Changes in regional body fat, lean body mass and body shape in trans persons using cross-sex hormonal therapy: results from a multicenter prospective study

Effect of Duration of Feminizing Hormone Therapy on Facial Fat Volumes

BACKGROUND

Gender-affirming feminizing hormone therapy induces body fat redistribution. However, the amount and timing of facial fat changes in response to feminizing hormone therapy are unknown, despite being relevant to counseling and surgical planning for facial gender-affirming surgery. The authors assessed the influence of feminizing hormone therapy duration on malar and temporal fat volume.

METHODS

Malar and temporal fat volumes were compared using computed tomography in transfeminine patients (age, 20 to 29 years; body mass index, 18.5 to 24.9) treated with feminizing hormone therapy for less than 2 years versus 2 years or longer. Patients with previous surgical or nonsurgical facial soft-tissue interventions were excluded. Multivariable linear regressions evaluated the contribution of hormone therapy duration to malar and temporal fat volumes.

RESULTS

A total of 45 patients were included, 30 (66.7%) treated with feminizing hormone therapy for 2 years or longer and 15 (33.3%) treated for less than 2 years (median [interquartile range], 44.5 [33.5 to 65.6] versus 15.0 [11.0 to 18.0] months; P < 0.001). Patients treated with hormone therapy for 2 years or longer demonstrated a 1.6-fold greater malar fat volume (5.5 [4.2 to 6.3] versus 3.4 [2.3 to 4.2] cm 3 ; P < 0.001) and 1.4-fold greater temporal fat volume (2.8 [2.4 to 3.6] cm 3 versus 2.0 [1.7 to 2.4] cm 3 ; P = 0.01) compared with those treated for less than 2 years. When accounting for other contributory variables, such as body mass index, skull size, and total soft-tissue depth, in multivariable linear regression models, hormone therapy duration of 2 years or longer independently predicted higher malar (β = 0.51, P < 0.001) and temporal (β = 0.32, P = 0.02) fat volumes.

CONCLUSION

Feminizing hormone therapy increases malar and temporal fat volumes by approximately 2 cm 3 and 0.8 cm 3 for each area, respectively, after 2 years of treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Metabolic benefits afforded by estradiol and testosterone in both sexes: clinical considerations

Testosterone (T) and 17β-estradiol (E2) are produced in male and female humans and are potent metabolic regulators in both sexes. When E2 and T production stops or decreases during aging, metabolic dysfunction develops and promotes degenerative metabolic and vascular disease. Here, we discuss the shared benefits afforded by E2 and T for metabolic function human females and males. In females, E2 is central to bone and vascular health, subcutaneous adipose tissue distribution, skeletal muscle insulin sensitivity, antiinflammatory immune function, and mitochondrial health. However, T also plays a role in female skeletal, vascular, and metabolic health. In males, T's conversion to E2 is fundamental to bone and vascular health, as well as prevention of excess visceral adiposity and the promotion of insulin sensitivity via activation of the estrogen receptors. However, T and its metabolite dihydrotestosterone also prevent excess visceral adiposity and promote skeletal muscle growth and insulin sensitivity via activation of the androgen receptor. In conclusion, T and E2 are produced in both sexes at sex-specific concentrations and provide similar and potent metabolic benefits. Optimizing levels of both hormones may be beneficial to protect patients from cardiometabolic disease and frailty during aging, which requires further study.

Gender-affirming hormone therapy for transgender and gender-diverse adults in Australia

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.

Time Course of Body Composition Changes in Transgender Adolescents During Puberty Suppression and Sex Hormone Treatment

CONTEXT

Transgender adolescents can undergo puberty suppression (PS) and subsequent gender-affirming hormone therapy (GAHT) but little information is available on the expected rate of physical changes.

OBJECTIVE

To investigate the time course of body composition changes during PS and GAHT.

METHODS

In this study, retrospective data of 380 trans boys and 168 trans girls treated with PS prior to GAHT from a gender identity clinic were included. Total lean and fat mass Z-scores using birth-assigned sex as reference were determined using dual-energy X-ray absorptiometry.

RESULTS

In trans boys, lean mass Z-scores decreased (-0.32, 95% CI -0.41; -0.23) and fat mass Z-scores increased (0.31, 95% CI 0.21; 0.41) in the first year of PS and remained stable thereafter. Lean mass Z-scores increased (0.92, 95% CI 0.81; 1.04) and fat mass Z-scores decreased (-0.43, 95% CI -0.57; -0.29) only during the first year of testosterone,. In trans girls, both lean and fat mass Z-scores gradually changed over 3 years of PS (respectively -1.13, 95% CI -1.29; -0.98 and 1.06, 95% CI 0.90; 1.23). In the first year of GAHT, lean mass Z-scores decreased (-0.19, 95% CI -0.36; -0.03) while fat mass Z-scores remained unchanged after 3 years (-0.02, 95% CI -0.20; 0.16).

CONCLUSION

Compared with peers, trans girls experienced ongoing lean mass decrease and fat mass increase during 3 years of PS while in trans boys smaller changes were observed that stabilized after 1 year. A large increase in lean mass Z-scores occurred only during the first year of testosterone treatment. In trans girls, body composition changed only slightly during GAHT. This information can improve counseling about treatment effects.

Transgender Women With Suppressed Testosterone Display Lower Burden of Coronary Disease Than Matched Cisgender Men

Context

Cardiovascular disease (CVD) in transgender women (TW) may be affected by gender-affirming hormone therapy (GAHT) and HIV, but few data compare TW on contemporary GAHT to well-matched controls.

Objective

We compared CVD burden and biomarker profiles between TW and matched cisgender men (CM).

Methods

Adult TW on GAHT (n = 29) were recruited for a cross-sectional study (2018-2020). CM (n = 48) from the former Multicenter AIDS Cohort Study were matched 2:1 to TW on HIV serostatus, age ±5 years, race/ethnicity, BMI category and antiretroviral therapy (ART) type. Cardiac parameters were measured by CT and coronary atherosclerosis by coronary CT angiography; sex hormone and biomarker concentrations were measured centrally from stored samples.

Results

Overall, median age was 53 years and BMI 29 kg/m2; 69% were non-white. All participants with HIV (71%) had viral suppression on ART. Only 31% of TW had testosterone suppression (<50 ng/dL, TW-S). Traditional CVD risk factors were similar between groups, except that TW-S had higher BMI than TW with non-suppressed testosterone (TW-T). TW-S had no evidence of non-calcified coronary plaque or advanced coronary stenosis, whereas TW-T and CM had similar burden. TW had lower prevalence of any coronary plaque, calcified plaque and mixed plaque than CM, regardless of testosterone concentrations and HIV serostatus. Estradiol but not testosterone concentrations moderately and negatively correlated with the presence of coronary plaque and stenosis. Small sample size limited statistical power.

Conclusion

Older TW with suppressed total testosterone on GAHT had no CT evidence of non-calcified coronary plaque or advanced coronary stenosis. Longitudinal studies to understand relationships between GAHT and CVD risk in TW are needed.

Body Composition and Metabolic Syndrome Components in Transgender/Gender Diverse Adolescents and Young Adults

Purpose: The objective of this study was to examine the association of designated sex at birth, body composition, and gender-affirming hormone treatment (GAHT) with the components of metabolic syndrome (MetS) (overweight/obesity, elevated blood pressure [BP], altered glucose metabolism, and dyslipidemia) in transgender/gender diverse (TGD) adolescents and young adults. Methods: TGD individuals underwent body composition studies by bioelectrical impedance analysis according to designated sex at birth, and their muscle-to-fat ratio (MFR) z-scores were calculated. Generalized estimating equations with binary logistic models (n = 326) were used to explore associations while adjusting for potential confounders. Results: A total of 55 TGD females and 111 TGD males, with mean age of 18 ± 1.9 years and median duration of GAHT of 1.4 years (interquartile range = 0.6-2.5), were enrolled. Overall, 118/166 (71%) of the TGD cohort showed evidence of at least one MetS component, with a significantly higher rate among TGD males compared with TGD females (91.1% vs. 50.9%, p < 0.001). TGD males were at increased odds for overweight/obesity, elevated/hypertensive BP, elevated triglycerides (TGs), and an atherogenic dyslipidemia index (TG/high-density lipoprotein cholesterol [HDL-c], TG:HDL-c). The odds of overweight/obesity increased by 44.9 for each standard deviation decrease in the MFR z-score, while the odds for an elevated TG:HDL-c index increased by 3.7. Psychiatric morbidity increased the odds for overweight/obesity by 2.89. Conclusions: After considering confounding variables, the TGD males on GAHT were found to be at an increased risk for cardiometabolic disease. Our observations support the importance of targeted medical nutrition intervention in this group of individuals.

