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Venkatesh VS, Nie T, Golub S, Stok KS, Hemmatian H, Desai R, Handelsman DJ, Zajac JD, Grossmann M, Davey RA. High circulating concentrations of estradiol are anabolic for bone mass and strength in an adult male to female transgender mouse model. Bone 2024; 186:117143. [PMID: 38866125 DOI: 10.1016/j.bone.2024.117143] [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: 03/25/2024] [Revised: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 06/14/2024]
Abstract
The effects of gender affirming hormone therapy (GAHT) on bone microarchitecture and fracture risk in adult transgender women is unclear. To investigate the concept that skeletal integrity and strength in trans women may be improved by treatment with a higher dose of GAHT than commonly prescribed, we treated adult male mice with a sustained, high dose of estradiol. Adult male mice at 16 weeks of age were administered ~1.3 mg estradiol by silastic implant, implanted intraperitoneally, for 12 weeks. Controls included vehicle treated intact females and males. High-dose estradiol treatment in males stimulated the endocortical deposition of bone at the femoral mid-diaphysis, increasing cortical thickness and bone area. This led to higher stiffness, maximum force, and the work required to fracture the bone compared to male controls, while post-yield displacement was unaffected. Assessment of the material properties of the bone showed an increase in both elastic modulus and ultimate stress in the estradiol treated males. Treatment of male mice with high dose estradiol was also anabolic for trabecular bone, markedly increasing trabecular bone volume, number and thickness in the distal metaphysis which was accompanied by an increase in the histomorphometric markers of bone remodelling, mineralizing surface/bone surface, bone formation rate and osteoclast number. In conclusion, a high dose of estradiol is anabolic for cortical and trabecular bone in a male to female transgender mouse model, increasing both stiffness and strength. These findings suggest that increasing the current dose of GAHT administered to trans women, while considering other potential adverse effects, may be beneficial to preserving their bone microstructure and strength.
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Affiliation(s)
- Varun S Venkatesh
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia; Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia.
| | - Tian Nie
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia.
| | - Suzanne Golub
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia.
| | - Kathryn S Stok
- Department of Biomedical Engineering, University of Melbourne, Parkville, Victoria 3010, Australia.
| | - Haniyeh Hemmatian
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia.
| | - Reena Desai
- ANZAC Research Institute, University of Sydney and Andrology, Concord Repatriation General Hospital, Concord, New South Wales 2137, Australia.
| | - David J Handelsman
- ANZAC Research Institute, University of Sydney and Andrology, Concord Repatriation General Hospital, Concord, New South Wales 2137, Australia.
| | - Jeffrey D Zajac
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia.
| | - Mathis Grossmann
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia; Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia.
| | - Rachel A Davey
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria 3084, Australia.
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Mullins TLK, Mullins ES. Thrombotic risk associated with gender-affirming hormone therapy. J Thromb Haemost 2024; 22:2129-2139. [PMID: 38795871 DOI: 10.1016/j.jtha.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/28/2024]
Abstract
Transgender and gender-expansive (TG) people-those who identify with a gender other than their assigned sex at birth-frequently experience gender dysphoria, which is associated with negative health outcomes. One key strategy for improving gender dysphoria is the use of gender-affirming hormone therapy (GAHT): estrogen for feminization and testosterone for masculinization. Estrogen use in cisgender women is associated with well-established changes in hemostatic parameters, including increases in prothrombotic factors and decreases in inhibitors of coagulation. Cisgender women using estrogen have an increased risk of thrombosis. Studies of thrombosis risk associated with estrogen GAHT in TG people are less robust, with some studies limited by the use of hormones and hormone management strategies that are no longer recommended. However, TG women using estrogen appear to be at increased risk of both arterial and venous thrombosis, which may increase with longer time on estrogen. Testosterone use in both cisgender and transgender men is associated with increases in hemoglobin and hematocrit, which can lead to erythrocytosis and thus increased risk of thrombosis. The results of studies evaluating thrombosis risk in the setting of testosterone use are mixed. This review presents an overview of alterations in hemostatic parameters and thrombosis risk associated with use of exogenous estrogen and testosterone. Understanding what is known and unknown about thrombosis risk associated with use of these hormones is essential for hematologists who may be asked to evaluate TG people and provide guidance on management of those who may be at increased risk of thrombosis.
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Affiliation(s)
- Tanya L Kowalczyk Mullins
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Eric S Mullins
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA; Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
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Nolan BJ, Cheung AS. Gender-affirming hormone therapy for transgender and gender-diverse adults in Australia. Intern Med J 2024. [PMID: 39056542 DOI: 10.1111/imj.16413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/29/2024] [Indexed: 07/28/2024]
Abstract
Gender-affirming hormone therapy (GAHT) is used by many transgender and gender-diverse adults to align physical characteristics with their gender identity, reduce gender incongruence and improve psychological functioning. This narrative review provides an overview of the initiation and monitoring of GAHT in an Australian context. Trans individuals treated with testosterone typically receive standard testosterone doses and formulations recommended for cisgender men, whereas those receiving estradiol GAHT are typically treated with estradiol in combination with an anti-androgen in those without orchidectomy. Proactive monitoring and mitigation of cardiovascular risk factors is pertinent in all transgender and gender-diverse adults and bone health is an important consideration in those using estradiol GAHT.
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Affiliation(s)
- Brendan J Nolan
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia
- Equinox Gender Diverse Clinic, Thorne Harbour Health, Melbourne, Victoria, Australia
| | - Ada S Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia
- Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia
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Edwardson S, Flower L, Fawcett E, Medlock R, Cheung AS, Kamaruddin K, McCormack VL, Agarwal S. Peri-operative care of transgender and gender-diverse individuals: guidance for clinicians and departments. Anaesthesia 2024. [PMID: 39043129 DOI: 10.1111/anae.16378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION The objective of this document is to guide best practice to ensure the safety and dignity of transgender and gender-diverse people in the peri-operative period. While transgender and gender-diverse people may have specific health needs in relation to gender dysphoria, their health requirements go beyond their gender identity. Most doctors will provide care to someone who is transgender or gender-diverse at some stage in their career. It is therefore important that all anaesthetists are educated on specific considerations when caring for these patients. METHODS A working party was assembled consisting of individuals with experience in direct clinical care of the relevant patient group, those who have expertise in endocrinology and gender-affirming hormones, educators on the topic of transgender and gender-diverse healthcare, and authors of both cisgender and transgender identities. After discussion among the working party, targeted searches of literature were undertaken. RESULTS The authors initially came up with a list of over 25 recommendations which was subsequently revised to a list of 15 recommendations after further review by the working party. These included airway assessment and management; management of hormonal therapy; relevant issues in obstetric anaesthesia; and hospital infrastructure and processes. CONCLUSIONS This document provides the first guidance produced to advise on best practice to ensure the safety and dignity of trans and gender-diverse individuals in the peri-operative period.
