesp), Rua Napoleão de Barros nº 859, Sao Paulo, 04024-002, Brazil
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Reddy V, Wurtz M, Patel SH, McCarthy M, Raval AP. Oral contraceptives and stroke: Foes or friends. Front Neuroendocrinol 2022; 67:101016. [PMID: 35870646 DOI: 10.1016/j.yfrne.2022.101016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/23/2022] [Accepted: 07/06/2022] [Indexed: 01/09/2023]
Abstract
Incidents of strokes are increased in young women relative to young men, suggesting that oral contraceptive (OC) use is one of the causes of stroke among young women. Long-term exposures to the varying combinations of estrogen and progestogen found in OCs affect blood clotting, lipid and lipoprotein metabolism, endothelial function, and de novo synthesis of neurosteroids, especially brain-derived 17β-estradiol. The latter is essential for neuroprotection, memory, sexual differentiation, synaptic transmission, and behavior. Deleterious effects of OCs may be exacerbated due to comorbidities like polycystic ovary syndrome, sickle cell anemia, COVID-19, exposures to endocrine disrupting chemicals, and conventional or electronic cigarette smoking. The goal of the current review is to revisit the available literature regarding the impact of OC use on stroke, to explain possible underlying mechanisms, and to identify gaps in our understanding to promote future research to reduce and cure stroke in OC users.
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Affiliation(s)
- Varun Reddy
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratory, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA; Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA
| | - Megan Wurtz
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratory, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA; Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA
| | - Shahil H Patel
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratory, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA; Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA
| | - Micheline McCarthy
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA
| | - Ami P Raval
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratory, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA; Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA; Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, FL, USA.
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Walcott Q, Dallman J, Crow H, Graves L, Marsh C. DXA Scan Variants in Transgender Patients. J Clin Densitom 2022; 25:615-621. [PMID: 35525792 DOI: 10.1016/j.jocd.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 11/29/2022]
Abstract
Transgender and gender non-conforming (TGNC) individuals face numerous barriers to healthcare, which contribute to many health disparities. TGNC persons may choose gender-affirming therapies with surgery and/or hormone replacement therapy (HRT) to manage gender incongruence. Despite the expanding use of HRT, the long-term outcomes on bone health and metabolism, are still relatively unknown in the TGNC population. In 2019, the International Society of Clinical Densitometry (ISCD) released an official position statement on the appropriate use of dual energy x-ray absorptiometry (DXA) to measure bone density in the TGNC population. In this study, we reviewed which "sex" is currently utilized among providers when performing DXA scans to calculate T- and Z-scores for TGNC persons and how this compares to the positions published by the ISCD. A retrospective analysis was performed utilizing HERON queries and subsequent chart review. HERON is a type of Informatics for Integrating Biology and the Bedside software that was utilized to find sets of patients of interest from electronic medical record data while preserving patient privacy through a query interface tool. Project specific sets including patient demographics, medications, gonadectomy, and DXA scan information was created in HERON to make this highly detailed data of specific patients available to the investigators on the platform, as reviewed and retrieved by the Institutional Review Board. The qualitative DXA data obtained from chart review was determined as "correct" or "incorrect" based on positions provided from the ISCD. 10 DXA scans that met inclusion criteria were obtained between 9 TGNC patients. In total, 18 T-scores and Z-scores of the 10 DXAs were reviewed and scored. Based on ISCD positions, 67% of the T-score and Z-scores were calculated incorrectly; using the erroneous "sex" based standard to compare scores. Like DXA scans, many current healthcare standards and protocols are based on a patient's sex or gender, which may cause confusion amongst healthcare personnel who have not received proper training regarding the TGNC population. In this study, 67% of T-scores and Z-scores were calculated incorrectly based on ISCD recommendations. An additional prospective research design is required to determine the consequences of incorrectly calculated DXA scans for TGNC patients. Furthermore, future research is needed to determine HRT's effects on bone mineral density in the TGNC population in the United States.
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Affiliation(s)
- Quinnlyn Walcott
- The University of Kansas School of Medicine, Kansas City, KS, USA.
