Evidence supporting the biologic nature of gender identity

Dermatological considerations for transgender and gender diverse patients: An Australian perspective

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.

The Role of Sex and Gender in Dermatology - From Pathogenesis to Clinical Implications

BACKGROUND

Sex and gender have increasingly been recognized as significant risk factors for many diseases, including dermatological conditions. Historically, sex and gender have often been grouped together as a single risk factor in the scientific literature. However, both may have a distinct impact on disease incidence, prevalence, clinical presentation, severity, therapeutic response, and associated psychological distress.

OBJECTIVES AND PROJECT DESCRIPTION

The mechanisms that underlie differences in skin diseases between males, females, men, and women remain largely unknown. The specific objectives of this review paper are:To highlight the biological differences between males and females (sex), as well as the sociocultural differences between men and women (gender) and how they impact the integumentary system.To perform a literature review to identify important sex- and gender-related epidemiological and clinical differences for various skin conditions belonging to a range of disease categories and to discuss possible biological and sociocultural factors that could explain the observed differences.To discuss dermatological skin conditions and gender-affirming treatments within the transgender community, a population of individuals who have a gender identity which is different than the gender identity they were assigned at birth.

FUTURE IMPACT

With the rising number of individuals that identify as non-binary or transgender within our increasingly diverse communities, it is imperative to recognize gender identity, gender, and sex as distinct entities. By doing so, clinicians will be able to better risk-stratify their patients and select treatments that are most aligned with their values. To our knowledge, very few studies have separated sex and gender as two distinct risk factors within the dermatology literature. Our article also has the potential to help guide future prevention strategies that are patient-tailored rather than using a universal approach.

Etiology of gender incongruence and its levels of evidence: A scoping review protocol

INTRODUCTION

Gender Incongruence refers to the discordance between biological sex and gender identity. Although it is possible to find literature reviews about the etiology of Gender Incongruence, almost all of these correspond to non-systematic narrative reviews, so they do not make explicit the methodology used in the collection and analysis of sources, even less its levels of evidence. In order to remedy this, we will conduct a scoping review to answer the question: what are the factors associated with gender incongruence and what level of evidence is there for each factor in the scientific literature?

METHODS AND ANALYSIS

We will conduct a scoping review according to the methodology specified in the JBI Manual for Evidence Synthesis (Chapter 11) and the PRISMA extension for scoping reviews (PRISMA-ScR). Four databases will be reviewed to identify papers that match our search criteria, followed by a screening of titles and abstracts, the complete reading of those articles that have not been excluded, and the coding of these using the data extraction instrument developed for this research (see S1 Appendix). Data extracted will be analyzed in terms of frequency counts of factors, types of factors and levels of evidence for each factor. Results will be presented in tabular or diagrammatic forms supported by a narrative summary.

FINDINGS

The present review will help to map the factors associated with incongruence between biological sex and gender identity, specifying their levels of evidence. This evidence-based knowledge will be useful for clinicians evaluating gender incongruence, especially given that international guidelines recommend careful assessment of factors that may interfere with the clarity of gender identity development and decision making.

One hundred twelve cases of 46, XY DSD patients after initial gender assignment: a short-term survey of gender role and gender dysphoria

Background

46, XY disorders of sex development (46, XY DSD) are congenital disorders with 46, XY chromosomal karyotype but inconsistent gonadal/phenotypic sex. One of the biggest concerns for parents and clinicians is the gender assignment. However, there is no standard uniform of care nor consensus at present. We sought to evaluate the current treatment's rationality and provide a reference basis for the gender reassignment in 46, XY DSD patients with a specific diagnosis.

Methods

We conducted a cross-sectional survey of gender role with the Pre-school Activities Inventory (PSAI), the Children's Sex Role Inventory (CSRI) in 46, XY DSD patients and set up control groups comparison. Psychiatrist assessed gender dysphoria in patients ≥ 8-year-old with the criteria of diagnostic and statistical manual of mental disorders, 5th edition (DSM-5).

