1
|
Zeigler G, Harrington CA, Rosendale N, Ganos C, Roldan V, Pace A, Alick-Lindstrom S, Orozco-Poore C, Deeb W, Hansen ML, L'Erario ZP. Neurologic Care for Transgender and Gender-Diverse People: A Review of Current Evidence and Clinical Implications. Neurol Clin Pract 2024; 14:e200332. [PMID: 38919931 PMCID: PMC11195436 DOI: 10.1212/cpj.0000000000200332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/11/2024] [Indexed: 06/27/2024]
Abstract
Purpose of Review To summarize the literature on neurologic care for transgender and gender-diverse (TGD) people and provide implications for clinical practice. Recent Findings There are limited data on the frequency and management of neurologic conditions among TGD people. TGD people have a higher prevalence of various neurologic conditions compared with cisgender or general population cohorts, including migraine, subjective cognitive decline, sleep disturbances, functional disorders, and cerebrovascular disease. Gender-affirming hormone therapy interacts with commonly prescribed neurologic medications and increases stroke risk among transfeminine people. Sex hormones and sex chromosomes may play a role in neurodegeneration and disability progression in neuroimmunologic diseases. Clitoral reduction surgeries on intersex children can cause neurologic disability and sexual dysfunction in adulthood. Socioeconomic disparities among TGD people contribute to health care barriers. Summary Neurologists should consider the unique experiences and health care needs of TGD people in their clinical practice and research protocols.
Collapse
Affiliation(s)
- Gwen Zeigler
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Cole A Harrington
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Nicole Rosendale
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Christos Ganos
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Valeria Roldan
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Anna Pace
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Sasha Alick-Lindstrom
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Casey Orozco-Poore
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Wissam Deeb
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Margaret L Hansen
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| | - Z Paige L'Erario
- Department of Neurology (GZ), Albany Medical College, NY; Department of Neurology (CAH), The Ohio State University College of Medicine, Columbus; Department of Neurology and Weill Institute for Neurosciences (NR), University of California San Francisco; Movement Disorder Clinic (CG), Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, University of Toronto, Toronto Western Hospital, Ontario, Canada; Facultad de Medicina Alberto Hurtado (VR), Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Neurology (AP), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology (SA-L), University of Texas Southwestern Medical Center, Dallas; Department of Pediatric Neurology (CO-P), University of California, Los Angeles; Department of Neurology (WD), UMass Memorial Medical Center and UMass Medical School, Worcester; The Ohio State University Wexner Medical Center (MLH), Columbus; Greenburgh Pride (ZPLE), Westchester, NY
| |
Collapse
|
2
|
Turino Miranda K, Greene DN, Collister D, Krasowski MD, Ahmed SB, Cirrincione LR, Rosas SE, Saad N, Pierre CC. A Holistic Framework for the Evaluation of Kidney Function in a Gender-Diverse Landscape. Am J Kidney Dis 2024; 84:232-240. [PMID: 38458377 DOI: 10.1053/j.ajkd.2024.01.522] [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: 09/05/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 03/10/2024]
Abstract
The most commonly used equations to estimate glomerular filtration rate incorporate a binary male-female sex coefficient, which has important implications for the care of transgender, gender-diverse, and nonbinary (TGD) people. Whether "sex assigned at birth" or a binary "gender identity" is most appropriate for the computation of estimated glomerular filtration rate (eGFR) is unknown. Furthermore, the use of gender-affirming hormone therapy (GAHT) for the development of physical changes to align TGD people with their affirmed gender is increasingly common, and may result in changes in serum creatinine and cystatin C, the biomarkers commonly used to estimate glomerular filtration rate. The paucity of current literature evaluating chronic kidney disease (CKD) prevalence and outcomes in TGD individuals on GAHT makes it difficult to assess any effects of GAHT on kidney function. Whether alterations in serum creatinine reflect changes in glomerular filtration rate or simply changes in muscle mass is unknown. Therefore, we propose a holistic framework to evaluate kidney function in TGD people. The framework focuses on kidney disease prevalence, risk factors, sex hormones, eGFR, other kidney function assessment tools, and the mitigation of health inequities in TGD people.