| | | | - Hanna Crow
- Department of Internal Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Leland Graves
- Department of Internal Medicine, The University of Kansas Health System, Kansas City, KS, USA
| | - Courtney Marsh
- Department of Obstetrics and Gynecology, The University of Kansas Health System, Kansas City, KS, USA
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:S1-S259. [PMID: 36238954 PMCID: PMC9553112 DOI: 10.1080/26895269.2022.2100644] [Citation(s) in RCA: 609] [Impact Index Per Article: 304.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
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Affiliation(s)
- E Coleman
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A E Radix
- Callen-Lorde Community Health Center, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - W P Bouman
- Nottingham Centre for Transgender Health, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - G R Brown
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- James H. Quillen VAMC, Johnson City, TN, USA
| | - A L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M B Deutsch
- Department of Family & Community Medicine, University of California-San Francisco, San Francisco, CA, USA
- UCSF Gender Affirming Health Program, San Francisco, CA, USA
| | - R Ettner
- New Health Foundation Worldwide, Evanston, IL, USA
- Weiss Memorial Hospital, Chicago, IL, USA
| | - L Fraser
- Independent Practice, San Francisco, CA, USA
| | - M Goodman
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Green
- Independent Scholar, Vancouver, WA, USA
| | - A B Hancock
- The George Washington University, Washington, DC, USA
| | - T W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - D H Karasic
- University of California San Francisco, San Francisco, CA, USA
- Independent Practice at dankarasic.com
| | - G A Knudson
- University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health, Vancouver, Canada
| | - S F Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - H F L Meyer-Bahlburg
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | - J Motmans
- Transgender Infopunt, Ghent University Hospital, Gent, Belgium
- Centre for Research on Culture and Gender, Ghent University, Gent, Belgium
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T O Nieder
- University Medical Center Hamburg-Eppendorf, Interdisciplinary Transgender Health Care Center Hamburg, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - S L Reisner
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - C Richards
- Regents University London, UK
- Tavistock and Portman NHS Foundation Trust, London, UK
| | | | - V Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - A C Tishelman
- Boston College, Department of Psychology and Neuroscience, Chestnut Hill, MA, USA
| | - M A A Van Trotsenburg
- Bureau GenderPRO, Vienna, Austria
- University Hospital Lilienfeld-St. Pölten, St. Pölten, Austria
| | - S Winter
- School of Population Health, Curtin University, Perth, WA, Australia
| | - K Ducheny
- Howard Brown Health, Chicago, IL, USA
| | - N J Adams
- University of Toronto, Ontario Institute for Studies in Education, Toronto, Canada
- Transgender Professional Association for Transgender Health (TPATH)
| | - T M Adrián
- Asamblea Nacional de Venezuela, Caracas, Venezuela
- Diverlex Diversidad e Igualdad a Través de la Ley, Caracas, Venezuela
| | - L R Allen
- University of Nevada, Las Vegas, NV, USA
| | - D Azul
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - H Bagga
- Monash Health Gender Clinic, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - K Başar
- Department of Psychiatry, Hacettepe University, Ankara, Turkey
| | - D S Bathory
- Independent Practice at Bathory International PLLC, Winston-Salem, NC, USA
| | - J J Belinky
- Durand Hospital, Guemes Clinic and Urological Center, Buenos Aires, Argentina
| | - D R Berg
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J U Berli
- Oregon Health & Science University, Portland, OR, USA
| | - R O Bluebond-Langner
- NYU Langone Health, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York, NY, USA
| | - M-B Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Plastic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - M L Bowers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - P J Brassard
- GrS Montreal, Complexe CMC, Montreal, Quebec, Canada
- Université de Montreal, Quebec, Canada
| | - J Byrne
- University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - L Capitán
- The Facialteam Group, Marbella International Hospital, Marbella, Spain
| | | | - J M Carswell
- Harvard Medical School, Boston, MA, USA
- Boston's Children's Hospital, Boston, MA, USA
| | - S C Chang
- Independent Practice, Oakland, CA, USA
| | - G Chelvakumar
- Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University, College of Medicine, Columbus, OH, USA
| | - T Corneil
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K B Dalke
- Penn State Health, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - G De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - E de Vries
- Nelson Mandela University, Gqeberha, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - A H Devor
- University of Victoria, Victoria, BC, Canada
| | - C Dhejne
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - A D'Marco
- UCTRANS-United Caribbean Trans Network, Nassau, The Bahamas
- D M A R C O Organization, Nassau, The Bahamas
| | - E K Edmiston
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Edwards-Leeper
- Pacific University, Hillsboro, OR, USA
- Independent Practice, Beaverton, OR, USA
| | - R Ehrbar
- Whitman Walker Health, Washington, DC, USA
- Independent Practice, Maryland, USA
| | - D Ehrensaft
- University of California San Francisco, San Francisco, CA, USA
| | - J Eisfeld
- Transvisie, Utrecht, The Netherlands
| | - E Elaut
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Clinical Experimental and Health Psychology, Ghent University, Gent, Belgium
| | - L Erickson-Schroth
- The Jed Foundation, New York, NY, USA
- Hetrick-Martin Institute, New York, NY, USA
| | - J L Feldman
- Institute for Sexual and Gender Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A D Fisher
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | - M M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA, USA
| | - L Gijs
- Institute of Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | - B P Hall
- Duke University Medical Center, Durham, NC, USA
- Duke Adult Gender Medicine Clinic, Durham, NC, USA
| | - T L D Hardy
- Alberta Health Services, Edmonton, Alberta, Canada
- MacEwan University, Edmonton, Alberta, Canada
| | - M S Irwig
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - A C Janssen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- RMIT University, Melbourne, Australia
- University of Brighton, Brighton, UK
| | - D T Klink
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, Gent, Belgium
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children's Hospital, Antwerp, Belgium
| | - B P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - L E Kuper
- Department of Psychiatry, Southwestern Medical Center, University of Texas, Dallas, TX, USA
- Department of Endocrinology, Children's Health, Dallas, TX, USA
| | - E J Kvach
- Denver Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M A Malouf
- Malouf Counseling and Consulting, Baltimore, MD, USA
| | - R Massey
- WPATH Global Education Institute
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - T Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - C McLachlan