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Affiliation(s)
- Stuart Edwardson
- Department of Anaesthesia and Intensive Care Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Luke Flower
- Department of Medicine, Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- Department of Intensive Care Medicine, London School of Intensive Care Medicine, London, UK
| | - Erik Fawcett
- Department of Anaesthesia, Queen Elizabeth Hospital, Woolwich, UK
| | - Rebecca Medlock
- Department of Anaesthetics and Critical Care Hospital, Great Western Hospital, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Ada S Cheung
- Trans Health Research Group, Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Melbourne, Australia
| | - Kamilla Kamaruddin
- General Practitioner in Transgender Health Care and Clinical Lead East of England Gender Service, Cambridge, UK
| | - Victoria L McCormack
- Department of Anaesthesia and Critical Care Medicine, Manchester Royal Infirmary, Manchester Foundation Trust, Manchester, UK
| | - Seema Agarwal
- Department of Anaesthesia and Critical Care Medicine, Wythenshawe Hospital, Manchester Foundation Trust, Manchester, UK
- Manchester University, Manchester, UK
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Turan Ş, Özulucan MT, Karataş U, Kavla Y, Koyuncu O, Durcan E, Durcan G, Bağhaki S. The effects of gender-affirming hormone therapy and mastectomy on psychopathology, body image, and quality of life in adults with gender dysphoria who were assigned female at birth. Qual Life Res 2024; 33:1937-1947. [PMID: 38656406 PMCID: PMC11176246 DOI: 10.1007/s11136-024-03664-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE Individuals with gender dysphoria (GD) may request hormone therapy and various surgical operations to change their physical characteristics. The present study aimed to investigate the effects of two treatments, mastectomy and gender-affirming hormone therapy (GAHT), on adults with GD who were assigned female at birth (GD AFAB). METHODS In this cross-sectional study, we gathered data from a total of 269 individuals in three groups: (a) untreated group (n = 121), (b) GAHT group (n = 84) who had been receiving treatment for at least 6 months, and (c) GAHT-MAST group (n = 64) who had been using GAHT for at least 6 months and had undergone mastectomy at least 3 months prior. All participants were asked to complete the Symptom Checklist-90-Revised (SCL-90-R), the Body Uneasiness Test (BUT), and the World Health Organization's Quality of Life Questionnaire- Brief Form, Turkish Version (WHOQOL-BREF-Tr). RESULTS We found that individuals in the untreated group had higher psychopathological symptoms and body uneasiness scores, and lower quality of life scores compared to both GAHT and GAHT-MAST groups. There was no difference in psychopathology between the GAHT-MAST group and the GAHT group, but body uneasiness scores were lower, and quality of life scores were higher in the GAHT-MAST group. CONCLUSION Our study suggests that individuals receiving GAHT improved mental health, body satisfaction, and overall quality of life. Combining mastectomy with GAHT may further enhance these benefits.
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Affiliation(s)
- Şenol Turan
- Department of Psychiatry, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye.
| | - Mahmut Taha Özulucan
- Graduate School of Health Science, Neuroscience PhD Program, Koç University, Istanbul, Türkiye
| | - Uğur Karataş
- Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Yasin Kavla
- Department of Psychiatry, Hınıs State Hospital, Erzurum, Türkiye
| | - Oğuzhan Koyuncu
- Department of Child and Adolescent Psychiatry, Medeniyet University, Istanbul, Türkiye
| | - Emre Durcan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Gizem Durcan
- Department of Child and Adolescent Psychiatry, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Semih Bağhaki
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye
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Sánchez Amador L, Becerra Fernández A, Aguilar Vilas MV, Rodríguez Torres R, Alonso Rodríguez MC. Body composition and risk for sarcopenia in transgender women. Nutrition 2024; 123:112398. [PMID: 38521048 DOI: 10.1016/j.nut.2024.112398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/18/2024] [Accepted: 02/13/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVES Body composition and strength of cisgender (cis) individuals are well established. However, those for transgender women (trans women) undergoing gender-affirming hormone therapy remain unclear. This study aimed to detect possible body composition and strength variations related to sarcopenia. METHODS This was a cross-sectional comparative study of 37 trans women, 34 cis men, and 34 cis women. Body composition was measured in all individuals by bioelectrical impedance analysis; prehensile strength by dynamometry was studied in trans women. RESULTS In this study, trans women had higher body mass index values than cis individuals (P < 0.01). Fat mass was 41% higher for trans women than cis men. Muscle mass (MM) was lower in trans women than cis men (-10%), and higher than cis women (24%). Bone mass was lower in trans women than cis men and higher in cis women (P < 0.01). Trans women's prehensile strengths were 25.26 kg for the right hand and 24.8 kg for the left. Appendicular skeletal muscle mass was 23.63 kg, and appendicular skeletal muscle mass index was 8.14 kg. CONCLUSION Trans women undergoing gender-affirming hormone therapy show a tendency to adapt body compartments to those of cis women with increased fat mass and reduced muscle mass. Prehensile strength in trans women was close to the cutoff points for sarcopenia risk. Nutrition, physical activity, strength, and body composition are important to avoid the possible risk for sarcopenia. More studies along these lines are necessary, especially in older adults.
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Affiliation(s)
- Laura Sánchez Amador
- Food, Nutrition and Public Health Strategies Research Group, University of Alcala, Alcalá de Henares, Madrid, Spain.
| | - Antonio Becerra Fernández
- Food, Nutrition and Public Health Strategies Research Group, University of Alcala, Alcalá de Henares, Madrid, Spain; Department of Biomedical Sciences, Faculty of Pharmacy, University of Alcala, Alcalá de Henares, Madrid, Spain
| | - María Victorina Aguilar Vilas
- Food, Nutrition and Public Health Strategies Research Group, University of Alcala, Alcalá de Henares, Madrid, Spain; Department of Biomedical Sciences, Faculty of Pharmacy, University of Alcala, Alcalá de Henares, Madrid, Spain
| | - Rosa Rodríguez Torres
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcala, Alcalá de Henares, Madrid, Spain
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Fowler JA, Warzywoda S, Reyment M, Crilly T, Franks N, Bisshop F, Wood P, Dean JA. One person, many changes: a socioecological qualitative analysis of the experiences of transfeminine individuals undergoing feminising gender-affirming hormone therapy. CULTURE, HEALTH & SEXUALITY 2024:1-17. [PMID: 38829652 DOI: 10.1080/13691058.2024.2358099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/17/2024] [Indexed: 06/05/2024]
Abstract
Gender-affirming hormone therapy (GAHT) comes with many physical, psychological, and social changes that are often considered in isolation. This research uses a socioecological lens with a sample of 15 Australian transfeminine individuals to investigate the changes experienced during GAHT. Semi-structured interviews were conducted in 2022, with verbatim transcripts analysed using deductive thematic analysis with Bronfenbrenner's Socioecological Model (SEM) as a framework. Analyses revealed two themes intersecting multiple levels of the SEM. Theme 1 contained two sub-themes and broadly encapsulated how interactions with others influenced GAHT experiences. Sub-theme 1 spoke to how stigma creates positive or negative experiences (through the macrosystem, the exosystem, and proximal processes), while sub-theme 2 described how GAHT causes internal changes that promoted stronger interpersonal relationships (person and proximal processes). Theme 2 described how changes occurred over time, with some changes being temporary, and others being delayed (person and time). These themes highlight the interconnected nature of the physical, psychological, and social changes and experiences that can occur during GAHT. Best-practice care for trans people undergoing GAHT needs to be multi-faceted and holistic in order to embed support across different SEM components.
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Affiliation(s)
- James A Fowler
- The University of Queensland, Faculty of Medicine, School of Public Health, Herston, QLD, Australia
| | - Sarah Warzywoda
- The University of Queensland, Faculty of Medicine, School of Public Health, Herston, QLD, Australia
| | - Mera Reyment
- The University of Queensland, Faculty of Health and Behavioural Sciences, School of Psychology, St Lucia, QLD, Australia
| | - Tyson Crilly
- The University of Queensland, Faculty of Health and Behavioural Sciences, School of Psychology, St Lucia, QLD, Australia
| | - Nia Franks
- School of Psychology and Counselling, Faculty of Health, Engineering and Sciences, Centre for Health Research, Institute for Resilient Regions, University of Southern Queensland, Ipswich, QLD, Australia
| | - Fiona Bisshop
- Holdsworth House Medical Practice, Brisbane, QLD, Australia
| | - Penny Wood
- Alexander Heights Family Practice, Perth, WA, Australia
| | - Judith A Dean
- The University of Queensland, Faculty of Medicine, School of Public Health, Herston, QLD, Australia
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Shepherd R, Angus LM, Mansell T, Arman B, Kim BW, Lange K, Burgner D, Kerr JA, Pang K, Zajac JD, Saffery R, Cheung A, Novakovic B. Impact of Distinct Anti-Androgen Exposures on the Plasma Metabolome in Feminizing Gender-Affirming Hormone Therapy. J Clin Endocrinol Metab 2024:dgae226. [PMID: 38609170 DOI: 10.1210/clinem/dgae226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/06/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
CONTEXT The plasma metabolome is a functional readout of metabolic activity and is associated with phenotypes exhibiting sexual dimorphism, such as cardiovascular disease. Sex hormones are thought to play a key role in driving sexual dimorphism. OBJECTIVE Gender-affirming hormone therapy (GAHT) is a cornerstone of transgender care, but longitudinal changes in the plasma metabolome with feminizing GAHT have not been described. METHODS Blood samples were collected at baseline and after three and six months of GAHT from transgender women (n = 53). Participants were randomized to different anti-androgens, cyproterone acetate or spironolactone. NMR-based metabolomics was used to measure 249 metabolic biomarkers in plasma. Additionally, we used metabolic biomarker data from an unrelated cohort of children and their parents (n = 3,748) to identify sex- and age-related metabolite patterns. RESULTS We identified 43 metabolic biomarkers altered after six months in both anti-androgen groups, most belonging to the very low- or low-density lipoprotein subclasses, with all but one showing a decrease. We observed a cyproterone acetate-specific decrease in glutamine, glycine, and alanine levels. Notably, of the metabolic biomarkers exhibiting the most abundant 'sex- and age-related' pattern (higher in assigned female children and lower in assigned female adults, relative to assigned males), 80% were significantly lowered after GAHT, reflecting a shift toward the adult female profile. CONCLUSION Our results suggest an anti-atherogenic signature in the plasma metabolome after the first six months of feminizing GAHT, with cyproterone acetate also reducing specific plasma amino acids. This study provides novel insight into the metabolic changes occurring across feminizing GAHT.
