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Toffoli Ribeiro C, Gois Í, da Rosa Borges M, Ferreira LGA, Brandão Vasco M, Ferreira JG, Maia TC, Dias-da-Silva MR. Assessment of parenteral estradiol and dihydroxyprogesterone use among other feminizing regimens for transgender women: insights on satisfaction with breast development from community-based healthcare services. Ann Med 2024; 56:2406458. [PMID: 39301885 PMCID: PMC11418065 DOI: 10.1080/07853890.2024.2406458] [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: 12/28/2023] [Revised: 04/30/2024] [Accepted: 08/12/2024] [Indexed: 09/22/2024] Open
Abstract
The practice of hormone therapy is crucial in aligning secondary sex characteristics with the gender identity of transgender adults. This study examines the effects of a commonly used injectable hormone combination, specifically estradiol enanthate with dihydroxyprogesterone acetophenide (EEn/DHPA), on serum hormonal levels and self-reported satisfaction with breast development in transwomen. Our research focused on a retrospective longitudinal study involving a large cohort of transwomen evaluated between 2020 and 2022, comprising 101 participants. We assessed serum levels of estradiol (E2), testosterone (T), luteinizing hormone (LH), and follicle-stimulating hormone (FSH), comparing the EEn/DHPA hormonal regimen with other combined estrogen-progestogen (CEP) therapies. Additionally, a subset of 43 transwomen completed a 5-question survey to evaluate self-reported satisfaction with breast development using Tanner scales. Our findings indicated that participants using the EEn/DHPA regimen exhibited significantly higher serum E2 levels (mean: 186 pg/mL ± 32 pg/mL) than those using other therapies (62 ± 7 pg/mL), along with lower FSH levels, but no significant differences in T and LH levels. Concerning satisfaction with breast development, 76% reported increased fulfillment with breast augmentation while using EEn/DHPA. These results suggest that an injectable, low-cost EEn/DHPA administered every three weeks could serve as an alternative feminizing regimen, particularly considering the extensive long-term experience of the local transgender community. Further longitudinal studies on the efficacy of feminizing-body effects and endovascular risks of various parenteral CEP types are warranted to improve primary healthcare provision for transgender persons.
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Affiliation(s)
- Camila Toffoli Ribeiro
- Hospital de Clínicas da Universidade Federal de Uberlândia, Uberlândia, Brazil
- Centro de Referência e Assistência Integral para a Saúde Transespecífica (CRAIST) HC/UFU, Uberlândia, Brazil
| | - Ísis Gois
- Núcleo TransUnifesp (NTU), Universidade Federal de São Paulo, São Paulo, Brazil
- Laboratory of Molecular and Translational Endocrinology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Lucas Garcia Alves Ferreira
- Laboratory of Molecular and Translational Endocrinology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | - Taciana Carla Maia
- Centro de Referência e Assistência Integral para a Saúde Transespecífica (CRAIST) HC/UFU, Uberlândia, Brazil
| | - Magnus Régios Dias-da-Silva
- Núcleo TransUnifesp (NTU), Universidade Federal de São Paulo, São Paulo, Brazil
- Laboratory of Molecular and Translational Endocrinology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
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Spencer J, Amos AJ, Clarke PHJ. Recommendations of the Queensland children's gender service external evaluation and their implications for health policy in Australia. Australas Psychiatry 2024:10398562241280351. [PMID: 39380394 DOI: 10.1177/10398562241280351] [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: 10/10/2024]
Abstract
OBJECTIVE To review the evaluation process and the implications for Australian health policy of the 2024 external clinical service evaluation of the Queensland Children's Gender Service (QCGS) and its recommendations. CONCLUSIONS Failing to perform a systematic review of the relevant literature, and adhering to discredited and ideologically based guidelines, the Review made recommendations lacking evidentiary support that have major implications for Queensland and other Australian health services. The evaluation report's recommendations reveal eight areas of concern about the clinic's functioning.
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Affiliation(s)
| | - Andrew James Amos
- Medicine and Dentistry, James Cook University Division of Tropical Health and Medicine, Townsville, QLD, Australia
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3
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Marino LG, Boguszewski KE, Stephens HF, Taylor JF. Capacity to consent: a scoping review of youth decision-making capacity for gender-affirming care. BMC Med Ethics 2024; 25:108. [PMID: 39379955 DOI: 10.1186/s12910-024-01107-y] [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: 06/04/2024] [Accepted: 09/24/2024] [Indexed: 10/10/2024] Open
Abstract
BACKGROUND Transgender and gender expansive (TGE) youth often seek a variety of gender-affirming healthcare services, including pubertal suppression and hormone therapy requiring that TGE youth and their parents participate in informed consent and decision making. While youth must demonstrate the ability to understand and appreciate treatment options, risks, benefits, and alternatives as well as make and express a treatment choice, standardized approaches to assess the capacity of TGE youth to consent or assent in clinical practice are not routinely used. This scoping review identified the currently available data regarding adolescent capacity to consent to gender-affirming medical treatments. METHODS Articles relevant to assessing adolescent capacity for clinical decision-making were identified using OVID Medline, Web of Science, and PubMed. Articles were reviewed and thematically analyzed. RESULTS Eight relevant articles were identified using three tools for measuring adolescent clinical decision-making capacity: Measure of Understanding, Measure of Competence, and MacArthur Competence Assessment Tool (MacCAT). These studies explored hypothetical treatment decisions, mental health treatment decisions, HIV treatment decisions, genetic testing decisions, and gender-affirming medical decisions. Only one study specifically examines the capacity of TGE youth to consent to medical treatments. Age was correlated with capacity in most, but not all studies. Other studies found cognitive measures (IQ, literacy, numeracy) may impact important aspects of capacity (understanding and reasoning). CONCLUSIONS For clinicians caring for TGE youth, tools such as the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) may prove useful, in conjunction with consideration of youth developmental abilities and utilization of shared decision-making practices. A standardized, collaborative approach to assessing TGE youth capacity would benefit TGE youth and their parents, and allow clinicians to more easily resolve ethical concerns.