Results

A total of 112 responders of 136 patients participated in this study (82.4%, aged 2–17.8 years, median age: 4-year-old). The follow-up period was from 6 months to 10 years (median: 2 years). Twenty-five females were reassigned to the male gender after a specific diagnosis (16/25 (64%) in 5 alfa-reductase-2 deficiency (5α-RD2), 5/25 (20%) in partial androgen insensitivity syndrome (PAIS), 4/25 (16%) in NR5A1gene mutation). Male gender assignment increased from 55.3 (n = 62) to 77.7% (n = 87). The median PSAI score was similar to the control males in 5α-RD2, PAIS, and NR5A1 gene mutation groups (p > 0.05); while identical to the control females in complete androgen insensitivity syndrome (CAIS) and CYP17A1 gene mutation groups (p > 0.05). PSAI score of children raised as male was higher than those of CAIS and CYP17A1 groups raised as female (p < 0.05). CSRI scale showed no statistical differences in the consistency of gender roles and reassigned gender between 46, XY DSD patients and control groups (p > 0.05). None of the patients over 8-year-old (n = 44) had gender dysphoria.

Conclusion

The reassigned gender in 46, XY DSD patients is consistent with their gender role during early childhood. None of them had gender dysphoria. The molecular diagnosis, gonadal function, and the gender reassignment are congruent within our Chinese cohort. Long-term follow-up and more evaluation are still required.

Considering Sex as a Biological Variable in Basic and Clinical Studies: An Endocrine Society Scientific Statement

In May 2014, the National Institutes of Health (NIH) stated its intent to "require applicants to consider sex as a biological variable (SABV) in the design and analysis of NIH-funded research involving animals and cells." Since then, proposed research plans that include animals routinely state that both sexes/genders will be used; however, in many instances, researchers and reviewers are at a loss about the issue of sex differences. Moreover, the terms sex and gender are used interchangeably by many researchers, further complicating the issue. In addition, the sex or gender of the researcher might influence study outcomes, especially those concerning behavioral studies, in both animals and humans. The act of observation may change the outcome (the "observer effect") and any experimental manipulation, no matter how well-controlled, is subject to it. This is nowhere more applicable than in physiology and behavior. The sex of established cultured cell lines is another issue, in addition to aneuploidy; chromosomal numbers can change as cells are passaged. Additionally, culture medium contains steroids, growth hormone, and insulin that might influence expression of various genes. These issues often are not taken into account, determined, or even considered. Issues pertaining to the "sex" of cultured cells are beyond the scope of this Statement. However, we will discuss the factors that influence sex and gender in both basic research (that using animal models) and clinical research (that involving human subjects), as well as in some areas of science where sex differences are routinely studied. Sex differences in baseline physiology and associated mechanisms form the foundation for understanding sex differences in diseases pathology, treatments, and outcomes. The purpose of this Statement is to highlight lessons learned, caveats, and what to consider when evaluating data pertaining to sex differences, using 3 areas of research as examples; it is not intended to serve as a guideline for research design.

Research gaps in medical treatment of transgender/nonbinary people

With the growing number of transgender and gender-nonbinary individuals who are becoming visible, it is clear that there is a need to develop a rigorous evidence base to inform care practice. Transgender health research is often limited to HIV/AIDS or mental health research and is typically subsumed in larger studies with general LGBTQ focus. Although the number of knowledgeable health care providers remains modest, the model for the medical approach to transgender health is shifting owing to growing social awareness and an appreciation of a biological component. Gender-affirming medicine facilitates aligning the body of the transgender person with the gender identity; typical treatment regimens include hormone therapy and/or surgical interventions. While broadly safe, hormone treatments require some monitoring for safety. Exogenous estrogens are associated with a dose-dependent increase in venous thromboembolic risk, and androgens stimulate erythropoiesis. The degree to which progressing gender-affirming hormone treatment changes cancer risk, cardiac heart disease risk, and/or bone health remains unknown. Guidelines referencing the potential exacerbation of cancer, heart disease, or other disease risk often rely on physiology models, because conclusive clinical data do not exist. Dedicated research infrastructure and funding are needed to address the knowledge gap in the field.

Medical transition for gender diverse patients

Purpose of review

The purpose of this review is to provide an up-to-date overview of gender-affirming hormone therapy, including the various hormone regimens available, the efficacy and potential risks of these treatments, and considerations for surveillance and long-term care.