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Affiliation(s)
- Rebecca Shepherd
- Molecular Immunity, Infection and Immunity Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Lachlan M Angus
- Department of Medicine (Austin Health), The University of Melbourne, Parkville, VIC, Australia
- Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
| | - Toby Mansell
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
- Inflammatory Origins, Infection and Immunity Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Bridget Arman
- Therapeutics Discovery and Vascular Function Group, Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, Heidelberg, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Bo Won Kim
- Molecular Immunity, Infection and Immunity Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
| | - Katherine Lange
- The Centre for Community Child Health, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
| | - David Burgner
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
- Inflammatory Origins, Infection and Immunity Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Jessica A Kerr
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
- University of Otago, Department of Psychological Medicine, Christchurch, New Zealand
- Murdoch Children's Research Institute, Centre for Adolescent Health, Population Health Theme, Parkville, VIC, Australia
- University of Melbourne, Department of Paediatrics, Parkville, VIC, Australia
| | - Ken Pang
- Brain and Mind Research, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
- Department of Adolescent Medicine, Royal Children's Hospital, Parkville, VIC, Australia
| | - Jeffrey D Zajac
- Department of Medicine (Austin Health), The University of Melbourne, Parkville, VIC, Australia
- Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
| | - Richard Saffery
- Molecular Immunity, Infection and Immunity Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
| | - Ada Cheung
- Department of Medicine (Austin Health), The University of Melbourne, Parkville, VIC, Australia
- Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
| | - Boris Novakovic
- Molecular Immunity, Infection and Immunity Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia
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9
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Sundaram V, Stark B, Jaswa E, Letourneau J, Mok-Lin E. Decision regret, and other mental health outcomes, following fertility preservation in the transgender individual compared to the cisgender woman. J Assist Reprod Genet 2024; 41:1077-1085. [PMID: 38332415 PMCID: PMC11052947 DOI: 10.1007/s10815-023-03013-5] [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: 05/01/2023] [Accepted: 12/20/2023] [Indexed: 02/10/2024] Open
Abstract
PURPOSE This study aimed to (1) determine differences in depression, anxiety, body image, quality-of-life (QOL), and decision regret scale (DRS) scores in transgender individuals undergoing fertility preservation (FP) compared to those who decline and (2) determine if DRS score following FP varies between transgender individuals and cisgender women. METHODS Sixteen transgender birth-assigned (BA) females and 13 BA males, undergoing FP consultation at an academic center between January 2016 and November 2019, were compared to each other and cisgender cohorts with pre-existing data: 201 women undergoing elective oocyte cryopreservation (EOC) between 2012 and 2016 and 44 women with cancer undergoing FP between 1993 and 2007. Outcomes included demographics; validated scales for depression, anxiety, body image, QOL (see below) in the trans cohort; DRS score in all three cohorts. RESULTS Of 29 transgender individuals participating, 10 BA females (62%) and 12 BA males (92%) underwent FP. Beck Depression Inventory II, Hospital Anxiety and Depression Scale, Body Image Scale for Transsexuals, Satisfaction with Life Scale, Short Form Health Survey-36, and DRS scores were not significantly different between trans individuals who underwent FP and those who declined. On univariate modeling, regret was significantly lower in transpeople undergoing FP compared to those who did not (OR 0.118, p = 0.03). BA female and BA male transpatients undergoing FP reported DRS median scores 5 (mean 9) and 7.5 (mean 15), respectively, both were not significantly different from cisgender women (p = 0.97, p = 0.25) nor from each other (p = 0.43). CONCLUSIONS Depression, anxiety, body image, and QOL, in a group of individuals presenting for FP consultation, appear similar between transpeople undergoing FP and not, while regret is significantly lower in those choosing FP. FP is an option for transgender individuals without significant differences in regret compared to cisgender women.
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Affiliation(s)
- Viji Sundaram
- Florida Institute for Reproductive Medicine, 836 Prudential Dr, Suite 902, Jacksonville, FL, 32207, USA.
| | - Brett Stark
- University of California, San Francisco, 499 Illinois St, San Francisco, CA, 94158, USA
| | - Eleni Jaswa
- University of California, San Francisco, 499 Illinois St, San Francisco, CA, 94158, USA
| | | | - Evelyn Mok-Lin
- University of California, San Francisco, 499 Illinois St, San Francisco, CA, 94158, USA
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10
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Lad SU, Sinopoli J, Khong B, Conroy B, Perzynski AT, Del Rincon JP. Clinical and sociodemographic characteristics as predictors for quality of life in transmasculine and transfeminine individuals receiving gender-affirming hormone therapy. Soc Sci Med 2024:116734. [PMID: 38490912 DOI: 10.1016/j.socscimed.2024.116734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 02/14/2024] [Accepted: 02/26/2024] [Indexed: 03/17/2024]
Abstract
Healthcare systems and providers have increasingly acknowledged the role and impact of social determinants in overall health. However, gender-diverse individuals face persistent health disparities due to their identities. There is limited research on the impact of clinical and sociodemographic characteristics on mood and quality of life (QoL) for transgender (TG) individuals. Our study aims to understand and better elucidate social and clinical characteristics of transmasculine (TM) and transfeminine (TF) individuals and their impact on quality of life and depressive symptoms. In this cross-sectional study, 298 TF and TM individuals on gender-affirming hormone therapy (GAHT) were surveyed about their demographic characteristics (age, gender identity, body mass index (BMI), and education), social needs, mood, and quality of life. Multivariable regression modelling was performed to assess the effect of each variable listed above on three domains of QoL (psychological, environmental, and physical) as well as depressive symptoms. We find that QoL scores are similar between TM and TF individuals, with scores in the psychological domain particularly low in both cohorts. TM individuals report higher rates of stress and restroom avoidance than TF individuals. In particular, psychological well-being (measured by the psychological domain of QoL and depressive symptoms) is significantly associated with increased BMI, financial instability, and stress in TM individuals while for TF individuals, psychological well-being is associated with stress and social integration. These data suggest that social circumstances are key drivers of QoL and psychological well-being among gender-diverse individuals receiving GAHT with specific differences between TF and TM individuals. This information may be utilized by healthcare providers and policymakers to address and improve clinical care and social policies to improve health equity for gender-diverse individuals.
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Affiliation(s)
- Saloni U Lad
- Cleveland Clinic Lerner College of Medicine, 9501 Euclid Ave., Cleveland, OH, 44195, USA.
| | - Jacob Sinopoli
- The Chester Summer Scholars Program, MetroHealth Medical System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA; Case Western Reserve University, Cleveland, OH, USA.
| | - Brian Khong
- Department of Medicine, MetroHealth System, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
| | - Britt Conroy
- Case Western Reserve University, Cleveland, OH, USA; Department of Urology and Family Medicine & Community Health, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH, 44106, USA.
| | - Adam T Perzynski
- Center for Healthcare Research and Policy, Case Western Reserve University at MetroHealth, 10900 Euclid Ave., Cleveland, OH, 44106, USA.
| | - Juan P Del Rincon
- Case Western Reserve University, Cleveland, OH, USA; Department of Medicine, MetroHealth System, Cleveland, OH, USA; Endocrinology and Metabolism Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA.