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Affiliation(s)
- Loren G Marino
- University of Virginia School of Medicine, Charlottesville, USA.
| | | | - Haley F Stephens
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, USA
| | - Julia F Taylor
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, USA
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Taylor J, Mitchell A, Hall R, Heathcote C, Langton T, Fraser L, Hewitt CE. Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: a systematic review. Arch Dis Child 2024:archdischild-2023-326669. [PMID: 38594047 DOI: 10.1136/archdischild-2023-326669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 02/10/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Treatment to suppress or lessen effects of puberty are outlined in clinical guidelines for adolescents experiencing gender dysphoria/incongruence. Robust evidence concerning risks and benefits is lacking and there is a need to aggregate evidence as new studies are published. AIM To identify and synthesise studies assessing the outcomes of puberty suppression in adolescents experiencing gender dysphoria/incongruence. METHODS A systematic review and narrative synthesis. Database searches (Medline, Embase, CINAHL, PsycINFO, Web of Science) were performed in April 2022, with results assessed independently by two reviewers. An adapted version of the Newcastle-Ottawa Scale for cohort studies was used to appraise study quality. Only moderate-quality and high-quality studies were synthesised. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines were used. RESULTS 11 cohort, 8 cross-sectional and 31 pre-post studies were included (n=50). One cross-sectional study was high quality, 25 studies were moderate quality (including 5 cohort studies) and 24 were low quality. Synthesis of moderate-quality and high-quality studies showed consistent evidence demonstrating efficacy for suppressing puberty. Height increased in multiple studies, although not in line with expected growth. Multiple studies reported reductions in bone density during treatment. Limited and/or inconsistent evidence was found in relation to gender dysphoria, psychological and psychosocial health, body satisfaction, cardiometabolic risk, cognitive development and fertility. CONCLUSIONS There is a lack of high-quality research assessing puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development. Bone health and height may be compromised during treatment. More recent studies published since April 2022 until January 2024 also support the conclusions of this review. PROSPERO REGISTRATION NUMBER CRD42021289659.
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Affiliation(s)
- Jo Taylor
- Department of Health Sciences, University of York, York, UK
| | - Alex Mitchell
- Department of Health Sciences, University of York, York, UK
| | - Ruth Hall
- Department of Health Sciences, University of York, York, UK
| | | | - Trilby Langton
- Department of Health Sciences, University of York, York, UK
| | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
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5
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Band IC, Dubois B, Ghofranian A, Nietsch KS, Lee JA, Friedenthal J, Copperman AB, Estevez SL. An Analysis of Fertility Preservation Offerings for Transgender Youth on United States Pediatric Hospital Websites. J Adolesc Health 2024:S1054-139X(24)00399-9. [PMID: 39365234 DOI: 10.1016/j.jadohealth.2024.08.008] [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: 02/02/2024] [Revised: 08/05/2024] [Accepted: 08/06/2024] [Indexed: 10/05/2024]
Abstract
PURPOSE To survey United States (U.S.) pediatric hospital websites for information about fertility preservation (FP) for transgender patients. Secondarily, to identify hospital characteristics associated with higher likelihood of publishing transgender-specific FP content on websites. METHODS This cross-sectional study included all U.S. pediatric hospitals from Children's Hospital Association excluding specialty hospitals. From September-December 2023, 2 independent researchers surveyed websites for: geographic location, academic affiliation, religious affiliation, presence of general and transgender-specific FP information, and specialties of FP providers. Fisher's exact and Pearson's Chi-square tests were used. RESULTS Of 177 websites surveyed, 41% (n = 73) published FP information, largely targeted to oncology patients (90%, n = 66). Only 8% (n = 15) of all websites mentioned FP for transgender youth. Based on website information, most fertility programs included a medical oncologist (80%, n = 53); fewer included a urologist (32%, n = 21), pediatric gynecologist (27%, n = 18) or reproductive endocrinologist (RE, 21%, n = 14). About half (n = 31) referred to affiliate REs. Presence of transgender-specific FP website content ranged from 0% to 5% in Southern divisions to 20% in New England (median = 10%). Secular (p < .001) and academic (p = .04) hospital websites were significantly more likely to include FP content. DISCUSSION Our findings highlight a gap in access to FP information for transgender youth on U.S. pediatric hospital websites. Few websites identify FP teams that include an RE or pediatric gynecologist, who specialize in FP for patients with ovaries. Access to FP information is critical to transgender youth who may desire genetically related children later in life. Strategies to assure this information is widely available are needed.
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Affiliation(s)
- Isabelle C Band
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Bethany Dubois
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Atoosa Ghofranian
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York; Reproductive Medicine Associates of New York, New York, New York
| | - Katrina S Nietsch
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joseph A Lee
- Reproductive Medicine Associates of New York, New York, New York
| | - Jenna Friedenthal
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York; Reproductive Medicine Associates of New York, New York, New York
| | - Alan B Copperman
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York; Reproductive Medicine Associates of New York, New York, New York
| | - Samantha L Estevez
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York; Reproductive Medicine Associates of New York, New York, New York; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Pattar BSB, Gulamhusein N, Rytz CL, Turino Miranda K, Beach LB, Marshall Z, Collister D, Greene DN, Whitley CT, Saad N, Dumanski SM, Harrison TG, Peace L, Newbert AM, Ahmed SB. Characterization of the literature informing health care of transgender and gender-diverse persons: A bibliometric analysis. PLoS One 2024; 19:e0309169. [PMID: 39365757 PMCID: PMC11452042 DOI: 10.1371/journal.pone.0309169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 08/05/2024] [Indexed: 10/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Transgender and gender-diverse (TGD) persons experience health inequities compared to their cisgender peers, which is in part related to limited evidence informing their care. Thus, we aimed to describe the literature informing care provision of TGD individuals. DATA SOURCE, ELIGIBILITY CRITERIA, AND SYNTHESIS METHODS Literature cited by the World Professional Association of Transgender Health Standards of Care Version 8 was reviewed. Original research articles, excluding systematic reviews (n = 74), were assessed (n = 1809). Studies where the population of interest were only caregivers, providers, siblings, partners, or children of TGD individuals were excluded (n = 7). Results were synthesized in a descriptive manner. RESULTS Of 1809 citations, 696 studies met the inclusion criteria. TGD-only populations were represented in 65% of studies. White (38%) participants and young adults (18 to 29 years old, 64%) were the most well-represented study populations. Almost half of studies (45%) were cross-sectional, and approximately a third were longitudinal in nature (37%). Overall, the median number of TGD participants (median [IQR]: 104 [32, 356]) included in each study was approximately one third of included cisgender participants (271 [47, 15405]). In studies where both TGD and cisgender individuals were included (n = 74), the proportion of TGD to cisgender participants was 1:2 [1:20, 1:1]. Less than a third of studies stratified results by sex (32%) or gender (28%), and even fewer included sex (4%) or gender (3%) as a covariate in the analysis. The proportion of studies with populations including both TGD and cisgender participants increased between 1969 and 2023, while the proportion of studies with study populations of unspecified gender identity decreased over the same time period. CONCLUSIONS While TGD participant-only studies make up most of the literature informing care of this population, longitudinal studies including a diversity of TGD individuals across life stages are required to improve the quality of evidence.
