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Betsi G, Goulia P, Sandhu S, Xekouki P. Puberty suppression in adolescents with gender dysphoria: an emerging issue with multiple implications. Front Endocrinol (Lausanne) 2024; 15:1309904. [PMID: 38988996 PMCID: PMC11235884 DOI: 10.3389/fendo.2024.1309904] [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: 10/08/2023] [Accepted: 05/17/2024] [Indexed: 07/12/2024] Open
Abstract
Controversy exists over puberty suppression (PS) in adolescents with gender dysphoria (GD). PS is preferentially achieved with GnRH analogues. By preventing the development of secondary sex characteristics, PS may improve psychological functioning, well-being, quality of life, emotional and behavioral (especially internalizing) problems and depressive symptoms, thus decreasing suicidality. PS can also extend the diagnostic period and give transgender adolescents time to explore their gender identity. GnRHa may also decrease the need for feminization/masculinization surgery. However, 2-year treatment with GnRHa may result in bone mass accrual retardation (decrease in BMD/BMAD z-scores), growth velocity deceleration (decrease in height SDS), increase in fat mass, temporary pause in oocyte/sperm maturation. The most common side effects of GnRHa are hot flashes, mood fluctuations, fatigue and headache. They are usually mild and rarely lead to GnRHa discontinuation. Based on current scientific evidence, PS could be recommended to adolescents who meet the diagnostic criteria of gender incongruence (by DSM-5 and/or ICD-11) and have long-lasting intense GD, which aggravates with puberty onset. Before initiating PS, possible mental issues should be addressed and informed consent (by the adolescent/caregiver) should be given, after counseling on probable reproductive effects of GnRHa. GnRHa can only be started after the adolescent has entered Tanner stage 2. Nevertheless, published studies are inadequate in number, small in size, uncontrolled and relatively short-term, so that it is difficult to draw safe conclusions on efficacy and safety of GnRHa. Large long-term randomized controlled trials are needed to expand knowledge on this controversial issue and elucidate the benefit and risks of PS.
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Affiliation(s)
- Grigoria Betsi
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Heraklion, Greece
| | - Panagiota Goulia
- Department of Psychiatry, Cambridgeshire and Peterborough National Health Service (NHS) Foundation Trust, Cambridge, United Kingdom
| | - Sophia Sandhu
- General Practice, Bridge Street Medical Practice, Cambridge, United Kingdom
| | - Paraskevi Xekouki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Heraklion, Greece
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2
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Nokoff NJ, Bothwell S, Rice JD, Cree MG, Kelsey MM, Moreau KL, Zeitler P, Nadeau KJ. Insulin sensitivity, body composition and bone mineral density after testosterone treatment in transgender youth with and without prior GnRH agonist therapy. J Clin Transl Endocrinol 2024; 36:100356. [PMID: 38948245 PMCID: PMC11214195 DOI: 10.1016/j.jcte.2024.100356] [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: 12/01/2023] [Revised: 05/14/2024] [Accepted: 05/31/2024] [Indexed: 07/02/2024] Open
Abstract
Background 1.8% of youth identify as transgender; a growing proportion are transgender male (female sex, male gender identity). Many receive gonadotropin releasing hormone agonist (GnRHa) therapy to suppress endogenous puberty and/or will start testosterone to induce secondary sex characteristics that align with gender identity. Objectives To determine the effects of 12 months of testosterone on cardiometabolic health among transgender youth, including insulin sensitivity, body composition, and bone mineral density and whether changes in outcomes differ based on prior GnRHa treatment. Methods Participants (n = 19, baseline age 15.0 ± 1.0 years) were examined prior to and 12 months after testosterone therapy in a longitudinal observational study. Fasted morning blood draw, a 2-hour 75-gram oral glucose tolerance test, body composition and bone mineral density (dual-energy X-ray absorptiometry) were assessed at baseline and 12 months. Insulin sensitivity was estimated by HOMA-IR and Matsuda index. Changes were compared with mixed linear regression models evaluating time (baseline, 12 months), group (GnRHa treatment yes/no), and their interaction. Results In the entire cohort, fasted insulin decreased (median [25,75 %ile]: -3 [-5, 0] mIU/L, p = 0.044) and 2-hour glucose increased (mean ± standard deviation): +18.5 ± 28.9 mg/dL, p = 0.013 from baseline after 12 months of testosterone therapy. There were no significant changes in HOMA-IR (p = 0.062) or Matsuda index (p = 0.096), nor by GnRHa status. Absolute (+6.2 [4.7, 7.5] kg, p = 0.016) and percent fat-free mass increased (+7.3 [5.4, 9.1] %, p = 0.003) and percent fat mass declined (-7.4 [-9.3, 5.3]%, p = 0.005) for the entire cohort. There were time*group interactions for absolute (p = 0.0007) and percent fat-free mass (p = 0.033). There were time*group interactions for bone mineral content (p = 0.006). Conclusions Twelve months of testosterone in transgender adolescents resulted in changes in body composition and bone mineral density, with baseline differences between the +/-GnRHa group and convergence after 12 months. There were no changes in insulin sensitivity over time or between groups.