Recent findings

Recent studies reaffirm that hormone therapy has positive physical and psychological effects for many transgender individuals. The overall risks of treatment are low. Transgender women may have an increased risk of venous thromboembolism and breast cancer based on recent cohort studies, but these findings have yet to be confirmed with randomized controlled trials. Important long-term considerations include metabolic, cardiovascular, and skeletal health.

Summary

High-quality, long-term studies on the effectiveness and safety of various gender-affirming hormone treatment regimens are lacking, but the currently available evidence suggests that it is overall safe and effective with appropriate oversight.

Endocrine treatment of transgender individuals: current guidelines and strategies

INTRODUCTION

This review summarizes gender affirming medical and surgical care available to transgender individuals, along with proposals to improve medically and culturally appropriate care.

AREAS COVERED

Transgender individuals are those whose gender identity differs from that recorded at birth (usually based on visualization of external sexual anatomy). In order to align the body with the patient's gender identity, clinicians can provide hormone therapy (HT) to bring sex hormone levels to the range associated with the patient's gender identity. At steady state, monitoring for maintenance of levels, as well as for known risks and complications, is required. Treating clinicians should have knowledge of trans assessment criteria, hormone therapy, surgical options, primary care, and mental health needs of transgender patients. A narrative literature review was conducted using Pubmed and EMBASE with articles then selected for relevance. The initial search terms were: androgen suppression, antiandrogen, breast development, chest reconstruction, cisgender, estrogen, fertility preservation, gender-affirming surgery, gender identity, gender incongruence, genital reconstruction, hormone replacement, hyperlipidemia, orchiectomy, prolactin, prostate atrophy, spermatogenesis, spironolactone, testosterone, thrombogenesis, transgender, and virilization.

EXPERT OPINION

Although guidelines exist and examples of training are available, systematic formal training must be implemented to truly mainstream high-quality gender-affirming health care .

A Universally Accepted Definition of Gender Will Positively Impact Societal Understanding, Acceptance, and Appropriateness of Health Care

When individuals do not conform to stereotypes associated with "male" or "female," they are often ridiculed, bullied, and rejected, which leads to depression, psychological problems, and even suicide. The number of individuals who identify themselves as transgender, gender queer, or who do not conform to societal norms with respect to gender appears to be increasing. Despite this apparent increase, clinicians and health care facilities are ill-prepared to meet the needs of these individuals in a professional and appropriate manner. Unfortunately, there is an inherit distrust of the medical community by individuals who do not conform to societal norms with respect to gender because of a perception that the medical community does not understand the unique challenges of these individuals. Therefore, reducing the social stigma associated with gender nonconforming individuals is one way to begin to break down barriers of distrust and enhance communication within and outside the medical community. In this review, we discuss the scant amount of scientific data on the biological origins of gender identity. We highlight the fact that the biological definition of gender remains elusive in part because molecular and biological techniques have not been available to accurately probe the development of gender identity. We therefore advocate for the importance of enhancing our knowledge of the origins of gender identity with advanced scientific tools. Enhancing scientific understanding of the biological origins of gender identity may reduce stigma and barriers to care.

Brain Sex Differences Related to Gender Identity Development: Genes or Hormones?

The complex process of sexual differentiation is known to be influenced by biological and environmental determinants. The present review has the aim of summarizing the most relevant studies on the biological basis of sexual development, and in particular, it focuses on the impact of sex hormones and genetic background on the development of sexual differentiation and gender identity. The authors conducted a search of published studies on Medline (from January 1948 to December 2019). The evidence suggests that the sexual dimorphic brain could be the anatomical substrate of psychosexual development, on which gonadal hormones may have a shaping role during prenatal and pubertal periods. Additionally, according to several heritability studies, genetic components may have a role, but a promising candidate gene has not been identified. Even though growing evidence underlines the primary role of biological factors on psychosexual development, further studies are necessary to better explain their complex interactions.

