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Selander-Han M, McGee S, Lo K. Female Reproductive Endocrine Disorders. Prim Care 2024; 51:431-443. [PMID: 39067969 DOI: 10.1016/j.pop.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
This article is a summary of normal menstrual bleeding and how to recognize abnormalities based on patient's symptoms as well as identify possible causes in order to direct treatment. This article discusses abnormal uterine bleeding including the definition, etiology, evaluation, and treatment. It also discusses primary ovarian insufficiency, transgender medicine, and menopause.
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Affiliation(s)
- Monica Selander-Han
- Department of Family Medicine, Tidelands Health, 4320 Holmestown Road, Myrtle Beach, SC 29588, USA.
| | - Shelby McGee
- Department of Family Medicine, Tidelands Health, 4320 Holmestown Road, Myrtle Beach, SC 29588, USA
| | - Keswick Lo
- Department of Family Medicine, Tidelands Health, 4320 Holmestown Road, Myrtle Beach, SC 29588, USA
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2
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Glodowski MB, Parra CM, Xin MK, Fino ME. Reproductive Considerations in the Transgender and Gender Diverse Population: A Review. Endocrinol Metab Clin North Am 2024; 53:471-482. [PMID: 39084820 DOI: 10.1016/j.ecl.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
Many transgender and gender diverse (TGD) individuals will be considering gender-affirming treatments during their reproductive lifespan. These medically necessary treatments have a negative impact on reproductive potential. All TGD individuals should be counseled regarding fertility. Options for fertility preservation for individuals who have undergone puberty include mature oocyte, embryo, and sperm cryopreservation. In prepubertal individuals, ovarian tissue cryopreservation may be considered, but testicular tissue cryopreservation remains experimental only. While there have been advances in the technology and standardization of reproductive health care for this population, many gaps remain in our knowledge which require further research.
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Affiliation(s)
- Michele B Glodowski
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, New York University Langone Health, 111 Broadway, 2nd Floor, New York, NY 10006, USA.
| | - Carlos M Parra
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics & Gynecology, New York University Langone Prelude Fertility Center, 159 East 53rd Street, 3rd Floor, New York, NY 10022, USA
| | - Madeline K Xin
- NYU Grossman School of Medicine, 550 First Avenue, New York, NY 10016, USA
| | - Mary Elizabeth Fino
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics & Gynecology, New York University Langone Prelude Fertility Center, 159 East 53rd Street, 3rd Floor, New York, NY 10022, USA
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3
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Manion A, James TS. Urinary Tract Infection in a Transgender Male: A Primary Care Approach. J Pediatr Health Care 2024:S0891-5245(24)00232-3. [PMID: 39186018 DOI: 10.1016/j.pedhc.2024.08.002] [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: 10/04/2023] [Revised: 07/29/2024] [Accepted: 08/02/2024] [Indexed: 08/27/2024]
Abstract
Navigating health care as a transgender adolescent presents a multitude of unique challenges that warrant careful consideration. Transgender individuals often encounter barriers such as a lack of knowledgeable health care providers, limited access to gender-affirming care, and concerns about confidentiality, safety, and acceptance. This case report of a transgender male with a history of a urinary tract infection examines the issues facing transgender adolescents in their pursuit of appropriate and sensitive health care and the need for normalizing gender-affirming medical care.
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4
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Agapoff J. Supporting and understanding non-binary & gender diverse youth: a physician's view. Child Adolesc Psychiatry Ment Health 2024; 18:105. [PMID: 39182103 DOI: 10.1186/s13034-024-00798-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2024] [Accepted: 08/17/2024] [Indexed: 08/27/2024] Open
Affiliation(s)
- Jamie Agapoff
- Department of Psychiatry, University of Hawai'i at Mānoa, John A. Burns School of Medicine, Honolulu, Hawai'i, USA.
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5
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Locke ER, Highland KB, Thornton JA, Sunderland KW, Funk W, Pav V, Brydum R, Larson NS, Schvey NA, Roberts CM, Klein DA. Time to Gender-Affirming Hormone Therapy Among US Military-Affiliated Adolescents and Young Adults. JAMA Pediatr 2024:2822490. [PMID: 39158896 PMCID: PMC11334009 DOI: 10.1001/jamapediatrics.2024.2835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 06/12/2024] [Indexed: 08/20/2024]
Abstract
Importance Use of exogenous sex steroid hormones, when indicated, may improve outcomes in adolescents and young adults with gender incongruence. Little is known about factors associated with the time from diagnosis of gender dysphoria to initiation of gender-affirming hormone therapy. Identification of inequities in time to treatment may have clinical, policy, and research implications. Objective To evaluate factors associated with time to initiation of gender-affirming hormone therapy after a diagnosis of gender dysphoria in adolescents and young adults receiving care within the US Military Health System. Design, Setting, and Participants This retrospective cohort study used TRICARE Prime billing and pharmacy data contained in the Military Health System Data Repository. Patients aged 14 to 22 years, excluding service members and their spouses, who received a diagnosis of gender dysphoria between September 1, 2016, and December 31, 2021, were included. The data were analyzed between August 30 and October 12, 2023. Exposures Included patient characteristics were race and ethnicity, age group, first sex assigned in the medical record, and TRICARE Prime sponsor military rank and service at the time of diagnosis. Health care and contextual characteristics included the year of diagnosis and the primary system in which the patient received health care. Main Outcomes and Measures The primary outcome was the time between initial diagnosis of gender dysphoria to the first prescription for gender-affirming hormone medication within a 2-year period. A Poisson generalized additive model was used to evaluate this primary outcome. Adjusted probability estimates were calculated per specified reference categories. Results Of the 3066 patients included (median [IQR] age, 17 [15-19] years; 2259 with first assigned gender marker of female [74%]), an unadjusted survival model accounting for censoring indicated that 37% (95% CI, 35%-39%) initiated therapy by 2 years. Age-adjusted curves indicated that the proportion initiating therapy by 2 years increased by age category (aged 14-16 years, 25%; aged 17-18 years, 39%; aged 19-22 years, 55%). Incidence rate ratios (IRRs) and 2-year adjusted probabilities indicated that longer times to hormone initiation were experienced by adolescents aged 14 to 16 years (IRR, 0.36; 95% CI, 0.30-0.44) and 17 to 18 years (IRR, 0.66; 95% CI, 0.54-0.79) compared with young adults aged 19 to 22 years and Black compared with White adolescents (IRR, 0.73; 95% CI, 0.54-0.99). Senior officer compared with junior enlisted insurance sponsor rank (IRR, 1.93; 95% CI, 1.04-3.55) and civilian compared with military health care setting (IRR, 1.21; 95% CI, 1.02-1.43) was associated with shorter time to hormone initiation. Conclusions and Relevance In this cohort study, most adolescents and young adults with a diagnosis of gender dysphoria receiving health care through the US military did not initiate exogenous sex steroid hormone therapy within 2 years of diagnosis. Inequities in time to treatment indicate the need to identify and reduce barriers to care.
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Affiliation(s)
- Evan R. Locke
- Department of Family Medicine, David Grant Medical Center, Travis Air Force Base, California
| | - Krista B. Highland
- Department of Anesthesiology, Uniformed Services University, Bethesda, Maryland
| | - Jennifer A. Thornton
- Clinical Investigation Facility, David Grant Medical Center, Travis Air Force Base, California
- Ripple Effect, Rockville, Maryland
| | - Kevin W. Sunderland
- Clinical Investigation Facility, David Grant Medical Center, Travis Air Force Base, California
- Ripple Effect, Rockville, Maryland
| | - Wendy Funk
- Kennell and Associates, Falls Church, Virginia
| | - Veronika Pav
- Kennell and Associates, Falls Church, Virginia
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Rick Brydum
- Kennell and Associates, Falls Church, Virginia
| | - Noelle S. Larson
- Department of Pediatrics, Uniformed Services University, Bethesda, Maryland
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Natasha A. Schvey
- Department of Medical and Clinical Psychology, Uniformed Services University, Bethesda, Maryland
| | | | - David A. Klein
- Department of Family Medicine, David Grant Medical Center, Travis Air Force Base, California
- Department of Pediatrics, Uniformed Services University, Bethesda, Maryland
- Department of Family Medicine, Uniformed Services University, Bethesda, Maryland
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6
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Handschuh PA, Reed MB, Murgaš M, Vraka C, Kaufmann U, Nics L, Klöbl M, Ozenil M, Konadu ME, Patronas EM, Spurny-Dworak B, Hahn A, Hacker M, Spies M, Baldinger-Melich P, Kranz GS, Lanzenberger R. Effects of gender-affirming hormone therapy on gray matter density, microstructure and monoamine oxidase A levels in transgender subjects. Neuroimage 2024; 297:120716. [PMID: 38955254 DOI: 10.1016/j.neuroimage.2024.120716] [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: 01/26/2024] [Revised: 06/14/2024] [Accepted: 06/29/2024] [Indexed: 07/04/2024] Open
Abstract
MAO-A catalyzes the oxidative degradation of monoamines and is thus implicated in sex-specific neuroplastic processes that influence gray matter (GM) density (GMD) and microstructure (GMM). Given the exact monitoring of plasma hormone levels and sex steroid intake, transgender individuals undergoing gender-affirming hormone therapy (GHT) represent a valuable cohort to potentially investigate sex steroid-induced changes of GM and concomitant MAO-A density. Here, we investigated the effects of GHT over a median time period of 4.5 months on GMD and GMM as well as MAO-A distribution volume. To this end, 20 cisgender women, 11 cisgender men, 20 transgender women and 10 transgender men underwent two MRI scans in a longitudinal design. PET scans using [11C]harmine were performed before each MRI session in a subset of 35 individuals. GM changes determined by diffusion weighted imaging (DWI) metrics for GMM and voxel based morphometry (VBM) for GMD were estimated using repeated measures ANOVA. Regions showing significant changes of both GMM and GMD were used for the subsequent analysis of MAO-A density. These involved the fusiform gyrus, rolandic operculum, inferior occipital cortex, middle and anterior cingulum, bilateral insula, cerebellum and the lingual gyrus (post-hoc tests: pFWE+Bonferroni < 0.025). In terms of MAO-A distribution volume, no significant effects were found. Additionally, the sexual desire inventory (SDI) was applied to assess GHT-induced changes in sexual desire, showing an increase of SDI scores among transgender men. Changes in the GMD of the bilateral insula showed a moderate correlation to SDI scores (rho = - 0.62, pBonferroni = 0.047). The present results are indicative of a reliable influence of gender-affirming hormone therapy on 1) GMD and GMM following an interregional pattern and 2) sexual desire specifically among transgender men.
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Affiliation(s)
- P A Handschuh
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria
| | - M B Reed
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria
| | - M Murgaš
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria
| | - C Vraka
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Austria
| | - U Kaufmann
- Department of Obstetrics and Gynecology, Medical University of Vienna, Austria
| | - L Nics
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Austria
| | - M Klöbl
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria
| | - M Ozenil
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Austria
| | - M E Konadu
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria
| | - E M Patronas
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Austria
| | - B Spurny-Dworak
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria
| | - A Hahn
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria
| | - M Hacker
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medical University of Vienna, Austria
| | - M Spies
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria
| | - P Baldinger-Melich
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria
| | - G S Kranz
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria; Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hong Kong, China
| | - R Lanzenberger
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria.