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Affiliation(s)
- Badal S. B. Pattar
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Nabilah Gulamhusein
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Chantal L. Rytz
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Keila Turino Miranda
- Cardiovascular Health and Autonomic Regulation Laboratory, Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Lauren B. Beach
- Department of Medical Social Sciences, Northwestern Feinberg School of Medicine, Chicago, Illinois, Unites States of America
| | - Zack Marshall
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - David Collister
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dina N. Greene
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, Unites States of America
| | - Cameron T. Whitley
- Department of Sociology, Western Washington University, Bellingham, Washington, United States of America
| | - Nathalie Saad
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sandra M. Dumanski
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tyrone G. Harrison
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Sofia B. Ahmed
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Women and Children’s Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
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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; 79:1102-1116. [PMID: 39043129 DOI: 10.1111/anae.16378] [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] [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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Stoody VB, Glick HR, Murphey AC, Sturza JM, Selkie EM. A Content Analysis of Transgender Health and Wellness Themes Shared Through Social Media. Clin Pediatr (Phila) 2024; 63:1352-1363. [PMID: 38135918 DOI: 10.1177/00099228231219499] [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] [Indexed: 12/24/2023]
Abstract
Transgender and gender-diverse (TGD) adolescents experience limited access to gender-affirming care (GAC) and information and use social media platforms for informational and social support. We conducted conventional content analysis of posts on the platform, Tumblr and applied univariate statistics to characterize health and wellness themes represented by this content. Content was predominantly transmasculine-relevant. Posts addressing the trans health care paradigm often co-occurred with content referencing affirmation logs, the physical and emotional impact of affirmation, surgery, and unspecified medical interventions. Gender-affirming hormone therapy was the most prevalent intervention referenced in posts related to non-professional/non-licensed medical care and advice requests. Transgender and gender-diverse youth-serving individuals can use this information to mitigate harm, enhance patient education, and improve the overall well-being of TGD youth. Further research is needed to characterize the effect of content encountered on social media on pediatric patient experiences and on outcomes of GAC.
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Affiliation(s)
- Vishvanie B Stoody
- Division of Adolescent Medicine, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Hannah R Glick
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Annie C Murphey
- Section of Emergency Medicine, The University of Chicago, Chicago, IL, USA
| | - Julie M Sturza
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ellen M Selkie
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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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; 178:1049-1056. [PMID: 39158896 PMCID: PMC11334009 DOI: 10.1001/jamapediatrics.2024.2835] [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: 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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10
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Morgan KM, Deshler LN, Tibbs MD, Qiao EM, Anger JT, Salmasi A, Marshall DC, Sanghvi P, Rose BS, Riviere P. Prostate Specific Antigen and Prostate Cancer in Gender Affirming Hormone Therapy for Transgender or Nonbinary Individuals. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)03409-6. [PMID: 39357786 DOI: 10.1016/j.ijrobp.2024.09.039] [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: 07/06/2024] [Revised: 09/13/2024] [Accepted: 09/20/2024] [Indexed: 10/04/2024]
Abstract
INTRODUCTION The effects of gender affirming hormone therapy on prostate specific antigen (PSA) and prostate cancer incidence in transgender or non-binary individuals (TGNB) born with prostate glands remains uncharacterized. METHODS The cohort included 1,024 self-identified TGNB individuals assigned male at birth who received PSA testing in the VA Healthcare System, matched by birth year to cisgender men. PSA changes were measuring using linear-mixed effects modeling accounting for repeated measured and matching. RESULTS Non-gonadotrophin releasing hormone agonist or antagonist (GnRH) therapy was associated with 1.30 ng/mL lower PSA (95% confidence interval (CI) 1.14-1.46, p < 0.001) and GnRH therapy was associated with 1.08 ng/mL lower PSA (95% CI 0.60-1.55, p < 0.001) compared with cisgender men. Among 450 TGNB individuals who had PSA testing before and after initiation of hormone therapy, non-GnRH and GnRH therapies resulted in 0.49 ng/mL decrease (95% CI 0.35-0.62, p<0.001) and 0.73 ng/mL decrease (95% CI 0.43-1.02, p<0.001), respectively, from median baseline of 0.70 ng/mL. From time of age 50, TGNB prostate cancer incidence was 1.79 per 1,000 patient-years versus 4.02 per 1,000 patient-years in cisgender men. CONCLUSIONS Gender affirming hormone therapies are associated with significant decreases in PSA, and TGNB individuals assigned male at birth remain at risk for prostate cancer. Future work should establish if a lower threshold for biopsy should be used in these contexts and if the decreased incidence is a result of ascertainment bias or hormone therapy resulting in a true decrease in the incidence of prostate cancer.
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Affiliation(s)
- Kylie M Morgan
- University of California San Diego, Department of Radiation Medicine and Applied Sciences, La Jolla, CA; University of California San Diego, Center for Health Equity and Education Research (CHEER), La Jolla, CA; Veterans Affairs San Diego, La Jolla, CA
| | - Leah N Deshler
- University of California San Diego, Department of Radiation Medicine and Applied Sciences, La Jolla, CA; University of California San Diego, Center for Health Equity and Education Research (CHEER), La Jolla, CA; Veterans Affairs San Diego, La Jolla, CA
| | - Michelle D Tibbs
- University of California San Diego, Department of Radiation Medicine and Applied Sciences, La Jolla, CA; University of California San Diego, Center for Health Equity and Education Research (CHEER), La Jolla, CA; Veterans Affairs San Diego, La Jolla, CA
| | - Edmund M Qiao
- University of California San Diego, Department of Radiation Medicine and Applied Sciences, La Jolla, CA; University of California San Diego, Center for Health Equity and Education Research (CHEER), La Jolla, CA; Veterans Affairs San Diego, La Jolla, CA
| | - Jennifer T Anger
- University of California San Diego, Department of Urology, La Jolla, CA
| | - Amirali Salmasi
- University of California San Diego, Department of Urology, La Jolla, CA
| | - Deborah C Marshall
- Icahn School of Medicine, Department of Radiation Oncology, Department of Population Health Science & Policy, New York, NY
| | - Parag Sanghvi
- University of California San Diego, Department of Radiation Medicine and Applied Sciences, La Jolla, CA
| | - Brent S Rose
- University of California San Diego, Department of Radiation Medicine and Applied Sciences, La Jolla, CA; University of California San Diego, Center for Health Equity and Education Research (CHEER), La Jolla, CA; Veterans Affairs San Diego, La Jolla, CA
| | - Paul Riviere
- University of California San Diego, Department of Radiation Medicine and Applied Sciences, La Jolla, CA; University of California San Diego, Center for Health Equity and Education Research (CHEER), La Jolla, CA; Veterans Affairs San Diego, La Jolla, CA.