- Professional Association for Transgender Health, South Africa
- Gender DynamiX, Cape Town, South Africa
| | - S D Morrison
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - S W Mosser
- Gender Confirmation Center, San Francisco, CA, USA
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - P M Neira
- Johns Hopkins Center for Transgender Health, Baltimore, MD, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, MD, USA
| | - U Nygren
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Speech and Language Pathology, Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - J M Oates
- La Trobe University, Melbourne, Australia
- Melbourne Voice Analysis Centre, East Melbourne, Australia
| | - J Obedin-Maliver
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford, CA, USA
| | - G Pagkalos
- Independent PracticeThessaloniki, Greece
- Military Community Mental Health Center, 424 General Military Training Hospital, Thessaloniki, Greece
| | - J Patton
- Talkspace, New York, NY, USA
- CytiPsychological LLC, San Diego, CA, USA
| | - N Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - K Rachlin
- Independent Practice, New York, NY, USA
| | - T Reed
- Gender Identity Research and Education Society, Leatherhead, UK
| | - G N Rider
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Ristori
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | | | - S A Roberts
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Boston's Children's Hospital, Boston, MA, USA
| | - K A Rodriguez-Wallberg
- Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - S M Rosenthal
- Division of Pediatric Endocrinology, UCSF, San Francisco, CA, USA
- UCSF Child and Adolescent Gender Center
| | - K Sabir
- FtM Phoenix Group, Krasnodar Krai, Russia
| | - J D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
| | - A I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - L J Seal
- Tavistock and Portman NHS Foundation Trust, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - K Spencer
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - C St Amand
- University of Houston, Houston, TX, USA
- Mayo Clinic, Rochester, MN, USA
| | - T D Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - J F Strang
- Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | - G B Taylor
- Atrium Health Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charlotte, NC, USA
| | - K Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - G G T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - L N Vala
- Independent Practice, Campbell, CA, USA
| | - N M Van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J F Veale
- School of Psychology, University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - J A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - B Vincent
- Trans Learning Partnership at https://spectra-london.org.uk/trans-learning-partnership, UK
| | - L M Wesp
- College of Nursing, University of Wisconsin MilwaukeeMilwaukee, WI, USA
- Health Connections Inc., Glendale, WI, USA
| | - M A West
- North Memorial Health Hospital, Robbinsdale, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - J Arcelus
- School of Medicine, University of Nottingham, Nottingham, UK
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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Abstract
Transgender and gender diverse (TGD) individuals may undergo a wide range of care during gender transition including mental health counseling, gender-affirming hormonal therapy, and various surgeries. Hormone therapy effectively converts the hormonal milieu into that of the affirmed gender and produces measurable alterations in serum markers for coronary artery disease and other hematologic conditions (eg, erythrocytosis, venous thrombosis). Although illegal in the United States, some transgender women may receive silicone injections for breast and soft tissue augmentation, which can lead to devastating local complications, as well as silicone migration, pulmonary embolism, systemic reactions, and death. Smoking rates are higher among transgender and sexual minority populations, placing them at elevated risk of smoking-related diseases, including lung cancer. Some opportunistic infections may be more common in the TGD populations, attributable to higher rates of coexisting infection with human immunodeficiency virus. Radiologists should be aware that these patients may develop cancer of their natal organs (eg, breast, prostate), especially as some of these tissues are not completely removed during gender-affirming surgery, which may manifest with thoracic involvement by secondary neoplasia. As more TGD patients seek medical care, thoracic radiologists can reasonably expect to interpret imaging performed in this population and should be aware of possible disease processes and potential complications of hormonal and surgical therapies.
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Krupka E, Curtis S, Ferguson T, Whitlock R, Askin N, Millar AC, Dahl M, Fung R, Ahmed SB, Tangri N, Walsh M, Collister D. The Effect of Gender-Affirming Hormone Therapy on Measures of Kidney Function: A Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol 2022; 17:1305-1315. [PMID: 35973728 PMCID: PMC9625103 DOI: 10.2215/cjn.01890222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/27/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Gender-affirming hormone therapy modifies body composition and lean muscle mass in transgender persons. We sought to characterize the change in serum creatinine, other kidney function biomarkers, and GFR in transgender persons initiating masculinizing and feminizing gender-affirming hormone therapy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We searched PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov from inception to September 16, 2020 for randomized controlled trials, observational studies, and case series that evaluated the change in serum creatinine, other kidney function biomarkers, and GFR before and after the initiation of gender-affirming hormone therapy in adult transgender persons. Two reviewers independently screened and abstracted data, and disagreements were resolved by a third reviewer. A random effects meta-analysis was performed to determine the change in outcomes over follow-up of 3, 6, and 12 months. RESULTS Of the 4758 eligible studies, 26 met the inclusion criteria, including nine studies that recruited 488 transgender men and 593 women in which data were meta-analyzed. There was heterogeneity in study design, populations, gender-affirming hormone therapy routes, and dosing. At 12 months after initiating gender-affirming hormone therapy, serum creatinine increased by 0.15 mg/dl (95% confidence interval, 0.00 to 0.29) in 370 transgender men and decreased by -0.05 mg/dl (95% confidence interval, -0.16 to 0.05) in 361 transgender women. No study reported the effect of gender-affirming hormone therapy on albuminuria, proteinuria, cystatin C, or measured GFR. CONCLUSIONS Gender-affirming hormone therapy increases serum creatinine in transgender men and does not affect serum creatinine in transgender women. The effect on gender-affirming hormone therapy on other kidney function biomarkers and measured GFR is unknown. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Change in Kidney Function Biomarkers in Transgender Persons on Gender Affirmation Hormone Therapy-A Systematic Review and Meta-Analysis, CRD42020214248.