Caring for the Transgender Patient: Grand Rounds Discussion From Beth Israel Deaconess Medical Center

The term transgender refers to persons whose gender identity is different from that recorded at birth. Similar to other marginalized populations, transgender patients commonly experience discrimination in the health care setting, and they may not have access to medical professionals who can provide competent care. In addition to primary medical and preventive health care, transgender patients need access to gender-affirming interventions, including hormone therapy and surgeries. In 2017, the Endocrine Society updated its clinical practice guideline for the care of transgender persons on the basis of the best available evidence from systematic reviews and individual studies. Among its general requirements for adolescents and recommendations for adults were the following: Involvement of a mental health professional who is knowledgeable about the diagnostic criteria for gender dysphoria and criteria for gender-affirming treatment, has training and experience in assessing psychopathology, and is willing to participate in ongoing care. Hormone therapy should be offered to transgender adult patients, with levels maintained within the normal range for gender identity and treatment appropriately monitored. Clinicians involved in the care of transgender adult patients should be knowledgeable about diagnostic criteria for gender dysphoria/gender incongruence, the use of medical and surgical gender-affirming interventions, and appropriate monitoring for reproductive organ cancer risk. Here, 2 clinicians with expertise in this area debate whether psychological evaluation is warranted in a transgender patient requesting gender-affirming hormones or surgery, the potential risks and benefits of estrogen therapy, and the role of the primary care practitioner in the care of transgender persons.

Predictive Pattern Classification Can Distinguish Gender Identity Subtypes from Behavior and Brain Imaging

The exact neurobiological underpinnings of gender identity (i.e., the subjective perception of oneself belonging to a certain gender) still remain unknown. Combining both resting-state functional connectivity and behavioral data, we examined gender identity in cisgender and transgender persons using a data-driven machine learning strategy. Intrinsic functional connectivity and questionnaire data were obtained from cisgender (men/women) and transgender (trans men/trans women) individuals. Machine learning algorithms reliably detected gender identity with high prediction accuracy in each of the four groups based on connectivity signatures alone. The four normative gender groups were classified with accuracies ranging from 48% to 62% (exceeding chance level at 25%). These connectivity-based classification accuracies exceeded those obtained from a widely established behavioral instrument for gender identity. Using canonical correlation analyses, functional brain measurements and questionnaire data were then integrated to delineate nine canonical vectors (i.e., brain-gender axes), providing a multilevel window into the conventional sex dichotomy. Our dimensional gender perspective captures four distinguishable brain phenotypes for gender identity, advocating a biologically grounded reconceptualization of gender dimorphism. We hope to pave the way towards objective, data-driven diagnostic markers for gender identity and transgender, taking into account neurobiological and behavioral differences in an integrative modeling approach.

Care of the Transgender Patient

Transgender persons are a diverse group whose gender identity differs from their sex recorded at birth. Some choose to undergo medical treatment to align their physical appearance with their gender identity. Barriers to accessing appropriate and culturally competent care contribute to health disparities in transgender persons, such as increased rates of certain types of cancer, substance abuse, mental health conditions, infections, and chronic diseases. Thus, it is important that clinicians understand the specific medical issues that are relevant to this population.

The Evolving Role of Pharmacists in Transgender Health Care

Pharmacists are increasingly part of a multifaceted team providing health care to members of the often marginalized transgender (TG) community. Some pharmacists, however, may feel unprepared to care for and interact with TG individuals. By providing comprehensive, respectful, and gender-affirming support, improving physical pharmacy environments with policies and procedures, pharmacists can be trustworthy providers for TG patients. This review focuses primarily on the health issues of TG persons and the pharmacist's role in promoting health, identifying barriers to health care, and providing health care resources for TG persons. The evolution of psychiatric diagnostic criteria, access to health care, and inclusion of TG, lesbian, gay, and bisexual topics in the educational curriculum are presented. Cultural competency and diversity training that addresses gender identity and sexual orientation issues should be important interdisciplinary and interprofessional activities for all health care professional education programs. Pharmacists play a key role in the health care needs of TG persons that include appropriate laboratory monitoring, complex pharmacotherapeutic challenges, and providing unbiased gender-affirming interactions. The pharmacy's physical environment, staff training, and policies and procedures can offer unique services to TG persons.

Effects of Sex Hormone Treatment on the Metabolic Syndrome in Transgender Individuals: Focus on Metabolic Cytokines

CONTEXT

Hormonal treatment in transgender persons affects many components of the metabolic syndrome (MS).