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Affiliation(s)
- Natalie J. Nokoff
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
- Ludeman Family Center for Women’s Health Research, USA
| | - Samantha Bothwell
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
| | - John D. Rice
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
- University of Michigan, Department of Biostatistics, USA
| | - Melanie G. Cree
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
- Ludeman Family Center for Women’s Health Research, USA
| | - Megan M. Kelsey
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
- Ludeman Family Center for Women’s Health Research, USA
| | - Kerrie L. Moreau
- Ludeman Family Center for Women’s Health Research, USA
- University of Colorado Anschutz Medical Campus, Department of Medicine, USA
| | - Philip Zeitler
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
| | - Kristen J. Nadeau
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
- Ludeman Family Center for Women’s Health Research, USA
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3
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Chen LM, Valentine A, Davis SM, Graber E, Fechner PY, Furniss A, Nahata L, Pyle L, Vyas AK, Vogiatzi MG, Nokoff NJ. Multicenter Analysis of Cardiometabolic-Related Diagnoses in Youth with Congenital Adrenal Hyperplasia: a PEDSnet study. J Clin Endocrinol Metab 2024:dgae362. [PMID: 38783717 DOI: 10.1210/clinem/dgae362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 05/25/2024]
Abstract
CONTEXT Small cohorts of youth with congenital adrenal hyperplasia (CAH) demonstrate increased risk of obesity and poor cardiometabolic health. OBJECTIVE To determine the odds of cardiometabolic-related diagnoses in youth with CAH compared to matched controls in a cross-sectional analysis in a large, multisite database (PEDSnet). DESIGN Electronic health record data (2009-2019) were used to determine odds of cardiometabolic-related outcomes based on diagnosis, anthropometric and laboratory data using logistic regression among youth with CAH vs. controls. SETTING Six PEDSnet sites. PATIENTS OR OTHER PARTICIPANTS Youth with CAH and >1 outpatient visit in PEDSnet (n=1,647) were propensity-score matched on 8 variables to controls (n=6,588). A subset of youth with classic CAH (n=547, with glucocorticoid and mineralocorticoid prescriptions) were matched to controls (n=2,188). INTERVENTION(S) N/A. MAIN OUTCOME MEASURE(S) Odds of having cardiometabolic-related diagnoses among youth over 2 years with CAH compared to matched controls. RESULTS Outcomes were calculated for all individuals with CAH (median age at last visit 12.9 years [7.3, 17.6]) and a subset with classic CAH (median age at last visit 11.6 years [4.7, 17.5]) compared to their matched controls. All patients with CAH had higher odds of overweight/obesity (odds ratio [95% confidence interval] 3.63 [3.24,4.07]), hypertension (3.07 [2.60,3.64]), dysglycemia (1.95 [1.35,2.82], dyslipidemia (2.28 [1.79,2.91]) and liver dysfunction (2.30 [1.91,2.76]) compared to matched controls. Patients with classic CAH had higher odds of overweight/obesity (3.21 [2.61,3.93]), hypertension (8.22 [6.71,10.08]), and liver dysfunction (2.11 [1.55,2.89]) compared to matched controls. CONCLUSIONS Overall, youth with CAH are at increased risk of diagnoses related to worse cardiometabolic health.