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Affiliation(s)
- Emily Krupka
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Sarah Curtis
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Thomas Ferguson
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Reid Whitlock
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Nicole Askin
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Adam C. Millar
- Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marshall Dahl
- Division of Endocrinology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Raymond Fung
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Sofia B. Ahmed
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
- Max Rady Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michael Walsh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences/McMaster University, Hamilton, Ontario, Canada
| | - David Collister
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
- Max Rady Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Population Health Research Institute, Hamilton Health Sciences/McMaster University, Hamilton, Ontario, Canada
- Section of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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LaVasseur C, Neukam S, Kartika T, Samuelson Bannow B, Shatzel J, DeLoughery TG. Hormonal therapies and venous thrombosis: Considerations for prevention and management. Res Pract Thromb Haemost 2022; 6:e12763. [PMID: 36032216 PMCID: PMC9399360 DOI: 10.1002/rth2.12763] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 04/12/2022] [Accepted: 05/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background Venous thromboses are well‐established complications of hormonal therapy. Thrombosis risk is seen with both hormonal contraceptive agents and with hormone replacement therapy for menopause and gender transition. Over the past several decades, large epidemiological studies have helped better define these risks. Objectives To review and discuss the differences in thrombosis risk of the many of hormonal preparations available as well as their interaction with patient‐specific factors. Methods We conducted a narrative review of the available literature regarding venous thrombosis and hormonal therapies including for contraception, menopausal symptoms, and gender transition. Results Thrombosis risk with estrogen‐containing compounds increases with increasing systemic dose of estrogen. While progesterone‐only–containing products are not associated with thrombosis, when paired with estrogen in combined oral contraceptives, the formulation of progesterone does impact the risk. These components, along with patient‐specific factors, may influence the choice of hormonal preparation. For patients who develop thrombosis on hormonal treatment, anticoagulation is protective against future thrombosis. Duration of anticoagulation is dependent on ongoing and future hormone therapy choice. Finally, the optimal management of hormone therapy for individuals diagnosed with prothrombotic illnesses such as COVID‐19 remains unclear. Conclusions When contemplating hormonal contraception or hormone replacement therapy, clinicians must consider a variety of factors including hormone type, dose, route, personal and family history of thrombosis, and other prothrombotic risk factors to make informed, personalized decisions regarding the risk of venous thrombosis.
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Affiliation(s)
- Corinne LaVasseur
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA
| | - Suvi Neukam
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA.,Division of Internal Medicine Oregon Health and Sciences University Portland Oregon USA
| | - Thomas Kartika
- Division of Hematology-Oncology Oregon Health and Sciences University Portland Oregon USA
| | - Bethany Samuelson Bannow
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA.,Division of Hematology-Oncology Oregon Health and Sciences University Portland Oregon USA.,The Hemophilia Center Oregon Health and Sciences University Portland Oregon USA
| | - Joseph Shatzel
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA.,Division of Hematology-Oncology Oregon Health and Sciences University Portland Oregon USA
| | - Thomas G DeLoughery
- Department of Medicine Oregon Health and Sciences University Portland Oregon USA.,Division of Hematology-Oncology Oregon Health and Sciences University Portland Oregon USA.,Division of Laboratory Medicine, Department of Pathology Oregon Health and Sciences University Portland Oregon USA
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LGBTQ+ Youth Health: An Unmet Need in Pediatrics. CHILDREN 2022; 9:children9071027. [PMID: 35884011 PMCID: PMC9325167 DOI: 10.3390/children9071027] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 11/19/2022]
Abstract
At present, lesbian, gay, bisexual, transgender, queer and intersex people (LGBTQ+) are increasingly being empowered to freely express themselves, particularly young people and rising generations. Although data underline the trend of more open expression of different sexual orientations and gender identities, LGBTQ+ adolescents still suffer discrimination in the health care framework. Inclusive care by providers to look after the health of LGBTQ+ indiviuals is needed. Pediatricians are often the first health care providers for LGBTQ+ youth facing their sexual and gender identities. Unfortunately, pediatricians have limited knowledge about LGBTQ+ issues, which keeps them from fulfilling the specific needs of LGBTQ+ youth. The purpose of this review is to frame the most important aspects of LGBTQ+ youths’ lives, including risks, difficulties and needs, that pediatricians should investigate and meet to provide these youth with better and more individualizedassistance regarding their health. A literature analysis showed that pediatricians have insufficient knowledge of and comfort with several items regarding the management of LGBTQ+ youths. Increased awareness and knowledge of the specific and exclusive needs of LGBTQ+ adolescents are mandatory, including dedicated pediatric LGBTQ+ health care training. This would give them the opportunity to forward an inclusive health care system, thus reducing the risks related to stigma, bullying and family rejection and promoting sex education. Further studies are needed to better evaluate the prevalence of LGBTQ+ youths, gender-based medicine in pediatrics and the effects of COVID-19 on the LGBTQ+ younth population due to increased risks of psychosocial suffering, isolation and mental diseases.