OBJECTIVE

To determine the role of direct hormonal effects, changes in metabolic cytokines, and body composition on metabolic outcomes.

DESIGN, SETTING, AND PARTICIPANTS

24 transwomen and 45 transmen from the European Network for the Investigation of Gender Incongruence were investigated at baseline and after 12 months of hormonal therapy.

OUTCOME MEASURES

Best predictors for changes in components of MS, applying least absolute shrinkage and selection operator regression.

RESULTS

In transwomen, a decrease in triglyceride levels was best explained by a decrease in fat mass and an increase in fibroblast growth factor 21 (FGF-21); the decrease in total and low-density lipoprotein cholesterol levels was principally due to a decrease in resistin. A decrease in high-density lipoprotein cholesterol depended on an inverse association with fat mass. In contrast, in transmen, an increase in low-density lipoprotein cholesterol was predicted by a decrease in FGF-21 and an increase in the waist/hip ratio; a decrease in the high-density lipoprotein/total cholesterol ratio depended on a decline in adiponectin levels. In transwomen, worsened insulin resistance and increased early insulin response seemed to be due to a direct treatment effect; however, improvements in hepatic insulin sensitivity in transmen were best predicted by a positive association with chemerin, resistin, and FGF-21 and were inversely related to changes in the waist/hip ratio and leptin and adipocyte fatty acid-binding protein levels.

CONCLUSIONS

The effects of hormonal therapy on different components of the MS are sex-specific and involve a complex interplay of direct hormonal effects, changes in body composition, and metabolic cytokine secretion.

Cross-sex testosterone therapy in ovariectomized mice: addition of low-dose estrogen preserves bone architecture

Cross-sex hormone therapy (XHT) is widely used by transgender people to alter secondary sex characteristics to match their desired gender presentation. Here, we investigate the long-term effects of XHT on bone health using a murine model. Female mice underwent ovariectomy at either 6 or 10 wk and began weekly testosterone or vehicle injections. Dual-energy X-ray absorptiometry (DXA) was performed (20 wk) to measure bone mineral density (BMD), and microcomputed tomography was performed to compare femoral cortical and trabecular bone architecture. The 6-wk testosterone group had comparable BMD with controls by DXA but reduced bone volume fraction, trabecular number, and cortical area fraction and increased trabecular separation by microcomputed tomography. Ten-week ovariectomy/XHT maintained microarchitecture, suggesting that estrogen is critical for bone acquisition during adolescence and that late, but not early, estrogen loss can be sufficiently replaced by testosterone alone. Given these findings, we then compared effects of testosterone with effects of weekly estrogen or combined testosterone/low-dose estrogen treatment after a 6-wk ovariectomy. Estrogen treatment increased spine BMD and microarchitecture, including bone volume fraction, trabecular number, trabecular thickness, and connectivity density, and decreased trabecular separation. Combined testosterone-estrogen therapy caused similar increases in femur and spine BMD and improved architecture (increased bone volume fraction, trabecular number, trabecular thickness, and connectivity density) to estrogen therapy and were superior compared with mice treated with testosterone only. These results demonstrate estradiol is critical for bone acquisition and suggest a new cross-sex hormone therapy adding estrogens to testosterone treatments with potential future clinical implications for treating transgender youth or men with estrogen deficiency.

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline

OBJECTIVE

To update the "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline," published by the Endocrine Society in 2009.

PARTICIPANTS

The participants include an Endocrine Society-appointed task force of nine experts, a methodologist, and a medical writer.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.

CONSENSUS PROCESS

Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines.

CONCLUSION

Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person's genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person's affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments-appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)-should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.