Collapse
Affiliation(s)
- Keila Turino Miranda
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dina N Greene
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington; LetsGetChecked Laboratories, Monrovia, California
| | - David Collister
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Sofia B Ahmed
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada; Alberta Kidney Disease Network, Calgary, Alberta, Canada; Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Sylvia E Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center, Boston, Massachusetts; Department of Nephrology, Beth Israel Deaconess Medical Centre, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Nathalie Saad
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christina C Pierre
- Department of Pathology and Laboratory Medicine, Penn Medicine Lancaster General Health, Lancaster, Pennsylvania; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
3
|
Ceolin C, Papa MV, Scala A, Sergi G, Garolla A. Getting old in the desired gender: a systematic review on aging diseases in transgender people. J Endocrinol Invest 2024; 47:1851-1862. [PMID: 38904914 PMCID: PMC11266207 DOI: 10.1007/s40618-024-02353-y] [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: 12/11/2023] [Accepted: 02/28/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION The growing demographic presence of the transgender (TGD) population has sparked an increase in clinical investigations focusing on the impacts of gender-affirming hormone therapy (GAHT) in adults with gender dysphoria. Despite this surge in studies, there remains a significant gap in the literature regarding the health status of older TGD individuals. This review aims to assess prevalent pathological conditions within the TGD population, specifically concentrating on aging-related diseases investigated to date. METHODS A systematic search across Embase Ovid, Scopus, PubMed, Cochrane Library, and Web of Science databases was conducted to identify articles reporting on the aging process in TGD individuals. Methodological quality was evaluated using Newcastle-Ottawa Scale (NOS) scores. RESULTS Initial database searches yielded 12,688 studies, which were refined to 18 through elimination of duplicates and title/abstract review. Following a comprehensive appraisal, nine studies were included in the systematic review. These articles, published between 2017 and 2023, involved a total of 5403 participants. The evidence indicates a noteworthy percentage of the TGD population being at risk for cardiovascular diseases, experiencing depression or disability, and demonstrating hesitancy toward major recommended screening programs. CONCLUSIONS Limited studies on older TGD individuals highlight not only an organic risk of chronic diseases but also a cognitive/psychiatric risk that should not be underestimated. Further research is imperative to deepen our understanding of the pathophysiological mechanisms involved in the health challenges faced by older TGD individuals.
Collapse
Affiliation(s)
- C Ceolin
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, via Giustiniani 2, 35128, Padua, Italy.
- Regional Reference Center for Gender Incongruence (CRRIG), Padua, Veneto, Italy.
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Aging Research Center, Stockholm, Sweden.
| | - M V Papa
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, via Giustiniani 2, 35128, Padua, Italy
| | - A Scala
- Regional Reference Center for Gender Incongruence (CRRIG), Padua, Veneto, Italy
- Unit of Andrology and Reproductive Medicine, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - G Sergi
- Geriatrics Division, Department of Medicine (DIMED), University of Padua, via Giustiniani 2, 35128, Padua, Italy
- Regional Reference Center for Gender Incongruence (CRRIG), Padua, Veneto, Italy
| | - A Garolla
- Regional Reference Center for Gender Incongruence (CRRIG), Padua, Veneto, Italy
- Unit of Andrology and Reproductive Medicine, Department of Medicine (DIMED), University of Padua, Padua, Italy
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Johnson EL, Bui E, Tassiopoulos K, Koretzky MO, Zepeda R, Gonzalez-Giraldo E, Gottesman RF. Prevalence of Epilepsy in People of Sexual and Gender Minoritized Groups. JAMA Neurol 2024:2821071. [PMID: 39037821 PMCID: PMC11264076 DOI: 10.1001/jamaneurol.2024.2243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/24/2024] [Indexed: 07/24/2024]
Abstract
Importance Epilepsy is a highly treatable condition for many people, but there are large treatment gaps with suboptimal seizure control in minoritized groups. The sexual and gender minority (SGM) community is at risk for health disparities, yet the burden of epilepsy in this community is not known. Objective To estimate the prevalence of active epilepsy among SGM people in the United States. Design, Setting, and Participants This was a cross-sectional, nationally representative survey study of community-dwelling US adults who answered questions about epilepsy, sexual orientation, and gender identity in the 2022 National Health Interview Survey (NHIS). Exposure Self-identification of transgender or gender-diverse identity, or sexual orientation including gay, lesbian, bisexual, or other orientation, excluding straight (ie, heterosexual). Main Outcomes and Measures Participants self-reported epilepsy status, medical treatment, seizure frequency, demographic characteristics, sexual orientation, and gender identity. Logistic regression was used to estimate the association of epilepsy with SGM identification. Results A total of 27 624 participants (15 050 [54%] women; 3231 [12%] Black; mean [SD] age, 48.2 [18.5] years) completed the NHIS and were included. Active epilepsy was present in 1.2% (95% CI, 1.0%-1.3%) of the population. A higher proportion of SGM adults than non-SGM adults reported active epilepsy (2.4% [95% CI, 1.4%-3.3%] vs 1.1% [95% CI, 1.0%-1.3%], respectively). After adjusting for age, race, ethnicity, income, and education, SGM people were more than twice as likely to report active epilepsy than were non-SGM adults (adjusted odds ratio, 2.14; 95% CI, 1.35-3.37). Conclusions and Relevance The findings suggest that SGM adults in the United States have a disproportionate prevalence of epilepsy. The reasons for this disparity are likely complex and may be associated with biological and psychosocial determinants of health unique to this population; as such, these individuals are in need of protected access to medical care.