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Crabtree L, Connelly KJ, Guerriero JT, Battison EAJ, Tiller-Ormord J, Sutherland SM, Moyer DN. A More Nuanced Story: Pediatric Gender-Affirming Healthcare is Associated With Satisfaction and Confidence. J Adolesc Health 2024:S1054-139X(24)00299-4. [PMID: 39140928 DOI: 10.1016/j.jadohealth.2024.06.016] [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: 02/15/2024] [Revised: 06/08/2024] [Accepted: 06/21/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE Pediatric gender-affirming medical care has strong research evidence and support, and transition-related regret is uncommon. Misinformation about regret has nonetheless been used to limit adolescents from accessing this care. This study is the first of a 3-part initiative to clarify long-term satisfaction and regret related to pediatric gender-affirming care (GAC). METHODS An anonymous survey was distributed to individuals of age 15 and older who participated in at least one prior appointment at a large pediatric gender clinic. The survey questions included (1) demographics; (2) use of gender-affirming interventions; (3) barriers to accessing medical interventions; (4) reasons for any discontinuation of medical interventions; (5) emotions associated with GAC; and (6) intervention-related regret. RESULTS Participants (N = 150; Mage = 18.6) were predominantly transmasculine-identified and/or assigned female at birth (86%). The most common emotions associated with GAC were satisfaction (88.0%) and confidence (86.7%). A total of 141 participants reported taking hormones, 30 of whom reported ever discontinuing (21.3%). Among these, 11 have already resumed hormones, and 16 might resume. Of the three with no plan to resume hormones, one is fully satisfied with the results, and the remaining two no longer identify as transgender. Only one participant (0.7% of those who ever took hormones) wishes they had never started testosterone or had top surgery, both of which occurred in adulthood. DISCUSSION Individuals who accessed GAC as adolescents are largely satisfied with this care. Care-related satisfaction and regret are more nuanced than sometimes portrayed and should not be used to limit access.
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Affiliation(s)
- Luca Crabtree
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon
| | - Kara J Connelly
- Department of Pediatrics, Oregon Health & Science University, School of Medicine, Portland, Oregon
| | - Jess T Guerriero
- Department of Pediatrics, Oregon Health & Science University, School of Medicine, Portland, Oregon
| | - Eleanor A J Battison
- Department of Pediatrics, Oregon Health & Science University, School of Medicine, Portland, Oregon
| | - Joshua Tiller-Ormord
- Department of Pediatrics, Oregon Health & Science University, School of Medicine, Portland, Oregon
| | - S Max Sutherland
- Department of Pediatrics, Oregon Health & Science University, School of Medicine, Portland, Oregon; Washington State University, Elson S. Floyd College of Medicine, Spokane, Washington
| | - Danielle N Moyer
- Department of Pediatrics, Oregon Health & Science University, School of Medicine, Portland, Oregon.
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Di Lisa FS, Villa A, Filomeno L, Arcuri T, Chiofalo B, Sanguineti G, Pizzuti L, Krasniqi E, Barba M, Sergi D, Lombardo F, Romanelli F, Botti C, Zoccali G, Ciliberto G, Vici P. Breast and cervical cancer in transgender men: literature review and a case report. Ther Adv Med Oncol 2024; 16:17588359241259466. [PMID: 39131728 PMCID: PMC11316962 DOI: 10.1177/17588359241259466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 05/14/2024] [Indexed: 08/13/2024] Open
Abstract
Transgender individuals exhibit a higher prevalence of cancer-related risk factors, such as substance abuse and sexually transmitted infections. These factors, coupled with suboptimal adherence to cancer screening recommendations, may lead to a higher incidence of cancers, such as breast and cervical cancer, and contribute to delayed diagnoses in transgender patients. Herein, we report a unique case of a transgender man with a history of alcohol and drug abuse, undergoing gender-affirming exogenous testosterone therapy, who developed synchronous locally advanced breast cancer and human papilloma virus (HPV)-related cervical cancer. He underwent concurrent chemoradiation for cervical cancer and surgery followed by endocrine therapy for breast cancer. The treatments were suboptimals due to patient's comorbidities, among them liver cirrhosis leading to an early death. Additionally, we have conducted a review of existing literature, including case reports, clinical studies, and review articles investigating the role of potential risk factors specifically related to breast and cervical tumors in transgender men. Gender-affirming testosterone therapy is common among transgender men to induce gender affirmation, but its link to breast cancer risk remains ambiguous, with studies being limited and sometimes contradictory. Conversely, HPV is a well-established cause of up to 99% of cervical cancers. Despite persistent risk for cervical cancer in transgender men who retain their cervix, several studies indicate notable disparities in screening adherence, due to personal and structural barriers. Moreover, alcohol and drug use disorders, commonly encountered in transgender population, may negatively influence the adherence to screening programs. Current cancer screening guidelines for this population are somewhat unclear, and specific programs based on more robust data are urgently required along with further tailored studies.
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Affiliation(s)
| | - Alice Villa
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Lorena Filomeno
- Phase IV Clinical Studies Unit, IRCCS Regina Elena National Cancer Institute, Via Elio Chianesi 53, Rome 00144, Italy
| | - Teresa Arcuri
- Phase IV Clinical Studies Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
- Medical Oncology A, Policlinico Umberto I, Department of Radiological, Oncological and Anatomo-Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Benito Chiofalo
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giuseppe Sanguineti
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Laura Pizzuti
- Division of Medical Oncology 1, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Eriseld Krasniqi
- Phase IV Clinical Studies Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Maddalena Barba
- Division of Medical Oncology 1, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Domenico Sergi
- Division of Medical Oncology 2, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Francesco Lombardo
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco Romanelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Claudio Botti
- Division of Breast Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giovanni Zoccali
- Department of Plastic and Reconstructive Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Gennaro Ciliberto
- Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Patrizia Vici
- Phase IV Clinical Studies Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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Ferreira-Filho ES, Lerner T, Soares-Júnior JM, Baracat EC. Gynecologic health care for LGBTQIA+ people. Int J Gynaecol Obstet 2024. [PMID: 39118470 DOI: 10.1002/ijgo.15844] [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: 02/12/2024] [Revised: 07/09/2024] [Accepted: 07/25/2024] [Indexed: 08/10/2024]
Abstract
Gender relations are a set of socially determined norms and rules that assign values, characteristics, and expectations to individuals based on their biological sex. These aspects also influence the clinician-patient relationship, since it has been for a long time based on cisheteronormativity. However, this attitude alienated the LGBTQIA+ community from health services. Global and specific gynecologic care needs to be offered to the LGBTQIA+ population, which has demands for sexual and reproductive health care. In this narrative review, we bring conceptual aspects, gender identity and expression, sexual history, screening for cancer and other care to the community.
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Affiliation(s)
| | - Theo Lerner
- Disciplina de Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, Brazil
| | - José Maria Soares-Júnior
- Disciplina de Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, Brazil
| | - Edmund Chada Baracat
- Disciplina de Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, Brazil
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10
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Hidalgo MA, Chen D, Tishelman AC, Olson-Kennedy J, Chan YM, Garofalo R, Petras H, Rosenthal SM, Ehrensaft D. Childhood Gender Diversity and Mental Health: Protocol for the Longitudinal, Observational Gender Journey Project. JMIR Res Protoc 2024; 13:e55558. [PMID: 39121472 PMCID: PMC11344181 DOI: 10.2196/55558] [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: 12/22/2023] [Revised: 04/18/2024] [Accepted: 06/14/2024] [Indexed: 08/11/2024] Open
Abstract
BACKGROUND Prepubertal transgender, nonbinary, and gender-diverse (TGD) children (ie, those asserting gender identity, expressing gender-role behavior outside of culturally defined norms for their sex registered at birth, or both) are presenting in greater numbers to pediatric gender clinics across the United States and abroad. A large subset of TGD children experiences gender dysphoria, that is, distress that arises from the incongruence between gender identity and sex registered at birth. A lack of consensus exists regarding care for prepubertal TGD children due, in part, to a dearth of empirical research on longitudinal developmental trajectories of gender identity, role behavior, and gender dysphoria (when present). OBJECTIVE The objective of this National Institutes of Health-funded study is to provide evidence to inform clinical care for prepubertal TGD children by establishing a US longitudinal cohort (N=248) of prepubertal TGD children and their caregivers that is followed prospectively at 6-month intervals across 18 months. METHODS At each timepoint, clinical and behavioral data are collected via web-based visit from child and caregiver reporters. Latent class analysis, among other methods, is used to identify subgroups and longitudinally characterize the gender identity and gender-role behavior of TGD children. These models will define longitudinal patterns of gender identity stability and characterize the relationship between TGD classes and mental and behavioral health outcomes, including the moderating role of social gender transition (when present), on these associations. RESULTS Baseline data collection (N=248) is complete, and the identification of TGD subgroups based on gender identity and expression using latent class analysis is anticipated in 2024. The completion of all 4 waves of data collection is anticipated in July 2024, coinciding with the start of a no-cost study extension period. We anticipate longitudinal analyses to be completed by winter 2024. CONCLUSIONS Through a longitudinal observational design, this research involving prepubertal TGD children and their caregivers aims to provide empirical knowledge on gender development in a US sample of TGD children, their mental health symptomology and functioning over time, and how family initiated social gender transition may predict or alleviate mental health symptoms or diagnoses. The research findings have promise for clinicians and families aiming to ensure the best developmental outcome for these children as they develop into adolescents. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/55558.
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Affiliation(s)
- Marco A Hidalgo
- Internal Medicine-Pediatrics and Preventive Medicine Section, Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, United States
- Gender Health Program, UCLA Health, University of California Los Angeles, Los Angeles, CA, United States
| | - Diane Chen
- Gender & Sex Development Program, Potocsnak Family Division of Adolescent and Young Adult Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Amy C Tishelman
- Department of Psychology and Neuroscience, Boston College, Chestnut Hill, MA, United States
| | - Johanna Olson-Kennedy
- Center for Transyouth Health and Development, Division of Adolescent and Young Adult Medicine, Children's Hospital Los Angeles, Los Angeles, CA, United States
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Yee-Ming Chan
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Robert Garofalo
- Gender & Sex Development Program, Potocsnak Family Division of Adolescent and Young Adult Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Hanno Petras
- National Capital Region Center, Pacific Institute for Research and Evaluation, Beltsville, MD, United States
| | - Stephen M Rosenthal
- Child and Adolescent Gender Center, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, United States
- Department of Pediatrics, Division of Pediatric Endocrinology, University of California San Francisco, San Francisco, CA, United States
| | - Diane Ehrensaft
- Child and Adolescent Gender Center, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, United States
- Department of Pediatrics, Division of Pediatric Endocrinology, University of California San Francisco, San Francisco, CA, United States
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11
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da Silva ED, Riveri RC, Spritzer PM, Fighera TM. Uterine changes in transgender men receiving testosterone therapy. Eur J Endocrinol 2024; 191:175-182. [PMID: 39049785 DOI: 10.1093/ejendo/lvae096] [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: 05/01/2024] [Revised: 07/16/2024] [Accepted: 07/24/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVES Despite regular gender-affirming hormone therapy (GAHT), the presence of uterine bleeding can occur occasionally and cause profound discomfort. This study aimed to evaluate the histologic features and immunohistochemical expression of estrogen (ER), progesterone (PR), and androgen receptors (AR) in the endometrium and myometrium of transgender men receiving testosterone therapy and relate them to clinical and hormonal characteristics. DESIGN Retrospective cross-sectional study. METHODS Thirty-four transgender men undergoing gender-affirming surgery were included. Clinical, sociodemographic, and laboratory data as well as anatomopathological and immunohistochemical findings were evaluated. RESULTS The participants' mean age was 42.35 (SD, 10.00) years, and body mass index was 28.16 (SD, 5.52) kg/m2. The mean GAHT duration before surgery was 5.36 (SD, 3.24) years. The mean testosterone levels were 814.98 (SD, 407.13) ng/dL, and estradiol levels were 55.22 (SD, 25.27) pg/mL. The endometrium was atrophic in 61.8%, proliferative in 17.6%, and secretory in 20.6%. Immunohistochemical receptor analysis revealed that endometrial epithelial cells expressed ER (90%) and PR (80%), with a lower expression of AR (30%). In stromal tissue, the median ER, PR, and AR expression was lower than that in the epithelium (60%, 70%, and 25%, respectively). The myometrium showed high expression of PR (90%) and ER (70%), with the highest expression of AR (65%) being localized to this region. CONCLUSIONS In the present study, GAHT induced an atrophic condition of the endometrium in two-thirds of the transgender men, with a limited AR expression in the endometrial region. The present results suggest that testosterone-based GAHT for a mean of 5 years is safe in transgender men achieving amenorrhea.