Controversies of Sex Re-assignment in Genetic Males with Congenital Inadequacy of the Penis

Sex assignment in 46XY genetic male children with congenital inadequacy of the penis (CIP) is controversial. Traditionally, children with penile length less than 2 cm at birth are considered unsuitable to be raised as males. They are typically re-assigned to female-sex and feminizing genitoplasty is usually done in infancy. However, the concept of cerebral androgen imprinting has caused paradigm shift in the philosophy of sex re-assignment. Masculinization of the brain, rather than length of the penis, is the modern criterion of sex re-assignment in CIP. This review summarizes the current understanding of the complex issue. In 46XY children with CIP, male-sex assignment appears appropriate in non-hormonal conditions such as idiopathic micropenis, aphallia and exstrophy. Female-sex re-assignment appears acceptable in complete androgen insensitivity (CAIS), while partial androgen insensitivity syndrome (PAIS) patients are highly dissatisfied with the assignment of either sex. Children with 5-alpha reductase deficiency are likely to have spontaneous penile lengthening at puberty. Hence, they are better raised as males. Although female assignment is common in pure gonadal dysgenesis, long-term results are not known to justify the decision.

When Gender Identity Doesn't Equal Sex Recorded at Birth: The Role of the Laboratory in Providing Effective Healthcare to the Transgender Community

BACKGROUND

Transgender is an umbrella term used to describe individuals who identify with a gender incongruent to or variant from their sex recorded at birth. Affirming gender identity through a variety of social, medical, and surgical interventions is critical to the mental health of transgender individuals. In recent years, awareness surrounding transgender identities has increased, which has highlighted the health disparities that parallel this demographic. These disparities are reflected in the experience of transgender patients and their providers when seeking clinical laboratory services.

CONTENT

Little is known about the effect of gender-affirming hormone therapy and surgery on optimal laboratory test interpretation. Efforts to diminish health disparities encountered by transgender individuals and their providers can be accomplished by increasing social and clinical awareness regarding sex/gender incongruence and gaining insight into the physiological manifestations and laboratory interpretations of gender-affirming strategies. This review summarizes knowledge required to understand transgender healthcare including current clinical interventions for gender dysphoria. Particular attention is paid to the subsequent impact of these interventions on laboratory test utilization and interpretation. Common nomenclature and system barriers are also discussed.

SUMMARY

Understanding gender incongruence, the clinical changes associated with gender transition, and systemic barriers that maintain a gender/sex binary are key to providing adequate healthcare to transgender community. Transgender appropriate reference interval studies are virtually absent within the medical literature and should be explored. The laboratory has an important role in improving the physiological understanding, electronic medical system recognition, and overall social awareness of the transgender community.

THE BIOLOGIC BASIS OF TRANSGENDER IDENTITY: 2D:4D FINGER LENGTH RATIOS IMPLICATE A ROLE FOR PRENATAL ANDROGEN ACTIVITY

OBJECTIVE

The biologic basis for gender identity is unknown. Research has shown that the ratio of the length of the second and fourth digits (2D:4D) in mammals is influenced by biologic sex in utero, but data on 2D:4D ratios in transgender individuals are scarce and contradictory. We investigated a possible association between 2D:4D ratio and gender identity in our transgender clinic population in Albany, New York.

METHODS

We prospectively recruited 118 transgender subjects undergoing hormonal therapy (50 female to male [FTM] and 68 male to female [MTF]) for finger length measurement. The control group consisted of 37 cisgender volunteers (18 females, 19 males). The length of the second and fourth digits were measured using digital calipers. The 2D:4D ratios were calculated and analyzed with unpaired t tests.

RESULTS

FTM subjects had a smaller dominant hand 2D:4D ratio (0.983 ± 0.027) compared to cisgender female controls (0.998 ± 0.021, P = .029), but a ratio similar to control males (0.972 ± 0.036, P =.19). There was no difference in the 2D:4D ratio of MTF subjects (0.978 ± 0.029) compared to cisgender male controls (0.972 ± 0.036, P = .434).

CONCLUSION

Our findings are consistent with a biologic basis for transgender identity and the possibilities that FTM gender identity is affected by prenatal androgen activity but that MTF transgender identity has a different basis.

ABBREVIATIONS

2D:4D = 2nd digit to 4th digit; FTM = female to male; MTF = male to female.

Alcohol-Related Blackouts, Negative Alcohol-Related Consequences, and Motivations for Drinking Reported by Newly Matriculating Transgender College Students

BACKGROUND

Many transgender college students struggle with identity formation and other emotional, social, and developmental challenges associated with emerging adulthood. A potential maladaptive coping strategy employed by such students is heavy drinking. Prior literature has suggested greater consumption and negative alcohol-related consequences (ARCs) in transgender students compared with their cisgender peers, but little is known about their differing experiences with alcohol-related blackouts (ARBs). We examined the level of alcohol consumption, the frequency of ARBs and other ARCs, and motivations for drinking reported by the largest sample of transgender college students to date.