Hormonal regulation in diabetes: Special emphasis on sex hormones and metabolic traits

Diabetes constitutes a significant global public health challenge that is rapidly reaching epidemic proportions. Among the non-communicable diseases, the incidence of diabetes is rising at an alarming rate. The International Diabetes Federation has documented a 9.09% prevalence of diabetes among individuals aged between 20 and 79 years. The interplay of gonadal hormones and gender differences is critical in regulating insulin sensitivity and glucose tolerance, and this dynamic is particularly crucial because of the escalating incidence of diabetes. Variations in insulin sensitivity are observed across genders, levels of adiposity, and age groups. Both estrogen and testosterone are seen to influence glucose metabolism and insulin sensitivity. This chapter surveys the present knowledge of sex differences, sex hormones, and chromosomes on insulin imbalance and diabetes development. It further highlights the influence of metabolic traits in diabetes and changes in sex hormones during diabetic pregnancy. Notably, even stressful lifestyles have been acknowledged to induce hormonal imbalances. Furthermore, it discusses the potential of hormonal therapy to help stabilize sex hormones in diabetic individuals and focuses on the most recent research investigating the correlation between sex hormones and diabetes.

Waist-to-Hip Ratio Predicts Sexual Perception and Responses to Sexual Assault Disclosures

The current work investigates the effects of target of perception's waist-to-hip ratio (WHR) on perceivers' judgments of sexual unrestrictedness and sexual victimization prototypicality. Studies 1a and 1b found that women with lower WHRs were perceived as relatively more sexually unrestricted. Studies 2a and 2b found that women with lower WHRs were perceived as relatively more prototypic of sexual victimization. Study 3 built on these findings to consider implications for responses to sexual assault disclosures. Perceivers disbelieved and minimized a disclosure of assault relatively more when made by a woman with a higher WHR. In sum, this body of work implicates WHR as a body cue that can inform consequential sexual perception. Thereby, this work identifies factors that could influence judgments of credibility of sexual violence reports, which may have implications for hesitancy to report sexual violence.

Priorities for efficacy trials of gender-affirming hormone therapy with estrogen: collaborative design and results of a community survey

PURPOSE

Treatment guidelines for gender-affirming hormone therapy with estrogen (GAHT-E) recommend specific dosing regimens based on limited data. Well-controlled efficacy trials are essential to tailoring treatment to patient goals as the guidelines recommend. The goal of this study was to take a foundational step toward designing community-centered effectiveness trials for gender-diverse individuals seeking GAHT-E.

METHODS

Our team developed a cross-sectional survey based on broad clinical experience and consultation with our community advisory board. The survey included 60 items covering demographics, transition history, goals and priorities for treatment, indicators of treatment success, sexual function goals, and future research priorities. The survey was distributed during the summer of 2021, primarily through social networks designed for gender-expansive individuals seeking treatment with estrogen.

RESULTS

A total of 1270 individuals completed the survey. Overall treatment goals most frequently rated "extremely important" or "very important" were the following: (1) improved satisfaction with life (81%), (2) appearing more feminine (80%), (3) appearing less masculine (77%), (4) improved mental health (76%), and (5) being seen as your true gender by others (75%). The three body characteristics most frequently rated "highest priority" or "high priority" among changes were the following: (1) facial hair (85%), (2) breast shape or size (84%), and (3) body shape (80%). The highest-rated research priority was comparing feminization with different routes of estrogen administration.

CONCLUSION

The goals and experiences of individuals seeking GAHT-E are diverse. Future clinical trials of GAHT-E should be grounded in the needs and priorities of community stakeholders.

Effects of gender-affirming hormone therapy on body fat: a retrospective case‒control study in Chinese transwomen

BACKGROUND

There is insufficient research on how gender-affirming hormone therapy (GAHT) affects body fat modifications in transwomen from China. It is unclear whether hormone therapy affects the prevalence of obesity and blood lipid levels within this population. The current research aimed to assess how GAHT and treatment duration had an impact on the change in and redistribution of body fat in Chinese transwomen.

METHODS

This study included 40 transwomen who had not received GAHT and 59 who had. Body fat, blood lipid, and blood glucose levels were measured. GAHT is mainly a pharmacologic (estrogen and anti-androgen) treatment. The study also stratified participants based on the duration of GAHT to assess its impact on body fat distribution. The duration of GAHT was within one year, one to two years, two to three years, or more than three years.

RESULTS

After receiving GAHT, total body fat increased by 19.65%, and the percentage of body fat increased by 17.63%. The arm, corrected leg, and leg regions showed significant increases in fat content (+ 24.02%, + 50.69%, and + 41.47%, respectively) and percentage (+ 25.19%, + 34.90%, and + 30.39%, respectively). The total visceral fat content decreased (-37.49%). Based on the diagnostic standards for a body mass index ≥ 28 or total body fat percentage ≥ 25% or 30%, the chance of developing obesity did not change significantly. Blood glucose levels significantly increased (+ 12.31%). Total cholesterol levels (-10.45%) decreased significantly. Fat changes in those who received GAHT for one to two years were significantly different from those who did not receive GAHT.

CONCLUSION

After receiving GAHT, total body fat and regional fat increased in Chinese transwomen, and the body fat distribution changed from masculine to feminine, especially during the first two years. However, neither the increase in total body fat percentage nor the decrease in visceral fat content didn't bring about significant changes in the incidence of obesity, nor did triglycerides or low-density lipoprotein-cholesterol.

Nutrition research and practice with transgender and gender non-conforming populations

The purpose of the present article is to describe the current state of sex and gender data collection in nutrition science research, discuss the effects of flawed data collection practices, highlight considerations for transgender and gender non-conforming populations and propose a sex- and gender-informed approach to human subjects research. Sex and gender are separate constructs that are often conflated in nutrition research and practice. Current nutrition surveillance programmes in the United States, United Kingdom and Ireland do not accurately capture sex and gender data, which undermines the accuracy of the analyses and excludes gender minorities. Transgender and gender non-conforming populations have distinct clinical and psychosocial nutrition considerations that require further research to inform nutrition policy and practice, such as anthropometric and biochemical changes with hormone therapy, eating disorders, food insecurity and nutrition as a source of empowerment or expression of gender identity. Researchers can apply a sex- and gender-informed approach to human subjects research by treating sex and gender as separate, relevant demographic data, appreciating gender as a fluid construct, and approaching data collection on gender minorities with sensitivity to privacy and confidentiality.

Musculoskeletal and cardiovascular considerations for transgender athletes

OBJECTIVE

Participation in athletics is essential for the overall well-being of transgender athletes and should be included as part of gender-affirming care. Surveys show physicians and athletic trainers want to provide appropriate care for transgender athletes but lack the proper knowledge and training to do so. Gender Affirming Hormone Therapy (GAHT) is part of gender-affirming care, yet the effects of GAHT on the cardiovascular and musculoskeletal health of transgender athletes is not well-understood. The purpose of this review was to discuss important musculoskeletal and cardiovascular considerations unique to transgender athletes and improve physician understanding in caring for transgender athletes.

METHODS

A representative selection of literature on the effects of GAHT on cardiovascular and musculoskeletal health was included in this review.

RESULTS

Estrogen therapy may increase the risk of venous thromboembolism (VTE) and stroke, and decrease blood pressure levels among transgender women, while studies on lipid profile are inconsistent among both transgender men and women. Transgender women receiving GAHT may also be at greater risk for bone fracture and ligamentous injuries.

CONCLUSION

Exercise is essential for the well-being of transgender individuals and special considerations regarding the cardiovascular and musculoskeletal health of transgender athletes should be incorporated into standard medical education. Educational programs for transgender patients and their support team should focus on preventative measures that can be taken to reduce the risk of adverse musculoskeletal and cardiovascular events. The PPE is an invaluable tool available to physicians to monitor the health and safety of transgender athletes and should be regularly updated as research on the health of transgender individuals continues to grow. Longitudinal and prospective studies should examine the effects of GAHT on the musculoskeletal and cardiovascular health of transgender athletes. Lastly, health care providers play an important role in the advancement of gender-neutral policies.