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Affiliation(s)
- Li-Min Chen
- Department of Pediatrics, University of Colorado Anschutz Medical Campus
- Department of Pediatrics, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung City, Taiwan
| | - Anna Valentine
- Department of Pediatrics, University of Colorado Anschutz Medical Campus
| | - Shanlee M Davis
- Department of Pediatrics, University of Colorado Anschutz Medical Campus
| | - Evan Graber
- Department of Pediatrics, Nemours Children's Health - Delaware
| | - Patricia Y Fechner
- Department of Pediatrics, University of Washington and Seattle Children's Hospital
| | - Anna Furniss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado Anschutz Medical Campus
| | - Leena Nahata
- Department of Pediatrics, The Ohio State University College of Medicine
- Center for Biobehavioral Health and Division of Endocrinology, Nationwide Children's Hospital
| | - Laura Pyle
- Department of Pediatrics, University of Colorado Anschutz Medical Campus
| | - Arpita K Vyas
- Department of Pediatrics, Washington University St. Louis, School of Medicine
| | - Maria G Vogiatzi
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Natalie J Nokoff
- Department of Pediatrics, University of Colorado Anschutz Medical Campus
- Ludeman Family Center for Women's Health Research, University of Colorado Anschutz Medical Campus
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4
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Steiger A, VanderVeen NT, Kang EH, Weimer AK. Resolution of metabolic dysfunction-associated steatohepatitis with estradiol in a transgender female: A case report. JPGN REPORTS 2024; 5:223-227. [PMID: 38756118 PMCID: PMC11093893 DOI: 10.1002/jpr3.12054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 11/06/2023] [Accepted: 01/16/2024] [Indexed: 05/18/2024]
Abstract
A 16-year-old trans female patient presented to our Gender Health Program for gender-affirming care. Her intake evaluation revealed signs of hepatocellular injury and fibrosis concerning for metabolic dysfunction-associated steatohepatitis (MASH) and she was referred to a Pediatric Hepatologist. Subsequent delays in initiating hormone therapy caused a decline in her mental health, and she began experiencing suicidal ideations. Gender-affirming hormone therapy has been shown to significantly reduce depressive symptoms and suicidal ideations in transgender and gender diverse youth, and studies in animal models suggest improvement in hepatic steatosis in response to estrogen. A multidisciplinary meeting with Gender Health, Psychiatry, and Hepatology appropriately weighed the benefits of life-saving hormone therapy and the possibility of an improvement in her comorbid liver condition with the risk of further liver damage from estrogen therapy. The teams and the patient agreed to start estradiol with subsequent resolution of laboratory and radiographic evidence of MASH.
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Affiliation(s)
- Athreya Steiger
- David Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
| | - Nathan T. VanderVeen
- David Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
- Department of Internal Medicine, Division of Internal Medicine & PediatricsUCLA HealthLos AngelesCaliforniaUSA
| | - Esther H. Kang
- David Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
- Department of Internal Medicine, Division of Internal Medicine & PediatricsUCLA HealthLos AngelesCaliforniaUSA
| | - Amy K. Weimer
- David Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
- Department of Internal Medicine, Division of Internal Medicine & PediatricsUCLA HealthLos AngelesCaliforniaUSA
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5
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Zytner ZJE, Stanley JR, Grewal P, Dettmer E, Toulany A, Palmert MR, Sorbara JC. Gender diversity among adolescents with obesity in a weight management programme. Clin Obes 2024:e12664. [PMID: 38622908 DOI: 10.1111/cob.12664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 03/11/2024] [Accepted: 03/30/2024] [Indexed: 04/17/2024]
Abstract
Gender dysphoria (GD) and obesity share commonalities, including associations with mental health comorbidities, disordered eating, body dissatisfaction and may intensify with physical and developmental changes during adolescence. While associations of obesity and gender diversity have been identified, rates of gender diversity among adolescents with obesity remain unclear. The aim was to examine gender diversity among adolescents with obesity in a weight management programme. A single-centre cross-sectional questionnaire study was conducted. Eligible adolescents received the Gender Identity/GD Questionnaire for Adolescents and Adults (GIDYQ-AA), a validated instrument measuring gender diversity and GD. Gender identities, sexual orientations, questionnaire scores, and frequency of GD (GIDYQ-AA score <3) were determined. The relationship of GIDYQ-AA scores and BMI Z-score (BMIz) was assessed. Of 72 consenting youth, 29 assigned females (AF) and 17 assigned males (AM) completed GIDYQ-AA and demographic questions. Seventeen (59%) AF reported non-heterosexual orientations, and 6 (21%) reported non-cisgender identities. One (6%) AM reported non-cisgender identity. Two (4%) AF individuals had GD based on GIDYQ-AA scores. GIDYQ-AA scores did not correlate with BMIz. In conclusion, adolescents with obesity, particularly AF with non-heterosexual orientation, reported high rates of non-cisgender identity and GD. Routine screening for gender-related concerns in weight management settings may be warranted.