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11
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Mills AR, Astle KN, Aragon KG. Considerations of gender-affirming care for transgender and gender-diverse youth. Am J Health Syst Pharm 2024; 81:e640-e647. [PMID: 38530876 DOI: 10.1093/ajhp/zxae085] [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: 03/23/2024] [Indexed: 03/28/2024] Open
Affiliation(s)
| | - Kevin N Astle
- University of South Florida Taneja College of Pharmacy, Tampa, FL, USA
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12
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Laidlaw MK, Jorgensen S. Exploring Safety in Gender-Affirming Hormonal Treatments: An Observational Study on Adverse Drug Events Using the Food and Drug Administration Adverse Event Reporting System Database. Ann Pharmacother 2024:10600280241278913. [PMID: 39295245 DOI: 10.1177/10600280241278913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2024] Open
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13
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Villa-Zapata L, Gomez-Lumbreras A. Reply: "Exploring Safety in Gender-Affirming Hormonal Treatments: An Observational Study on Adverse Drug Events Using the Food and Drug Administration Adverse Event Reporting System Database". Ann Pharmacother 2024:10600280241277860. [PMID: 39295239 DOI: 10.1177/10600280241277860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2024] Open
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14
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Feil K, Pabst L, Reider S, Schuchter S, Ciresa-König A, Toth B. The vaginal microbiome of transgender men receiving gender-affirming hormonal therapy in comparison to that of cisgender women. Sci Rep 2024; 14:21526. [PMID: 39277646 PMCID: PMC11401930 DOI: 10.1038/s41598-024-72365-4] [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: 05/14/2024] [Accepted: 09/06/2024] [Indexed: 09/17/2024] Open
Abstract
The vaginal microbiome of trans men and menopausal women is suspected to be similar due to a lack of estrogen leading to the absence of lactobacilli. However, data are scarce. We performed an analysis of the vaginal microbiome of trans men (n = 25) in comparison to that of menopausal (n = 25) and premenopausal women (n = 25). The vaginal microbiome of trans men and menopausal women showed a higher alpha diversity than that of premenopausal women. Various beta diversity indices (e.g., Bray‒Curtis (Un-)Weigthed Unifrac), showed significant differences in community composition between trans men and premenopausal (p < 0.001) and menopausal women (p < 0.001). The vaginal microbiome of trans men is characterized by a loss of Lactobacillus and an increase in bacteria associated with the intestinal flora (e.g., Campylobacter, Anaerococcus, Dialister, Prevotella). The abundance of Dialister and Prevotella decreased with the length of hormonal therapy in trans men. The Nugent score, Pap smear and HPV status did not differ between the study groups. The vaginal microbiome of trans men differs from that of premenopausal women but shows similarities to that of menopausal women. The duration of hormonal therapy in trans men may have important impacts on the vaginal microbiome and thus possibly on the risk for STIs.
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Affiliation(s)
- Katharina Feil
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Lisa Pabst
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Simon Reider
- Department of Internal Medicine 2, Medical University of Innsbruck, Innsbruck, Austria.
| | - Stefanie Schuchter
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexandra Ciresa-König
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Toth
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Innsbruck, Austria
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15
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Bermúdez-Pozuelo L, Sordo Del Castillo L, Belza Egozcue MJ, Triviño Caballero R. [Healthcare for trans people in primary care]. Med Clin (Barc) 2024; 163:253-259. [PMID: 38697894 DOI: 10.1016/j.medcli.2024.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 05/05/2024]
Affiliation(s)
- Laura Bermúdez-Pozuelo
- Departamento de Salud Pública y Materno-Infantil, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - Luis Sordo Del Castillo
- Departamento de Salud Pública y Materno-Infantil, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España; CIBER en Epidemiología y Salud Pública (CIBERESP), Madrid, España; Fundación para la Investigación Biomédica, Hospital Clínico San Carlos (IDISCC), Madrid, España.
| | - María José Belza Egozcue
- CIBER en Epidemiología y Salud Pública (CIBERESP), Madrid, España; Escuela Nacional de Salud, Instituto de Salud Carlos III, Madrid, España
| | - Rosana Triviño Caballero
- Departamento de Salud Pública y Materno-Infantil, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
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16
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Ralph P, Mahoud M, Schlager D, Lee WG, Wafa R, Williamson E, Butler G, Ralph D, Sangster P. United Kingdom data collection of semen quality in transgender adolescent females seeking fertility preservation. Fertil Steril 2024:S0015-0282(24)02218-0. [PMID: 39245338 DOI: 10.1016/j.fertnstert.2024.09.006] [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: 09/22/2023] [Revised: 09/02/2024] [Accepted: 09/03/2024] [Indexed: 09/10/2024]
Abstract
OBJECTIVE Increasing numbers of adolescents with gender dysphoria start gonadotropin-releasing hormone agonists to halt puberty, minimizing psychological distress. The uncertainty of long-term effects of this medication, and the subsequent likelihood of accessing gender-affirming hormone treatment, highlights the importance of fertility preservation before starting hormone treatment. We investigated the take-up, hormonal profile, and sperm quality in adolescents undergoing fertility preservation via cryopreservation by masturbation or surgical sperm retrieval, before starting hormonal therapy. DESIGN Data were prospectively maintained from a tertiary UK-based hospital. A total of 122 people <19 years, mean age 15.2 ± 1.7 years, referred by gender clinics and general practitioners, were included in this cohort study. SETTING UK tertiary hospital centre based in London. PATIENTS Participants were counseled for fertility preservation, and serum testosterone, follicle-stimulating hormone, and luteinizing hormone levels were recorded before providing semen samples. INTERVENTION Masturbation semen samples were classified as normal (>15 mil/mL), oligozoospermia (1-15 mil/mL), cryptozoospermia (<1 mil/mL), or azoospermia. If the sample was insufficient or the person was unwilling to masturbate, surgical sperm retrieval was offered in a stepwise manner using electroejaculation, testicular sperm extraction (TESE) ± microdissection testicular sperm extraction (mTESE). MAIN OUTCOME MEASURES Quality of semen produced by participants, via masturbation or surgical sperm retrieval, was analyzed to determine if it was good enough to cryopreserve for future fertility use. RESULTS Of 122 participants, 23 (19%) declined sample storage. In the masturbation group (average age, 16.3 years), 78 people produced 106 samples. Of 106 samples, 86 were stored-43.7% were normospermic, 35.9% oligozoospermic, 8.7% cryptozoospermic, and 11.7% azoospermic. Overall, semen parameters varied but were generally abnormal, illustrated by only 43.7% of the masturbation samples produced being normospermic. For surgical sperm retrieval subjects (average age, 15.2 years), electroejaculation was successful in 4 of 21 people, whereas the rest proceeded with TESE/mTESE. Encouragingly, 16 of 21 subjects had an average of 5 vials stored, and all participants had a testosterone level >8 nmol/L. Semen parameters in this subcohort were poor but possibly adequate for intracytoplasmic sperm injection. CONCLUSIONS In this large database of transgender girls referred for fertility preservation in the United Kingdom, fertility preservation is possible, even with those unwilling to masturbate. Long-term data are required to check the health of these gametes, observing live birth rates using these preserved gametes.