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11
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Craft RM, Sewell CM, Taylor TM, Vo MS, Delevich K, Morgan MM. Impact of continuous testosterone exposure on reproductive physiology, activity, and pain-related behavior in young adult female rats. Horm Behav 2024; 158:105469. [PMID: 38091929 DOI: 10.1016/j.yhbeh.2023.105469] [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: 09/01/2023] [Revised: 12/02/2023] [Accepted: 12/04/2023] [Indexed: 02/05/2024]
Abstract
Testosterone may reduce pain in cisgender women and transgender men. Rodents can provide a useful model for investigating physiological effects of hormone therapy. To this end, continuous-release testosterone or blank (placebo) capsules were implanted s.c. into young adult female rats, and three weeks later rats were either ovariectomized or sham-ovariectomized. Testosterone treatment that mimicked previously reported endogenous levels in males eliminated estrous cycling and decreased uterine weight. Testosterone also significantly increased body weight and suppressed the increases in daily wheel running observed in placebo controls over time. Subsequent ovariectomy or sham-ovariectomy decreased wheel running in all groups, but testosterone-treated rats recovered significantly more quickly than did placebo-treated rats. Neither testosterone nor ovariectomy significantly altered hindpaw mechanical threshold. Two weeks after sham/ovariectomy surgery, injection of Complete Freund Adjuvant (CFA) into one hindpaw reduced wheel running and mechanical threshold in all groups; running significantly decreased from the first to second day after CFA in testosterone- but not in placebo-treated rats. Morphine 1.0 but not 3.2 mg/kg increased CFA-suppressed wheel running similarly in all groups, whereas both doses of morphine increased CFA-suppressed mechanical threshold. These data suggest that weeks-long testosterone treatment with or without ovariectomy may provide a useful physiological model of testosterone therapy as used in human gender transition. Although testosterone administered at levels similar to those in gonadally intact males tended to hasten female rats' recovery from surgery, it did not decrease maximal pain-related behaviors after surgery or hindpaw inflammatory insult, nor did it alter opioid antinociception.
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Affiliation(s)
- Rebecca M Craft
- Department of Psychology, Washington State University, Pullman and Vancouver, WA, United States of America.
| | - Christyne M Sewell
- Department of Psychology, Washington State University, Pullman and Vancouver, WA, United States of America
| | - Tessa M Taylor
- Department of Psychology, Washington State University, Pullman and Vancouver, WA, United States of America
| | - Mai Suong Vo
- Department of Psychology, Washington State University, Pullman and Vancouver, WA, United States of America
| | - Kristen Delevich
- Department of Integrative Physiology and Neuroscience, Washington State University, Pullman, WA, United States of America
| | - Michael M Morgan
- Department of Psychology, Washington State University, Pullman and Vancouver, WA, United States of America
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12
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Hassan B, Schuster CR, Ascha M, Del Corral G, Fischer B, Liang F. Association of High Body Mass Index With Postoperative Complications After Chest Masculinization Surgery. Ann Plast Surg 2024; 92:174-180. [PMID: 37917575 DOI: 10.1097/sap.0000000000003737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
PURPOSE Body mass index (BMI) requirements for transgender and nonbinary patients undergoing chest masculinization surgery (CMS) are not standardized and based on small sample sizes. This is the largest and first national retrospective study to determine the association between BMI and postoperative complications. METHODS The National Surgical Quality Improvement Program 2012-2020 was queried for CMS patients. The primary outcome was incidence of at least one complication within 30 days. Secondary outcomes were incidence of major and minor complications. Body mass index (in kilograms per square meter) was categorized as category 0 (<30), 1 (30-34.9), 2 (35-39.9), 3 (40-44.9), 4 (45-49.9), and 5 (≥50). Logistic regression was used to evaluate the association between BMI and outcomes. RESULTS Of 2317 patients, median BMI was 27.4 kg/m 2 (interquartile range, 23.4-32.2 kg/m 2 ). Body mass index range was 15.6 to 64.9 kg/m 2 . While increasing BMI was significantly associated with greater odds of at least one complication, no patients experienced severe morbidity, regardless of BMI. Patients with BMI ≥50 kg/m 2 had an adjusted odds ratio [aOR, 95% confidence interval (CI)] of 3.63 (1.02-12.85) and 36.62 (2.96->100) greater odds of at least one complication and urinary tract infection compared with nonobese patients, respectively. Patients with BMI ≥35 kg/m 2 had an adjusted odds ratio (95% CI) of 5.06 (1.5-17.04) and 5.13 (1.89-13.95) greater odds of readmission and surgical site infection compared with nonobese patients, respectively. CONCLUSIONS Chest masculinization surgery in higher BMI patients is associated with greater odds of unplanned readmission. Given the low risk for severe complications in higher BMI individuals, we recommend re-evaluation of BMI cutoffs for CMS patients.
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Affiliation(s)
- Bashar Hassan
- From the Department of Plastic and Reconstructive Surgery, Center for Transgender and Gender Expansive Health, Johns Hopkins University
| | | | - Mona Ascha
- From the Department of Plastic and Reconstructive Surgery, Center for Transgender and Gender Expansive Health, Johns Hopkins University
| | - Gabriel Del Corral
- Department of Plastic and Reconstructive Surgery, Medstar Georgetown University Hospital, Baltimore
| | - Beverly Fischer
- The Advanced Center for Plastic Surgery, Lutherville-Timonium, MD
| | - Fan Liang
- From the Department of Plastic and Reconstructive Surgery, Center for Transgender and Gender Expansive Health, Johns Hopkins University
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13
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Gu Y, Tang GT, Cheung ASZ, Sebaratnam DF. Dermatological considerations for transgender and gender diverse patients: An Australian perspective. Australas J Dermatol 2024; 65:24-36. [PMID: 37919972 DOI: 10.1111/ajd.14179] [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: 08/01/2023] [Revised: 10/04/2023] [Accepted: 10/08/2023] [Indexed: 11/04/2023]
Abstract
Transgender and gender diverse (TGD) individuals are a group that experiences significant health disparities. In the multidisciplinary management of TGD patients, dermatologists may participate in managing skin- and hair-related issues which contribute to gender affirmation and to the cutaneous sequelae of gender-affirming hormone therapy. This review aims to highlight the unique needs of TGD patients, particularly from the perspective of Australian dermatologists. We review appropriate terminology critical for TGD care, gender affirmation in the Australian healthcare landscape, dermatological considerations for TGD patients and considerations for management.
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Affiliation(s)
- Yaron Gu
- Faculty of Medicine and Health, The University of New South Wales, Kensington, New South Wales, Australia
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Gia Toan Tang
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, Victoria, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
| | - Ada Sau-Zhuen Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, Victoria, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
| | - Deshan Frank Sebaratnam
- Faculty of Medicine and Health, The University of New South Wales, Kensington, New South Wales, Australia
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia
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14
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Cheung AS, Zwickl S, Miller K, Nolan BJ, Wong AFQ, Jones P, Eynon N. The Impact of Gender-Affirming Hormone Therapy on Physical Performance. J Clin Endocrinol Metab 2024; 109:e455-e465. [PMID: 37437247 PMCID: PMC10795902 DOI: 10.1210/clinem/dgad414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/14/2023]
Abstract
CONTEXT The inclusion of transgender people in elite sport has been a topic of debate. This narrative review examines the impact of gender-affirming hormone therapy (GAHT) on physical performance, muscle strength, and markers of endurance. EVIDENCE ACQUISITION MEDLINE and Embase were searched using terms to define the population (transgender), intervention (GAHT), and physical performance outcomes. EVIDENCE SYNTHESIS Existing literature comprises cross-sectional or small uncontrolled longitudinal studies of short duration. In nonathletic trans men starting testosterone therapy, within 1 year, muscle mass and strength increased and, by 3 years, physical performance (push-ups, sit-ups, run time) improved to the level of cisgender men. In nonathletic trans women, feminizing hormone therapy increased fat mass by approximately 30% and decreased muscle mass by approximately 5% after 12 months, and steadily declined beyond 3 years. While absolute lean mass remains higher in trans women, relative percentage lean mass and fat mass (and muscle strength corrected for lean mass), hemoglobin, and VO2 peak corrected for weight was no different to cisgender women. After 2 years of GAHT, no advantage was observed for physical performance measured by running time or in trans women. By 4 years, there was no advantage in sit-ups. While push-up performance declined in trans women, a statistical advantage remained relative to cisgender women. CONCLUSION Limited evidence suggests that physical performance of nonathletic trans people who have undergone GAHT for at least 2 years approaches that of cisgender controls. Further controlled longitudinal research is needed in trans athletes and nonathletes.