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Affiliation(s)
- Eliane Dias da Silva
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), 90035-003 Porto Alegre, RS, Brazil
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre (HCPA), 90035-903 Porto Alegre, RS, Brazil
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre (HCPA), 90035-903 Porto Alegre, RS, Brazil
| | - Raquel Camara Riveri
- Department of Pathology, Universidade Federal do Rio Grande do Sul (UFRGS), 90035-003 Porto Alegre, RS, Brazil
| | - Poli Mara Spritzer
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), 90035-003 Porto Alegre, RS, Brazil
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre (HCPA), 90035-903 Porto Alegre, RS, Brazil
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre (HCPA), 90035-903 Porto Alegre, RS, Brazil
- Laboratory of Molecular Endocrinology, Department of Physiology, Universidade Federal do Rio Grande do Sul (UFRGS), 90035-003 Porto Alegre, RS, Brazil
| | - Tayane Muniz Fighera
- Postgraduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul (UFRGS), 90035-003 Porto Alegre, RS, Brazil
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre (HCPA), 90035-903 Porto Alegre, RS, Brazil
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre (HCPA), 90035-903 Porto Alegre, RS, Brazil
- Department of Internal Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), 90035-003 Porto Alegre, RS, Brazil
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12
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McDeavitt K. Paediatric gender medicine: Longitudinal studies have not consistently shown improvement in depression or suicidality. Acta Paediatr 2024; 113:1757-1771. [PMID: 38829183 DOI: 10.1111/apa.17309] [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: 03/03/2024] [Revised: 05/12/2024] [Accepted: 05/22/2024] [Indexed: 06/05/2024]
Abstract
AIM Systematic literature reviews have found the evidence for hormonal interventions in paediatric-age patients with gender dysphoria is of low certainty. Studies in this field have all been observational, and generally of low quality. Nevertheless, some experts assert that the observational studies in this field have consistently found improvement in mental health, and therefore constitute sufficient evidentiary basis for hormonal interventions. The present review sought to characterise results of the longitudinal clinical research studies that have reported depression and suicidality outcomes. METHODS The present review collated, from examination of six existing reviews, 14 longitudinal clinical research studies that have specifically investigated depression and/or suicidality outcomes. RESULTS Significantly positive depression outcomes were reported in six studies, and significantly positive suicidality outcomes in two studies. Outcomes were negative in the largest study. Notably, some studies articulated positive conclusions about hormonal interventions even in the setting of insignificant, small or negative findings. CONCLUSIONS Analysis of longitudinal clinical research in this field showed inconsistent demonstration of benefit with respect to depression and suicidality. This analysis suggests that, contrary to assertions of some experts and North American professional medical organisations, the impact of hormonal interventions on depression and suicidality in this population is unknown.
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Affiliation(s)
- Kathleen McDeavitt
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
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13
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Bakker J. Neurobiological characteristics associated with gender identity: Findings from neuroimaging studies in the Amsterdam cohort of children and adolescents experiencing gender incongruence. Horm Behav 2024; 164:105601. [PMID: 39029340 DOI: 10.1016/j.yhbeh.2024.105601] [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: 01/09/2024] [Revised: 07/05/2024] [Accepted: 07/05/2024] [Indexed: 07/21/2024]
Abstract
This review has been based on my invited lecture at the annual meeting of the Society for Behavioral Neuroendocrinology in 2023. Gender incongruence is defined as a marked and persistent incongruence between an individual's experienced gender and the sex assigned at birth. A prominent hypothesis on the etiology of gender incongruence proposes that it is related to an altered or less pronounced sexual differentiation of the brain. This hypothesis has primarily been based on postmortem studies of the hypothalamus in transgender individuals. To further address this hypothesis, a series of structural and functional neuroimaging studies were conducted in the Amsterdam cohort of children and adolescents experiencing gender incongruence. Additional research objectives were to determine whether any sex and gender differences are established before or after puberty, as well as whether gender affirming hormone treatment would affect brain development and function. We found some evidence in favor of the sexual differentiation hypothesis at the functional level, but this was less evident at the structural level. We also observed some specific transgender neural signatures, suggesting that they might present a unique brain phenotype rather than being shifted towards either end of the male-female spectrum. Our results further suggest that the years between childhood and mid-adolescence represent an important period in which puberty-related factors influence several neural characteristics, such as white matter development and functional connectivity patterns, in both a sex and gender identity specific way. These latter observations thus lead to the important question about the possible negative consequences of delaying puberty on neurodevelopment. To further address this question, larger-scale, longitudinal studies are required to increase our understanding of the possible neurodevelopmental impacts of delaying puberty in transgender youth.
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Affiliation(s)
- Julie Bakker
- GIGA Neurosciences, University of Liège, Belgium.
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14
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Serchen J, Hilden DR, Beachy MW. Lesbian, Gay, Bisexual, Transgender, Queer, and Other Sexual and Gender Minority Health Disparities: A Position Paper From the American College of Physicians. Ann Intern Med 2024; 177:1099-1103. [PMID: 38914001 DOI: 10.7326/m24-0636] [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: 06/26/2024] Open
Abstract
Lesbian, gay, bisexual, transgender, queer, or other sexual and gender minorities (LGBTQ+) populations in the United States continue to experience disparities in health and health care. Discrimination in both health care and society at large negatively affects LGBTQ+ health. Although progress has been made in addressing health disparities and reducing social inequality for these populations, new challenges have emerged. There is a pressing need for physicians and other health professionals to take a stance against discriminatory policies as renewed federal and state public policy efforts increasingly impose medically unnecessary restrictions on the provision of gender-affirming care. In this position paper, the American College of Physicians (ACP) reaffirms and updates much of its long-standing policy on LGBTQ+ health to strongly support access to evidence-based, clinically indicated gender-affirming care and oppose political efforts to interfere in the patient-physician relationship. Furthermore, ACP opposes institutional and legal restrictions on undergraduate, graduate, and continuing medical education and training on gender-affirming care and LGBTQ+ health issues. This paper also offers policy recommendations to protect the right of all people to participate in public life free from discrimination on the basis of their gender identity or sexual orientation and encourages the deployment of inclusive, nondiscriminatory, and evidence-based blood donation policies for members of LGBTQ+ communities. Underlying these beliefs is a reaffirmed commitment to promoting equitable access to quality care for all people regardless of their sexual orientation and gender identity.
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Affiliation(s)
- Josh Serchen
- American College of Physicians, Washington, DC (J.S.)
| | | | - Micah W Beachy
- University of Nebraska Medical Center, Omaha, Nebraska (M.W.B.)
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15
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McDeavitt K. Further Considerations on Gender-Affirming Care. JAMA Pediatr 2024; 178:841. [PMID: 38949826 DOI: 10.1001/jamapediatrics.2024.1863] [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] [Indexed: 07/02/2024]
Affiliation(s)
- Kathleen McDeavitt
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
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16
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Pontes-Silva A, Lopes AL. Physiological factors affecting the performance of transgender athletes: a debate that lacks biological plausibility. J Physiol 2024; 602:3863-3864. [PMID: 38899380 DOI: 10.1113/jp287038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 06/05/2024] [Indexed: 06/21/2024] Open
Affiliation(s)
- André Pontes-Silva
- Postgraduate Program in Physical Therapy, Department of Physical Therapy, Universidade Federal de São Carlos, São Carlos, SP, Brazil
| | - André Luiz Lopes
- Postgraduate Program in Human Movement Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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17
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Murano-Kinney S. Banning Puberty-Pausing Medications Endangers Transgender Adolescents. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:4-8. [PMID: 39158419 DOI: 10.1080/15265161.2024.2371117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
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18
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Simko S, Popa O, Stuparich M. Gender affirming care for the minimally invasive gynecologic surgeon. Curr Opin Obstet Gynecol 2024; 36:301-312. [PMID: 38597457 DOI: 10.1097/gco.0000000000000956] [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: 04/11/2024]
Abstract
PURPOSE OF REVIEW Given the current political climate and the release of an updated version of the World Professional Association for Transgender Health's guidelines, this review assesses recent updates in the care of transgender and gender diverse (TGD) patients, specifically related to care provided by gynecologists. RECENT FINDINGS The number of people identifying as TGD and pursuing gender affirming care is increasing. Contraception for these patients is underdiscussed and high rates of pelvic pain and irregular bleeding were identified. Rates of regret are low following gender affirming surgeries, and studies have repeatedly shown their benefits for gender dysphoria. A minimally invasive approach is recommended for gender affirming hysterectomy, and the decision to proceed with bilateral salpingo-oophorectomy should be based on shared decision making. Surgical techniques include ensuring an adequate margin when taking the infundibulopelvic ligament, and consideration for two-layer vaginal cuff closure. SUMMARY Gynecologists play a key role in the care of TGD patients. Recent reviews have found extensive gaps in our knowledge, including a lack of guidelines for cancer prevention, effects of testosterone on benign conditions, and the long-term effects of bilateral salpingo-oophorectomy on health outcomes for patients on testosterone.
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Affiliation(s)
- Sarah Simko
- University of California Riverside School of Medicine, Riverside, California, USA
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19
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da Silva ED, Spritzer PM, Fighera TM. Persistent vaginal bleeding during gender-affirming hormone therapy in transgender men. J Endocrinol Invest 2024; 47:2053-2060. [PMID: 38300501 DOI: 10.1007/s40618-023-02296-w] [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: 09/18/2023] [Accepted: 12/28/2023] [Indexed: 02/02/2024]
Abstract
PURPOSE While it is common for menstrual cycles to cease within the initial 6 months of treatment, there are instances where some transgender men may not experience this cessation. We analyzed transgender men undergoing gender-affirming hormone therapy (GAHT) with testosterone who experienced breakthrough bleeding in order to identify the factors associated with this condition. METHODS In this case-control study, 24 transgender men in the case group and 48 in the control group were assessed for clinical, sociodemographic, hormonal, and body composition variables using dual-energy X-ray absorptiometry. All participants had been on GATH for at least 6 months. RESULTS A few transgender men experienced persistent breakthrough bleeding, which was associated with decreased testosterone levels and free androgen index (FAI) compared with controls (p = 0.002 and p = 0.008, respectively). Among individuals with breakthrough bleeding, 50% had testosterone levels below the lowest tertile calculated for the sample, compared with 18.8% on controls (p = 0.007). After therapy adjustment, testosterone levels increased compared with the values obtained in the initial bleeding episode (p = 0.031). Eight transgender men required the addition of an oral progestogen to achieve amenorrhea, and these individuals had higher BMI than those in whom the adjustment of the parenteral testosterone dose was adequate (p = 0.026). A univariate prevalence ratio analysis revealed a negative association of persistent bleeding with testosterone levels (p = 0.028) and FAI levels (p = 0.019). CONCLUSION Higher BMI and lower levels of testosterone and FAI were the main factors associated with breakthrough bleeding in transgender men.
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Affiliation(s)
- E D da Silva
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90035 003, Brazil
- Postgraduate Program in Endocrinology, Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - P M Spritzer
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90035 003, Brazil.