METHODS

A Web survey from an alcohol-prevention program, AlcoholEdu for College™, assessed student demographics and drinking-related behaviors, experiences, and motivations of newly matriculating first-year college students. A self-reported drinking calendar was used to examine each of the following measures over the previous 14 days: number of drinking days, total number of drinks, and maximum number of drinks on any single day. A 7-point Likert scale was used to measure ARCs, ARBs, and drinking motivations. Transgender students of both sexes were compared with their cisgender peers.

RESULTS

A total of 989 of 422,906 students (0.2%) identified as transgender. Over a 14-day period, transgender compared with cisgender students were more likely to consume alcohol over more days, more total drinks, and a greater number of maximum drinks on a single day. Transgender students (36%) were more likely to report an ARB than cisgender students (25%) as well as more negative academic, confrontation-related, social, and sexual ARCs. Transgender respondents more often cited stress reduction, social anxiety, self-esteem issues, and the inherent properties of alcohol as motivations for drinking. For nearly all measures, higher values were yielded by male-to-female than female-to-male transgender students.

CONCLUSIONS

Transgender compared with cisgender first-year students engage in higher-risk drinking patterns and experience more ARBs and other negative ARCs. Broad institutional efforts are required to address the unique circumstances of transgender men and women and to reduce negative ARCs in college students, regardless of their sex or gender identity.

Perioperative Care of the Transgender Patient

Transgender patients are individuals whose gender identity is not related to their biological sex. Assuming a new gender identity that does not conform to societal norms often results in discrimination and barriers to health care. The exact number of transgender patients is unknown; however, these patients are increasingly seen in health care. Transgender individuals may experience provider-generated discrimination in health care facilities, including refusal of service, disrespect, and abuse, which contribute to depression and low self-esteem. Transgender therapies include mental health counseling for depression and low self-esteem, hormone therapy, and sex reassignment surgery. Health care professionals require cultural competence, an understanding of the different forms of patient identification, and adaptive approaches to care for transgender patients. VA (Veterans Affairs) hospitals provide a model for the care for transgender patients and staff.

12-months metabolic changes among gender dysphoric individuals under cross-sex hormone treatment: a targeted metabolomics study

Metabolomic analyses in epidemiological studies have demonstrated a strong sexual dimorphism for most metabolites. Cross-sex hormone treatment (CSH) in transgender individuals enables the study of metabolites in a cross-gender setting. Targeted metabolomic profiling of serum of fasting transmen and transwomen at baseline and following 12 months of CSH (N = 20/group) was performed. Changes in 186 serum metabolites and metabolite ratios were determined by targeted metabolomics analysis based on ESI-LC-MS/MS. RandomForest (RF) analysis was applied to detect metabolites of highest interest for grouping of transwomen and transmen before and after initiation of CSH. Principal component analysis (PCA) was performed to check whether group differentiation was achievable according to these variables and to see if changes in metabolite levels could be explained by a priori gender differences. PCA predicted grouping of individuals-determined by the citrulline/arginine-ratio and the amino acids lysine, alanine and asymmetric dimethylarginine - in addition to the expected grouping due to changes in sex steroids and body composition. The fact that most of the investigated metabolites did, however, not change, indicates that the majority of sex dependent differences in metabolites reported in the literature before may primarily not be attributable to sex hormones but to other gender-differences.

Circulating androgens correlate with resting-state MRI in transgender men

Despite mounting evidence regarding the underlying neurobiology in transgender persons, information regarding resting-state activity, particularly after hormonal treatment, is lacking. The present study examined differences between transgender persons on long-term cross-sex hormone therapy and comparisons on two measures of local functional connectivity, intensity of spontaneous resting-state activity (low frequency fluctuations, LFF) and local synchronization of specific brain areas (regional homogeneity, ReHo). Nineteen transgender women (TW, male-to-female), 19 transgender men (TM, female-to-male), 21 non-transgender men (NTM) and 20 non-transgender women (NTW) underwent a resting-state MRI scan. The results showed differences between transgender persons and non-transgender comparisons on both LFF and ReHo measures in the frontal cortex, medial temporal lobe, and cerebellum. More interestingly, circulating androgens correlated for TM in the cerebellum and regions of the frontal cortex, an effect that was associated with treatment duration in the cerebellum. By comparison, no associations were found for TW with estrogens. These data provide first evidence for a potential masculinization of local functional connectivity in hormonally-treated transgender men.