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Affiliation(s)
- Ada S Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg 3084, Australia
| | - Sav Zwickl
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
| | | | - Brendan J Nolan
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg 3084, Australia
| | - Alex Fang Qi Wong
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne 3084, Australia
| | - Patrice Jones
- Institute for Health and Sport (IHeS), Victoria University, Footscray 3011, Australia
| | - Nir Eynon
- Institute for Health and Sport (IHeS), Victoria University, Footscray 3011, Australia
- Australian Regenerative Medicine Institute, Monash University, Clayton 3800, Australia
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15
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Zwickl S, Ruggles T, Wong AFQ, Ginger A, Angus LM, Eshin K, Cook T, Cheung AS. Disruption of gender-affirming health care, and COVID-19 illness, testing, and vaccination among trans Australians during the pandemic: a cross-sectional survey. Med J Aust 2024; 220:23-28. [PMID: 37994182 PMCID: PMC10952718 DOI: 10.5694/mja2.52169] [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: 05/16/2023] [Accepted: 08/23/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVES To assess rates of disruption of gender-affirming health care, of coronavirus disease 2019 (COVID-19) illness, testing, and vaccination, and of discrimination in health care among Australian trans people during the COVID-19 pandemic. DESIGN, SETTING Online cross-sectional survey (1-31 May 2022); respondents were participants recruited by snowball sampling for TRANSform, an Australian longitudinal survey-based trans health study, 1 May - 30 June 2020. PARTICIPANTS People aged 16 years or older, currently living in Australia, and with a gender different to their sex recorded at birth. MAIN OUTCOME MEASURES Proportions of respondents who reported disruptions to gender-affirming health care, COVID-19 illness, testing, and vaccination, and positive and negative experiences during health care. RESULTS Of 875 people invited, 516 provided valid survey responses (59%). Their median age was 33 years (interquartile range, 26-45 years); 193 identified as women or trans women (37%), 185 as men or trans men (36%), and 138 as non-binary (27%). Of 448 respondents receiving gender-affirming hormone therapy, 230 (49%) reported disruptions to treatment during the pandemic; booked gender-affirming surgery had been cancelled or postponed for 37 of 85 respondents (44%). Trans-related discrimination during health care was reported by a larger proportion of participants than in a pre-pandemic survey (56% v 26%). COVID-19 was reported by 132 respondents (26%), of whom 49 reported health consequences three months or more after the acute illness (37%; estimated Australian rate: 5-10%). Three or more COVID-19 vaccine doses were reported by 448 participants (87%; Australian adult rate: 70%). CONCLUSIONS High rates of COVID-19 vaccination among the trans people we surveyed may reflect the effectiveness of LGBTIQA+ community-controlled organisation vaccination programs and targeted health promotion. Training health care professionals in inclusive services for trans people could improve access to appropriate health care and reduce discrimination.
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Affiliation(s)
| | | | | | | | - Lachlan M Angus
- The University of MelbourneMelbourneVIC
- Austin HealthMelbourneVIC
| | | | | | - Ada S Cheung
- The University of MelbourneMelbourneVIC
- Austin HealthMelbourneVIC
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16
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Rezaei SJ, Miranda N, Bene NC, Ganor O. The Current State of Transgender Health Curricula in Graduate Surgical Education: A Systematic Review of Survey Data. JOURNAL OF SURGICAL EDUCATION 2023; 80:1826-1835. [PMID: 37658003 DOI: 10.1016/j.jsurg.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/29/2023] [Accepted: 08/02/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVES Transgender and gender diverse (TGD) individuals in the U.S. face significant healthcare disparities, which can be further exacerbated by providers' unfamiliarity with this population's specific needs. ACGME currently does not have requirements for gender-affirming surgery (GAS) in the residency programs of surgical specialties that are responsible for providing this care. This systematic review evaluates gender-affirming care (GAC) and GAS training in surgical residency programs in the U.S. through the analysis of survey respondent data. METHODS Six databases (PubMed, Embase, Web of Science and Scopus, Cochrane Library and Google Scholar) were searched in December 2022 and May 2023. The search process ultimately yielded 22 survey-based studies, published between 2015 and 2023, with responses from 3020 respondents (2582 trainees and/or attending physicians, 438 program directors). RESULTS Six different surgical specialties were the focus of included studies, and common questions revolved around GAS training availability, comfort in treating TGD patients, and the importance of GAS in graduate surgical education (GSE). Less than half of trainees indicated that they received some form of previous GAC or GAS training, and less than half of program directors indicated that their residency or fellowship program offered such training. CONCLUSIONS While comfort levels around treating TGD patients ranged, the studies indicated an overall perceived importance of GAS training. These findings highlight the need to incorporate GAS training into graduate surgical education to improve access to and quality of care for TGD patients.
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Affiliation(s)
- Shawheen J Rezaei
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts; Stanford University School of Medicine, Stanford, California.
| | - Noah Miranda
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts; UMass Chan Medical School, Worcester, Massachusetts
| | - Nicholas C Bene
- Division of Plastic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Oren Ganor
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
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17
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Yaish I, Gindis G, Greenman Y, Moshe Y, Arbiv M, Buch A, Sofer Y, Shefer G, Tordjman K. 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. Transgend Health 2023; 8:485-493. [PMID: 38130980 PMCID: PMC10732161 DOI: 10.1089/trgh.2023.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
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.
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Affiliation(s)
- Iris Yaish
- Institute of Endocrinology, Metabolism, and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Guy Gindis
- Institute of Endocrinology, Metabolism, and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Yona Greenman
- Institute of Endocrinology, Metabolism, and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Yaffa Moshe
- Institute of Endocrinology, Metabolism, and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Mira Arbiv
- Institute of Endocrinology, Metabolism, and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Assaf Buch
- Institute of Endocrinology, Metabolism, and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Yael Sofer
- Institute of Endocrinology, Metabolism, and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Gabi Shefer
- Institute of Endocrinology, Metabolism, and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Karen Tordjman
- Institute of Endocrinology, Metabolism, and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
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18
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Miro EW, Taylor E, Curtin A, Newman MG, Ose D, Knox J. Cumulative Incidence of All-Cause Knee Injury, Concussion, and Stress Fracture among Transgender Patients on Gender-Affirming Hormone Therapy: An Exploratory Retrospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7060. [PMID: 37998291 PMCID: PMC10671107 DOI: 10.3390/ijerph20227060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023]
Abstract
Previous research has shown a discrepancy in incidences of knee injuries, stress fractures, and concussions between cisgender men and women. Little is known regarding the incidence of musculoskeletal injuries among patients on gender-affirming hormone therapy (GAHT). This retrospective cohort study examines cumulative incidence of knee injuries, concussions, and stress fracture injuries among transgender patients on GAHT at one health system from 2011-2020. Using relevant ICD-9 and 10 codes, incidences of knee injury, concussion, and stress fracture were calculated. Cohorts included 1971 transgender and 3964 cisgender patients. Transgender patients had significantly higher incidence of all-cause knee injuries over the study period, 109 (5.5%) versus 175 (4.4%) (p < 0.001; OR: 2.14, 95% CI [1.17-3.92]). Subgroup analysis showed significantly higher incidence of knee injuries among cisgender men (5.6%) versus cisgender women (4.1%) (p = 0.042) and among transgender women (6.6%) versus cisgender women (4.1%) (p = 0.005). There were no significant differences between incidences of concussion and stress fracture between groups. This sample showed that patients on GAHT had increased cumulative incidences of all-cause knee injury compared to controls but similar cumulative incidences of concussion and bone-stress injuries. Transgender women on exogenous estrogen had significantly higher cumulative incidences of all-cause knee injuries compared to cisgender women.