- Postgraduate Program in Endocrinology, Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
- Department of Physiology and Postgraduate Program in Physiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
| | - T M Fighera
- Gynecological Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90035 003, Brazil
- Postgraduate Program in Endocrinology, Medicine School, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Transdisciplinary Gender Identity Program, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
- Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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20
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Stamatiou R, Kararigas G. Participation of transgender and gender diverse persons in cardiovascular clinical trials. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 44:100420. [PMID: 39070126 PMCID: PMC11282972 DOI: 10.1016/j.ahjo.2024.100420] [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: 12/15/2023] [Revised: 04/01/2024] [Accepted: 06/25/2024] [Indexed: 07/30/2024]
Abstract
Study objective Transgender persons face increased risk in developing cardiovascular diseases due to administration of hormonal therapy used for gender expression, or due to the presence of other risk factors, such as minority stress and difficulty to have full access to health care. Even though the need for gender diversity in research has been identified, the number of clinical trials including transgender persons remains low. The aim of this study was to highlight gaps in inclusion of transgender individuals in cardiovascular clinical research. Design setting A search in the pubmed.com database, as well as in the clinicaltrials.gov repository, was performed with search terms regarding transgender persons and cardiovascular diseases. Main outcome measures The inclusion of transgender persons in cardiovascular clinical trials was evaluated. Results and conclusions This study revealed that there is only a small number of cardiovascular clinical trials including or studying transgender persons. This finding demonstrates the overall lack of clinical trials regarding cardiovascular health in transgender individuals and is indicative of their under-representation in clinical research.
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Affiliation(s)
- Rodopi Stamatiou
- Department of Physiology, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- School of Biology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Kararigas
- Department of Physiology, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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21
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Gaither TW, Williams KC, Mann C, Weimer A, Ng G, Litwin MS. Needs of transgender children and adolescents presenting to an urban gender health program. J Pediatr Urol 2024; 20:706.e1-706.e7. [PMID: 38981783 DOI: 10.1016/j.jpurol.2024.06.035] [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: 02/05/2024] [Revised: 06/02/2024] [Accepted: 06/24/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Youth who identify as transgender and gender diverse (TGD) are increasingly presenting to pediatric providers. Gender-affirming surgery is often delayed until after a patient reaches the age of majority; however, patients may desire surgery at a younger age. OBJECTIVE We explore the specific clinical needs of this vulnerable population, including surgical requests. STUDY DESIGN We present a cross-sectional study of patient intake interviews at time of presentation to our gender health program from 2017 to 2020. We summarize patient demographics, medical histories, and gender-affirming care needs by gender identity and age of presentation. RESULTS Of 92 patients analyzed, those included were 19 trans girls, 55 trans boys, and 18 non-binary individuals. The median age of our sample was 15 (range 5-17). The median age (IQR) while first questioning gender was 10 (7-12). Sexual orientation was variable with 28 (43%) not sure/unknown. The majority of patients present for primary care services (grade schoolers 75%, early teens 78%, and late teens 77%, p = 0.97) and hormone management (grade schoolers 42%, early teens 62%, and late teens 77%, p = 0.06). Late teens were more likely to present for surgical services (49%) compared to grade schoolers (25%) and early teens (11%), p = 0.001. Prior psychiatric diagnoses were common in all age groups. Trans girls were interested in a variety of affirming procedures whereas trans boys and non-binary individuals primarily sought chest surgery (see summary figure). CONCLUSION Pediatric gender affirming care needs are varied and multidisciplinary within our center. By age 16, about half of TGD individuals are seeking surgical services. On average, there was a 4-5 year delay from age at first questioning one's gender and presenting to our gender health program. Primary care physicians in particular may prepare to serve this complex population by familiarizing themselves with treatment needs, including developing a network of competent surgical referrals.
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Affiliation(s)
- Thomas W Gaither
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, USA.
| | - Kristen C Williams
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Christopher Mann
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Amy Weimer
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Gladys Ng
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Mark S Litwin
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, USA; Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, USA; School of Nursing, University of California, Los Angeles, USA
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22
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Mullins TLK, Mullins ES. Thrombotic risk associated with gender-affirming hormone therapy. J Thromb Haemost 2024; 22:2129-2139. [PMID: 38795871 DOI: 10.1016/j.jtha.2024.05.015] [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: 02/09/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/28/2024]
Abstract
Transgender and gender-expansive (TG) people-those who identify with a gender other than their assigned sex at birth-frequently experience gender dysphoria, which is associated with negative health outcomes. One key strategy for improving gender dysphoria is the use of gender-affirming hormone therapy (GAHT): estrogen for feminization and testosterone for masculinization. Estrogen use in cisgender women is associated with well-established changes in hemostatic parameters, including increases in prothrombotic factors and decreases in inhibitors of coagulation. Cisgender women using estrogen have an increased risk of thrombosis. Studies of thrombosis risk associated with estrogen GAHT in TG people are less robust, with some studies limited by the use of hormones and hormone management strategies that are no longer recommended. However, TG women using estrogen appear to be at increased risk of both arterial and venous thrombosis, which may increase with longer time on estrogen. Testosterone use in both cisgender and transgender men is associated with increases in hemoglobin and hematocrit, which can lead to erythrocytosis and thus increased risk of thrombosis. The results of studies evaluating thrombosis risk in the setting of testosterone use are mixed. This review presents an overview of alterations in hemostatic parameters and thrombosis risk associated with use of exogenous estrogen and testosterone. Understanding what is known and unknown about thrombosis risk associated with use of these hormones is essential for hematologists who may be asked to evaluate TG people and provide guidance on management of those who may be at increased risk of thrombosis.
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Affiliation(s)
- Tanya L Kowalczyk Mullins
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Eric S Mullins
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA; Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
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23
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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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24
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Brandon-Friedman RA, Tabb A, Imburgia TM, Swafford TR, Fortenberry JD, Canada M, Donahue KL. Perspectives of Gender-Diverse Youth and Caregivers Facing Gender-Affirming Medical Intervention Bans. LGBT Health 2024. [PMID: 39042666 DOI: 10.1089/lgbt.2024.0079] [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: 07/25/2024] Open
Abstract
Purpose: In the past 2 years, nearly all 50 states have debated bills seeking to ban minors' access to gender-affirming medical interventions, with many being passed into law. This study documents gender-diverse youths' (GDY) and their caregivers' experiences as they grapple with how such laws impact their families. Methods: Sixteen GDY and 16 caregivers participating in a longitudinal study of the impact of gender-affirming care on GDYs' well-being were interviewed about how the legal and social discourse was impacting them and their families. When interviewed, some participants had completed only the initial intake, others had completed the intake and an initial medical consultation, and a few had recently started gender-affirming hormones. Thematic analysis was used to identify common threads in the youths' and caregivers' experiences. Results: Four main themes were identified: Direct effects of losing access to gender-affirming medical interventions, reflecting how losing access to care would impact well-being; growing hostility toward the gender-diverse community, noting increasing social negativity; personal and social upheaval, reflecting the many aspects of families' lives affected; and galvanization into social action, documenting drives to effect social change. Conclusion: Laws banning gender-affirming medical interventions impact GDY and their families beyond limiting access to medical care. They increase the social stressors, cause social network disruptions, increase hostility toward the gender-diverse community, and lead some GDY and caregivers to engage more politically to protect their community. Gender-affirming health care providers need to recognize how the social and political environment impact GDY and their families to provide high-quality, person-centered care.
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Affiliation(s)
- Richard A Brandon-Friedman
- Division of Adolescent Medicine, Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana, USA
- School of Social Work, Indiana University, Indianapolis, Indiana, USA
| | - Ali Tabb
- School of Social Work, Indiana University, Indianapolis, Indiana, USA
| | - Teresa M Imburgia
- Division of Adolescent Medicine, Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana, USA
- School of Social Work, Indiana University, Indianapolis, Indiana, USA
| | - Tayon R Swafford
- School of Social Work, Indiana University, Indianapolis, Indiana, USA
| | - J Dennis Fortenberry
- Division of Adolescent Medicine, Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Meredith Canada
- School of Social Work, Indiana University, Indianapolis, Indiana, USA
| | - Kelly L Donahue
- Division of Adolescent Medicine, Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana, USA
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25
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Edwardson S, Flower L, Fawcett E, Medlock R, Cheung AS, Kamaruddin K, McCormack VL, Agarwal S. Peri-operative care of transgender and gender-diverse individuals: guidance for clinicians and departments. Anaesthesia 2024. [PMID: 39043129 DOI: 10.1111/anae.16378] [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: 06/12/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION The objective of this document is to guide best practice to ensure the safety and dignity of transgender and gender-diverse people in the peri-operative period. While transgender and gender-diverse people may have specific health needs in relation to gender dysphoria, their health requirements go beyond their gender identity. Most doctors will provide care to someone who is transgender or gender-diverse at some stage in their career. It is therefore important that all anaesthetists are educated on specific considerations when caring for these patients. METHODS A working party was assembled consisting of individuals with experience in direct clinical care of the relevant patient group, those who have expertise in endocrinology and gender-affirming hormones, educators on the topic of transgender and gender-diverse healthcare, and authors of both cisgender and transgender identities. After discussion among the working party, targeted searches of literature were undertaken. RESULTS The authors initially came up with a list of over 25 recommendations which was subsequently revised to a list of 15 recommendations after further review by the working party. These included airway assessment and management; management of hormonal therapy; relevant issues in obstetric anaesthesia; and hospital infrastructure and processes. CONCLUSIONS This document provides the first guidance produced to advise on best practice to ensure the safety and dignity of trans and gender-diverse individuals in the peri-operative period.
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Affiliation(s)
- Stuart Edwardson
- Department of Anaesthesia and Intensive Care Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Luke Flower
- Department of Medicine, Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- Department of Intensive Care Medicine, London School of Intensive Care Medicine, London, UK
| | - Erik Fawcett
- Department of Anaesthesia, Queen Elizabeth Hospital, Woolwich, UK
| | - Rebecca Medlock
- Department of Anaesthetics and Critical Care Hospital, Great Western Hospital, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Ada S Cheung
- Trans Health Research Group, Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Melbourne, Australia
| | - Kamilla Kamaruddin
- General Practitioner in Transgender Health Care and Clinical Lead East of England Gender Service, Cambridge, UK
| | - Victoria L McCormack
- Department of Anaesthesia and Critical Care Medicine, Manchester Royal Infirmary, Manchester Foundation Trust, Manchester, UK
| | - Seema Agarwal
- Department of Anaesthesia and Critical Care Medicine, Wythenshawe Hospital, Manchester Foundation Trust, Manchester, UK
- Manchester University, Manchester, UK
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Okano SHP, Braga GC, Cantelli DAL, Filho LASP, Brito LGO, Lara LADS. Effect of testosterone formulations on hematocrit in transgender individuals: A systematic review. Andrology 2024. [PMID: 39011565 DOI: 10.1111/andr.13695] [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: 05/11/2024] [Revised: 06/26/2024] [Accepted: 07/02/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Approximately, 11% of trans men experience erythrocytosis diagnosis due to testosterone administration during the first year of the gender-affirming hormone treatment (GAHT). OBJECTIVES To identify and compare the effect of different testosterone formulations on hematocrit (Hct) and diagnose erythrocytosis in trans men. MATERIALS AND METHODS This systematic review was based on PRISMA guidelines. We performed an electronic search of PubMed, Embase, and Web of Science in January 2024. The Newcastle-Ottawa scale was used to evaluate the quality of evidence in the observational studies. RESULTS Of the 152 records retrieved, 18 met the eligibility criteria. Studies observed an increase of up to 5% in Hct in trans men using injectable testosterone undecanoate (TU), and up to 6.9% in trans men using intermediate injectable testosterone esters (TE). Trans men using TE experience a larger increase in serum Hct levels compared to those receiving TU. Erythrocytosis prevalence varies according to the cutoff used (50%, 52%, and 54%). Erythrocytosis was also associated with tobacco use, age at initiation of hormone therapy, body mass index (BMI), and pulmonary conditions. Studies that evaluated the effect of testosterone formulation on erythrocytosis diagnosis present conflicting result. Trans men have a hazard ratio of 7.4 (95% CI: 4.1, 13.4) of developing erythrocytosis compared to cisgender men, using a 52% hematocrit cutoff. CONCLUSION All testosterone formulations result in an increase in Hct, irrespective of dose, formulation, and administration method. Smoking, higher age at initiation of the testosterone therapy, higher BMI, and a predisposing medical history are associated with this increase in Hct. The difference in effect of TE and TU on Hct is conflicting, although it is important to point out that these data come from observational studies, retrospective, and with a small-sample size.