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Affiliation(s)
- Philippa Ralph
- Urology, University College London Hospitals (UCLH), London, United Kingdom.
| | - Mohammed Mahoud
- Urology, University College London Hospitals (UCLH), London, United Kingdom
| | - Daniel Schlager
- Urology, University College London Hospitals (UCLH), London, United Kingdom
| | - Wai Gin Lee
- Urology, University College London Hospitals (UCLH), London, United Kingdom
| | - Raheala Wafa
- Urology, University College London Hospitals (UCLH), London, United Kingdom
| | | | - Gary Butler
- Paediatric and Adolescent Endocrinology, University College London Hospitals (UCLH), London, United Kingdom; University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - David Ralph
- Urology, University College London Hospitals (UCLH), London, United Kingdom
| | - Philippa Sangster
- Urology, University College London Hospitals (UCLH), London, United Kingdom
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17
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Pauli D. [Adolescents with Gender Incongruence - Special Case Constellations]. ZEITSCHRIFT FUR KINDER- UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2024. [PMID: 39239978 DOI: 10.1024/1422-4917/a000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Abstract
Adolescents with Gender Incongruence - Special Case Constellations Abstract: Adolescents with gender incongruence and gender identity variants have a high rate of accompanying mental disorders, such as depression, autism spectrum disorders, or eating disorders. Yet, the interaction between gender incongruence, gender dysphoric distress, and accompanying mental disorders is complex and varies considerably from case to case. We need an individualized approach and careful professional assessment to help those affected and their guardians make informed decisions regarding possible treatment steps in complex case constellations. Maintaining careful process support and planning of the treatment steps can help to resolve blocked development processes in adolescents with gender incongruence and accompanying psychological disorders or in young people with unstable gender identity development.
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Affiliation(s)
- Dagmar Pauli
- Psychiatrische Universitätsklinik Zürich, Schweiz
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18
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Slack DJ, Krishnamurthy N, Chen D, Contreras-Castro FG, Safer JD. Evaluating the risk of venous thromboembolism in transfeminine and gender diverse people: A retrospective analysis. Endocr Pract 2024:S1530-891X(24)00663-3. [PMID: 39233010 DOI: 10.1016/j.eprac.2024.08.014] [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: 05/21/2024] [Revised: 08/02/2024] [Accepted: 08/05/2024] [Indexed: 09/06/2024]
Abstract
OBJECTIVE The risk of venous thromboembolism (VTE) with feminizing gender-affirming hormone therapy (GAHT) is an area of concern. This analysis aimed to assess whether GAHT and other potential risk factors are associated with VTE in transfeminine and gender diverse (TGD) individuals. METHODS We conducted a chart review of 2,126 TGD adults receiving care within a large urban health system. The primary outcomes were the prevalence of VTE and odds ratios for the association of VTE with insurer, use of estrogen, and select comorbidities. RESULTS A history of VTE was documented in 0.8% of the cohort. Those with a history of VTE were older (p<.001), more often self-identified as Hispanic or Black compared to white or Asian (p<.05) and were more likely to have Medicaid or Medicare (p<.01) when compared to those without a history of VTE. The prevalence of hyperlipidemia (p<.001), diabetes mellitus (p<.05), and hypercoagulable conditions (p<.001) were all greater in the +VTE group. Hyperlipidemia (p<.001), diabetes mellitus (p<.05), and insurer (p<.05) were associated with increased odds of VTE in univariate analyses. None of the exposure variables analyzed were associated with VTE when controlling for age, race, and the number of comorbidities. CONCLUSIONS The prevalence of VTE in our cohort was lower than previously observed. VTE was not associated with any one risk factor, including estrogen use, when controlling for age, race, and the number of comorbidities. Those of advanced age and those with multiple cardiometabolic comorbidities may benefit from increased surveillance and mitigation of modifiable risk factors.
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Affiliation(s)
- Daniel J Slack
- Division of Endocrinology, Department of Medicine, Icahn School of Medicine at Mount Sinai,.
| | | | | | | | - Joshua D Safer
- Division of Endocrinology, Department of Medicine, Icahn School of Medicine at Mount Sinai,; Center for Transgender Medicine and Surgery, Mount Sinai Health System
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19
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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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20
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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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21
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Huang Y, Loo NM, Chang AY, Yu Z, McKenna AL, Ritchie C, Metcalfe AM, Nakhleh RE, Krishna M, Taner CB, Yang L. Hepatic Adenomatosis in a Transgender Man on Gender-Affirming Testosterone Therapy. ACG Case Rep J 2024; 11:e01483. [PMID: 39262622 PMCID: PMC11390042 DOI: 10.14309/crj.0000000000001483] [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: 04/15/2024] [Accepted: 07/26/2024] [Indexed: 09/13/2024] Open
Abstract
The management of hepatic adenoma in transgender individuals undergoing gender-affirming hormone therapy remains unclear, especially whether treatment should be based on sex assigned at birth or therapy patient received. We presented a transgender man, female at birth, with hepatic adenomatosis with molecular profile differed from typical adenomas in cisgender males on testosterone. Discontinuing testosterone led to autoinfarction of the adenoma, allowing the avoidance of invasive treatments and resumption of gender-affirming hormone therapy. This case underscores the necessity for personalized care in the growing transgender population and challenges current consensus of treatment based on sex assigned at birth, emphasizing a tailored approach.
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Affiliation(s)
- Yuting Huang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Nicole M Loo
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | - Alice Y Chang
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Zachary Yu
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | - Amanda L McKenna
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | | | | | | | - Murli Krishna
- Department of Pathology, Mayo Clinic, Jacksonville, FL
| | - C Burcin Taner
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | - Liu Yang
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
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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; 38:101908. [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] [MESH Headings] [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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Tselovalnikova T, Fatima I, Barthel B. Gender-Affirming Hormone Therapy With Estrogen Causing Gallstone Associated Acute Pancreatitis. AACE Clin Case Rep 2024; 10:210-213. [PMID: 39372825 PMCID: PMC11447547 DOI: 10.1016/j.aace.2024.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 07/10/2024] [Accepted: 07/17/2024] [Indexed: 10/08/2024] Open
Abstract
Background/Objective Although estrogen is one of the main agents used to treat transgender women, there are few reports of acute pancreatitis (AP) of this illness in this group. The objective of this report is to describe a transgender woman who developed AP in the setting of estrogen treatment and gallstone disease. Case Report A 38-year-old transgender woman presented with severe abdominal pain and vomiting. Her medical history included gender dysphoria managed with gender-affirming hormone therapy comprising estradiol valerate, progesterone, and spironolactone. Initial management involved supportive care, antibiotic therapy, and endoscopic retrograde cholangiopancreatography with biliary stent placement. Imaging confirmed acute interstitial edematous pancreatitis without necrosis, guiding treatment decisions toward laparoscopic cholecystectomy. Pathological examination revealed multiple gallstones, affirming the diagnosis of AP secondary to choledocholithiasis, likely associated with estrogen use. Postprocedural recovery was uneventful, with eventual removal of the biliary stent and resolution of symptoms. Discussion There are only 7 reported cases in literature on estrogen-induced AP in transgender individuals undergoing gender-affirming hormone therapy. Most of these were primarily linked to hypertriglyceridemia. Conclusion High-dose estrogen therapy in transgender women can elevate the risk of AP through the development of gallstones, underscoring the importance of thorough patient evaluation and discussion of risks assessment prior to initiating hormone therapy.