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Affiliation(s)
- Zachary J E Zytner
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joshua R Stanley
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Preeti Grewal
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth Dettmer
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alene Toulany
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Division of Adolescent Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mark R Palmert
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Julia C Sorbara
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Division of Endocrinology, The Hospital for Sick Children, Toronto, Ontario, Canada
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6
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Borger O, Perl L, Yackobovitch-Gavan M, Sides R, Brener A, Segev-Becker A, Sheppes T, Weinstein G, Oren A, Lebenthal Y. Body Composition and Metabolic Syndrome Components in Transgender/Gender Diverse Adolescents and Young Adults. LGBT Health 2024. [PMID: 38557208 DOI: 10.1089/lgbt.2023.0065] [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: 04/04/2024] Open
Abstract
Purpose: The objective of this study was to examine the association of designated sex at birth, body composition, and gender-affirming hormone treatment (GAHT) with the components of metabolic syndrome (MetS) (overweight/obesity, elevated blood pressure [BP], altered glucose metabolism, and dyslipidemia) in transgender/gender diverse (TGD) adolescents and young adults. Methods: TGD individuals underwent body composition studies by bioelectrical impedance analysis according to designated sex at birth, and their muscle-to-fat ratio (MFR) z-scores were calculated. Generalized estimating equations with binary logistic models (n = 326) were used to explore associations while adjusting for potential confounders. Results: A total of 55 TGD females and 111 TGD males, with mean age of 18 ± 1.9 years and median duration of GAHT of 1.4 years (interquartile range = 0.6-2.5), were enrolled. Overall, 118/166 (71%) of the TGD cohort showed evidence of at least one MetS component, with a significantly higher rate among TGD males compared with TGD females (91.1% vs. 50.9%, p < 0.001). TGD males were at increased odds for overweight/obesity, elevated/hypertensive BP, elevated triglycerides (TGs), and an atherogenic dyslipidemia index (TG/high-density lipoprotein cholesterol [HDL-c], TG:HDL-c). The odds of overweight/obesity increased by 44.9 for each standard deviation decrease in the MFR z-score, while the odds for an elevated TG:HDL-c index increased by 3.7. Psychiatric morbidity increased the odds for overweight/obesity by 2.89. Conclusions: After considering confounding variables, the TGD males on GAHT were found to be at an increased risk for cardiometabolic disease. Our observations support the importance of targeted medical nutrition intervention in this group of individuals.
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Affiliation(s)
- Ophir Borger
- The Institute of Pediatric Endocrinology and Diabetes, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- The Nutrition and Dietetics Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Liat Perl
- The Institute of Pediatric Endocrinology and Diabetes, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Yackobovitch-Gavan
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roni Sides
- The Nutrition and Dietetics Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Avivit Brener
- The Institute of Pediatric Endocrinology and Diabetes, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Segev-Becker
- The Institute of Pediatric Endocrinology and Diabetes, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamar Sheppes
- The Institute of Pediatric Endocrinology and Diabetes, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Psychological Services, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Asaf Oren
- The Institute of Pediatric Endocrinology and Diabetes, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- The Nutrition and Dietetics Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yael Lebenthal
- The Institute of Pediatric Endocrinology and Diabetes, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- The Nutrition and Dietetics Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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7
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Ristori J, Motta G, Meriggiola MC, Bettocchi C, Crespi C, Falcone M, Lombardo F, Maggi M, Morelli G, Colao AM, Isidori AM, Fisher AD. A comment from SIGIS, SIE and SIAMS: "Puberty blockers in transgender adolescents-a matter of growing evidence and not of ideology". J Endocrinol Invest 2024; 47:479-481. [PMID: 37695460 DOI: 10.1007/s40618-023-02173-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/02/2023] [Indexed: 09/12/2023]
Affiliation(s)
- J Ristori
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, Careggi University Hospital, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - G Motta
- Endocrinology, Diabetology and Metabolism Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - M C Meriggiola
- Division of Gynecology and Human Reproduction Physiopathology, IRCSS Azienda Ospedaliero Universitaria di Bologna, University of Bologna, Bologna, Italy