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Boogers LS, Reijtenbagh SJP, Wiepjes CM, van Trotsenburg ASP, den Heijer M, Hannema SE. Time Course of Body Composition Changes in Transgender Adolescents During Puberty Suppression and Sex Hormone Treatment. J Clin Endocrinol Metab 2024; 109:e1593-e1601. [PMID: 38128064 PMCID: PMC11244207 DOI: 10.1210/clinem/dgad750] [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: 10/03/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 12/23/2023]
Abstract
CONTEXT Transgender adolescents can undergo puberty suppression (PS) and subsequent gender-affirming hormone therapy (GAHT) but little information is available on the expected rate of physical changes. OBJECTIVE To investigate the time course of body composition changes during PS and GAHT. METHODS In this study, retrospective data of 380 trans boys and 168 trans girls treated with PS prior to GAHT from a gender identity clinic were included. Total lean and fat mass Z-scores using birth-assigned sex as reference were determined using dual-energy X-ray absorptiometry. RESULTS In trans boys, lean mass Z-scores decreased (-0.32, 95% CI -0.41; -0.23) and fat mass Z-scores increased (0.31, 95% CI 0.21; 0.41) in the first year of PS and remained stable thereafter. Lean mass Z-scores increased (0.92, 95% CI 0.81; 1.04) and fat mass Z-scores decreased (-0.43, 95% CI -0.57; -0.29) only during the first year of testosterone,. In trans girls, both lean and fat mass Z-scores gradually changed over 3 years of PS (respectively -1.13, 95% CI -1.29; -0.98 and 1.06, 95% CI 0.90; 1.23). In the first year of GAHT, lean mass Z-scores decreased (-0.19, 95% CI -0.36; -0.03) while fat mass Z-scores remained unchanged after 3 years (-0.02, 95% CI -0.20; 0.16). CONCLUSION Compared with peers, trans girls experienced ongoing lean mass decrease and fat mass increase during 3 years of PS while in trans boys smaller changes were observed that stabilized after 1 year. A large increase in lean mass Z-scores occurred only during the first year of testosterone treatment. In trans girls, body composition changed only slightly during GAHT. This information can improve counseling about treatment effects.
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Affiliation(s)
- Lidewij Sophia Boogers
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center location VUMC, 1081 HV Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center location VUMC, 1081 HV Amsterdam, The Netherlands
| | | | - Chantal Maria Wiepjes
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center location VUMC, 1081 HV Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center location VUMC, 1081 HV Amsterdam, The Netherlands
| | - Adrianus Sarinus Paulus van Trotsenburg
- Department of Endocrinology and Metabolism, and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center location VUMC, 1081 HV Amsterdam, The Netherlands
- Department of Pediatric Endocrinology, Amsterdam University Medical Center location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Martin den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center location VUMC, 1081 HV Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center location VUMC, 1081 HV Amsterdam, The Netherlands
| | - Sabine Elisabeth Hannema
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center location VUMC, 1081 HV Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, and Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center location VUMC, 1081 HV Amsterdam, The Netherlands
- Department of Pediatric Endocrinology, Amsterdam University Medical Center location AMC, 1105 AZ Amsterdam, The Netherlands
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McNamara M, Gentry KR, Sequeira GM, Kidd KM. State-Level Bans on the Care of Transgender and Gender Diverse Youth in the United States: Implications for Ethics and Advocacy. J Pediatr 2024; 274:114182. [PMID: 38964438 DOI: 10.1016/j.jpeds.2024.114182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 05/26/2024] [Accepted: 06/26/2024] [Indexed: 07/06/2024]
Affiliation(s)
| | - Katherine R Gentry
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, WA; Seattle Children's Hospital, Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle, WA
| | - Gina M Sequeira
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Kacie M Kidd
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV
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Roberge S, Roberge T, Corathers S, Nasomyont N. Determinants of Bone Mass Accrual in Transgender and Gender Diverse Youth Undergoing Pubertal Suppression Therapy. J Clin Densitom 2024; 27:101505. [PMID: 38936233 DOI: 10.1016/j.jocd.2024.101505] [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: 03/16/2024] [Revised: 06/10/2024] [Accepted: 06/10/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION/BACKGROUND Gender-affirming care for gender diverse and transgender (GDTG) youth includes puberty suppression with gonadotropin-releasing hormone agonists (GnRHa). Puberty is a critical period of bone mass accrual, and pubertal suppression may impact bone health. Previous studies have shown a decrease in areal bone mineral density (aBMD) Z-score while on puberty suppression. However, the rate of bone mass accrual and its determinants during GnRHa therapy are not known. METHODOLOGY This is a retrospective chart review of GDTG youth with aBMD assessment within six months of starting GnRHa monotherapy at Cincinnati Children's Hospital Medical Center between 01/2011 and 12/2022. In individuals with follow-up aBMD assessment, we calculated their aBMD velocity and generated Z-scores using reference data from the Bone Mineral Density in Childhood Study. The determinants of baseline height-adjusted aBMD and aBMD velocity Z-scores were assessed with multiple linear regression models. RESULTS Thirty-six participants (36% assigned female at birth (AFAB), mean age at first aBMD assessment 12 ± 1.1 years) had baseline height-adjusted aBMD Z-score of -0.053 ± 0.79. Among 16 participants with follow-up aBMD assessment, the mean aBMD velocity Z-score was -0.42 ± 1.13 (-0.27 ± 0.79 in AFAB vs -0.52 ± 1.32 in assigned male at birth, p = 0.965). Baseline aBMD Z-scores significantly correlated with age at the first aBMD assessment (adjusted R2 0.124, p = 0.02) with combined modeling including age at first aBMD assessment and BMI Z-score being most significant (adjusted R2 0.21, p = 0.008). Only BMI Z-scores were positively associated with the aBMD-velocity Z-scores (adjusted R2 0.255, p = 0.046). CONCLUSIONS GDTG youth undergoing GnRHa therapy appeared to have below-average aBMD velocity Z-scores. A lower BMI Z-score was a determinant of lower baseline height-adjusted aBMD and aBMD velocity Z-scores. Building on previous studies, our study highlights aBMD velocity as a novel technique for bone health surveillance in GDTG youth.
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Affiliation(s)
- Samantha Roberge
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Taylor Roberge
- Department of Science and Health, University of Cincinnati Clermont College, Batavia, OH, USA
| | - Sarah Corathers
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nat Nasomyont
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Klein DA, Gonzalez XB, Highland KB, Thornton JA, Sunderland KW, Funk W, Pav V, Brydum R, Schvey NA, Roberts CM. Variation in Time-to-Gender-Affirming Hormone Therapy in US Active Duty Service Members. Med Care 2024; 62:481-488. [PMID: 38761163 DOI: 10.1097/mlr.0000000000002011] [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: 05/20/2024]
Abstract
BACKGROUND Beginning in July 2016, transgender service members in the US military were allowed to receive gender-affirming medical care, if so desired. OBJECTIVE This study aimed to evaluate variation in time-to-hormone therapy initiation in active duty Service members after the receipt of a diagnosis indicative of gender dysphoria in the Military Health System. RESEARCH DESIGN This retrospective cohort study included data from those enrolled in TRICARE Prime between July 2016 and December 2021 and extracted from the Military Health System Data Repository. PARTICIPANTS A population-based sample of US Service members who had an encounter with a relevant International Classification of Diseases 9/10 diagnosis code. MEASURES Time-to-gender-affirming hormone initiation after diagnosis receipt. RESULTS A total of 2439 Service members were included (M age 24 y; 62% white, 16% Black; 12% Latine; 65% Junior Enlisted; 37% Army, 29% Navy, 25% Air Force, 7% Marine Corps; 46% first recorded administrative assigned gender marker female). Overall, 41% and 52% initiated gender-affirming hormone therapy within 1 and 3 years of diagnosis, respectively. In the generalized additive model, time-to-gender-affirming hormone initiation was longer for Service members with a first administrative assigned gender marker of male relative to female ( P <0.001), and Asian and Pacific Islander ( P =0.02) and Black ( P =0.047) relative to white Service members. In time-varying interactions, junior enlisted members had longer time-to-initiation, relative to senior enlisted members and junior officers, until about 2-years postinitial diagnosis. CONCLUSION The significant variation and documented inequities indicate that institutional data-driven policy modifications are needed to ensure timely access for those desiring care.
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Affiliation(s)
- David A Klein
- Department of Family Medicine, Uniformed Services University, Bethesda, MD
- Department of Pediatrics, Uniformed Services University, Bethesda, MD
- Department of Family Medicine, David Grant Medical Center, Travis Air Force Base, CA
| | - Xenia B Gonzalez
- Department of Family Medicine, David Grant Medical Center, Travis Air Force Base, CA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD
| | - Jennifer A Thornton
- Clinical Investigations, David Grant Medical Center, Travis Air Force Base, CA
- Ripple Effect, Rockville, MD
| | - Kevin W Sunderland
- Clinical Investigations, David Grant Medical Center, Travis Air Force Base, CA
- Ripple Effect, Rockville, MD
| | - Wendy Funk
- Kennell and Associates, Falls Church, VA
| | - Veronika Pav
- Kennell and Associates, Falls Church, VA
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | | | - Natasha A Schvey
- Department of Medical and Clinical Psychology, Uniformed Services University, Bethesda, MD
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Muir CA, Guttman-Jones M, Man EJ. Effects of gender affirming hormone treatment in transgender individuals - a retrospective cohort study. Endocrine 2024; 85:370-379. [PMID: 38386168 DOI: 10.1007/s12020-024-03736-0] [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: 11/18/2023] [Accepted: 02/06/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE Gender affirming hormone treatment (GAHT) results in measurable changes to anthropomorphic, biochemical and hormonal variables that are important to patients and their health care professionals to guide treatment. This study sought to quantify changes which occur in response to initiation of GAHT. METHODS We performed a retrospective cohort study of outcomes in transgender and gender diverse (TGD) patients starting GAHT. The primary outcome was proportion of patients and time required to achieve optimal hormone levels after commencement of GAHT. Additional analyses were performed to assess whether clinical and biochemical factors were associated with likelihood of achieving target hormone levels. RESULTS 345 patients were included. Among 154 transmasculine individuals, 116 (75%) achieved a testosterone level >10 nmol/L during follow-up at a median of 4-months (IQR 4-9). No clinical or biochemical factors were significantly associated with likelihood of reaching therapeutic testosterone concentrations in transmen. Among 191 transfeminine individuals, 131 (72%) achieved a testosterone level <2.0 nmol/L during follow-up at a median of 4-months (IQR 3-9). Factors associated with increased likelihood of testosterone suppression were use of subdermal estradiol implants as well as cyproterone acetate as an androgen antagonist. Changes in differing directions were observed during repeated measures of lipids, liver function, and blood count between transmasculine and transfeminine individuals, reflecting the important effects of testosterone and estradiol on biochemical tests ordered as part of routine clinical care. CONCLUSION Most TGD patients achieve target testosterone levels within 9 months of GAHT initiation. Adverse effects of GAHT are rare, and are usually mild.