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Affiliation(s)
- Tatiana Tselovalnikova
- Department of Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Ifrah Fatima
- Department of Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Brandon Barthel
- Department of Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
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Nikzad N, Fisher AR, Pillai A, Targownik LE, Te HS, Aronsohn A, Paul S. Considerations in gender-affirming hormone therapy in transgender and gender diverse patients undergoing liver transplantation. Am J Transplant 2024; 24:1567-1572. [PMID: 38729612 DOI: 10.1016/j.ajt.2024.05.002] [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] [Received: 03/12/2024] [Revised: 04/26/2024] [Accepted: 05/06/2024] [Indexed: 05/12/2024]
Abstract
Liver transplantation is lifesaving for patients with end-stage liver disease. Similar to the role of transplantation for patients with end-stage liver disease, gender-affirming hormone therapy (GAHT) can be lifesaving for transgender and gender diverse (TGGD) patients who experience gender dysphoria. However, management of such hormone therapy during the perioperative period is unknown and without clear guidelines. Profound strides can be made in improving care for TGGD patients through gender-affirming care and appropriate management of GAHT in liver transplantation. In this article, we call for the transplant community to acknowledge the integral role of GAHT in the care of TGGD liver transplant candidates and recipients. We review the current literature and describe how the transplant community is ethically obligated to address this health care gap. We suggest tangible steps that clinicians may take to improve health outcomes for this minoritized patient population.
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Affiliation(s)
- Newsha Nikzad
- Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Andrew R Fisher
- Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Anjana Pillai
- Department of Gastroenterology, Hepatology & Nutrition, Center for Liver Disease, University of Chicago Medicine, Chicago, Illinois, USA
| | - Laura E Targownik
- Department of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
| | - Helen S Te
- Department of Gastroenterology, Hepatology & Nutrition, Center for Liver Disease, University of Chicago Medicine, Chicago, Illinois, USA
| | - Andrew Aronsohn
- Department of Gastroenterology, Hepatology & Nutrition, Center for Liver Disease, University of Chicago Medicine, Chicago, Illinois, USA
| | - Sonali Paul
- Department of Gastroenterology, Hepatology & Nutrition, Center for Liver Disease, University of Chicago Medicine, Chicago, Illinois, USA.
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Sagar RC, Millson-Brown V. Gender-affirming hormone treatment modalities for transfemale & non-binary transfeminine individuals: A UK perspective. Best Pract Res Clin Endocrinol Metab 2024; 38:101921. [PMID: 39232976 DOI: 10.1016/j.beem.2024.101921] [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] [Indexed: 09/06/2024]
Abstract
Gender incongruence and the number of people seeking gender affirming hormone treatment has dramatically risen in the last two decades. In the UK, transgender women and non-binary transfeminine individuals are typically treated with simultaneous suppression of endogenous testosterone production through anti-androgens and exogenous oestradiol replacement. Oestrogen replacement comes in different forms and is primarily given as transdermal (gel or patch) or oral preparations in the UK. Decisions around preparation choice are based on a combination of individual preference and/or mitigating the chance of complications based on individual risk profiles. Time frames to achieve female physical changes are largely predictable and managing expectations of individuals prior to commencing treatment is highly important. Common complications include venous thromboembolism, liver dysfunction and effects on fertility, thus individuals should be thoroughly counselled prior to commencing treatment. This article provides an overview of the management and considerations of gender-affirming hormone treatment in transgender women and non-binary transfeminine individuals.
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Affiliation(s)
- Rebecca C Sagar
- Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, LS2 9JT, United Kingdom
| | - Victoria Millson-Brown
- Gender Identity Service, The Newsam Centre, Seacroft Hospital, Leeds LS14 6UH, United Kingdom.
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26
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Rothman MS, Ariel D, Kelley C, Hamnvik OPR, Abramowitz J, Irwig MS, Soe K, Davidge-Pitts C, Misakian AL, Safer JD, Iwamoto SJ. The Use of Injectable Estradiol in Transgender and Gender Diverse Adults: A Scoping Review of Dose and Serum Estradiol Levels. Endocr Pract 2024; 30:870-878. [PMID: 38782202 DOI: 10.1016/j.eprac.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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/01/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Feminizing gender-affirming hormone therapy is the mainstay of treatment for many transgender and gender diverse people. Injectable estradiol preparations are recommended by the World Professional Association for Transgender Health Standards of Care 8 and the Endocrine Society guidelines. Many patients prefer this route of administration, but few studies have rigorously assessed optimal dosing or route. METHODS We performed a scoping review of the available data on estradiol levels achieved with various dosages of estradiol injections in transgender and gender diverse adults on feminizing gender-affirming hormone therapy. We also report on testosterone suppression, route (ie, subcutaneous vs intramuscular), and type of injectable estradiol ester as well as timing of blood draw relative to the most recent dose, where available. RESULTS The data we reviewed suggest that the current guidelines, which recommend starting doses 2 to 10 mg weekly or 5 to 30 mg every 2 weeks of estradiol cypionate or valerate, are too high and likely lead to patients having supraphysiologic levels across much of their injection cycle. CONCLUSIONS The optimal starting dose for injectable estradiol remains unclear and whether it should differ for cypionate and valerate. Based on the data available, we suggest that clinicians start injectable estradiol cypionate or valerate via subcutaneous or intramuscular injections at a dose ≤5 mg weekly and then titrate accordingly to keep levels within guideline-recommended range. Future studies should assess timing of injections and subsequent levels more precisely across the injection cycle and between esters.