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Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review. Sex Med Rev 2022; 10:636-647. [PMID: 37051961 DOI: 10.1016/j.sxmr.2022.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The transmasculine and gender diverse (TMGD) spectrum includes transgender men and non-binary individuals whose sex was assigned female at birth. Many TMGD patients pursue treatment with exogenous testosterone to acquire masculine characteristics. Some may choose to undergo gynecological gender-affirming surgery for total hysterectomy with bilateral salpingectomy and/or bilateral oophorectomy (TH/BSO). The decision to retain or remove the ovaries in the setting of chronic testosterone therapy has implications on reproductive health, oncologic risk, endocrine management, cardiovascular health, bone density and neurocognitive status. However, there is limited evidence on the long-term outcomes from this intervention. OBJECTIVE Here we review health-related outcomes of oophorectomy in TMGD population treated with chronic testosterone therapy in order to guide clinicians and patients in the decision to retain or remove their ovaries. METHOD We conducted a systematic literature review following PRISMA guidelines. MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library databases were searched for peer-reviewed studies published prior to October 26, 2021 that: (i) included transgender men/TMGD individuals in the study populations; (ii) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (iii) specifically discussed ovaries, hysterectomy, oophorectomy, ovariectomy, or gonadectomy. RESULTS We identified 469 studies, of which 39 met our inclusion criteria for this review. Three studies discussed fertility outcomes, 11 assessed histopathological changes to the ovaries, 6 discussed ovarian oncological outcomes, 8 addressed endocrine considerations, 3 discussed cardiovascular health outcomes, and 8 discussed bone density. No studies were found that examined surgical outcomes or neurocognitive changes. CONCLUSION There is little information to guide TMGD individuals who are considering TH/BSO versus TH/BS with ovarian retention. Our review suggests that there is limited evidence to suggest that fertility preservation is successful after TH/BS with ovarian retention. Current evidence does not support regular reduction in testosterone dosing following oophorectomy. Estradiol levels are likely higher in individuals that choose ovarian retention, but this has not been clearly demonstrated. Although bone mineral density decreases following oophorectomy, data demonstrating an increased fracture risk are lacking. No studies have described the specific impact on neurocognitive function, or changes in operative complications. Further research evaluating long-term health outcomes of oophorectomy for TMGD individuals treated with chronic testosterone therapy is warranted to provide comprehensive, evidence-based healthcare to this patient population. Sahil Kumar, Smita Mukherjee, Cormac O'Dwyer, et al. Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review. Sex Med Rev 2022;XX:XXX-XXX.
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Ackley E, Halker Singh RB. Sex and gender: Opportunities to expand research and understanding within headache medicine. Headache 2022; 62:771-773. [DOI: 10.1111/head.14351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 05/21/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Elizabeth Ackley
- Department of Neurology Children’s Hospital Colorado Aurora Colorado USA
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Alpert AB, Scout NFN, Schabath MB, Adams S, Obedin-Maliver J, Safer JD. Gender- and Sexual Orientation- Based Inequities: Promoting Inclusion, Visibility, and Data Accuracy in Oncology. Am Soc Clin Oncol Educ Book 2022; 42:1-17. [PMID: 35658501 DOI: 10.1200/edbk_350175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Sexual and gender minority (SGM) people, including agender, asexual, bisexual, gay, gender diverse, genderqueer, genderfluid, intersex, lesbian, nonbinary, pansexual, queer, and transgender people, comprise approximately 10% or more of the U.S. population. Thus, most oncologists see SGM patients whether they know it or not. SGM people experience stigma and structural discrimination that lead to cancer disparities. Because of the lack of systematic and comprehensive data collection, data regarding SGM cancer incidence, outcomes, and treatment responses are limited. Collection of data regarding sexual orientation, gender identity, transgender identity and/or experience, anatomy, and serum hormone concentrations in oncology settings would drastically increase collective knowledge about the impact of stigma and biologic markers on cancer outcomes. Increasing the safety of oncology settings for SGM people will require individual, institutional, and systems changes that will likely improve oncologic care for all patients.