The impact of gender-affirming hormone therapy on nutrition-relevant biochemical measures

Gender-affirming hormone therapy carries the potential risk for shifts in biochemical markers that may impact cardiometabolic, hematologic, hepatic, and renal health. The critical evaluation of biochemical data is an integral part of a comprehensive nutrition assessment; therefore, nutrition professionals should be aware of shifts that are expected during the course of masculinizing and feminizing hormone therapy. Changes in important biochemical values along with binary sex-specific standards for interpreting laboratory data can pose significant challenges for nutrition professionals working with transgender and gender-diverse patients who receive gender-affirming hormone therapy. Overall, research on the biochemical impact of masculinizing and feminizing hormone therapy is nascent and limited. Methodologies and outcomes measured are heterogenous across studies, introducing complexities that impede researchers from drawing definitive conclusions. In light of these limitations, this narrative review aims to describe the potential implications of masculinizing and feminizing hormone therapy regimens on biochemical measures that may influence nutrition strategies and interventions to promote optimal health.

Trans men can achieve adequate muscular development through low-dose testosterone therapy: A long-term study on body composition changes

BACKGROUND

Transgender individuals undergo the gender-affirming hormone therapy (GAHT) to achieve physical changes consistent with their gender identity. Few studies are available on the long-term safety and efficacy of GAHT.

OBJECTIVES

To investigate the long-term physical effects and the safety of the testosterone therapy for trans men and to assess the impact of differential hormone dose.

MATERIALS AND METHODS

Trans men who initiated GAHT between May 2000 and December 2021 were included in this retrospective analysis. Physical findings (body mass index, body fat percentage (BFP), lean body mass (LBM), and grip strength), blood testing results (hemoglobin, hematocrit, uric acid, creatinine, total cholesterol, triglycerides, and total testosterone), and menstrual cessation were recorded. We assessed the effects of testosterone on body composition changes and laboratory parameters, comparing a low-dose group (≤ 62.5 mg/wk) to a high-dose group (> 62.5 mg/wk).

RESULTS

Of 291 participants, 188 patients (64.6%) were in the low-dose group and 103 (35.4%) in the high-dose group. Cumulative menstrual cessation rates up to 12 months were not significantly different between groups. Both groups showed a decrease in BFP and an increase in LBM during the first year of therapy, followed by a slight increase in both over the long term. The high-dose group exhibited greater LBM gains during the first year. Higher hormone doses and lower initial LBM values were associated with LBM increases at 3 and 6 months (3 mo, P = 0.006, P < 0.001; 6 mo, P = 0.015, P < 0.001). There were no long-term, dose-dependent side effects such as polycythemia or dyslipidemia.

CONCLUSION

Long-term GAHT for trans men is safe and effective. Low-dose testosterone administration is sufficient to increase LBM in trans men. Higher testosterone doses can lead to an earlier increase in muscle mass.

The International Olympic Committee framework on fairness, inclusion and nondiscrimination on the basis of gender identity and sex variations does not protect fairness for female athletes

The International Olympic Committee (IOC) recently published a framework on fairness, inclusion, and nondiscrimination on the basis of gender identity and sex variations. Although we appreciate the IOC's recognition of the role of sports science and medicine in policy development, we disagree with the assertion that the IOC framework is consistent with existing scientific and medical evidence and question its recommendations for implementation. Testosterone exposure during male development results in physical differences between male and female bodies; this process underpins male athletic advantage in muscle mass, strength and power, and endurance and aerobic capacity. The IOC's "no presumption of advantage" principle disregards this reality. Studies show that transgender women (male-born individuals who identify as women) with suppressed testosterone retain muscle mass, strength, and other physical advantages compared to females; male performance advantage cannot be eliminated with testosterone suppression. The IOC's concept of "meaningful competition" is flawed because fairness of category does not hinge on closely matched performances. The female category ensures fair competition for female athletes by excluding male advantages. Case-by-case testing for transgender women may lead to stigmatization and cannot be robustly managed in practice. We argue that eligibility criteria for female competition must consider male development rather than relying on current testosterone levels. Female athletes should be recognized as the key stakeholders in the consultation and decision-making processes. We urge the IOC to reevaluate the recommendations of their Framework to include a comprehensive understanding of the biological advantages of male development to ensure fairness and safety in female sports.

The Impact of Gender-Affirming Hormone Therapy on Physical Performance

CONTEXT

The inclusion of transgender people in elite sport has been a topic of debate. This narrative review examines the impact of gender-affirming hormone therapy (GAHT) on physical performance, muscle strength, and markers of endurance.

EVIDENCE ACQUISITION

MEDLINE and Embase were searched using terms to define the population (transgender), intervention (GAHT), and physical performance outcomes.

EVIDENCE SYNTHESIS

Existing literature comprises cross-sectional or small uncontrolled longitudinal studies of short duration. In nonathletic trans men starting testosterone therapy, within 1 year, muscle mass and strength increased and, by 3 years, physical performance (push-ups, sit-ups, run time) improved to the level of cisgender men. In nonathletic trans women, feminizing hormone therapy increased fat mass by approximately 30% and decreased muscle mass by approximately 5% after 12 months, and steadily declined beyond 3 years. While absolute lean mass remains higher in trans women, relative percentage lean mass and fat mass (and muscle strength corrected for lean mass), hemoglobin, and VO2 peak corrected for weight was no different to cisgender women. After 2 years of GAHT, no advantage was observed for physical performance measured by running time or in trans women. By 4 years, there was no advantage in sit-ups. While push-up performance declined in trans women, a statistical advantage remained relative to cisgender women.

CONCLUSION

Limited evidence suggests that physical performance of nonathletic trans people who have undergone GAHT for at least 2 years approaches that of cisgender controls. Further controlled longitudinal research is needed in trans athletes and nonathletes.

Human Immunodeficiency Virus as a Risk Factor for Cardiovascular Disease

The developments in HIV treatments have increased the life expectancy of people living with HIV (PLWH), a situation that makes cardiovascular disease (CVD) in that population as relevant as ever. PLWH are at increased risk of CVD, and our understanding of the underlying mechanisms is continually increasing. HIV infection is associated with elevated levels of multiple proinflammatory molecules, including IL-6, IL-1β, VCAM-1, ICAM-1, TNF-α, TGF-β, osteopontin, sCD14, hs-CRP, and D-dimer. Other currently examined mechanisms include CD4 + lymphocyte depletion, increased intestinal permeability, microbial translocation, and altered cholesterol metabolism. Antiretroviral therapy (ART) leads to decreases in the concentrations of the majority of proinflammatory molecules, although most remain higher than in the general population. Moreover, adverse effects of ART also play an important role in increased CVD risk, especially in the era of rapid advancement of new therapeutical options. Nevertheless, it is currently believed that HIV plays a more significant role in the development of metabolic syndromes than treatment-associated factors. PLWH being more prone to develop CVD is also due to the higher prevalence of smoking and chronic coinfections with viruses such as HCV and HBV. For these reasons, it is crucial to consider HIV a possible causal factor in CVD occurrence, especially among young patients or individuals without common CVD risk factors.

Cystatin C-Based eGFR Changes during Gender-Affirming Hormone Therapy in Transgender Individuals

BACKGROUND

Men with CKD tend to experience a faster eGFR decline than women, potentially because of sex hormones. Limited research exists regarding the effect of gender-affirming hormone therapy (GAHT) on kidney function. Furthermore, monitoring kidney function during GAHT is challenging because serum creatinine is confounded by body composition. To investigate the relationship between sex hormones and kidney function, we studied the changes of serum creatinine and serum cystatin C, a filtration marker less affected by sex, during 1 year of GAHT.

METHODS

As part of the European Network for the Investigation of Gender Incongruence study, we measured serum creatinine and serum cystatin C in 260 transgender women and 285 transgender men before and 12 months after initiating GAHT. Transgender women received estradiol plus cyproterone acetate, while transgender men received testosterone. Cystatin C-based eGFR was calculated using the full-age-spectrum equation.

RESULTS

In transgender women, cystatin C decreased by 0.069 mg/L (95% confidence interval [CI], 0.049 to 0.089), corresponding with a 7 ml/min per 1.73 m 2 increase in eGFR. In transgender men, cystatin C increased by 0.052 mg/L (95% CI, 0.031 to 0.072), corresponding with a 6 ml/min per 1.73 m 2 decrease in eGFR. Creatinine concentrations decreased (-0.065 mg/dl; 95% CI, -0.076 to -0.054) in transgender women and increased (+0.131 mg/dl; 95% CI, 0.119 to 0.142) in transgender men. Changes in creatinine-based eGFR varied substantially depending on the sex used in the equation.

CONCLUSIONS

In this cohort of transgender individuals, cystatin C-based eGFR increased with estradiol and antiandrogen therapy and decreased with testosterone therapy.