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Affiliation(s)
- Christopher A Muir
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.
| | - Mihal Guttman-Jones
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Elspeth J Man
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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Strand N, Gomez DA, Kacel EL, Morrison EJ, St Amand CM, Vencill JA, Pagan-Rosado R, Lorenzo A, Gonzalez C, Mariano ER, Reece-Nguyen T, Narouze S, Mahdi L, Chadwick AL, Kraus M, Bechtle A, Kling JM. Concepts and Approaches in the Management of Transgender and Gender-Diverse Patients. Mayo Clin Proc 2024; 99:1114-1126. [PMID: 38960496 DOI: 10.1016/j.mayocp.2023.12.027] [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: 08/19/2022] [Revised: 12/10/2023] [Accepted: 12/28/2023] [Indexed: 07/05/2024]
Abstract
The terms transgender and gender diverse (TGD) describe persons whose gender is different from the sex assigned to them at birth. While TGD persons have experienced a rise in cultural and social visibility in recent decades, they continue to experience significant health inequities, including adverse health outcomes and multiple barriers to accessing medical care. Transgender and gender-diverse persons are at a higher risk for pain conditions than their cisgender counterparts, but research on chronic pain management for TGD persons is lacking. Clinicians from all disciplines must be informed of best practices for managing chronic pain in the TGD population. This includes all aspects of care including history, physical examination, diagnosis, treatment, and perioperative management. Many TGD persons report delaying or avoiding care because of negative interactions with medical practitioners who do not have sufficient training in navigating the specific health care needs of TGD patients. Furthermore, TGD persons who do seek care are often forced to educate their practitioners on their specific health care needs. This paper provides an overview of existing knowledge and recommendations for physicians to provide culturally and medically appropriate care for TGD persons.
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Affiliation(s)
- Natalie Strand
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Phoenix, AZ, USA
| | - Diego Alan Gomez
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Elizabeth L Kacel
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Eleshia J Morrison
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Colt M St Amand
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA; Department of Psychology, University of Houston, TX, USA, and the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Jennifer A Vencill
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA; Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert Pagan-Rosado
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Andrea Lorenzo
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Cesar Gonzalez
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA, and Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Travis Reece-Nguyen
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Stanford Children's Hospital, Palo Alto, CA, USA
| | - Samer Narouze
- Center for Pain Relief, Summa Western Reserve Hospital, Cuyahoga Falls, OH, USA
| | - Layth Mahdi
- Department of Emergency Medicine, NYP Brooklyn Methodist, Brooklyn, New York
| | - Andrea L Chadwick
- Department of Anesthesiology, Pain, and Perioperative Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Molly Kraus
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Phoenix, AZ, USA
| | - Alexandra Bechtle
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Juliana M Kling
- Division of Women's Health Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
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Stanley JR, Ratnapalan S. Patient education and counselling of fertility preservation for transgender and gender diverse people: A scoping review. Paediatr Child Health 2024; 29:231-237. [PMID: 39045475 PMCID: PMC11261822 DOI: 10.1093/pch/pxad050] [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: 01/04/2023] [Accepted: 06/17/2023] [Indexed: 07/25/2024] Open
Abstract
Objectives To examine patient education, counselling practices, decision aids, and education resources related to fertility preservation for transgender and gender diverse (TGD) youth and young adults. Methods A scoping review was conducted using a comprehensive literature search (Ovid MEDLINE, PubMed Medline, OVID Embase, Ovid PsychoINFO, and Cochrane Central Register of Controlled Trials) conducted from 1806 to October 21, 2022. Inclusion criteria involved abstracts and articles on patient education, counselling, decision aids or education resources regarding fertility preservation for TGD youth and adults. Results Of 1,228 identified articles and abstracts, only six articles met inclusion criteria. Three key themes were identified: (1) patient education and counselling practices (n = 4), with majority of patients receiving fertility preservation counselling at their respective centres; (2) decision aids and strategies for clinicians on fertility preservation for TGD individuals (n = 2) and; (3) patient education resources (n = 1). There was a paucity of literature on decision aids and patient education resources. Conclusions This study highlights the need to further develop and evaluate decision aids for healthcare providers and patient education resources, including eLearning modules, around fertility preservation for TGD individuals.
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Affiliation(s)
- Joshua R Stanley
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Savithiri Ratnapalan
- Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Sánchez-Varela N, Ferreiro-Abuin L, Durán-González A, Mosteiro-Miguéns DG, Portela-Romero M. [Recommendations for Primary Health Care for transgender people]. Semergen 2024; 50:102222. [PMID: 38569226 DOI: 10.1016/j.semerg.2024.102222] [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: 12/21/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 04/05/2024]
Abstract
The WHO defines Primary Health Care as essential health care, based on practical, scientifically founded and socially acceptable methods and technologies, made available to all individuals and families in the community, through their full participation, and at a cost that the community and the country can bear, at each and every stage of their development, in a spirit of self-responsibility and self-determination. With the intention of fulfilling the basic objective of caring for and promoting health in all the groups that make up our current society, the need arises to focus on certain groups in which the actions of Primary Care are currently consensual or poorly protocolised, as is the case with the health care of transgender people.
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Affiliation(s)
- N Sánchez-Varela
- Centro de Saúde Concepción Arenal, Área Sanitaria Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - L Ferreiro-Abuin
- Centro de Saúde Concepción Arenal, Área Sanitaria Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - A Durán-González
- Centro de Saúde Concepción Arenal, Área Sanitaria Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - D G Mosteiro-Miguéns
- Centro de Saúde Concepción Arenal, Área Sanitaria Santiago de Compostela, Santiago de Compostela, A Coruña, España.
| | - M Portela-Romero
- Centro de Saúde Concepción Arenal, Área Sanitaria Santiago de Compostela, Santiago de Compostela, A Coruña, España; Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Santiago de Compostela, A Coruña, España; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Santiago de Compostela, A Coruña, España
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Eitel KB, Hodax JK. Evaluation and medical care of intersex and gender diverse youth. Pediatr Radiol 2024; 54:1352-1362. [PMID: 38782777 DOI: 10.1007/s00247-024-05948-y] [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: 03/18/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
While there is considerable overlap in the treatment of patients with intersex traits and differences in sex development (I/DSD) with transgender and gender diverse (TGD) youth, the initial medical evaluation varies significantly. I/DSD youth often present due to differences in genitalia development in infancy or pubertal development in adolescence, and this leads to comprehensive biochemical, radiologic, and genetic evaluation. TGD youth, however, tend to have typical development noted at birth and during puberty, but present with a gender identity that does not align with their sex assigned at birth and do not require evaluation for underlying pathology. For both I/DSD and TGD youth, the mainstays of treatment are to better align one's physical appearance to their gender identity. This review discusses the non-medical and medical interventions utilized in gender affirming care. A multidisciplinary team of mental health providers, pediatric medical providers, and surgeons is recommended for providing gender affirming care to both I/DSD youth and TGD youth and their families. Radiologists have an important role in initial evaluation of I/DSD youth and in ongoing monitoring of growth and bone mineral density during puberty induction in I/DSD and TGD youth.
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Affiliation(s)
- Kelsey B Eitel
- Division of Endocrinology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, M/S OC.7.920, PO Box 5371, Seattle, 98105, WA, USA
| | - Juanita K Hodax
- Division of Endocrinology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, M/S OC.7.920, PO Box 5371, Seattle, 98105, WA, USA.
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Lake JE, Feng H, Hyatt AN, Miao H, Debroy P, Funderburg N, Ailstock K, Dobs A, Haberlen S, Magnani JW, Margolick JB, McGowan K, Palella FJ, Witt MD, Bhasin S, Budoff MJ, Post WS, Brown TT. Transgender Women With Suppressed Testosterone Display Lower Burden of Coronary Disease Than Matched Cisgender Men. J Endocr Soc 2024; 8:bvae120. [PMID: 38974987 PMCID: PMC11223995 DOI: 10.1210/jendso/bvae120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Indexed: 07/09/2024] Open
Abstract
Context Cardiovascular disease (CVD) in transgender women (TW) may be affected by gender-affirming hormone therapy (GAHT) and HIV, but few data compare TW on contemporary GAHT to well-matched controls. Objective We compared CVD burden and biomarker profiles between TW and matched cisgender men (CM). Methods Adult TW on GAHT (n = 29) were recruited for a cross-sectional study (2018-2020). CM (n = 48) from the former Multicenter AIDS Cohort Study were matched 2:1 to TW on HIV serostatus, age ±5 years, race/ethnicity, BMI category and antiretroviral therapy (ART) type. Cardiac parameters were measured by CT and coronary atherosclerosis by coronary CT angiography; sex hormone and biomarker concentrations were measured centrally from stored samples. Results Overall, median age was 53 years and BMI 29 kg/m2; 69% were non-white. All participants with HIV (71%) had viral suppression on ART. Only 31% of TW had testosterone suppression (<50 ng/dL, TW-S). Traditional CVD risk factors were similar between groups, except that TW-S had higher BMI than TW with non-suppressed testosterone (TW-T). TW-S had no evidence of non-calcified coronary plaque or advanced coronary stenosis, whereas TW-T and CM had similar burden. TW had lower prevalence of any coronary plaque, calcified plaque and mixed plaque than CM, regardless of testosterone concentrations and HIV serostatus. Estradiol but not testosterone concentrations moderately and negatively correlated with the presence of coronary plaque and stenosis. Small sample size limited statistical power. Conclusion Older TW with suppressed total testosterone on GAHT had no CT evidence of non-calcified coronary plaque or advanced coronary stenosis. Longitudinal studies to understand relationships between GAHT and CVD risk in TW are needed.
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Affiliation(s)
- Jordan E Lake
- Department of Medicine, UTHealth Houston, Houston, TX 77030, USA
| | - Han Feng
- Tulane Research and Innovation for Arrhythmia Discoveries-TRIAD Center, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Ana N Hyatt
- Department of Medicine, UTHealth Houston, Houston, TX 77030, USA
| | - Hongyu Miao
- Department of Statistics and College of Nursing, Florida State University, Tallahassee, FL 32306, USA
| | - Paula Debroy
- Department of Medicine, UTHealth Houston, Houston, TX 77030, USA
| | - Nicholas Funderburg
- Division of Medical Laboratory Science, The Ohio State University, Columbus, OH 43210, USA
| | - Kate Ailstock
- Division of Medical Laboratory Science, The Ohio State University, Columbus, OH 43210, USA
| | - Adrian Dobs
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Sabina Haberlen
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Joseph B Margolick
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Kate McGowan
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Frank J Palella
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Mallory D Witt
- Department of Medicine, Lundquist Institute, Torrance, CA 90502, USA
| | - Shalender Bhasin
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Matthew J Budoff
- Department of Medicine, Lundquist Institute, Torrance, CA 90502, USA
| | - Wendy S Post
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Todd T Brown
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
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Cortez S, Moog D, Lewis C, Williams K, Herrick CJ, Fields ME, Gray T, Guo Z, Nicol G, Baranski T. Effectiveness and Safety of Different Estradiol Regimens in Transgender Females: A Randomized Controlled Trial. J Endocr Soc 2024; 8:bvae108. [PMID: 38962490 PMCID: PMC11220669 DOI: 10.1210/jendso/bvae108] [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: 03/04/2024] [Indexed: 07/05/2024] Open
Abstract
Background A goal of gender-affirming hormone therapy (GAHT) for transgender women is to use estradiol to suppress endogenous production of testosterone. However, the effects of different estradiol regimens and route of administration on testosterone suppression is unknown. This is the first open-label randomized trial comparing different GAHT regimens for optimal estradiol route and dosing. Objective To evaluate 1 month and 6 months testosterone suppression <50 ng/dL with pulsed (once- or twice-daily sublingual 17-beta estradiol) and continuous (transdermal 17-beta estradiol) GAHT. Methods This study was conducted at an outpatient adult transgender clinic. Thirty-nine transgender women undergoing initiation of GAHT were randomly assigned to receive either once-daily sublingual, twice-daily sublingual, or transdermal 17-beta estradiol. All participants received spironolactone as an antiandrogen. Doses were titrated at monthly intervals to achieve total testosterone suppression <50 ng/dL. Results Transdermal 17-beta estradiol resulted in more rapid suppression of total testosterone, lower estrone levels, with no differences in estradiol levels when compared to once-daily and twice-daily sublingual estradiol. Moreover, there was no difference in the mean estradiol dose between the once-daily and twice-daily sublingual 17-beta estradiol group. Conclusion Continuous exposure with transdermal 17-beta estradiol suppressed testosterone production more effectively and with lower overall estradiol doses relative to once or twice daily sublingual estradiol. Most transgender women achieved cisgender women testosterone levels within 2 months on 1 or 2 0.1 mg/24 hours estradiol patches. Given no difference between once- or twice-daily sublingual estradiol, pulsed 17-beta estradiol likely provides no benefit for testosterone suppression.