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Affiliation(s)
- Ash B Alpert
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI.,Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | - N F N Scout
- National LGBT Cancer Network, Providence, RI
| | - Matthew B Schabath
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Spencer Adams
- School of Interdisciplinary Health Programs, Western Michigan University, Kalamazoo, MI
| | - Juno Obedin-Maliver
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, CA
| | - Joshua D Safer
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York, NY.,Mount Sinai Center for Transgender Medicine and Surgery, New York, NY
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Review on the Transgender Literature: Where Are We Now and a Step beyond the Current Practice? ENDOCRINES 2022. [DOI: 10.3390/endocrines3020026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The transgender concept is described as a clinically significant distress due to the incongruity between the experienced gender and assigned gender. A transgender person carries a gender identity that is different from their assigned sex at birth. Transgender people may be binary: male to female (transgender women) or female to male (transgender men) or genderqueer (non-binary, fluid or variable gender expression). The binary concept has been described in transgender population, where the term transwomen is used to describe people assigned male at birth (AMAB) who are recognized as females during gender transition; with the term transmen where they are assigned female at birth (AFAB) and are then recognized as males in gender transition. According to the DSM-5 classification, gender dysphoria is described when a transgender person develops clinically relevant bio-psychosocial suffering. Currently, the transgender population has gained massive public awareness through social media and gained a considerable level of attention globally. Several studies on transgender populations from different parts of the world have shown real discrimination and stigma towards transgender people, which sometimes acts as a barrier to the provision of the required care for them. Lack of access to the required information, legal issues, lack of solutions to fertility problems, financial constraints, and psychological and emotional obstacles, together with risk of sexually transmitted infections, including human immunodeficiency virus (HIV), all make the life of a transgender person more complicated. Testosterone therapy is a hormone-based therapy for transgender men that provides a body image tallying with the favored gender identification, whereas estrogen and androgen-suppressing agents are used in transgender females to produce changes compatible with their required gender identity. Gender affirmation surgery is a broad term, under which the genital reconstruction is described as a major component. Psychological conditions such as depression, substance abuse, suicidal deaths, and sexually transmitted infections, particularly among males having sex with males, are reported at a significantly higher rate among transgender populations. Cardiovascular morbidity is higher among this population, and continuous medical surveillance is warranted. Medical care provision to transgender populations should be handled with great care, while attending to the unmet needs of this population, as this care should extend beyond routine hormonal therapy and gender reassignment surgery.
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Bretherton I, Ghasem-Zadeh A, Leemaqz SY, Seeman E, Wang X, McFarlane T, Spanos C, Grossmann M, Zajac JD, Cheung AS. Bone Microarchitecture in Transgender Adults: A Cross-Sectional Study. J Bone Miner Res 2022; 37:643-648. [PMID: 34981566 PMCID: PMC9305455 DOI: 10.1002/jbmr.4497] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/23/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
Gender-affirming hormone therapy aligns physical characteristics with an individual's gender identity, but sex hormones regulate bone remodeling and influence bone morphology. We hypothesized that trans men receiving testosterone have compromised bone morphology because of suppression of ovarian estradiol production, whereas trans women receiving estradiol, with or without anti-androgen therapy, have preserved bone microarchitecture. We compared distal radial and tibial microarchitecture using high-resolution peripheral quantitative computed tomography images in a cross-sectional study of 41 trans men with 71 cis female controls, and 40 trans women with 51 cis male controls. Between-group differences were expressed as standardized deviations (SD) from the mean in age-matched cisgender controls with 98% confidence intervals adjusted for cross-sectional area (CSA) and multiple comparisons. Relative to cis women, trans men had 0.63 SD higher total volumetric bone mineral density (vBMD; both p = 0.01). Cortical vBMD and cortical porosity did not differ, but cortices were 1.11 SD thicker (p < 0.01). Trabeculae were 0.38 SD thicker (p = 0.05) but otherwise no different. Compared with cis men, trans women had 0.68 SD lower total vBMD (p = 0.01). Cortical vBMD was 0.70 SD lower (p < 0.01), cortical thickness was 0.51 SD lower (p = 0.04), and cortical porosity was 0.70 SD higher (p < 0.01). Trabecular bone volume (BV/TV) was 0.77 SD lower (p < 0.01), with 0.57 SD fewer (p < 0.01) and 0.30 SD thicker trabeculae (p = 0.02). There was 0.56 SD greater trabecular separation (p = 0.01). Findings at the distal radius were similar. Contrary to each hypothesis, bone microarchitecture was not compromised in trans men, perhaps because aromatization of administered testosterone prevented bone loss. Trans women had deteriorated bone microarchitecture either because of deficits in microstructure before treatment or because the estradiol dosage was insufficient to offset reduced aromatizable testosterone. Prospective studies are needed to confirm these findings. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Ingrid Bretherton
- Department of Medicine, The University of Melbourne, Heidelberg, Australia.,Endocrinology (Austin Health), The University of Melbourne, Heidelberg, Australia
| | - Ali Ghasem-Zadeh
- Department of Medicine, The University of Melbourne, Heidelberg, Australia
| | - Shalem Y Leemaqz
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Ego Seeman
- Department of Medicine, The University of Melbourne, Heidelberg, Australia.,Endocrinology (Austin Health), The University of Melbourne, Heidelberg, Australia