| | - C Bettocchi
- Department of Urology, University of Foggia, Foggia, Italy
| | - C Crespi
- Endocrinology, Diabetology and Metabolism Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - M Falcone
- Department of Urology, A.O.U. Città della Salute e della Scienza di Torino, Molinette Hospital, Turin, Italy
| | - F Lombardo
- Department of Experimental Medicine, University of Rome "La Sapienza", Rome, Italy
| | - M Maggi
- Endocrinology Unit, "Mario Serio" Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - G Morelli
- Urology Department, University of Pisa, Pisa, Italy
| | - A M Colao
- Cattedra Unesco "Educazione alla Salute e allo Sviluppo Sostenibile", University "Federico II", Naples, Italy
- UNESCO Chair on Health Education and Sustainable Development, Federico II University, Naples, Italy
| | - A M Isidori
- Department of Experimental Medicine, University of Rome "La Sapienza", Rome, Italy
| | - A D Fisher
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, Careggi University Hospital, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.
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8
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Preston S, Lopez X. Legislation, medicine, and politics: care for gender diverse youth. Curr Opin Endocrinol Diabetes Obes 2024; 31:43-52. [PMID: 38010030 DOI: 10.1097/med.0000000000000845] [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] [Indexed: 11/29/2023]
Abstract
PURPOSE OF REVIEW A recent increase in legislation in the United States prohibiting gender-affirming care (GAC) for transgender youth follows a wave of its politicization despite support from all pertinent mainstream medical associations. This review describes the standards of GAC for transgender youth, the origins of legislation prohibiting this care, a review of current legislation in the United States and a discussion on the impact on patients, providers, and the medical field. RECENT FINDINGS A critical evaluation of historical parallels and current organizations supporting this legislation reveals it stems not from concerns within the medical field but from political and religious interests. This intrusion sets a dangerous precedent, undermining evidence-based medicine, providers' ability to practice according to standards of care, and patients' and guardians' autonomy and medical decision-making. This wave of antitrans rhetoric and legislation has resulted in threats to health providers and hospitals, 'moral distress" in providers, and migration of providers and patients from hostile states. SUMMARY Similar to antiabortion legislation, these legislative efforts will likely result in negative health outcomes and worsening disparities. The medical community must confront these forces directly through an understanding of the political and structural forces at play and adopting strategies to leverage collective power.
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Affiliation(s)
- Stephanie Preston
- Department of Plastic & Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Ximena Lopez
- Department of Pediatrics, University of California San Diego, USA
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9
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Usselman CW, Lindsey ML, Robinson AT, Habecker BA, Taylor CE, Merryman WD, Kimmerly D, Bender JR, Regensteiner JG, Moreau KL, Pilote L, Wenner MM, O'Brien M, Yarovinsky TO, Stachenfeld NS, Charkoudian N, Denfeld QE, Moreira-Bouchard JD, Pyle WG, DeLeon-Pennell KY. Guidelines on the use of sex and gender in cardiovascular research. Am J Physiol Heart Circ Physiol 2024; 326:H238-H255. [PMID: 37999647 PMCID: PMC11219057 DOI: 10.1152/ajpheart.00535.2023] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/02/2023] [Accepted: 11/21/2023] [Indexed: 11/25/2023]
Abstract
In cardiovascular research, sex and gender have not typically been considered in research design and reporting until recently. This has resulted in clinical research findings from which not only all women, but also gender-diverse individuals have been excluded. The resulting dearth of data has led to a lack of sex- and gender-specific clinical guidelines and raises serious questions about evidence-based care. Basic research has also excluded considerations of sex. Including sex and/or gender as research variables not only has the potential to improve the health of society overall now, but it also provides a foundation of knowledge on which to build future advances. The goal of this guidelines article is to provide advice on best practices to include sex and gender considerations in study design, as well as data collection, analysis, and interpretation to optimally establish rigor and reproducibility needed to inform clinical decision-making and improve outcomes. In cardiovascular physiology, incorporating sex and gender is a necessary component when optimally designing and executing research plans. The guidelines serve as the first guidance on how to include sex and gender in cardiovascular research. We provide here a beginning path toward achieving this goal and improve the ability of the research community to interpret results through a sex and gender lens to enable comparison across studies and laboratories, resulting in better health for all.