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Affiliation(s)
- Emily W. Miro
- Division of Family Medicine, Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT 84108, USA
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19
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Glick H, Tang M, Daignault-Newton S, Hadj-Moussa M. Assessment of neophallus length following metoidioplasty. Transl Androl Urol 2023; 12:1390-1396. [PMID: 37814700 PMCID: PMC10560337 DOI: 10.21037/tau-23-155] [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: 03/08/2023] [Accepted: 08/03/2023] [Indexed: 10/11/2023] Open
Abstract
Background An increasing number of gender diverse individuals are presenting for gender affirming care. An option for genital gender affirming surgery (gGAS) in transmasculine individuals is metoidioplasty, creating a small neophallus from enlarged clitoral tissue following prolonged testosterone exposure. The goal of this study is to understand factors which contribute to greater exposed neophallus length following metoidioplasty. Methods We performed a retrospective chart review on patients presenting to a single academic institution who underwent a metoidioplasty. All operations were performed using the Belgrade technique with or without urethral lengthening depending on patient preference. Results Twenty-seven patients underwent metoidioplasty from 2017-2022. Sixteen had recorded stretched clitoral length (pre-operatively) and exposed neophallus length (post-operatively). The median length of time on testosterone therapy was 4.6 years. The median stretched clitoral length was 5.8 cm, and exposed neophallus length was 6 cm. There was a strong correlation between pre-operative length and post-operative length (ρ=0.9; P<0.0001). There were no correlations between pre-operative length or exposed neophallus length and BMI (ρ=-0.02, P=0.93; ρ=0.05, P=0.83, respectively). Time on testosterone does not correlate with stretched clitoral length nor exposed neophallus length (ρ=-0.28, P=0.15; ρ=-0.35, P=0.18, respectively). Conclusions Patients considering metoidioplasty often wonder how large their neophallus will be. We found that patients can expect exposed neophallus length to be about 0.6 cm longer than their pre-operative stretched clitoral length. No evidence of association of time on testosterone nor BMI with exposed neophallus length was found. This information is crucial for gender diverse patients to make informed decisions about gGAS.
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Affiliation(s)
| | - Michael Tang
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
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20
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Nolan BJ, Zwickl S, Locke P, Zajac JD, Cheung AS. Early Access to Testosterone Therapy in Transgender and Gender-Diverse Adults Seeking Masculinization: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2331919. [PMID: 37676662 PMCID: PMC10485726 DOI: 10.1001/jamanetworkopen.2023.31919] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 07/27/2023] [Indexed: 09/08/2023] Open
Abstract
Importance Testosterone treatment is a necessary component of care for some transgender and gender-diverse individuals. Observational studies have reported associations between commencement of gender-affirming hormone therapy and improvements in gender dysphoria and depression, but there is a lack of data from randomized clinical trials. Objective To assess the effect of testosterone therapy compared with no treatment on gender dysphoria, depression, and suicidality in transgender and gender-diverse adults seeking masculinization. Design, Setting, and Participants A 3-month open-label randomized clinical trial was conducted at endocrinology outpatient clinics and primary care clinics specializing in transgender and gender-diverse health in Melbourne, Australia, from November 1, 2021, to July 22, 2022. Participants included transgender and gender-diverse adults aged 18 to 70 years seeking initiation of testosterone therapy. Interventions Immediate initiation of testosterone commencement (intervention group) or no treatment (standard care waiting list of 3 months before commencement). This design ensured no individuals would be waiting longer than the time to standard care. Main Outcomes and Measures The primary outcome was gender dysphoria, as measured by the Gender Preoccupation and Stability Questionnaire. Secondary outcomes included the Patient Health Questionnaire-9 (PHQ-9) to assess depression and the Suicidal Ideation Attributes Scale (SIDAS) to assess suicidality. Questionnaires were undertaken at 0 and 3 months. The evaluable cohort was analyzed. Results Sixty-four transgender and gender-diverse adults (median [IQR] age, 22.5 [20-27] years) were randomized. Compared with standard care, the intervention group had a decrease in gender dysphoria (mean difference, -7.2 points; 95% CI, -8.3 to -6.1 points; P < .001), a clinically significant decrease in depression (ie, change in score of 5 points on PHQ-9; mean difference, -5.6 points; 95% CI, -6.8 to -4.4 points; P < .001), and a significant decrease in suicidality (mean difference in SIDAS score, -6.5 points; 95% CI, -8.2 to -4.8 points; P < .001). Resolution of suicidality assessed by PHQ-9 item 9 occurred in 11 individuals (52%) with immediate testosterone commencement compared with 1 (5%) receiving standard care (P = .002). Seven individuals reported injection site pain/discomfort and 1 individual reported a transient headache 24 hours following intramuscular administration of testosterone undecanoate. No individual developed polycythemia. Conclusions and Relevance In this open-label randomized clinical trial of testosterone therapy in transgender and gender-diverse adults, immediate testosterone compared with no treatment significantly reduced gender dysphoria, depression, and suicidality in transgender and gender-diverse individuals desiring testosterone therapy. Trial Registration ANZCTR Identifier: ACTRN1262100016864.
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Affiliation(s)
- Brendan J. Nolan
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
- Equinox Gender Diverse Clinic, Thorne Harbour Health, Abbotsford, Victoria, Australia
| | - Sav Zwickl
- Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
| | - Peter Locke
- Equinox Gender Diverse Clinic, Thorne Harbour Health, Abbotsford, Victoria, Australia
| | - Jeffrey D. Zajac
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
| | - Ada S. Cheung
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Heidelberg, Victoria, Australia
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21
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Doyle DM, Lewis TOG, Barreto M. A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people. Nat Hum Behav 2023; 7:1320-1331. [PMID: 37217739 PMCID: PMC10444622 DOI: 10.1038/s41562-023-01605-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/12/2023] [Indexed: 05/24/2023]
Abstract
This systematic review assessed the state and quality of evidence for effects of gender-affirming hormone therapy on psychosocial functioning. Forty-six relevant journal articles (six qualitative, 21 cross-sectional, 19 prospective cohort) were identified. Gender-affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress. Evidence for quality of life was inconsistent, with some trends suggesting improvements. There was some evidence of affective changes differing for those on masculinizing versus feminizing hormone therapy. Results for self-mastery effects were ambiguous, with some studies suggesting greater anger expression, particularly among those on masculinizing hormone therapy, but no increase in anger intensity. There were some trends toward positive change in interpersonal functioning. Overall, risk of bias was highly variable between studies. Small samples and lack of adjustment for key confounders limited causal inferences. More high-quality evidence for psychosocial effects of gender-affirming hormone therapy is vital for ensuring health equity for transgender people.
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Affiliation(s)
- David Matthew Doyle
- Department of Medical Psychology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands.
| | - Tom O G Lewis
- Department of Psychology, University of Exeter, Exeter, UK
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22
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Ashley F, Tordoff DM, Olson-Kennedy J, Restar AJ. Randomized-controlled trials are methodologically inappropriate in adolescent transgender healthcare. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2023; 25:407-418. [PMID: 39055634 PMCID: PMC11268232 DOI: 10.1080/26895269.2023.2218357] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Background Despite multiple rigorous observational studies documenting the association between positive mental health outcomes and access to puberty blockers, hormone therapy, and transition-related surgeries among adolescents, some jurisdictions have banned or are attempting to ban gender-affirming medical interventions for minors due to an absence of randomized-controlled trials (RCTs) proving their mental health benefits. Methods This article critically reviews whether RCTs are methodologically appropriate for studying the association between adolescent gender-affirming care and mental health outcomes. Results The scientific value of RCTs is severely impeded when studying the impact of gender-affirming care on the mental health of trans adolescent. Gender-affirming interventions have physiologically evident effects and are highly desired by participants, giving rise to concerns over adherence, drop-out, response bias, and generalizability. Complementary and well-designed observational studies can instead be used to ground reliable recommendations for clinical practice and policymaking in adolescent trans healthcare, without the need for RCTs. Conclusion The lack of RCTs on the mental health impacts of gender-affirming care for trans adolescents does not entail that gender-affirming interventions are based on insufficient evidence. Given the methodological limitations of RCTs, complementary and well-designed observational studies offer more reliable scientific evidence than RCTs and should be considered of sufficient quality to guide clinical practice and policymaking.