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Affiliation(s)
- Micol S Rothman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado.
| | - Danit Ariel
- Division of Endocrinology, Gerontology and Metabolism, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Carly Kelley
- Division of Endocrinology and Metabolism, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Ole-Petter R Hamnvik
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital-Harvard Medical School, Boston, Massachusetts
| | - Jessica Abramowitz
- Division of Endocrinology and Metabolism, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael S Irwig
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center-Harvard Medical School, Boston, Massachusetts
| | - Kyaw Soe
- Division of Endocrinology and Metabolism, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Endocrinology, Diabetes and Lipid section, Medicine Service, Veterans Affairs North Texas Health Care System, Dallas, Texas
| | - Caroline Davidge-Pitts
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Aaron L Misakian
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, California
| | - Joshua D Safer
- Department of Medicine, Mount Sinai Center for Transgender Medicine and Surgery and Division of Endocrinology, Diabetes and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sean J Iwamoto
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Endocrinology Section, Medicine Service, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
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27
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Ahmed S, Oberlin JM, Bowsher B. Case 1: Clitoromegaly, Oligomenorrhea, and Hirsutism in a 17-year-old Transgender Male. Pediatr Rev 2024; 45:505-508. [PMID: 39217121 DOI: 10.1542/pir.2022-005608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 08/14/2022] [Accepted: 08/15/2022] [Indexed: 09/04/2024]
Affiliation(s)
| | - John M Oberlin
- Division of Endocrinology, Department of Pediatrics, Brooke Army Medical Center, JBSA-Fort Sam Houston, TX
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28
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Angus LM, Mikołajczyk M, Cheung AS, Kasielska-Trojan AK. Validation of Breast Idea Volume Estimator Application in Transfeminine People. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6131. [PMID: 39228424 PMCID: PMC11368210 DOI: 10.1097/gox.0000000000006131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 07/12/2024] [Indexed: 09/05/2024]
Abstract
Background Accurate estimation of breast volume is important as researchers aim to achieve optimal feminization for transfeminine people. The Breast Idea Volume Estimator (BIVE) application allows estimation of breast volume using two-dimensional (2D) photographs but has not been validated in the chests of people who have undergone testosterone-mediated puberty. Methods To estimate breast volume, clinical photographs and 3D scans were collected at baseline and 6 months, as a prespecified secondary outcome of a randomized clinical trial of antiandrogen therapy in transfeminine people commencing hormone therapy. BIVE was used to estimate breast volume by two independent researchers and compared with the gold standard of 3D scan calculated volume at different timepoints. Statistical analysis was performed, including the mean absolute difference, standard error of measurement, and intraclass correlation, to determine accuracy, precision, and interrater agreement. Results Clinical photography and 3D scans were collected from 82 breasts of 41 participants. The median (interquartile range) age of participants was 25 (22-28) years, and the median (interquartile range) body mass index was 24.6 (21.2-28.9) kg/m2. The BIVE sagittal and transverse algorithms demonstrated robust performance, with mean absolute difference less than 20 mL and intraclass correlation greater than 0.87 indicating clinical reliability with high interrater agreement. Conclusions BIVE provided an accurate, precise, and reliable measure of breast volume in the chests of people who have undergone testosterone-mediated puberty, compared with the gold standard of 3D scan.
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Affiliation(s)
- Lachlan M. Angus
- From the Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Maksym Mikołajczyk
- Plastic, Reconstructive and Aesthetic Surgery Clinic, Medical University of Łódź, Łódź, Poland
| | - Ada S. Cheung
- From the Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
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29
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Nolan BJ, Cheung AS. Gender-affirming hormone therapy for transgender and gender-diverse adults in Australia. Intern Med J 2024; 54:1450-1457. [PMID: 39056542 DOI: 10.1111/imj.16413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 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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30
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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; 38:101909. [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] [MESH Headings] [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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31
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Vijapura C, Wahab R, Patel M, Miles RC, Brown AL. Breast/chest imaging findings and clinical considerations in transgender patients. Clin Radiol 2024:S0009-9260(24)00497-5. [PMID: 39322531 DOI: 10.1016/j.crad.2024.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 07/11/2024] [Accepted: 08/26/2024] [Indexed: 09/27/2024]
Abstract
The transgender population, a historically marginalized group, is growing in size, visibility, and cultural acceptance. However, lack of provider knowledge contributes to the disparities and discrimination that this group continues to face in the healthcare setting. Special considerations for transgender individuals undergoing imaging for breast/chest care can improve health equity, including appropriate evidence-based screening, tailored protocols, and inclusive radiology facilities. This article will focus on the imaging findings that can be seen in transgender patients during the course of gender-affirming care, which may involve hormone therapy and/or surgery. Relevant examples of benign and malignant pathologies that can be seen in transgender patients will be highlighted, and their imaging on mammogram, ultrasound, and magnetic resonance imaging (MRI) will be reviewed.
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Affiliation(s)
- C Vijapura
- University of Cincinnati, 3188 Bellevue Ave, Cincinnati, OH 45219, USA.
| | - R Wahab
- Vanderbilt University Medical Center, 1161 21(st) Avenue South, Nashville, TN 37232, USA.
| | - M Patel
- The Ohio State University Wexner Medical Center, 395 W. 12(th) Avenue, Columbus, OH 43210, USA.
| | - R C Miles
- Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA.
| | - A L Brown
- University of Cincinnati, 3188 Bellevue Ave, Cincinnati, OH 45219, USA.
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32
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Swislocki ALM, Eisenberg ML. A Review on Testosterone: Estradiol Ratio-Does It Matter, How Do You Measure It, and Can You Optimize It? World J Mens Health 2024; 42:42.e75. [PMID: 39344113 DOI: 10.5534/wjmh.240029] [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: 02/06/2024] [Revised: 05/15/2024] [Accepted: 06/12/2024] [Indexed: 10/01/2024] Open
Abstract
There is a natural balance between the major sex steroids, testosterone and estradiol, controlled by gonadal secretion and peripheral conversion by aromatase. This balance is impacted by a variety of inborn and acquired conditions, and, more recently, by a growing use of exogenous testosterone therapy and off-label aromatase use under the guise of "men's health." We summarize reported testosterone:estradiol ratios, both naturally occurring and with pharmacologic manipulation and consider the ramifications of significant changes in these ratios. However, significant limitations exist in terms of steroid separation and measurement techniques, timing of samples, and lack of consistency from one assay to another, as well as definition of normative data. Limited data on the testosterone:estradiol ratio in men exists, particularly due to the scan data on concurrent estradiol values in men receiving testosterone therapy or aromatase inhibitors. Nonetheless, there seems to be a range of apparently beneficial values of the testosterone: estradiol radio at between 10 and 30, calculated as: testosterone in ng/dL/estradiol in pg/mL. Higher values appear to be associated with improved spermatogenesis and reduced bone density while lower values are associated with thyroid dysfunction. While there is growing awareness of the significance of the testosterone:estradiol ratio, and a sense of a desired range, the optimal value has not yet been determined. Further work is needed to clarify the measurement strategies and clearly-defined outcome measures related to the testosterone:estradiol ratio.