Research priorities for gender nonconforming/transgender youth: gender identity development and biopsychosocial outcomes

PURPOSE OF REVIEW

The review summarizes relevant research focused on prevalence and natural history of gender nonconforming/transgender youth, and outcomes of currently recommended clinical practice guidelines. This review identifies gaps in knowledge, and provides recommendations foci for future research.

RECENT FINDINGS

Increasing numbers of gender nonconforming youth are presenting for care. Clinically useful information for predicting individual psychosexual development pathways is lacking. Transgender youth are at high risk for poor medical and psychosocial outcomes. Longitudinal data examining the impact of early social transition and medical interventions are sparse. Existing tools to understand gender identity and quantify gender dysphoria need to be reconfigured to study a more diverse cohort of transgender individuals. Increasingly, biomedical data are beginning to change the trajectory of scientific investigation.

SUMMARY

Extensive research is needed to improve understanding of gender dysphoria, and transgender experience, particularly among youth. Recommendations include identification of predictors of persistence of gender dysphoria from childhood into adolescence, and a thorough investigation into the impact of interventions for transgender youth. Finally, examining the social environments of transgender youth is critical for the development of appropriate interventions necessary to improve the lives of transgender people.

Personality and gender differences in global perspective

Men's and women's personalities appear to differ in several respects. Social role theories of development assume gender differences result primarily from perceived gender roles, gender socialization and sociostructural power differentials. As a consequence, social role theorists expect gender differences in personality to be smaller in cultures with more gender egalitarianism. Several large cross-cultural studies have generated sufficient data for evaluating these global personality predictions. Empirically, evidence suggests gender differences in most aspects of personality-Big Five traits, Dark Triad traits, self-esteem, subjective well-being, depression and values-are conspicuously larger in cultures with more egalitarian gender roles, gender socialization and sociopolitical gender equity. Similar patterns are evident when examining objectively measured attributes such as tested cognitive abilities and physical traits such as height and blood pressure. Social role theory appears inadequate for explaining some of the observed cultural variations in men's and women's personalities. Evolutionary theories regarding ecologically-evoked gender differences are described that may prove more useful in explaining global variation in human personality.

Gender Identity and Sex Role of Patients Operated on for Bladder Exstrophy-Epispadias

PURPOSE

We evaluated whether genital deformity has an impact on gender identity and sex role in patients operated on for bladder exstrophy-epispadias complex.

MATERIALS AND METHODS

A total of 62 adolescents and adults operated on for bladder exstrophy-epispadias complex were mailed questionnaires evaluating gender identity (Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults) and sex role (Bem Sex Role Inventory). Of the patients 33 responded and the results were compared with 99 gender matched controls.

RESULTS

On the gender identity questionnaire female patients had median scores similar to those of their gender matched controls (4.93 vs 4.89, p = 0.412) but in males the score was lower compared to controls (4.87 vs 4.96, p = 0.023), indicating somewhat more conflicted gender identity. However, no patient had gender dysphoria. Female sex role index was higher in female patients vs controls (5.9 vs 5.3, p = 0.003) but was comparable between male patients and controls (5.2 vs 5.0, p = 0.459). Masculine sex role indices were comparable between female patients and controls as well as between male patients and controls. Of 32 patients 17 were considered to have androgynous sex role, as were 24 of 97 controls (p = 0.004). The exact diagnosis (bladder exstrophy or epispadias) or dissatisfaction with appearance of the genitals had no impact on gender identity or on sex role indices.

CONCLUSIONS

Male patients had lower gender identity scores compared to controls and female sex role was enhanced among female patients. Androgynous sex role was more common in patients vs controls. Gender dysphoria was not noted in any patient.