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Affiliation(s)
- Florence Ashley
- Faculty of Law & Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | | | - Johanna Olson-Kennedy
- The Center for Transyouth Health and Development, Division of Adolescent Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Arjee J. Restar
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
- Research Education Institute for Diverse Scholars (REIDS), School of Public Health, Yale University, New Haven, CT, USA
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23
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Cheung AS, Nolan BJ, Zwickl S. Transgender health and the impact of aging and menopause. Climacteric 2023; 26:256-262. [PMID: 37011669 DOI: 10.1080/13697137.2023.2176217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Gender affirming hormone therapy (GAHT) is used by many transgender people to reduce gender incongruence and improve psychological functioning. As GAHT shares many similarities with menopausal hormone therapy, clinicians supporting people through menopause are ideally placed to manage GAHT. This narrative review provides an overview of transgender health and discusses long-term effects of GAHT to consider when managing transgender individuals across the lifespan. Menopause is less relevant for transgender individuals who take GAHT (often given lifelong) to achieve sex steroid concentrations generally in the range of the affirmed gender. For people using feminizing hormone therapy, there is an elevated risk of venous thromboembolism, myocardial infarction, stroke and osteoporosis relative to cisgender individuals. For trans people using masculinizing hormone therapy, there is an increased risk of polycythemia, probable higher risk of myocardial infarction and pelvic pain which is poorly understood. Proactive mitigation of cardiovascular risk factors is important for all transgender people and optimization of bone health is important for those using feminizing hormones. With a lack of research to guide GAHT in older age, a shared decision-making approach is recommended for the provision of GAHT to achieve individual goals whilst minimizing potential adverse effects.
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Affiliation(s)
- A S Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Australia
| | - B J Nolan
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Australia
| | - S Zwickl
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Australia
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24
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Toribio M, Cetlin M, Fulda ES, Chu SM, Gómez Tejeda Zañudo J, Poteat T, Donelan K, Zanni MV. Hormone Prescription and HIV Screening/Preventive Practices Among Clinicians Providing Care for Transgender Individuals. Transgend Health 2023; 8:64-73. [PMID: 36824383 PMCID: PMC9942173 DOI: 10.1089/trgh.2021.0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose Through a survey-based approach, we sought to investigate regional differences in gender-affirming hormone therapy (GAHT) prescribing practices, as well as HIV screening and prevention practices among clinicians providing care to transgender individuals. Methods Our survey was disseminated between December 2019 and January 2021 to clinicians who prescribe GAHT within New England (United States). Between-group differences in GAHT prescribing and HIV screening/prevention practices were evaluated by practice setting and subspecialty. Results Of the 20 survey respondents, 55% practiced in health care settings affiliated with an academic institution, 45% practiced in a community-based health care setting, and 30% were Endocrinologists. Clinicians in community-based health care settings reported more frequently prescribing oral 17β-estradiol (p=0.02) and spironolactone (p=0.007) for feminizing GAHT compared with clinicians in health care settings affiliated with an academic institution, who reported more frequently prescribing leuprolide (p=0.03). For masculinizing GAHT, clinicians from health care settings affiliated with an academic institution reported more frequently prescribing topical testosterone (p=0.03). There were no significant between-group differences in reported barriers to initiation or reasons for stopping GAHT. While non-Endocrinologists reported "often" or "always" offering HIV screening, most Endocrinologists reported "rarely" or "never" offering HIV screening and "rarely" or "never" offering pre-exposure or postexposure prophylaxis to their transgender patients. Conclusions Regional GAHT prescribing practices varied by setting. Additional research is needed to better understand whether these differences translate to differences in GAHT efficacy and side-effects. Further, HIV screening/prevention practices varied by subspecialty. Integrated GAHT and HIV screening/prevention across subspecialties could help reduce the disproportionate burden of HIV faced by the transgender community.
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Affiliation(s)
- Mabel Toribio
- Metabolism Unit, Division of Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Madeline Cetlin
- Metabolism Unit, Division of Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Evelynne S. Fulda
- Metabolism Unit, Division of Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah M. Chu
- Metabolism Unit, Division of Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jorge Gómez Tejeda Zañudo
- Eli and Edythe L. Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Tonia Poteat
- Department of Social Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Karen Donelan
- Health Policy Research Center at the Mongan Institute, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Markella V. Zanni
- Metabolism Unit, Division of Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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25
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Ford K, Huggins E, Sheean P. Characterising body composition and bone health in transgender individuals receiving gender-affirming hormone therapy. J Hum Nutr Diet 2022; 35:1105-1114. [PMID: 35509260 PMCID: PMC9790536 DOI: 10.1111/jhn.13027] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/26/2022] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Ky Ford
- Department of Applied Health SciencesLoyola University ChicagoMaywoodIllinoisUSA
| | | | - Patricia Sheean
- Department of Applied Health SciencesLoyola University ChicagoMaywoodIllinoisUSA
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26
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Restar A, Dusic EJ, Garrison-Desany H, Lett E, Everhart A, Baker KE, Scheim AI, Beckham SW, Reisner S, Rose AJ, Mimiaga MJ, Radix A, Operario D, Hughto JM. Gender affirming hormone therapy dosing behaviors among transgender and nonbinary adults. HUMANITIES & SOCIAL SCIENCES COMMUNICATIONS 2022; 9:304. [PMID: 36636110 PMCID: PMC9833814 DOI: 10.1057/s41599-022-01291-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/25/2022] [Indexed: 06/17/2023]
Abstract
Gender-affirming hormones have been shown to improve psychological functioning and quality of life among transgender and nonbinary (trans) people, yet, scant research exists regarding whether and why individuals take more or less hormones than prescribed. Drawing on survey data from 379 trans people who were prescribed hormones, we utilized multivariable logistic regression models to identify factors associated with hormone-dosing behaviors and content analysis to examine the reasons for dose modifications. Overall, 24% of trans individuals took more hormones than prescribed and 57% took less. Taking more hormones than prescribed was significantly associated with having the same provider for primary and gender-affirming care and gender-based discrimination. Income and insurance coverage barriers were significantly associated with taking less hormones than prescribed. Differences by gender identity were also observed. Addressing barriers to hormone access and cost could help to ensure safe hormone-dosing behaviors and the achievement trans people's gender-affirmation goals.
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Affiliation(s)
- Arjee Restar
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Behavioral and Social Sciences, Yale University School of Public Health, New Haven, CT, USA
- Center for Applied Transgender Studies, Chicago, IL, USA
| | - E. J. Dusic
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Henri Garrison-Desany
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elle Lett
- Center for Applied Transgender Studies, Chicago, IL, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Avery Everhart
- Center for Applied Transgender Studies, Chicago, IL, USA
- Population, Health, & Place Program, Spatial Sciences Institute, Dornsife College of Letters, Arts, & Sciences, University of Southern California, Los Angeles, CA, USA
| | - Kellan E. Baker
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Whitman-Walker Institute, Washington, DC, USA
| | - Ayden I. Scheim
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - S. Wilson Beckham
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sari Reisner
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Adam J. Rose
- Hebrew University School of Public Health, Jerusalem, Israel
| | - Matthew J. Mimiaga
- UCLA Center for LGBTQ+ Advocacy, Research & Health, Los Angeles, CA, USA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Asa Radix
- Department of Behavioral and Social Sciences, Yale University School of Public Health, New Haven, CT, USA
- Department of Epidemiology, Columbia University, New York, NY, USA
- Callen-Lorde Community Health Center, New York, NY, USA
| | - Don Operario
- Departments of Behavioral and Social Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Jaclyn M.W. Hughto
- Departments of Behavioral and Social Sciences and Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Fenway Health, The Fenway Institute, Boston, MA, USA
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Abstract
The use of gender-affirming hormone therapy is found almost universally in transgendered and nonbinary patients presenting for gender-affirming surgical procedures of the face, neck, and voice. Surgeons caring for this population need to be aware of the effects, reasonable expectations, and limitations as well as potential perioperative risks of both continuation and discontinuation of hormone therapy.