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Affiliation(s)
- Charlotte W Usselman
- Cardiovascular Health and Autonomic Regulation Laboratory, Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Merry L Lindsey
- School of Graduate Studies, Meharry Medical College, Nashville, Tennessee, United States
- Research Service, Nashville Veterans Affairs Medical Center, Nashville, Tennessee, United States
| | - Austin T Robinson
- Neurovascular Physiology Laboratory, School of Kinesiology, Auburn University, Auburn, Alabama, United States
| | - Beth A Habecker
- Department of Chemical Physiology and Biochemistry and Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, United States
| | - Chloe E Taylor
- School of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
| | - W David Merryman
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, United States
| | - Derek Kimmerly
- Autonomic Cardiovascular Control and Exercise Laboratory, Division of Kinesiology, School of Health and Human Performance, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jeffrey R Bender
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale Cardiovascular Research Center, New Haven, Connecticut, United States
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Judith G Regensteiner
- Divisions of General Internal Medicine and Cardiology, Department of Medicine, Ludeman Family Center for Women's Health Research, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Kerrie L Moreau
- Division of Geriatrics, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
- Eastern Colorado Health Care System, Geriatric Research Education and Clinical Center, Aurora, Colorado, United States
| | - Louise Pilote
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Megan M Wenner
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, United States
| | - Myles O'Brien
- School of Physiotherapy and Department of Medicine, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Timur O Yarovinsky
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale Cardiovascular Research Center, New Haven, Connecticut, United States
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Nina S Stachenfeld
- John B. Pierce Laboratory, New Haven, Connecticut, United States
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, United States
| | - Nisha Charkoudian
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, United States
| | - Quin E Denfeld
- School of Nursing and Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, United States
| | - Jesse D Moreira-Bouchard
- Q.U.E.E.R. Lab, Programs in Human Physiology, Department of Health Sciences, Boston University College of Health and Rehabilitation Sciences: Sargent College, Boston, Massachusetts, United States
| | - W Glen Pyle
- IMPART Team Canada Network, Dalhousie Medicine, Saint John, New Brunswick, Canada
- Department of Biomedical Sciences, University of Guelph, Guelph, Ontario, Canada
| | - Kristine Y DeLeon-Pennell
- School of Medicine, Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, United States
- Research Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, United States
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10
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Taweh O, Moreira JD. Proposed mechanisms of hypertension and risk of adverse cardiovascular outcomes in LGBT communities. Am J Physiol Heart Circ Physiol 2023; 325:H522-H528. [PMID: 37477686 DOI: 10.1152/ajpheart.00346.2023] [Citation(s) in RCA: 2] [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: 06/12/2023] [Revised: 07/13/2023] [Accepted: 07/18/2023] [Indexed: 07/22/2023]
Abstract
Hypertension (HTN), a highly prevalent public issue affecting one in two adults in the United States, has recently been shown to differentially burden individuals belonging to marginalized communities, such as the lesbian, gay, bisexual, and transgender (LGBT) communities. The minority stress theory posits that a unique combination of marginalization-related psychosocial stressors and coping behaviors may underlie the increased burden of diseases like HTN in LGBT populations. Uncontrolled or poorly managed HTN often leads to the development of adverse cardiovascular outcomes, such as heart failure (HF). Despite our understanding of minority stress theory and demonstrated associations between LGBT identities and HTN, the mechanisms whereby psychosocial stress drives HTN in LGBT populations remain unclear. This mini-review discusses the physiological systems governing blood pressure and the epidemiology of HTN across different subgroups of LGBT people. In addition, we propose mechanisms demonstrated in the general population whereby psychological stress has been implicated in elevating blood pressure that may be occurring in LGBT populations. Finally, we discuss the limitations of current studies and methodological frameworks to make suggestions for study designs to better delineate the mechanisms of psychosocial stress-related HTN in LGBT communities.