| | - Xiaofang Wang
- Department of Medicine, The University of Melbourne, Heidelberg, Australia
| | - Thomas McFarlane
- Department of Medicine, The University of Melbourne, Heidelberg, Australia
| | - Cassandra Spanos
- Department of Medicine, The University of Melbourne, Heidelberg, Australia
| | - Mathis Grossmann
- Department of Medicine, The University of Melbourne, Heidelberg, Australia.,Endocrinology (Austin Health), The University of Melbourne, Heidelberg, Australia
| | - Jeffrey D Zajac
- Department of Medicine, The University of Melbourne, Heidelberg, Australia.,Endocrinology (Austin Health), The University of Melbourne, Heidelberg, Australia
| | - Ada S Cheung
- Department of Medicine, The University of Melbourne, Heidelberg, Australia.,Endocrinology (Austin Health), The University of Melbourne, Heidelberg, Australia
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The effects of gender-affirming hormone therapy on cardiovascular and skeletal health: A literature review. Metabol Open 2022; 13:100173. [PMID: 35282421 PMCID: PMC8907681 DOI: 10.1016/j.metop.2022.100173] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/23/2022] [Accepted: 03/01/2022] [Indexed: 01/09/2023] Open
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Kerrebrouck M, Vantilborgh A, Collet S, T’Sjoen G. Thrombophilia and hormonal therapy in transgender persons: A literature review and case series. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:377-391. [PMID: 36324880 PMCID: PMC9621226 DOI: 10.1080/26895269.2022.2025551] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Background: Venous thromboembolism (VTE) is a rare side effect of hormonal therapy in transgender persons. Prothrombotic genetic variants can increase this risk. For this reason, previous VTE and/or genetic thrombophilia may be considered by some as contraindications to hormonal treatment. Aim: To formulate directions for clinical practice about the indications for thrombophilia screening and when to consider combination therapy of therapeutic anticoagulation and hormonal treatment as a safe alternative to withholding hormonal treatment. Methods: We conducted a literature search and describe a case series. All adult patients with gender dysphoria and a known prothrombotic genetic variant or history of VTE were invited by letter to participate in this study. Results: In our center, thrombophilia screening before start of hormonal treatment was restricted to those with a personal or family history of VTE. Sixteen individuals with a history of VTE and/or an underlying prothrombogenic condition were described. The time of follow up varied from 4 months to 20 years. Seven trans women had a positive thrombophilia screening (2 Factor V Leiden (FVL), 1 FVL + anticardiolipin antibodies, 1 FVL + high Factor VIII coagulant activity, 1 protein C deficiency, 1 prothrombin mutation, 1 positive lupus anticoagulant). Three trans women experienced an unprovoked VTE after start of hormonal therapy of which one lead to a positive thrombophilia screening. One VTE event in a trans woman was assumed to be provoked by surgery. Five trans men were identified with a prothrombogenic mutation (3 FVL, 1 protein C deficiency, 1 prothrombin mutation). One trans man, with a negative thrombophilia screen, experienced multiple provoked VTE events before start of hormonal therapy. Conclusion: Based on our literature review and case series we offer guidance when confronted with patients with previous VTE and/or genetic thrombophilia requesting hormonal interventions.
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Affiliation(s)
| | - Anna Vantilborgh
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - Sarah Collet
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Guy T’Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
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50
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Pigozzi F, Bigard X, Steinacker J, Wolfarth B, Badtieva V, Schneider C, Swart J, Bilzon JLJ, Constantinou D, Dohi M, Di Luigi L, Fossati C, Bachl N, Li G, Papadopoulou T, Casasco M, Janse van Rensburg DC(C, Kaux JF, Rozenstoka S, Casajus JA, Zelenkova I, Ak E, Ulkar B, Arroyo F, Ionescu A, Pedrinelli A, Miller M, Singleton P, Shroff M, Webborn N, Barrett J, Hamilton B, Geistlinger M, Beltrami G, Migliorini S, Dienstbach-Wech L, Bermon S, Pitsiladis YP. Joint position statement of the International Federation of Sports Medicine (FIMS) and European Federation of Sports Medicine Associations (EFSMA) on the IOC framework on fairness, inclusion and non-discrimination based on gender identity and sex variations. BMJ Open Sport Exerc Med 2022; 8:e001273. [PMID: 35127133 PMCID: PMC8739444 DOI: 10.1136/bmjsem-2021-001273] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The IOC recently published its framework on fairness, inclusion and non-discrimination based on gender identity and sex variations. This framework is drafted mainly from a human rights perspective, with less consideration for medical/scientific issues. The framework places the onus for gender eligibility and classification entirely on the International Federations (IFs), even though most will not have the capacity to implement the framework. The position of no presumption of advantage is contrary to the 2015 IOC consensus. Implementation of the 2021 framework will be a major challenge for IFs that have already recognised the inclusion of trans and women athletes with differences of sexual development (DSD) using a scientific/medical solution. The potential consequences for sports that need to prioritise fairness or safety could be one of two extremes (1) exclusion of all transgender or DSD athletes on the grounds of advantage or (2) self-identification that essentially equates to no eligibility rules. Exclusion of all transgender or DSD athletes is contrary to the Olympic charter and unlawful in many countries. While having no gender eligibility rules, sport loses its meaning and near-universal support. Athletes should not be under pressure to undergo medical procedures or treatment to meet eligibility criteria. However, if an athlete is fully informed and consents, then it is their free choice to undergo carefully considered or necessary interventions for gender classification for sport to compete fairly and safely in their chosen gender. Free choice is a fundamental human right, but so is the right to fair and safe competition.