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28
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Le A, Huang KJ, Cirrincione LR. Regulation of drug-metabolizing enzymes by sex-related hormones: clinical implications for transgender medicine. Trends Pharmacol Sci 2022; 43:582-592. [PMID: 35487786 DOI: 10.1016/j.tips.2022.03.006] [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: 11/07/2021] [Revised: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
Transgender medicine is a diverse and growing clinical field with unmet gaps in pharmacological knowledge. Hormone therapy (testosterone or estrogen treatment), one part of the standard of medical care for transgender adults, aligns secondary sex characteristics with an individual's gender identity and expression. Despite established effects of sex steroids on drug-metabolizing enzyme expression and activity in vitro and in animal models, the effect of long-term, supraphysiological sex hormone treatment on drug metabolism in transgender adults is not yet established. Here, we synthesize available in vitro and animal model data with pharmacological concepts in transgender medicine to predict potential effects of sex steroids on drug-metabolizing enzymes, and their relationship with potential hormone-drug interactions, in transgender medicine.
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Affiliation(s)
- An Le
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kai J Huang
- Center for Transyouth Health and Development, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Nolan BJ, Zwickl S, Wong AFQ, Locke P, Simpson S, Li L, Zajac JD, Cheung AS. Testosterone concentrations and prescription patterns of 1% testosterone gel in transgender and gender diverse individuals. Ther Adv Endocrinol Metab 2022; 13:20420188221083512. [PMID: 35296035 PMCID: PMC8918760 DOI: 10.1177/20420188221083512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background Masculinising hormone therapy with testosterone is used to align an individual's physical characteristics with their gender identity. Standard testosterone doses and formulations recommended for hypogonadal cisgender men are typically administered, although there are currently limited data evaluating the use of 1% testosterone gel in gender-affirming hormone therapy regimens. Objectives The objective of the study was to assess the prescription patterns and serum total testosterone concentrations achieved with 1% testosterone gel in trans and gender diverse individuals. Materials and Methods A retrospective cross-sectional analysis was undertaken of trans individuals at a primary and secondary care clinic in Melbourne, Australia. Sixty-seven individuals treated with 1% testosterone gel were included. Primary outcomes were testosterone dose and serum total testosterone concentration achieved. Results Median age was 25 (22-30) years and median duration of testosterone therapy was 12 (7-40) months. Thirty-five (52%) individuals had a nonbinary gender identity. Initial median testosterone dose was 25 mg (12.5-31.3) daily. Fifty-two (78%) individuals commenced doses <50 mg daily, the recommended starting dose for hypogonadal cisgender men. Median total testosterone concentration achieved was 11.9 nmol/l (7.3-18.6). Polycythaemia (haematocrit >0.5) was documented in eight of 138 (6%) laboratory results in six individuals. Discussion and Conclusions One percent testosterone gel achieves serum total testosterone concentrations in the cisgender male reference range. A high proportion of individuals had a nonbinary gender identity and most individuals commenced a lower dose than that typically administered to hypogonadal cisgender men, potentially related to slow or 'partial' masculinisation goals.
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Affiliation(s)
- Brendan J. Nolan
- Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, VIC, Australia
- Equinox Gender Diverse Clinic, Thorne Harbour Health, Abbotsford, VIC, Australia
| | - Sav Zwickl
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, VIC, Australia
| | - Alex F. Q. Wong
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, VIC, Australia
| | - Peter Locke
- Equinox Gender Diverse Clinic, Thorne Harbour Health, Abbotsford, VIC, Australia
| | - Satu Simpson
- Equinox Gender Diverse Clinic, Thorne Harbour Health, Abbotsford, VIC, Australia
| | - Ling Li
- Equinox Gender Diverse Clinic, Thorne Harbour Health, Abbotsford, VIC, Australia
| | - Jeffrey D. Zajac
- Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, VIC, Australia
| | - Ada S. Cheung
- Department of Medicine, Austin Health, The University of Melbourne, 145 Studley Road, Heidelberg, VIC 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
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30
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Restriction of Access to Healthcare and Discrimination of Individuals of Sexual and Gender Minority: An Analysis of Judgments of the European Court of Human Rights from an Ethical Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19052650. [PMID: 35270340 PMCID: PMC8909593 DOI: 10.3390/ijerph19052650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 01/27/2023]
Abstract
Individuals of sexual and gender minority (SGM) form a vulnerable group with specific healthcare needs that might be prone to experience discrimination and restrictions regarding their access to healthcare. As the judgments of the European Court of Human Rights (ECtHR) offer a normative perspective on these issues, we analyzed them systematically (1) to identify whether and in what manner ECtHR's judgments concern restriction of access to healthcare for SGM individuals and (2) to identify and categorize the ways of discrimination to which SGM individuals are exposed. We conducted a systematic search of the database of the ECtHR's judgments with the use of specified search terms. Descriptive statistics were performed on the identified judgments. Subsequently, we analyzed the judgments with the use of a qualitative method of thematic analysis. We identified n = 73 cases relevant for our study. In n = 7 (9.59%) of judgments, we found limitations of access to healthcare for SGM individuals, e.g., in cases of restrictions for transsexual individuals to receive hormone or surgical therapy. We regard this as a specific form of discrimination. Furthermore, we identified five other categories of discrimination: restriction of parental rights, failure to respect one's gender identity/sexual orientation, discrimination by jurisdiction, prohibition of promotion, and verbal/physical attacks. The ECtHR proves to have a balanced view on the sensitive topic of sexual self-determination condemning any form of discrimination or restriction of access to healthcare. However, there is a need for further research on discriminatory acts by other individuals, e.g., healthcare providers, rather than by public authorities.
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31
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Affiliation(s)
- Ada S Cheung
- Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Victoria, Australia
- Gender Clinic, Department of Endocrinology, Austin Health, Victoria, Australia
| | - Teddy Cook
- ACON, Surry Hills, New South Wales, Australia
| | - Ariel Ginger
- Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Victoria, Australia
- Gender Clinic, Department of Endocrinology, Austin Health, Victoria, Australia
| | - Sav Zwickl
- Trans Health Research Group, Department of Medicine (Austin Health), University of Melbourne, Victoria, Australia
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32
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Bordas N, Stojanovic B, Bizic M, Szanto A, Djordjevic ML. Metoidioplasty: Surgical Options and Outcomes in 813 Cases. Front Endocrinol (Lausanne) 2021; 12:760284. [PMID: 34721306 PMCID: PMC8548780 DOI: 10.3389/fendo.2021.760284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Metoidioplasty is a variant of phalloplasty for transmen that includes the creation of the neophallus from a hormonally enlarged clitoris, urethral lengthening and scrotoplasty. The procedure results in male appearance of genitalia, voiding in standing position and preserved sexual arousal, but without possibility for penetrative intercourse. We evaluated outcomes of metoidioplasty at our center, based on latest surgical refinements. METHODS During the period of 14 years (from February 2006 to April 2020), 813 transmen with mean age of 24.4 years and mean body mass index of 24.6, underwent one stage metoidioplasty. Hysterectomy was simultaneously performed in 156, and mastectomy in 58 cases. Hysterectomy, mastectomy and metoidioplasty were done as a one-stage procedure in 46 transmen. Patients are divided in 5 groups, depending on the type of urethroplasty. Postoperative questionnaires were used to evaluate cosmetic and functional outcomes, as well as patients' satisfaction. RESULTS Follow-up ranged from 16 to 180 months (mean 94 months). Mean surgery time was 170 minutes and mean hospital stay was 3 days. Length of the neophallus ranged from 4.8 cm to 10.2 cm (mean 5.6 cm). Urethroplasty was complication-free in 89.5% of cases, and ranged between 81% to 90.3% in different groups. Urethral fistula and stricture occured in 8.85% and 1.70% of cases, respectively. Other complications included testicular implant rejection in 2%, testicular displacement in 3.20% and vaginal remnant in 9.60% of cases. From 655 patients who answered the questionnaire, 79% were totally satisfied and 20% mainly satisfied with the result of surgery. All patients reported voiding in standing position and good sexual arousal of the neophallus, without possibility for penetrative intercourse due to small size of the neophallus. CONCLUSION Metoidioplasty has good cosmetic and functional outcomes, with low complication rate and high level of patients' satisfaction. In transmen who request total phalloplasty after metoidioplasty, all available phalloplasty techniques are feasable.
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Affiliation(s)
- Noemi Bordas
- Department of Urology, Semmelweis Hospital, Kiskunhalas, Hungary
- Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade, Serbia
| | - Borko Stojanovic
- Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marta Bizic
- Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Arpad Szanto
- Urology Clinic, University of Pecs, Pecs, Hungary
| | - Miroslav L. Djordjevic
- Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Miroslav L. Djordjevic,
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