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Affiliation(s)
- Omar Taweh
- T. H. Chan School of Medicine, University of Massachusetts Worcester, Worcester, Massachusetts, United States
| | - Jesse D Moreira
- Q.U.E.E.R. Laboratory, Programs in Human Physiology, Department of Health Sciences, Boston University Sargent College, Boston, Massachusetts, United States
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11
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Nokoff NJ, Senefeld J, Krausz C, Hunter S, Joyner M. Sex Differences in Athletic Performance: Perspectives on Transgender Athletes. Exerc Sport Sci Rev 2023; 51:85-95. [PMID: 37057897 PMCID: PMC10330580 DOI: 10.1249/jes.0000000000000317] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
Sex hormone concentrations, particularly testosterone, are primary determinants of sex-based differences in athletic and sports performance, and this relationship may inform fair competition and participation for athletes. This article describes the sex-based dichotomy in testosterone and the implications for sex-based differences in individual sports performance, including factors that relate to athletic performance for transgender individuals, and areas of future investigation.
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Affiliation(s)
- Natalie J Nokoff
- Division of Endocrinology, Department of Pediatrics, University of Colorado Anschutz Medical Campus
| | - Jonathon Senefeld
- Department of Anesthesiology & Perioperative Medicine and Department of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN
| | - Csilla Krausz
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Sandra Hunter
- Exercise Science Program, Department of Physical Therapy, and Athletic & Human Performance Research Center, Marquette University, Milwaukee, WI
| | - Michael Joyner
- Department of Anesthesiology & Perioperative Medicine and Department of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, MN
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12
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Diaz-Thomas AM, Golden SH, Dabelea DM, Grimberg A, Magge SN, Safer JD, Shumer DE, Stanford FC. Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement. J Clin Endocrinol Metab 2023; 108:1533-1584. [PMID: 37191578 PMCID: PMC10653187 DOI: 10.1210/clinem/dgad124] [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: 02/24/2023] [Indexed: 05/17/2023]
Abstract
Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.
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Affiliation(s)
- Alicia M Diaz-Thomas
- Department of Pediatrics, Division of Endocrinology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Sherita Hill Golden
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Dana M Dabelea
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Adda Grimberg
- Department of Pediatrics, Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Sheela N Magge
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Joshua D Safer
- Department of Medicine, Division of Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10001, USA
| | - Daniel E Shumer
- Department of Pediatric Endocrinology, C.S. Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
| | - Fatima Cody Stanford
- Massachusetts General Hospital, Department of Medicine-Division of Endocrinology-Neuroendocrine, Department of Pediatrics-Division of Endocrinology, Nutrition Obesity Research Center at Harvard (NORCH), Boston, MA 02114, USA
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13
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Stevens SD. Obesity in Sexual and Gender Minority Populations: Prevalence and Correlates. Curr Obes Rep 2023:10.1007/s13679-023-00499-z. [PMID: 37140879 DOI: 10.1007/s13679-023-00499-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to explore the prevalence and correlates of obesity among members of sexual and gender minority (SGM) populations. RECENT FINDINGS Research overall finds higher rates of obesity among lesbian and bisexual women than heterosexual women, lower rates of obesity among gay and bisexual men than heterosexual men, and inconsistent findings on obesity among transgender individuals. Rates of mental health disorders and disordered eating are high among all SGM groups. Rates of comorbid medical conditions differ among groups. More research needs to be conducted within all SGM groups but particularly among transgender populations. All members of SGM encounter stigma, including when seeking healthcare, and this may lead to individuals avoiding healthcare. Therefore, it is important to educate providers about population-specific factors. This article serves as an overview of important considerations for providers treating individuals within SGM populations.
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Affiliation(s)
- Serena D Stevens
- Cleveland Clinic Bariatric and Metabolic Institute, 9500 Euclid Ave./M61, Cleveland, OH, 44195, USA.
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14
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O'Connell MA, Pang KC. Cardiometabolic Outcomes in Transgender Youth. J Clin Endocrinol Metab 2022; 107:e4380-e4381. [PMID: 36221797 DOI: 10.1210/clinem/dgac592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Michele A O'Connell
- Department of Adolescent Medicine, The Royal Children's Hospital, Parkville, Victoria, 3052, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, 3052, Australia
| | - Ken C Pang
- Department of Adolescent Medicine, The Royal Children's Hospital, Parkville, Victoria, 3052, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, 3052, Australia
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