Sublingual Estradiol Offers No Apparent Advantage Over Combined Oral Estradiol and Cyproterone Acetate for Gender-Affirming Hormone Therapy of Treatment-Naive Trans Women: Results of a Prospective Pilot Study

Purpose

Chronic gender-affirming hormone therapy (GAHT) with sublingual estradiol (SLE) has not been studied. We aimed to compare GAHT with SLE only, to combined oral (CO) estradiol and cyproterone acetate, in treatment-naive trans women.

Methods

Twenty-two trans women enrolled into either the CO arm or the SLE-only arm (0.5 mg four times daily) in this 6-month prospective study. Anthropometric and laboratory variables were collected at baseline and 3 and 6 months. At the study beginning and end, body composition was measured by dual-energy X-ray absorptiometry and bioelectrical impedance, and gender dysphoria, sexual desire, and function were assessed by validated questionnaires.

Results

Subjects in the SLE were older, 26.3±5.8 years versus 20.1±2.3 years, p=0.006. All anthropometric, body composition, and laboratory variables were identical at baseline. Although dysphoria appeared greater, and sexual function lower at baseline in the CO group, this canceled out after age adjustment. Both treatments induced similar biochemical and hormonal changes. Creatinine, hemoglobin and cholesterol decreased significantly, while testosterone was suppressed to the same level in both groups: 3.22 [1.47-5.0] nmol/L in the SLE group and 2.41 [0.55-8.5] nmol/L in the CO, p=0.65. Significant changes in body composition toward a more feminine body were noted in both groups. Dysphoria did not significantly improve in either group, while sexual desire and function decreased at six months in both, p<0.001.

Conclusions

Both treatments achieved similar clinical changes. At this stage, SLE, which repeatedly induces alarming excursions of serum estradiol throughout the day, appears to offer no advantage over the CO approach.

Expected vs. perceived effects of gender-affirming hormone therapy among transmasculine adolescents

OBJECTIVES

Gender-affirming testosterone therapy is increasingly prescribed among transmasculine adolescents and has been associated with improved mental health outcomes. However, expected and perceived effects of testosterone have not previously been compared in this population.

METHODS

We compared desired and reported effects of testosterone in all consecutive transmasculine adolescents followed at a large interdisciplinary gender diversity clinic in North America. Participants received a prescription for testosterone and were first seen between November 2016 and May 2021. Our study was a retrospective audit of case notes. We collected self-reported desired effects prior to initiation of testosterone and self-reported perceived effects from participants' medical records up to 24 months after initiation. The masculinizing effects of testosterone considered in our study were increased body/facial hair, voice deepening/Adam's apple growth, increased muscle mass, clitoromegaly, and body fat redistribution.

RESULTS

There were 76 participants included in this study. Mean age at prescription of testosterone was 16.31 years (standard deviation: 0.99 years). The effects desired by the greatest proportion of participants prior to initiation were increased body/facial hair (69 %) and voice deepening/Adam's apple growth (52 %). These same two effects were the most reported by participants, reaching 80 % report rates at 12 months, and increasing steadily across the 24-month follow-up period.

CONCLUSIONS

Our study shows that for most, but not all gender diverse adolescents undergoing testosterone therapy, the most expected physical changes were seen in the first year of gender-affirming treatment. More research and provider education are needed to offer optimal counseling for adolescents undergoing gender-affirming hormone therapy.

Cardiovascular Risk Factors in Transgender People after Gender-Affirming Hormone Therapy

INTRODUCTION

In the last decade, healthcare for the transgender population has increased considerably in many countries thanks to depathologization movements and the easier accessibility of medical assistance. The age at which they request to start gender-affirming hormones (GAHs) is increasingly younger. The cardiovascular risk associated with hormonal treatment is a novel research field, and the published studies are heterogeneous and inconclusive. Our objective is to determine the metabolic impact of GAHs in the transgender people treated in our Gender Identity Treatment Unit.

METHODS

We designed a pre-post study to analyze changes in anthropometric parameters (weight and body mass index), analytical determinations (fasting blood glucose, glycated hemoglobin, and lipoproteins), and blood pressure control in the transgender population treated with GAHs in Puerta del Mar University Hospital. These variables were collected before and one year after hormonal therapy.

RESULTS

A total of 227 transgender people were recruited between 2017 and 2020, 97 (40.09%) transwomen and 136 (59.91%) transmen. The average age at which GAHs began was 18 years. Weight, body mass index, and blood pressure increased significantly in both genders. Transmen showed a more atherogenic lipid profile, with a decrease in cholesterol LDL (p < 0.001) and an increase in triglycerides (p < 0.001). The risk of developing prediabetes or diabetes did not increase one year after treatment, although non-specific alterations in carbohydrate metabolism were detected, such as an increase in glycated hemoglobin in transmen (p = 0.040) and fasting blood glucose in transwomen (p = 0.008). No thromboembolic processes or cardiovascular events were reported during the first year of treatment.

CONCLUSION

In our setting, transgender people developed changes in their metabolic profiles in the first year after hormonal treatment. Both transmen and transwomen showed early alterations in lipid and carbohydrate metabolism, slight elevations in blood pressure, and a tendency to gain weight. This makes lifestyle interventions necessary from the beginning of GAHs.

Skeletal Muscle Function Is Altered in Male Mice on Low-Dose Androgen Receptor Antagonist or Estrogen Receptor Agonist

In males, skeletal muscle function may be altered by shifts in either circulating testosterone or estrogen. We examined the effect of acute (2-week) exposures to 17α-ethinyl estradiol (EE2), an estrogen receptor (ER) agonist, or flutamide, an androgen receptor (AR) antagonist, on the contractile function of individual skeletal muscle fibers from slow-contracting soleus and fast-contracting extensor digitorum longus muscles from adult male mice. Single fiber specific tension (force divided by cross-sectional area) was decreased with flutamide treatment in all myosin heavy chain (MHC) fiber types examined (I, IIA, and IIB); similar effects were observed with EE2 treatment but only in the fastest-contracting MHC IIB fibers. The decreases in maximally Ca2+-activated specific tension were primarily a result of fewer strongly bound myosin-actin cross-bridges, with flutamide treatment also showing lower myofilament lattice stiffness. Myosin-actin cross-bridge kinetics were slower in MHC IIA fibers in flutamide-treated mice, but faster in EE2-treated mice, indicating that contractile velocity may be affected differently in this fiber type, which is commonly expressed in human skeletal muscle. Importantly, these effects were observed in the absence of outcomes previously used to evaluate ER agonists or AR antagonists in rodents including weight of reproductive organs or mammary gland morphology. Our findings indicate that substantial shifts in skeletal muscle function occur in male mice following acute exposures to low doses of a pharmacological ER agonist and an AR antagonist. These results suggest that countermeasures to maintain physical function may be needed early in situations that induce similar ER agonist and AR antagonist conditions.

Sex non-specific growth charts and potential clinical implications in the care of transgender youth

Introduction

The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) created separate growth charts for girls and boys because growth patterns and rates differ between sexes. However, scenarios exist in which this dichotomizing "girls versus boys" approach may not be ideal, including the care of non-binary youth or transgender youth undergoing transitions consistent with their gender identity. There is therefore a need for growth charts that age smooth differences in pubertal timing between sexes to determine how youth are growing as "children" versus "girls or boys" (e.g., age- and sex-neutral, compared to age- and sex-specific, growth charts).

Methods

Employing similar statistical techniques and datasets used to create the CDC 2000 growth charts, we developed age-adjusted, sex non-specific growth charts for height, weight, and body mass index (BMI), and z-score calculators for these parameters. Specifically, these were created using anthropometric data from five US cross-sectional studies including National Health Examination Surveys II-III and National Health and Nutrition Examination Surveys I-III. To illustrate contemporary clinical practice, we overlaid our charts on CDC 2000 girls and boys growth charts.

Results

39,119 youth 2-20 years old (49.5% female; 66.7% non-Hispanic White; 21.7% non-Hispanic Black) were included in the development of our growth charts, reference ranges, and z-score calculators. Respective curves were largely superimposable through around 10 years of age after which, coinciding with pubertal onset timing, differences became more apparent.

Discussion

We conclude that age-adjusted, sex non-specific growth charts may be used in clinical situations such as transgender youth in which standard "girls versus boys" growth charts are not ideal. Until longitudinal auxological data are available in these populations, our growth charts may help to assess a transgender youth's growth trajectory and weight classification, and expectations surrounding these.