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Affiliation(s)
- Fabio Pigozzi
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Rome, Italy
- Villa Stuart Sport Clinic, FIFA Medical Center of Excellence, Rome, Italy
| | - Xavier Bigard
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- European Federation of Sports Medicine Associations (EFSMA), Lausanne, Switzerland
- Union Cycliste Internationale (UCI), Aigle, Switzerland
| | - Juergen Steinacker
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Division of Sports and Rehabilitation Medicine, Department of Internal Medicine, Ulm University Hospital, Ulm, Germany
| | - Bernd Wolfarth
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Department of Sports Medicine, Humboldt University and Charité University School of Medicine, Berlin, Germany
| | - Victoriya Badtieva
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Moscow Research and Practical Center for Medical Rehabilitation, Restorative and Sports Medicine, Moscow Healthcare Department, Moscow, Russian Federation
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia, Moscow, Russian Federation
| | - Christian Schneider
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Orthopaedic Center Theresie, Munich, Germany
| | - Jeroen Swart
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Health through Physical Activity, Lifestyle and Sport Research Centre (HPALS), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - James Lee John Bilzon
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Department for Health, University of Bath, Bath, UK
| | - Demitri Constantinou
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Centre for Exercise Science and Sports Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Michiko Dohi
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Sports Medical Center, Japan Institute of Sport Sciences, Tokyo, Japan
| | - Luigi Di Luigi
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Unit of Endocrinology, Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Rome, Italy
| | - Chiara Fossati
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Rome, Italy
- Villa Stuart Sport Clinic, FIFA Medical Center of Excellence, Rome, Italy
| | - Norbert Bachl
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Institute of Sports Science, University of Vienna, Vienna, Austria
- Austrian Institute of Sports Medicine, Vienna, Austria
| | - Guoping Li
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- National Institute of Sports Medicine, Beijing, China
| | - Theodora Papadopoulou
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- European Federation of Sports Medicine Associations (EFSMA), Lausanne, Switzerland
- Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK
| | - Maurizio Casasco
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- European Federation of Sports Medicine Associations (EFSMA), Lausanne, Switzerland
- FIMS Collaborating Center of Sports Medicine, Institute of Sports Medicine in Milan (Istituto di Medicina dello Sport di Milano), Milano, Italy
| | - Dina Christina (Christa) Janse van Rensburg
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Section Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- Medical Board Member, World Netball, Manchester, UK
| | - Jean-François Kaux
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- SportS2, Liège University and University Hospital of Liège, Liège, Belgium
| | - Sandra Rozenstoka
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- FIMS Collaboration Centre of Sports Medicine, Sports laboratory, Riga, Latvia
| | - Jose-Antonio Casajus
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- GENUD research group, FIMS Collaborating Center of Sports Medicine, Department of Physiatry and Nursing, University of Zaragoza, Zaragoza, Spain
| | - Irina Zelenkova
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- GENUD research group, FIMS Collaborating Center of Sports Medicine, Department of Physiatry and Nursing, University of Zaragoza, Zaragoza, Spain
| | - Emre Ak
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- FIMS Collaborating Center of Sports Medicine, Gloria Sports Arena Belek, Antalya, Turkey
| | - Bulent Ulkar
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Sports Medicine Department, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Francisco Arroyo
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- FIMS Collaborating Center of Sports Medicine, Guadalajara, Mexico
| | - Anca Ionescu
- European Federation of Sports Medicine Associations (EFSMA), Lausanne, Switzerland
- Sports Medicine, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania
| | - André Pedrinelli
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- Department of Orthopaedics, University of São Paulo Medical School, São Paulo, Brazil
| | - Mike Miller
- World Olympians Association (WOA), Lausanne, Switzerland
| | | | - Malav Shroff
- World Olympians Association (WOA), Lausanne, Switzerland
| | - Nick Webborn
- School of Sport and Health Sciences, University of Brighton, Eastbourne, UK
- Medical Committee, International Paralympic Committee (IPC), Bonn, Germany
| | - James Barrett
- The Gender Identity Clinic Tavistock and Portman NHS Foundation Trust, London, UK
| | - Blair Hamilton
- School of Sport and Health Sciences, University of Brighton, Eastbourne, UK
- Centre for Stress and Age-related Disease, University of Brighton, Brighton, UK
| | - Michael Geistlinger
- Department of Public, International and European Law, Unit International Law, University of Salzburg, Salzburg, Austria
| | - Gianfranco Beltrami
- Medical Commission, World Baseball Softball Confederation, Pully, Switzerland
- Faculty of Sport Sciences, University of Parma, Parma, Italy
| | | | - Lenka Dienstbach-Wech
- Department of Orthopaedics, Spine and Trauma Surgery, Hospital zum Heiligen Geist Frankfurt, Frankfurt, Germany
| | - Stéphane Bermon
- World Athletics, Health and Science Department, Monaco
- LAMHESS, Université Côte d’Azur, Nice, France
| | - Yannis P Pitsiladis
- International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
- European Federation of Sports Medicine Associations (EFSMA), Lausanne, Switzerland
- School of Sport and Health Sciences, University of Brighton, Eastbourne, UK
- Centre for Stress and Age-related Disease, University of Brighton, Brighton, UK
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