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Affiliation(s)
- Samuel Cortez
- Department of Pediatrics, Division of Endocrinology, Diabetes, and Metabolism, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Dominic Moog
- Washington University School of Medicine in St. Louis, St. Louis,, MO 63110, USA
| | - Christopher Lewis
- Department of Pediatrics, Division of Endocrinology, Diabetes, and Metabolism, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Kelley Williams
- Department of Medicine, Division of Endocrinology, Diabetes, and Lipid Metabolism, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Cynthia J Herrick
- Department of Medicine, Division of Endocrinology, Diabetes, and Lipid Metabolism, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Melanie E Fields
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
- Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Teddi Gray
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Zhaohua Guo
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Ginger Nicol
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
| | - Thomas Baranski
- Department of Medicine, Division of Endocrinology, Diabetes, and Lipid Metabolism, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA
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Turan Ş, Özulucan MT, Karataş U, Kavla Y, Koyuncu O, Durcan E, Durcan G, Bağhaki S. The effects of gender-affirming hormone therapy and mastectomy on psychopathology, body image, and quality of life in adults with gender dysphoria who were assigned female at birth. Qual Life Res 2024; 33:1937-1947. [PMID: 38656406 PMCID: PMC11176246 DOI: 10.1007/s11136-024-03664-6] [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] [Accepted: 04/05/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE Individuals with gender dysphoria (GD) may request hormone therapy and various surgical operations to change their physical characteristics. The present study aimed to investigate the effects of two treatments, mastectomy and gender-affirming hormone therapy (GAHT), on adults with GD who were assigned female at birth (GD AFAB). METHODS In this cross-sectional study, we gathered data from a total of 269 individuals in three groups: (a) untreated group (n = 121), (b) GAHT group (n = 84) who had been receiving treatment for at least 6 months, and (c) GAHT-MAST group (n = 64) who had been using GAHT for at least 6 months and had undergone mastectomy at least 3 months prior. All participants were asked to complete the Symptom Checklist-90-Revised (SCL-90-R), the Body Uneasiness Test (BUT), and the World Health Organization's Quality of Life Questionnaire- Brief Form, Turkish Version (WHOQOL-BREF-Tr). RESULTS We found that individuals in the untreated group had higher psychopathological symptoms and body uneasiness scores, and lower quality of life scores compared to both GAHT and GAHT-MAST groups. There was no difference in psychopathology between the GAHT-MAST group and the GAHT group, but body uneasiness scores were lower, and quality of life scores were higher in the GAHT-MAST group. CONCLUSION Our study suggests that individuals receiving GAHT improved mental health, body satisfaction, and overall quality of life. Combining mastectomy with GAHT may further enhance these benefits.
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Affiliation(s)
- Şenol Turan
- Department of Psychiatry, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye.
| | - Mahmut Taha Özulucan
- Graduate School of Health Science, Neuroscience PhD Program, Koç University, Istanbul, Türkiye
| | - Uğur Karataş
- Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Yasin Kavla
- Department of Psychiatry, Hınıs State Hospital, Erzurum, Türkiye
| | - Oğuzhan Koyuncu
- Department of Child and Adolescent Psychiatry, Medeniyet University, Istanbul, Türkiye
| | - Emre Durcan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Gizem Durcan
- Department of Child and Adolescent Psychiatry, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Semih Bağhaki
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye
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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; 11:359-369. [PMID: 38557208 DOI: 10.1089/lgbt.2023.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 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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40
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Knaus S, Steininger J, Klinger D, Riedl S. Body Mass Index Distributions and Obesity Prevalence in a Transgender Youth Cohort - A Retrospective Analysis. J Adolesc Health 2024; 75:127-132. [PMID: 38752964 DOI: 10.1016/j.jadohealth.2024.03.005] [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: 10/20/2023] [Revised: 02/20/2024] [Accepted: 03/04/2024] [Indexed: 06/18/2024]
Abstract
PURPOSE To evaluate differences in auxological parameters between transgender and cisgender adolescents. METHODS Retrospective analysis of auxological data of 269 transgender and gender diverse patients (75% assigned female at birth or AFAB, 25% assigned male at birth or AMAB) at the outpatient clinic for Pediatric Endocrinology at the Vienna General Hospital. All were treatment naïve at initial measurement. Height and weight data were compared to current World Health Organization (WHO) standards, defining a standard deviation score (SDS) of ≥ 1 ≤ 2 as overweight and > 2 as obese. RESULTS In our untreated transgender population (mean age 15.7 years), 20% were overweight and 17% obese. Mean BMI was 0.64 SDS above the WHO average (p < .001). This result was more pronounced in the AFAB subgroup (+0.73 SDS, p < .001) than in the AMAB group (+0.37 SDS, p = .07). The AMAB group showed markedly higher BMI variance compared to WHO standards (p < .001) and to the AFAB group (p = .03), due to a higher relative number of underweight observations. When correcting for psychiatric diagnosis, transgender patients were still significantly overweight (p < .001). In patients for whom data both pregender-affirming hormone therapy and during gender-affirming hormone therapy was available (n = 133), BMI SDS did not change significantly over time (p = .22). DISCUSSION We observed significantly higher rates of overweight and obesity in our adolescent transgender cohort. The reasons are likely complex and multifactorial. This makes eating and exercise behaviors central in both transgender care and future research.
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Affiliation(s)
- Sarah Knaus
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria.
| | - Johanna Steininger
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Diana Klinger
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Stefan Riedl
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria; St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
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Menezes DP, de Lira ZS, Araújo ANBD, de Almeida AAF, Gomes ADOC, Moraes BT, Lucena JA. Prosodic Differences in the Voices of Transgender and Cisgender Women: Self-Perception of Voice - An Auditory and Acoustic Analysis. J Voice 2024; 38:844-857. [PMID: 35135714 DOI: 10.1016/j.jvoice.2021.12.020] [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: 10/14/2021] [Revised: 12/22/2021] [Accepted: 12/28/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The voice is an important parameter for identifying the speaker's gender. Transgender people seek to adapt their bodies to gender identity, and transgender women have greater difficulties in achieving vocal acceptance. In this context, the evaluation of the various parameters of the voice of transgender and cisgender women is essential to make it possible to propose appropriate intervention measures. OBJECTIVES To identify the differences in vocal characteristics of transgender and cisgender women. METHODS An sectional study was conducted. The sample comprised 20 transgender women and 20 cisgender women who underwent evaluation of acoustic parameters, emotional prosody, self-perception, and perception of gender by lay listeners. RESULTS The vocal characteristics of transgender and cisgender women differ in terms of the following parameters: f0, glottal noise excitation (GNE), vocal intensity, speech range profile (SRP), the first three formants of the vowel /a/, and in terms of emotional prosody, including duration and melodic contour. Higher values were mostly found in the cisgender population, except for noise level and vocal intensity. In addition, in most cases lay listeners identified the voices of transgender women as belonging to the male gender. There was a negative correlation between vocal dissatisfaction and f0 among transgender women. CONCLUSIONS Even though they perform vocal adjustments, the voices of transgender women are different from cisgender women in terms of acoustic parameters, vocal extension, and emotional prosody including duration and melodic contour. These differences have repercussions on the perception of gender by listeners.
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Affiliation(s)
- Danielle Pereira Menezes
- Speech-Language Pathology and Audiology Department, Graduate Program in Human Communication Health at the Federal University of Pernambuco. Health Sciences Center, Recife, Pernambuco, Brazil.
| | - Zulina Souza de Lira
- Speech-Language Pathology and Audiology Department, Graduate Program in Human Communication Health at the Federal University of Pernambuco. Health Sciences Center, Recife, Pernambuco, Brazil
| | - Ana Nery Barbosa de Araújo
- *Speech-Language Pathology and Audiology Department, at the Federal University of Pernambuco. Health Sciences Center, Recife, Pernambuco, Brazil
| | - Anna Alice Figueirêdo de Almeida
- Speech-Language Pathology and Audiology Department, Graduate Program in Speech Therapy at the Federal University of Paraíba. Health Sciences Center, João Pessoa, Paraíba, Brazil
| | - Adriana de Oliveira Camargo Gomes
- Speech-Language Pathology and Audiology Department, Graduate Program in Human Communication Health at the Federal University of Pernambuco. Health Sciences Center, Recife, Pernambuco, Brazil
| | - Bruno Teixeira Moraes
- Surgery Department, Health Sciences Center. University Federal of Pernambuco, Recife, Pernambuco, Brazil
| | - Jonia Alves Lucena
- Speech-Language Pathology and Audiology Department, Graduate Program in Human Communication Health at the Federal University of Pernambuco. Health Sciences Center, Recife, Pernambuco, Brazil
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42
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Berner AM, Atkinson SE. The implications of hormone treatment for cancer risk, screening and treatment in transgender individuals. Best Pract Res Clin Endocrinol Metab 2024:101909. [PMID: 38964988 DOI: 10.1016/j.beem.2024.101909] [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] [Indexed: 07/06/2024]
Abstract
There is evidence that gender-affirming hormone treatment (GAHT) for transgender individuals modulates their risk for specific malignancies including breast and prostate cancer, and meningiomas. However, there is insufficient data to make precise risk estimates accounting for age and inherited cancer risk. As such, screening recommendations remain broad. Even less evidence exists for best practice in the management of active or historical cancers in the transgender population. Guidance is therefore mainly extrapolated from cisgender populations but with considerations of the significant benefits of GAHT in the face of any hormonal risk. Clinical experience, the multidisciplinary team and shared decision making with the patient are vital in providing person-centred care, while further research is acquired.
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Affiliation(s)
- Alison May Berner
- Barts Cancer Institute, Queen Mary University of London, United Kingdom; Gender Identity Clinic London, Tavistock and Portman NHS Trust, United Kingdom.
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43
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Dimakopoulou A, Seal LJ. Testosterone and other treatments for transgender males and non-binary trans masculine individuals. Best Pract Res Clin Endocrinol Metab 2024:101908. [PMID: 38997938 DOI: 10.1016/j.beem.2024.101908] [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] [Indexed: 07/14/2024]
Abstract
Testosterone therapy is the main hormonal treatment offered in transmen to alleviate somatic gender dysphoria. Testosterone can be administered via topical or injectable preparations to achieve physical changes resulting in masculinisation and improve quality of life for the treated individuals. The aim of our paper is to outline methods for testosterone replacement, their impact on main body systems of transmen, potential associated health risks and long term follow up. Androgen use in transgender medicine is safe with appropriate endocrine guidance and monitoring. Studies with longer follow-up period, including those who may prefer low dose testosterone, interested in pregnancy or older people may further improve the management of female-to-male transgender persons.
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Affiliation(s)
- A Dimakopoulou
- Department of Endocrinology, Gender Identity Clinic, Tavistock & Portman NHS Foundation Trust, London, UK
| | - L J Seal
- Department of Endocrinology, Gender Identity Clinic, Tavistock & Portman NHS Foundation Trust, London, UK; St George's University of London Medical School, UK.