Fit Transitioning: When Can Transgender Airmen Fitness Test in Their Affirmed Gender?

INTRODUCTION

Transgender individuals have served openly in the U.S. Military since 2016. Official policies for transgender servicemembers continue to evolve, including approaches to physical fitness testing of transgender servicemembers. There is a paucity of scientific data regarding the effects of gender affirming hormone therapy (GAHT) on athletic performance for the past 24 months of treatment. Identification of expected trends in performance during and after gender transition is essential to allow for the development of appropriate military policy regarding when to assess servicemembers' fitness by standards of their affirmed gender.

MATERIALS AND METHODS

We identified Department of the Air Force transgender patients using the Transgender Health Medical Evaluation Unit database and recorded dates of GAHT initiation through a retrospective chart review. We recorded performance values for the Air Force physical fitness test components 1 year before and up to 4 years after GAHT initiation. Performance measures were maximum sit-ups in 1 minute, push-ups in 1 minute, and 1.5-mile run time. Pre- and post-GAHT scores were compared using one-sample T-test to mean scores of Air Force-wide cisgender averages to assess for significant difference between affirmed transgender and cisgender airmen. We then performed the two one-sided test (TOST) procedure for equivalence with upper and lower bounds set at 1 SD from the means for cisgender airmen. Finally, using Z-scores, average transgender group scores were assigned a percentile rank with their respect to affirmed gender throughout the transition process.

RESULTS

Following initiation of GAHT, transgender males demonstrated statistically significant worse performance than cisgender males in all events until 3 years of GAHT. Their average scores would have attained a comfortable passing score within 1 year of GAHT. Transgender females' performance showed statistically significantly better performance than cisgender females until 2 years of GAHT in run times and 4 years in sit-up scores and remained superior in push-ups at the study's 4-year endpoint. TOST confirmed equivalence at all points where statistical difference was not demonstrated. Servicemembers approximate their pre-GAHT assigned gender percentile ranking in their affirmed gender in a manner consistent with hypothesis and TOST testing in the push-up event for both transgender males and females and in the 1.5-mile run event for transgender males.

CONCLUSIONS

In a sample of Air Force adult transgender patients, athletic performance measures demonstrate variable rates of change depending on the patients' affirmed gender and differ by physical fitness test component. Based on this study, transgender females should begin to be assessed by the female standard no later than 2 years after starting GAHT, while transgender males could be assessed by their affirmed standard no earlier than 3 years after initiating GAHT.

Physical fitness, hormonal profile, nutritional and psychological aspects assessment of transgender women volleyball players submitted to physical tests: protocol paper of a prospective cohort

To evaluate aerobic capacity, strength and other physiological, nutritional, and psychological variables which may influence the performance of transgender women (TW) athletes and compare them to cisgender women (CW) and cisgender men (CM) athletes, as well as changes in TW performance over the course of a year. Prospective cohort study including three groups: TW, CW and CM volleyball athletes. Subjects will be comprehensively assessed at two different moments: baseline and after 6-12 months of adequate hormonal therapy. Evaluation will comprise clinical, medical, nutritional and psychological interviews, incremental treadmill cardiopulmonary exercise testing, hand grip strength test, vertical jump test, analysis of sleep quality (Pittsburgh Sleep Quality Index), hormonal profile, echocardiogram, analysis of resting energy expenditure, assessment of bone mass and body composition through dual-energy X-ray absorptiometry scans, and untargeted metabolomic analysis. CW and CM matched by age, body mass index and level of physical activity will undergo a similar evaluation. The assessment of the strength, aerobic capacity, haematological, nutritional and psychological status of TW using gold-standard tests will contribute to understanding the impact of oestrogen therapy on the exercise performance of these athletes and how they compare with CW and CM.

Prevalence of cancer risk factors among transgender and gender diverse individuals: a cross-sectional analysis using UK primary care data

BACKGROUND

Transgender and gender diverse (TGD) individuals experience an incongruence between their assigned birth sex and gender identity. They may have a higher prevalence of health conditions associated with cancer risk than cisgender people.

AIM

To examine the prevalence of several cancer risk factors among TGD individuals compared with cisgender individuals.

DESIGN AND SETTING

A cross-sectional analysis was conducted using data from the UK's Clinical Practice Research Datalink to identify TGD individuals between 1988-2020, matched to 20 cisgender men and 20 cisgender women on index date (date of diagnosis with gender incongruence), practice, and index age (age at index date). Assigned birth sex was determined from gender-affirming hormone use and procedures, and sex-specific diagnoses documented in the medical record.

METHOD

The prevalence of each cancer risk factor was calculated and the prevalence ratio by gender identity was estimated using log binomial or Poisson regression models adjusted for age and year at study entry, and obesity where appropriate.

RESULTS

There were 3474 transfeminine (assigned male at birth) individuals, 3591 transmasculine (assigned female at birth) individuals, 131 747 cisgender men, and 131 827 cisgender women. Transmasculine people had the highest prevalence of obesity (27.5%) and 'ever smoking' (60.2%). Transfeminine people had the highest prevalence of dyslipidaemia (15.1%), diabetes (5.4%), hepatitis C infection (0.7%), hepatitis B infection (0.4%), and HIV infection (0.8%). These prevalence estimates remained elevated in the TGD populations compared with cisgender persons in the multivariable models.

CONCLUSION

Multiple cancer risk factors are more prevalent among TGD individuals compared with cisgender individuals. Future research should examine how minority stress contributes to the increased prevalence of cancer risk factors in this population.

Implications of gender-affirming endocrine care for sports participation

Many transgender (trans) individuals utilize gender-affirming hormone therapy (GAHT) to promote changes in secondary sex characteristics to affirm their gender. Participation rates of trans people in sport are exceedingly low, yet given high rates of depression and increased cardiovascular risk, the potential benefits of sports participation are great. In this review, we provide an overview of the evidence surrounding the effects of GAHT on multiple performance-related phenotypes, as well as current limitations. Whilst data is clear that there are differences between males and females, there is a lack of quality evidence assessing the impact of GAHT on athletic performance. Twelve months of GAHT leads to testosterone concentrations that align with reference ranges of the affirmed gender. Feminizing GAHT in trans women increases fat mass and decreases lean mass, with opposite effects observed in trans men with masculinizing GAHT. In trans men, an increase in muscle strength and athletic performance is observed. In trans women, muscle strength is shown to decrease or not change following 12 months of GAHT. Haemoglobin, a measure of oxygen transport, changes to that of the affirmed gender within 6 months of GAHT, with very limited data to suggest possible reductions in maximal oxygen uptake as a result of feminizing GAHT. Current limitations of this field include a lack of long-term studies, adequate group comparisons and adjustment for confounding factors (e.g. height and lean body mass), and small sample sizes. There also remains limited data on endurance, cardiac or respiratory function, with further longitudinal studies on GAHT needed to address current limitations and provide more robust data to inform inclusive and fair sporting programmes, policies and guidelines.

The molecular consequences of androgen activity in the human breast

Estrogen and progesterone have been extensively studied in the mammary gland, but the molecular effects of androgen remain largely unexplored. Transgender men are recorded as female at birth but identify as male and may undergo gender-affirming androgen therapy to align their physical characteristics and gender identity. Here we perform single-cell-resolution transcriptome, chromatin, and spatial profiling of breast tissues from transgender men following androgen therapy. We find canonical androgen receptor gene targets are upregulated in cells expressing the androgen receptor and that paracrine signaling likely drives sex-relevant androgenic effects in other cell types. We also observe involution of the epithelium and a spatial reconfiguration of immune, fibroblast, and vascular cells, and identify a gene regulatory network associated with androgen-induced fat loss. This work elucidates the molecular consequences of androgen activity in the human breast at single-cell resolution.

Indoxyl sulfate mediates low handgrip strength and is predictive of high hospitalization rates in patients with end-stage renal disease

Background and aims

Sarcopenia has a higher occurrence rate in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) than in the general population. Low handgrip strength-and not sarcopenia per se-is associated with clinical outcomes in patients with CKD, including cardiovascular mortality and hospitalization. The factors contributing to low handgrip strength are still unknown. Accordingly, this study aimed to determine whether uremic toxins influence low handgrip strength in patients with CKD.