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Affiliation(s)
- Arthur L M Swislocki
- Medical Service, VA Northern California Health Care System, Martinez, CA, USA
- Department of Medicine, UC Davis School of Medicine, Sacramento, CA, USA.
| | - Michael L Eisenberg
- Urology Department, Stanford University School of Medicine, Stanford, CA, USA
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33
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Ramasamy I. Gender Reassignment and the Role of the Laboratory in Monitoring Gender-Affirming Hormone Therapy. J Clin Med 2024; 13:5134. [PMID: 39274346 PMCID: PMC11396367 DOI: 10.3390/jcm13175134] [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: 07/15/2024] [Revised: 08/18/2024] [Accepted: 08/26/2024] [Indexed: 09/16/2024] Open
Abstract
Transgender people experience distress due to gender incongruence (i.e., a discrepancy between their gender identity and sex assigned at birth). Gender-affirming hormone treatment (GAHT) is a part of gender reassignment treatment. The therapeutic goals of the treatment are to develop the physical characteristics of the affirmed gender as far as possible. Guidelines have been developed for GAHT, which recommend dosage as well as different formulations of oestrogen and testosterone for treatment. Questions arise about the metabolic side effects of hormone treatment. Establishing reference ranges for common analytes in transgender individuals remains a task for laboratory medicine. It has been suggested once GAHT is commenced, the reference ranges for affirmed gender are reported for red blood cells, haemoglobin and haematocrit. For transgender assigned-female-at-birth (AFAB) people, testosterone concentrations are recommended to be within the reference interval established for cisgender men and for transgender assigned-male-at-birth (AMAB) people, estradiol concentrations are within the reference range for cisgender women. Sex-specific reference ranges are available for certain laboratory tests, and these may be organ (e.g., heart)-specific. Transgender-specific reference ranges may be a requirement for such tests. Laboratories may need to make decisions on how to report other tests in the transgender population, e.g., eGFR. Interpretation of further tests (e.g., reproductive hormones) can be individualized depending on clinical information. Electronic medical record systems require fields for gender identity/biological sex at birth so that laboratory results can be flagged appropriately. In this review, we aim to summarise the current position of the role of the laboratory in the clinical care of the transgender individual. Prior to the review, we will summarise the genetics of sex determination, the aetiology of gender incongruence, and the recommendations for GAHT and monitoring for the transgender population.
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34
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Kauffman AS. Androgen Inhibition of Reproductive Neuroendocrine Function in Females and Transgender Males. Endocrinology 2024; 165:bqae113. [PMID: 39207217 PMCID: PMC11393496 DOI: 10.1210/endocr/bqae113] [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: 07/05/2024] [Revised: 08/23/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
Ovarian function is controlled by pituitary secretion of luteinizing hormone (LH) and follicle stimulating hormone (FSH), which in turn are governed by gonadotropin releasing hormone (GnRH) secreted from the brain. A fundamental principle of reproductive axis regulation is negative feedback signaling by gonadal sex steroids back to the brain to fine-tune GnRH and gonadotropin secretion. Endogenous negative feedback effects can be mimicked by exogenous steroid treatments, including androgens, in both sexes. Indeed, a growing number of clinical and animal studies indicate that high levels of exogenous androgens, in the typically male physiological range, can inhibit LH secretion in females, as occurs in males. However, the mechanisms by which male-level androgens inhibit GnRH and LH secretion still remain poorly understood, and this knowledge gap is particularly pronounced in transgender men (individuals designated female at birth but identifying as male). Indeed, many transgender men take long-term gender-affirming hormone therapy that mimics male-level testosterone levels. The impact of such gender-affirming testosterone on the reproductive axis, both at the ovarian and neuroendocrine level, is a long-understudied area that still requires further investigation. Importantly, the few concepts of androgen actions in females mostly come from studies of polycystic ovary syndrome, which does not recapitulate a similar androgen milieu or a pathophysiology of inhibited LH secretion as occurs in testosterone-treated transgender men. This review summarizes clinical evidence indicating that exogenous androgens can impair neuroendocrine reproductive function in both female individuals and transgender men and highlights emerging experimental data supporting this in recently developed transgender rodent models.
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Affiliation(s)
- Alexander S Kauffman
- Department of OBGYN and Reproductive Sciences, University of California San Diego, La Jolla, CA 92093, USA
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35
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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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36
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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 PMCID: PMC11344916 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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37
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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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38
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Bacot-Davis VR, Moran AH. Transgender preventative health-chest/breast cancer screening. FRONTIERS IN HEALTH SERVICES 2024; 4:1434536. [PMID: 39206444 PMCID: PMC11349637 DOI: 10.3389/frhs.2024.1434536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024]
Abstract
Cancer mortality rates have decreased over the last 48 years attributable to standardized cancer screenings. These screenings were developed without deliberate inclusion of transgender and non-binary populations. While specialists are familiar regarding cancer screening in this distinct population, those in primary care might be more limited. As such, we aimed to develop a screening risk tool that combines the Breast Cancer Risk Assessment Tool (Gail model) with the updated American College of Radiology Appropriateness Criteria-Transgender Breast Cancer Screening, into an online questionnaire designed to accommodate primary care physicians performing routine health screenings to advise appropriate imaging and referral for this population. This new tool can be used for transgender chest/breast risk assessment whereas the Gail model alone was developed without transgender populations in mind, with the aim of early detection and cancer prevention in this historically underserved healthcare population.
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Affiliation(s)
- Valjean R. Bacot-Davis
- Department of Medicine-Pediatrics, Stony Brook University Hospital, Stony Brook, NY, United States
| | - Allison H. Moran
- Department of Social Work, State University of New York at Albany, School of Social Welfare, Richardson Hall, Albany, NY, United States
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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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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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Grimstad F, Trotman G, Krempasky C, Belkind U, Jarin J, Cizek S. NASPAG Clinical Opinion: The Care of Transgender and Gender Nonbinary Adolescents and Young Adults. J Pediatr Adolesc Gynecol 2024:S1083-3188(24)00256-0. [PMID: 39111690 DOI: 10.1016/j.jpag.2024.07.007] [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: 05/21/2024] [Revised: 07/15/2024] [Accepted: 07/26/2024] [Indexed: 09/16/2024]
Abstract
Transgender and gender nonbinary (TGNB) adolescents and young adults (AYA) may present to clinicians with reproductive health expertise for the spectrum of gynecologic, sexual, and reproductive care. As such, clinicians should be knowledgeable in the many facets of gender-affirming care. This clinical opinion reviews language associated with gender diversity and gender-affirming care; current clinical, social, and political barriers faced by TGNB AYA; and the creation of welcoming and inclusive clinical spaces for TGNB AYA. It discusses social, medical, and surgical affirmation processes, and focuses on gynecologic care topics which may arise in the care of TGNB AYA, including those who undergo medical or surgical therapies. This includes menstrual suppression, breakthrough bleeding on testosterone, sexual health, fertility, and the pelvic care of individuals following gender affirming vulvovaginoplasty.
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Affiliation(s)
- Frances Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts.
| | - Gylynthia Trotman
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai and Mount Sinai Kravis Children's Hospital, New York, New York; Department of Pediatrics, Icahn School of Medicine at Mount Sinai and Mount Sinai Kravis Children's Hospital, New York, New York
| | | | - Uri Belkind
- Callen Lorde Community Health Center, New York, New York
| | - Jason Jarin
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stephanie Cizek
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
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44
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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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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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46
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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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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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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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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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50
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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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