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44
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Tienforti D, Savignano G, Spagnolo L, Di Giulio F, Baroni MG, Barbonetti A. Biochemical liver damage during gender affirming therapy in trans adults assigned female at birth: a meta-analysis. J Endocrinol Invest 2024:10.1007/s40618-024-02418-y. [PMID: 38909133 DOI: 10.1007/s40618-024-02418-y] [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: 04/25/2024] [Accepted: 06/17/2024] [Indexed: 06/24/2024]
Abstract
PURPOSE To assess the effects of testosterone (T)-based gender affirming hormone therapy (GAHT) on liver blood tests (LBTs) in assigned female at birth adults, using a meta-analytic approach. METHODS Prospective and retrospective studies were selected that reported the prevalence of biochemical liver damage (BLD) and LBTs changes during T therapy. Data collected included pre-and-during therapy alanine-aminotransferase (ALT), aspartate-aminotransferase (AST), gamma-glutamyl-transferase (GGT), and alkaline phosphatase (ALP) mean concentration values. RESULTS The prevalence of BLD in 14 studies on 1698 subjects was 1% (95% CI 0.00-3.00; I2 = 14.1%; p = 0.82). In 17 studies on 2758 subjects, GAHT was associated with a statistically (but not clinically) significant increase in AST, GGT and ALP at 12 months and ALT at 3-7 (MD: 1.19 IU/l; 95% CI 0.31, 2.08; I2: 0%), at 12 (MD: 2.31 IU/l; 95% CI 1.41, 3.21; I2: 29%), but with no more significant increase at 24 months (MD: 1.71 IU/l; 95% CI -0.02, 3.44; I2: 0%). CONCLUSIONS Analysis of aggregate estimates confirms a low risk of BLD and abnormalities in LBTs, transient in most cases, during T-based GAHT, thus suggesting a limited need for careful liver monitoring in AFAB people.
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Affiliation(s)
- D Tienforti
- Andrology Unit, Department of Clinical Medicine, Life, Health and Environmental Sciences, University of L'Aquila, 67100, L'Aquila, Italy.
| | - G Savignano
- Andrology Unit, Department of Clinical Medicine, Life, Health and Environmental Sciences, University of L'Aquila, 67100, L'Aquila, Italy
| | - L Spagnolo
- Andrology Unit, Department of Clinical Medicine, Life, Health and Environmental Sciences, University of L'Aquila, 67100, L'Aquila, Italy
| | - F Di Giulio
- Andrology Unit, Department of Clinical Medicine, Life, Health and Environmental Sciences, University of L'Aquila, 67100, L'Aquila, Italy
| | - M G Baroni
- Andrology Unit, Department of Clinical Medicine, Life, Health and Environmental Sciences, University of L'Aquila, 67100, L'Aquila, Italy
| | - A Barbonetti
- Andrology Unit, Department of Clinical Medicine, Life, Health and Environmental Sciences, University of L'Aquila, 67100, L'Aquila, Italy
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45
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Khanijow K, Neira PM, Streed CG. Considerations for adult transgender patients in the hospital setting. J Hosp Med 2024. [PMID: 38923287 DOI: 10.1002/jhm.13439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 06/05/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Keshav Khanijow
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paula M Neira
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, Maryland, USA
| | - Carl G Streed
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
- GenderCare Center, Boston Medical Center, Boston, Massachusetts, USA
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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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Grimstad FW, Boskey ER, Clark RS, Ferrando CA. Management of breakthrough bleeding in transgender and gender diverse individuals on testosterone. Am J Obstet Gynecol 2024:S0002-9378(24)00667-7. [PMID: 38876414 DOI: 10.1016/j.ajog.2024.06.004] [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: 03/01/2024] [Revised: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND While many transgender and gender diverse individuals rapidly achieve amenorrhea on testosterone, emerging data have identified that breakthrough bleeding can occur in up to one-third of individuals with long-term use. Breakthrough bleeding can worsen dysphoria and patients may seek management to reattain amenorrhea. Because of this, there is a need to assess efficacy of management approaches. OBJECTIVE The primary aim of the study was to evaluate methods used by patients and their providers to manage breakthrough bleeding which arises after 1 year of testosterone use. Secondary aims included describing the diagnostic approaches to breakthrough bleeding, and proposing an algorithm for classification and management of breakthrough bleeding in this patient population. STUDY DESIGN This was an institutional review board-approved single tertiary center, retrospective chart review of transgender and gender diverse individuals on testosterone gender affirming hormone therapy who experienced breakthrough bleeding after 1 year of use. Charts were reviewed to determine patient characteristics, testosterone use, and breakthrough bleeding management approaches. RESULTS Of the 96 individuals who had been on testosterone for 1 year and experienced breakthrough bleeding, 97% (n=93) engaged in at least 1 approach to management. The mean age at initiation of testosterone was 21.9 (standard deviation 5.4) and the median duration of time on testosterone was 54.5 months (interquartile range 33.5, 82). Only 16% (n=15) were using menstrual suppression at the time of their breakthrough bleeding episode. Breakthrough bleeding was successfully managed in 77 (79%), following between 1 and 4 attempted approaches. More than half of management attempts (63%) were successful on the first try. When management approaches were analyzed independently, the range of success associated with any particular approach was between 33% and 100%. Other than hysterectomy, which was fully successful at managing breakthrough bleeding, no approach was significantly better than no intervention. This was true both for individuals who did and did not bleed with missed testosterone doses. Regardless of what approach was used, after a failed attempt, the next attempt was successful in more than half of individuals. Of the 16 who underwent hysterectomy, 1 did so in part as a first line approach to manage breakthrough bleeding. CONCLUSION In this study, use of medical management methods was not found to be superior to observation alone in the management of breakthrough bleeding. In the absence of data supporting superiority of any method, we recommend tailoring method attempts to patients' goals.
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Affiliation(s)
- Frances W Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA; Center for Urogynecology & Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, OH.
| | - Elizabeth R Boskey
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Surgery, Harvard Medical School, Boston, MA; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Rachael S Clark
- Case Western University School of Medicine, Cleveland, OH; Department of Obstetrics & Gynecology, University of Massachusetts, Worcester, MA
| | - Cecile A Ferrando
- Center for Urogynecology & Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, OH; Case Western University School of Medicine, Cleveland, OH
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48
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Levine SB. What is the Purpose of the Initial Psychiatric Evaluation of Minors with Gender Dysphoria. JOURNAL OF SEX & MARITAL THERAPY 2024; 50:773-786. [PMID: 38856025 DOI: 10.1080/0092623x.2024.2362774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
The rising incidence of trans youth throughout the world and the new policy of many European countries and 25 US states that psychotherapy should be the first therapeutic response to Gender Dysphoria have made a reexamination of a comprehensive psychiatric evaluation (CPE) urgently relevant. Two conflicting views of the purpose of the CPE exist based on etiologic beliefs and convictions about the best therapeutic approach. This paper provides one clinician's synthesis of the elements, processes, goals, values, benchmarks of CPE and its usual recommendation for psychotherapy. The CPE recommended herein provides cogent hypotheses about the origins of the intrapsychic creation of a trans identity that are to be strengthened, weakened, or supplanted by explanations that emerge from psychotherapy. It also strengthens familial bonds and clarifies the intention to improve the mental health, social function, and autonomy of the minor. The inescapable ethical tensions that surround trans minor health care are discussed. The recommended CPE does not prevent subsequent medical interventions.
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Affiliation(s)
- Stephen B Levine
- Clinical Professor of Psychiatry, Case Western Reserve University, Cleveland, Ohio, USA
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Dijkman BAM, Liberton NPTJ, te Slaa S, Smit JM, Wiepjes CM, Dreijerink KMA, den Heijer M, Verdaasdonk RM, de Blok CJM. A comparative study of 3D measuring methods for monitoring breast volume changes. PLoS One 2024; 19:e0305059. [PMID: 38843166 PMCID: PMC11156285 DOI: 10.1371/journal.pone.0305059] [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] [Received: 06/07/2023] [Accepted: 05/21/2024] [Indexed: 06/09/2024] Open
Abstract
Three-dimensional (3D) imaging techniques are promising new tools for measuring breast volume, for example in gender-affirming therapy. Transgender individuals can be treated with gender-affirming hormone therapy (GAHT). A robust method for monitoring breast volume changes is critical to be able to study the effects of feminizing GAHT. The primary aim of this study was to compare the accuracy of three 3D devices (Vectra XT, Artec LEO and iPhone XR) for measuring modest breast volume differences using a mannequin. The secondary aim of this study was to evaluate these methods in several performance domains. We used reference prostheses of increasing volumes and compared the volumes using GOM-inspect software. For Vectra XT 3D images, manufacturer-provided software was used to calculate volumes as well. The scanning methods were ranked based on their performance in a total of five categories: volume estimations, costs, user-friendliness, test subject-friendliness and technical aspects. The 3D models analyzed with GOM-inspect showed relative mean estimate differences from the actual volumes of 9.1% for the Vectra XT, 7.3% for the Artec LEO and 14% for the iPhone XR. For the Vectra XT models analyzed with the built-in software this was 6.2%. Root mean squared errors (RMSE) calculated based on the GOM-inspect volume analyses showed mean RMSEs of 2.27, 2.54 and 8.93 for the Vectra XT, Artec LEO and iPhone XR, respectively. The Vectra software had a mean RMSE of 3.00. In the combined performance ranking, the Vectra XT had the most favorable ranking, followed by the Artec LEO and the iPhone XR. The Vectra XT and Artec LEO are the preferred scanners to monitor breast development due to the combination of higher accuracy and overall performance. The current study shows that 3D techniques can be used to adequately measure modest breast volume differences and therefore will be useful to study for example breast changes in transgender individuals using feminizing GAHT. These observations may also be relevant in other fields of 3D imaging research.
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Affiliation(s)
- Benthe A. M. Dijkman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University, Amsterdam, the Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Niels P. T. J. Liberton
- Department of Medical Technology, 3D Innovation Lab, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Sjoerd te Slaa
- Department of Medical Technology, 3D Innovation Lab, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Jan Maerten Smit
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University, Amsterdam, the Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam Movement Sciences, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Chantal M. Wiepjes
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University, Amsterdam, the Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Koen M. A. Dreijerink
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University, Amsterdam, the Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Martin den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University, Amsterdam, the Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Rudolf M. Verdaasdonk
- Faculty of Science and Technology, Health Technology Implementation, University of Twente, Enschede, the Netherlands
| | - Christel J. M. de Blok
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University, Amsterdam, the Netherlands
- Department of Endocrinology and Metabolism, Amsterdam UMC, VU University, Amsterdam, the Netherlands
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50
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Gerritse K, Martens C, Bremmer MA, Kreukels BPC, de Boer F, Molewijk BC. "I Should've Been Able to Decide for Myself, but I Didn't Want to Be Left Alone." A Qualitative Interview Study of Clients' Ethical Challenges and Norms Regarding Decision-Making in Gender-Affirming Medical Care. JOURNAL OF HOMOSEXUALITY 2024; 71:1757-1781. [PMID: 37097132 DOI: 10.1080/00918369.2023.2201972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
This qualitative study aimed to map and provide insight into the ethical challenges and norms of adult transgender and gender diverse (TGD) clients in gender-affirming medical care (GAMC). By doing so, we seek to make an empirical and constructive contribution to the dialogue on and moral inquiry into what good decision-making in GAMC should entail. We conducted 10 semi-structured interviews with adult Dutch TGD people who received GAMC. In our thematic analysis, we (1) included both ethical challenges and norms, (2) differentiated between explicit and implicit ethical challenges and norms, and (3) ascertained the specific context in which the latter emerged. We identified the following themes: (1) clients should be in the lead, (2) harm should be prevented, and (3) the decision-making process should be attuned to the individual client. These themes arose in the context of (1) a precarious client-clinician relationship and (2) distinct characteristics of GAMC. Our findings highlight divergent and dynamic decisional challenges and normative views-both within individual clients and among them. We conclude that there is no single ideal model of good decision-making in GAMC and argue that elucidating and jointly deliberating on decisional norms and challenges should be an inherent part of co-constructing good decision-making.
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Affiliation(s)
- Karl Gerritse
- Department of Ethics, Law, and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Liaison Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Casper Martens
- Department of Ethics, Law, and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marijke A Bremmer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Liaison Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Baudewijntje 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, The Netherlands
| | - Fijgje de Boer
- Department of Ethics, Law, and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bert C Molewijk
- Department of Ethics, Law, and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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