Materials and methods

This cohort study lasted from August 2018 to January 2020. The participants were divided into three groups: the control group [estimated glomerular filtration rate (eGFR) ≥ 60 ml/min], an advanced CKD group (eGFR = 15-60 ml/min), and an ESRD group (under maintenance renal replacement therapy). All participants underwent handgrip strength measurement, dual-energy X-ray absorptiometry, and blood sampling for myokines (irisin, myostatin, and interleukin 6) and indoxyl sulfate. Sarcopenia was defined according to the Asian Working Group for Sarcopenia consensus as low appendicular skeletal muscle index (appendicular skeletal muscle/height2 of < 7.0 kg/m2 in men and < 5.4 kg/m2 in women) and low handgrip strength (< 28 kg in men and < 18 kg in women).

Results

Among the study participants (control: n = 16; CKD: n = 17; and ESRD: n = 42), the ESRD group had the highest prevalence of low handgrip strength (41.6 vs. 25% and 5.85% in the control and CKD groups, respectively; p < 0.05). The sarcopenia rate was similar among the groups (12.5, 17.6, and 19.5% for the control, CKD, and ESRD groups, respectively; p = 0.864). Low handgrip strength was associated with high hospitalization rates within the total study population during the 600-day follow-up period (p = 0.02). The predictions for cardiovascular mortality and hospitalization were similar among patients with and without sarcopenia (p = 0.190 and p = 0.094). The serum concentrations of indoxyl sulfate were higher in the ESRD group (227.29 ± 92.65 μM vs. 41.97 ± 43.96 μM and 6.54 ± 3.45 μM for the CKD and control groups, respectively; p < 0.05). Myokine concentrations were similar among groups. Indoxyl sulfate was associated with low handgrip strength in univariate and multivariate logistic regression models [univariate odds ratio (OR): 3.485, 95% confidence interval (CI): 1.372-8.852, p = 0.001; multivariate OR: 8.525, 95% CI: 1.807-40.207, p = 0.007].

Conclusion

Handgrip strength was lower in the patients with ESRD, and low handgrip strength was predictive of hospitalization in the total study population. Indoxyl sulfate contributed to low handgrip strength and counteracted the benefits of myokines in patients with CKD.

Clinical Concerns on Sex Steroids Variability in Cisgender and Transgender Women Athletes

In the female athletic community, there are several endogenous and exogenous variables that influence the status of the hypothalamus-pituitary-ovarian axis and serum sex steroid hormones concentrations (e. g., 17β-estradiol, progesterone, androgens) and their effects. Moreover, female athletes with different sex chromosome abnormalities exist (e. g., 46XX, 46XY, and mosaicism). Due to the high variability of sex steroid hormones serum concentrations and responsiveness, female athletes may have different intra- and inter-individual biological and functional characteristics, health conditions, and sports-related health risks that can influence sports performance and eligibility. Consequently, biological, functional, and/or sex steroid differences may exist in the same and in between 46XX female athletes (e. g., ovarian rhythms, treated or untreated hypogonadism and hyperandrogenism), between 46XX and 46XY female athletes (e. g., treated or untreated hyperandrogenism/disorders of sexual differentiation), and between transgender women and eugonadal cisgender athletes. From a healthcare perspective, dedicated physicians need awareness, knowledge, and an understanding of sex steroid hormones' variability and related health concerns in female athletes to support physiologically healthy, safe, fair, and inclusive sports participation. In this narrative overview, we focus on the main clinical relationships between hypothalamus-pituitary-ovarian axis function, endogenous sex steroids and health status, health risks, and sports performance in the heterogeneous female athletic community.

LGBTQ+ Perspective in Hand Surgery: Surgeon and Patient

Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) individuals and patients face high levels of discrimination both in the workplace and in the clinic setting, with more than 25% of LGBTQ+ people experiencing discrimination in the workplace due to their sexual orientation. Hand Surgery stands to continue to advance by encouraging the brightest students into the field no matter their background. LGBTQ+ patients also have specific needs within the field of Hand Surgery, where we are uniquely positioned to treat them or guide them by being well versed in the needs of the community.

Gender-affirming hormonal therapy for transgender and gender-diverse people-A narrative review

As the number of transgender and gender-diverse (TGD) people accessing gender-affirming care increases, the need for healthcare professionals (HCPs) providing gender-affirming hormonal therapy (GAHT) also increases. This chapter provides an overview of the HCPs interested in getting involved in providing GAHT.

Techniques and Applications of Lower Extremity Feminization and Masculinization

Background

Significant differences exist between feminine and masculine lower extremities, and this region contributes to gender dysphoria in transgender and nonbinary individuals.

Methods

A systematic review was conducted for primary literature on lower extremity (LE) gender affirmation techniques as well as anthropometric differences between male and female lower extremities, which could guide surgical planning. Multiple databases were searched for articles before June 2, 2021 using Medical Subject Headings. Data on techniques, outcomes, complications, and anthropometrics were collected.

Results

A total of 852 unique articles were identified: 17 met criteria for male and female anthropometrics and 1 met criteria for LE surgical techniques potentially applicable to gender affirmation. None met criteria for LE gender affirmation techniques specifically. Therefore, this review was expanded to discuss surgical techniques for the LE, targeting masculine and feminine anthropometric ideals. LE masculinization can target feminine qualities, such as mid-lateral gluteal fullness and excess subcutaneous fat in the thigh and hips. Feminization can target masculine qualities like a low waist-to-hip ratio, mid-lateral gluteal concavity, calf hypertrophy, and body hair. Cultural differences and patient body habitus, which influence what is considered "ideal" for both sexes, should be discussed. Applicable techniques include hormone therapy, lipo-contouring, fat grafting, implant placement, and botulinum toxin injection, among others.

Conclusions

Due to lack of existing outcomes-based literature, gender affirmation of the lower extremities will rely on application of an array of existing plastic surgery techniques. However, quality outcomes data for these procedures is required to determine best practices.

Concentration of hs-Troponin in small cohort of transgender patients

INTRODUCTION

Sex-differences in high sensitivity troponin (hs-Tn) concentrations are well established. There is, however, limited data to guide interpretation of hs-Tn in transgender patients, particularly those receiving gender-affirming hormone therapy. Our purpose was to evaluate troponin testing in transgender patients.

METHODS

Transgender adults attending a routine clinic visit provided demographic data, medical history, and venous blood samples. Patients with congestive heart failure or chronic kidney disease were excluded. hs-Tn was measured using the Architect Stat High Sensitivity Troponin-I (Abbott), Access 2 hsTnI (Beckman Coulter), and Elecsys Troponin T Gen 5 STAT (Roche) assays. hs-Tn below the limit of detection (LOD) is reported as the lower limit of detection (LLOD) RESULTS: Of 63 subjects, 76 % were transgender women. We found no significant difference in median hs-Tn concentrations or proportions of hs-Tn > LOD.

CONCLUSION

In this cohort of stable transgender patients without CHF or CKD, we did not observe differences in hs-Tn concentrations between transgender women and transgender men. Meaningful conclusions are limited owing to inadequate sample size and population differences. Further research on hs-troponin concentrations in this underrepresented, vulnerable population is needed.

Visceral fat and attribute-based medicine in chronic kidney disease

Visceral adipose tissue plays a central role in obesity and metabolic syndrome and is an independent risk factor for both cardiovascular and metabolic disorders. Increased visceral adipose tissue promotes adipokine dysregulation and insulin resistance, leading to several health issues, including systemic inflammation, oxidative stress, and activation of the renin-angiotensin-aldosterone system. Moreover, an increase in adipose tissue directly and indirectly affects the kidneys by increasing renal sodium reabsorption, causing glomerular hyperfiltration and hypertrophy, which leads to increased proteinuria and kidney fibrosis/dysfunction. Although the interest in the adverse effects of obesity on renal diseases has grown exponentially in recent years, the relationship between obesity and renal prognosis remains controversial. This may be attributed to the long clinical course of obesity, numerous obesity-related metabolic complications, and patients' attributes. Multiple individual attributes influencing the pathophysiology of fat accumulation make it difficult to understand obesity. In such cases, it may be effective to elucidate the pathophysiology by conducting research tailored to individual attributes from the perspective of attribute-based medicine/personalized medicine. We consider the appropriate use of clinical indicators necessary, according to attributes such as chronic kidney disease stage, level of visceral adipose tissue accumulation, age, and sex. Selecting treatments and clinical indicators based on individual attributes will allow for advancements in the clinical management of patients with obesity and chronic kidney disease. In the clinical setting of obesity-related nephropathy, it is first necessary to accumulate attribute-based studies resulting from the accurate evaluation of visceral fat accumulation to establish evidence for promoting personalized medicine.

Characterising body composition and bone health in transgender individuals receiving gender-affirming hormone therapy

BACKGROUND

Gender-affirming hormone therapy (GAHT) is prescribed to produce secondary sex characteristics aligning external anatomy with gender identity to mitigate gender dysphoria. Transgender women are generally treated with oestrogens and anti-androgens, whereas transgender men are treated with testosterone. The objective of this narrative review was to characterise the influence of GAHT on body composition and bone health in the transgender population to help address weight concerns and chronic disease risk.

METHODS

Studies were extracted from PubMed and Scopus and limited to only those utilising imaging technologies for precise adipose tissue, lean mass, and bone mineral density (BMD) quantification.

RESULTS

Although methodologies differed across the 20 investigations that qualified for inclusion, clear relationships emerged. Specifically, among transgender women, most studies supported associations between oestrogen therapy and decreases in lean mass and increases in both, fat mass and body mass index (BMI). Within transgender men, all studies reported associations between testosterone therapy and increases in lean mass, and although not as consistent, increases in BMI and decreases in fat mass. No consistent changes in BMD noted for either group.

CONCLUSIONS

Additional research is needed to appropriately assess and evaluate the implications of these body composition changes over time (beyond 1 year) in larger, more diverse groups across all BMI categories. Future studies should also seek to evaluate nutrient intake, energy expenditure and other important lifestyle habits to diminish health disparities within this vulnerable population. Policies are needed to help integrate registered dietitians into the routine care of transgender individuals.

Obesity Pillars Roundtable: Body mass index and body composition in Black and Female individuals. Race-relevant or racist? Sex-relevant or sexist?

Background

Body mass index (BMI or weight in kilograms/height in meters2) is the most common metric to diagnose overweight and obesity. However, a body composition analysis more thoroughly assesses adiposity, percent body fat, lean body mass (i.e., including skeletal muscle), and sometimes bone mineral density. BMI is not an accurate assessment of body fat in individuals with increased or decreased muscle mass; the diagnostic utility of BMI in individuals is also influenced by race and sex.

Methods

Previous Obesity Pillars Roundtables addressed the diagnostic limitations of BMI, the importance of android and visceral fat (especially among those with South and East Asian ancestry), and considerations of obesity among individuals who identify as Hispanic, diverse in sexual-orientation, Black, Native American, and having ancestry from the Mediterranean and Middle East regions. This roundtable examines considerations of BMI in Black and female individuals.

Results

The panelists agreed that body composition assessment was a more accurate measure of adiposity and muscle mass than BMI. When it came to matters of race and sex, one panelist felt: "race is a social construct and not a defining biology." Another felt that: "BMI should be a screening tool to prompt further evaluation of adiposity that utilizes better diagnostic tools for body composition." Regarding bias and misperceptions of resistance training in female individuals, another panelist stated: "I have spent my entire medical career taking care of women and have never seen a woman unintentionally gain 'too much' muscle mass and bulk up from moderate strength training."

Conclusions

Conveying the importance of race and sex regarding body composition has proven challenging, with the discussion sometimes devolving into misunderstandings or misinformation that may be perceived as racist or sexist. Body composition analysis is the ultimate diagnostic equalizer in addressing the inaccuracies and biases inherent in the exclusive use of BMI.

Hormonothérapies de transition chez les personnes transgenres

Aujourd’hui encore, la prise en charge médicale des personnes transgenres pâtit d’une insuffisance d’offre de soins et de formation des soignants. La mise en œuvre d’une hormonothérapie est souvent souhaitée par les personnes transgenres et il est nécessaire qu’un médecin sache l’instaurer et la suivre tout au long de la transition. Nous abordons dans cette revue le traitement hormonal féminisant (THF) chez les femmes transgenres adultes, et le traitement hormonal masculinisant (THM) chez les hommes transgenres adultes.

Effects of androgens on glucose metabolism

Type 2 diabetes (T2D) and obesity are common and associated with increased morbidity and mortality. Cross-sectional and longitudinal studies have demonstrated a clear association between T2D, obesity and reduced total testosterone concentration. This relationship becomes less significant or absent with correction for changes in body composition, supporting the notion that changes in body composition are mediating these effects. Moreover, this mediating effect of body composition changes is bi-directional, as evidenced by interventional studies of weight loss and testosterone treatment. On the one hand, in obese men, serum testosterone increases markedly with weight loss. On the other hand, testosterone improves body composition. This relationship is driven by multiple complex interaction between obesity and insulin resistance and the hypothalamic-pituitary-testicular axis, at all levels. Data from randomised control trials have demonstrated that intervention with testosterone therapy increases muscle mass and reduces adiposity. Most recently it has been shown that treatment with testosterone prevents progression of impaired glucose tolerance to T2D, or reverses newly diagnosed T2D beyond lifestyle intervention alone. At present there are insufficient safety data to support the use of testosterone for prevention of type 2 diabetes.

Metabolic effects of estradiol versus testosterone in complete androgen insensitivity syndrome

PURPOSE

To study differences in metabolic outcomes between testosterone and estradiol replacement in probands with complete androgen insensitivity syndrome (CAIS).

METHODS

In this multicentre, double-blind, randomized crossover trial, 26 women with CAIS were included of whom 17 completed the study. After a two-months run in phase with estradiol, probands either received transdermal estradiol followed by crossover to transdermal testosterone or vice versa. After six months, differences in lipids, fasting glucose, insulin, hematocrit, liver parameters and blood pressure between the treatment phases were investigated.

RESULTS

Linear mixed models adjusted for period and sequence did not reveal major group differences according to treatment for the investigated outcomes. In each treatment group, there were however significant uniform changes in BMI and cholesterol. BMI increased significantly, following six months of estradiol ( + 2.7%; p = 0.036) as well as testosterone treatment ( + 2.8%; p = 0.036). There was also a significant increase in total ( + 10.4%; p = 0.001) and LDL-cholesterol ( + 29.2%; p = 0.049) and a decrease in HDL-cholesterol (-15.8%; p < 0.001) following six months of estradiol as well as six months of testosterone treatment (total cholesterol: + 14.6%; p = 0.008; LDL-cholesterol: + 39.1%; p = 0.005, HDL-cholesterol: -15.8%; p = 0.004). Other parameters remained unchanged.

CONCLUSION

Transdermal estradiol as well as testosterone treatment in women with CAIS results in worsening in lipid profiles. Given the relatively small sample size, subtle group differences in other metabolic parameters may have remained undetected.

The Regulation of Adipose Tissue Health by Estrogens

Obesity and its' associated metabolic diseases such as type 2 diabetes and cardiometabolic disorders are significant health problems confronting many countries. A major driver for developing obesity and metabolic dysfunction is the uncontrolled expansion of white adipose tissue (WAT). Specifically, the pathophysiological expansion of visceral WAT is often associated with metabolic dysfunction due to changes in adipokine secretion profiles, reduced vascularization, increased fibrosis, and enrichment of pro-inflammatory immune cells. A critical determinate of body fat distribution and WAT health is the sex steroid estrogen. The bioavailability of estrogen appears to favor metabolically healthy subcutaneous fat over visceral fat growth while protecting against changes in metabolic dysfunction. Our review will focus on the role of estrogen on body fat partitioning, WAT homeostasis, adipogenesis, adipocyte progenitor cell (APC) function, and thermogenesis to control WAT health and systemic metabolism.

Forensic alcohol calculations in transgender individuals undergoing gender-affirming hormonal treatment

There are an increasing number of individuals undergoing gender‐affirming hormonal treatment (GAHT) to treat gender dysphoria. Current forensic alcohol calculations require knowledge of the sex of the individual, but this may disadvantage trans people as research has demonstrated that there are physiological changes in individuals who are undergoing GAHT. Using previously published studies on total body water (TBW) in cis individuals, and the known changes in lean body mass and hematocrit in trans individuals, it is possible to estimate TBW in trans individuals and compare them to those cis equation estimations. When using these revised rubrics, we determined that for trans women the use of the cis male anthropometric TBW equation only gives a small underestimation of TBW (0.9%) compared to the underestimation of TBW using the cis female TBW equation (−17.7%). For trans men, the use of the cis female TBW equation gives the largest disadvantage, underestimating TBW by −10.8% compared to the cis male TBW equation, that overestimates TBW by 6.6%. For this reason, we recommend that if the sex at birth of an individual is not known or disclosed, any forensic alcohol calculations in a forensic alcohol reports are made assuming that the gender declared by the individual is their sex at birth. Further research to develop validated anthropometric TBW equations are urgently needed as to not disadvantage trans people when forensic alcohol calculations are carried out.

Gender-affirming hormone therapy: An updated literature review with an eye on the future

In line with increasing numbers of transgender (trans) and gender nonbinary people requesting hormone treatment, the body of available research is expanding. More clinical research groups are presenting data, and the numbers of participants in these studies are rising. Many previous review papers have focused on all available data, as these were scarce, but a more recent literature review is timely. Hormonal regimens have changed over time, and older data may be less relevant for today's practice. In recent literature, we have found that even though mental health problems are more prevalent in trans people compared to cisgender people, less psychological difficulties occur, and life satisfaction increases with gender-affirming hormone treatment (GAHT) for those who feel this is a necessity. With GAHT, body composition and contours change towards the affirmed sex. Studies in bone health are reassuring, but special attention is needed for adolescent and adult trans women, aiming at adequate dosage of hormonal supplementation and stimulating therapy compliance. Existing epidemiological data suggest that the use of (certain) estrogens in trans women induces an increased risk of myocardial infarction and stroke, the reason that lifestyle management can be an integral part of trans health care. The observed cancer risk in trans people does not exceed the known cancer-risk differences between men and women. Now it is time to integrate the mostly reassuring data, to leave the overly cautious approach behind, to not copy the same research questions repeatedly, and to focus on longer follow-up data with larger cohorts.

Influence of Maturity Status on Kinanthropometric and Physical Fitness Variables in Adolescent Female Volleyball Players

The aim of this research was to analyze differences in kinanthropometric characteristics and physical performance in relation to maturity status, as well as to determine if age, maturity offset or kinanthropometric variables could predict better performance in physical fitness tests. A total of 152 female volleyball players (14.16 ± 1.25 years old) underwent a kinanthropometric assessment, followed by a physical fitness assessment composed of different tests. The age at peak height velocity (APHV) was calculated, and the sample was divided according to biological maturation into three groups. Significant differences were observed in kinanthropometric variables (p < 0.001–0.026), with early maturers showing higher values. Age, body mass, Cormic index, relative arm span, ∑8 skinfolds, fat mass, corrected arm and thigh girths, muscle mass and biacromial and biiliocristal breadths were the variables that best predicted performance in the physical tests (p < 0.001–0.024). The more mature players showed higher values in most of the kinanthropometric variables, with the more remarkable differences being in body mass, height, arm span and sitting height, and those related to adiposity and absolute body composition, and with structural variables being the most influential on the physical tests. Age had a determinant influence on the differences found between groups in strength and power-related test performance.

Incident Diabetes Risk Is Not Increased in Transgender Individuals Using Hormone Therapy

CONTEXT

In trans women receiving hormone therapy, body fat and insulin resistance increases, with opposite effects in trans men. These metabolic alterations may affect the risk of developing type 2 diabetes in trans women and trans men.

CONTEXT

We aimed to compare the incidence of type 2 diabetes of adult trans women and trans men during hormone therapy with rates from their birth-assigned sex in the general population.

METHODS

Retrospective data from the Amsterdam Cohort of Gender Dysphoria with transgender individuals on hormone therapy between 1972 and 2018 were linked to a nationwide health data registry. Because no central registry of diabetes is available, the occurrence of diabetes was inferred from the first dispense of a glucose-lowering agent. Standardized incidence ratios (SIR) were computed for trans women and trans men in comparison with the same birth sex from the general population.

RESULTS

Compared with their birth-assigned sex in the general population, no difference in the incidence of type 2 diabetes mellitus was observed in trans women (N = 2585, 90 cases; SIR 0.94; 95% CI, 0.76-1.14) or trans men (N = 1514, 32 cases; SIR 1.40; 95% CI, 0.96-1.92).

CONCLUSION

Despite studies reporting an increase in insulin resistance in feminizing hormone therapy and a decrease in insulin resistance in masculinizing hormone therapy, the incidence of diabetes in transgender individuals after initiation of hormone therapy was not different compared with the general population.

Influence of biological maturation status on selected anthropometric and physical fitness variables in adolescent male volleyball players

Background

The identification of sport talent among adolescent athletes is a topic that in recent years has been a major focus of interest for both the scientific community and sport managers. Both anthropometry and physical performance through fitness tests have demonstrated to be key elements. Biological maturation, due to its influence on anthropometric variables and physical fitness, has also been studied in relation to sport talent identification.

Objective

To analyse differences according to biological maturation status in anthropometric characteristics and performance in physical fitness tests, and to determine which variables predict better performance in physical fitness tests in adolescent volleyball players.

Methods

A cross-sectional design was followed to collect the data. A total of 48 male sub-elite volleyball players (14.17 ± 0.73 years) completed a socio-demographic and sports ad hoc questionnaire. Anthropometric variables were measured following the guidelines of the International Society for the Advancement in Kinanthropometry (ISAK) including four basic measurements (body mass, height, sitting height and arm span); eight skinfolds (triceps, biceps, subscapular, iliac crest, supraspinale, abdominal, thigh and calf); four girths (arm relaxed, flexed and tensed arm, middle thigh and calf); five breadths (biacromial, biileocrestal, humerus, femur and bi-styloid); three lengths (acromiale-radiale, radiale-stylion and stylion-medio dactilion); and a height (ilioespinale). Physical fitness was assessed, including the sit-and-reach, back scratch, long jump, medicine ball throw, counter movement jump (CMJ), 20 meters sprint, and agility tests. Furthermore, maturity offset and age at peak height velocity (APHV) was calculated.

Results

Significant differences were found in the body mass (Mean Difference, MD = 20.86-30.75), height (MD = 11.72-19.09), sitting height (MD = 4.27-10.27), arm span (MD = 12.91-20.78), body mass index (MD = 3.72-5.63), upper limb length (MD = 7.76), corrected muscle girths (MD = 2.06-9.31), ∑6 and 8 skinfolds (MD = 3.67-50.21) fat mass and percentage (MD = 0.30-11.58), muscle (MD = 4.13-10.64) and bone mass (MD = 1.61-3.54) (p < 0.001-0.030), showing higher values the early maturers. In the physical fitness tests, significant differences were observed in the medicine ball throw (MD = 1.26-2.80) and in CMJ power (MD = 156.71-379.85) (p < 0.001). Regression models identified fat mass percentage predicted worse physical test performance (p < 0.001), while age, maturation offset, muscle and bone variables were predictors of better physical performance (p < 0.001).

Conclusions

Significant differences based upon the stages of biological maturation were found in the anthropometric and physical condition variables in favor of the players whose maturation process was more advanced, with the variables related to fat and adipose, muscle and bone development conditioning their performance in the physical condition tests.

Bone Microarchitecture in Transgender Adults: A Cross-Sectional Study

Gender-affirming hormone therapy aligns physical characteristics with an individual's gender identity, but sex hormones regulate bone remodeling and influence bone morphology. We hypothesized that trans men receiving testosterone have compromised bone morphology because of suppression of ovarian estradiol production, whereas trans women receiving estradiol, with or without anti-androgen therapy, have preserved bone microarchitecture. We compared distal radial and tibial microarchitecture using high-resolution peripheral quantitative computed tomography images in a cross-sectional study of 41 trans men with 71 cis female controls, and 40 trans women with 51 cis male controls. Between-group differences were expressed as standardized deviations (SD) from the mean in age-matched cisgender controls with 98% confidence intervals adjusted for cross-sectional area (CSA) and multiple comparisons. Relative to cis women, trans men had 0.63 SD higher total volumetric bone mineral density (vBMD; both p = 0.01). Cortical vBMD and cortical porosity did not differ, but cortices were 1.11 SD thicker (p < 0.01). Trabeculae were 0.38 SD thicker (p = 0.05) but otherwise no different. Compared with cis men, trans women had 0.68 SD lower total vBMD (p = 0.01). Cortical vBMD was 0.70 SD lower (p < 0.01), cortical thickness was 0.51 SD lower (p = 0.04), and cortical porosity was 0.70 SD higher (p < 0.01). Trabecular bone volume (BV/TV) was 0.77 SD lower (p < 0.01), with 0.57 SD fewer (p < 0.01) and 0.30 SD thicker trabeculae (p = 0.02). There was 0.56 SD greater trabecular separation (p = 0.01). Findings at the distal radius were similar. Contrary to each hypothesis, bone microarchitecture was not compromised in trans men, perhaps because aromatization of administered testosterone prevented bone loss. Trans women had deteriorated bone microarchitecture either because of deficits in microstructure before treatment or because the estradiol dosage was insufficient to offset reduced aromatizable testosterone. Prospective studies are needed to confirm these findings. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).