Collapse
Affiliation(s)
- Emily L. Johnson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Esther Bui
- Department of Neurology, University of Toronto School of Medicine, Toronto, Ontario, Canada
| | - Karina Tassiopoulos
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Maya Overby Koretzky
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rodrigo Zepeda
- Department of Neurology, University of Texas Southwestern School of Medicine, Dallas
| | | | - Rebecca F. Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
7
|
Hayes-Lattin M, Krivicich LM, Bragg JT, Rogerson A, Salzler MJ. Considerations for the care of transgender patients in orthopaedics and sports medicine: a narrative review. Br J Sports Med 2024:bjsports-2023-107703. [PMID: 38997148 DOI: 10.1136/bjsports-2023-107703] [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: 07/01/2024] [Indexed: 07/14/2024]
Abstract
Orthopaedic and sports medicine clinicians can improve outcomes for transgender patients by understanding the physiological effects of gender-affirming hormone therapy (GAHT). This narrative review investigated the role of GAHT on bone mineral density, fracture risk, thromboembolic risk, cardiovascular health and ligament/tendon injury in this population. A search from the PubMed database using relevant terms was performed. Studies were included if they were levels 1-3 evidence. Due to the paucity of studies on ligament and tendon injury risk in transgender patients, levels 1-3 evidence on the effects of sex hormones in cisgender patients as well as basic science studies were included for these two topics. This review found that transgender patients on GAHT have an elevated fracture risk, but GAHT has beneficial effects on bone mineral density in transgender women. Transgender women on GAHT also have an increased risk of venous thromboembolism, stroke and myocardial infarction compared with cisgender women. Despite these elevated risks, studies have found it is safe to continue GAHT perioperatively for both transgender women and men undergoing low-risk operations. Orthopaedic and sports medicine clinicians should understand these unique health considerations for equitable patient care.
Collapse
Affiliation(s)
| | - Laura M Krivicich
- Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jack T Bragg
- Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ashley Rogerson
- Department of Orthopaedics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Matthew J Salzler
- Department of Orthopaedics, Tufts Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
8
|
Ministrini S, Padro T. MicroRNA in cardiometabolic health and disease: The perspectives of sex, gender and personalised medicine. Eur J Clin Invest 2024; 54:e14223. [PMID: 38623918 DOI: 10.1111/eci.14223] [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: 03/01/2024] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Personalized medicine represents a novel and integrative approach that focuses on an individual's genetics and epigenetics, precision medicine, lifestyle and exposures as key players of health status and disease phenotypes. METHODS In this narrative review, we aim to carefully discuss the current knowledge on gender disparities in cardiometabolic diseases, and we consider the sex- specific expression of miRNAs and their role as promising tool in precision medicine. RESULTS Personalised medicine overcomes the restricted care of patient based on a binomial sex approach, by enriching itself with a holistic and dynamic gender integration. Recognized as a major worldwide health emergency, cardiometabolic disorders continue to rise, impacting on health systems and requiring more effective and targeted strategies. Several sex and gender drivers might affect the onset and progression of cardiometabolic disorders in males and females at multiple levels. In this respect, distinct contribution of genetic and epigenetic mechanisms, molecular and physiological pathways, sex hormones, visceral fat and subcutaneous fat and lifestyle lead to differences in disease burden and outcomes in males and females. CONCLUSIONS Sex and gender play a pivotal role in precision medicine because the influence the physiology of each individual and the way they interact with environment from intrauterine life.
Collapse
Affiliation(s)
- Stefano Ministrini
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Teresa Padro
- Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain
- Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV) Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
9
|
de Silva NL, Dimakopoulou A, Quinton O, Jayasena CN. Metabolic and cardiovascular risks of hormone treatment for transgender individuals. Best Pract Res Clin Endocrinol Metab 2024:101907. [PMID: 38942618 DOI: 10.1016/j.beem.2024.101907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Identifying metabolic and cardiovascular risks of gender-affirming hormone therapy (GAHT) is challenging due to other confounding variables that affect patient outcomes and the diversity of treatment regimes. Masculinising hormone therapy produces atherogenic lipid profiles, while effects on other metabolic parameters are not consistent. There is insufficient evidence to conclude if cardiovascular disease risk among transmen is increased. The effects of feminising hormone therapy on metabolic parameters do not demonstrate a consistent pattern in the available literature. However, the risk of venous thromboembolism is greater in transwomen than in cis-gender men and women with a possible increase in cardiovascular disease risk. It is recommended to discuss the potential effects of GAHT on cardiovascular health and encourage patients seeking GAHT to adopt a healthy lifestyle. Performing baseline and periodic assessments of cardiovascular risk factors would enable early identification and interventions. In high-risk individuals, the cardiovascular effects of hormonal regimes might impact the treatment decision.
Collapse
Affiliation(s)
- Nipun Lakshitha de Silva
- Department of Clinical Sciences, Faculty of Medicine, General Sir John Kotelawala Defence University, Sri Lanka; Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK.
| | - Anastasia Dimakopoulou
- Tavistock and Portman NHS Foundation Trust, Gender Identity Clinic, Lief House, London, UK.
| | - Oliver Quinton
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK.
| | - Channa N Jayasena
- Department of Metabolism, Digestion and Reproduction, Imperial College, London, UK.
| |
Collapse
|
10
|
Dimakopoulou A, Seal LJ. Testosterone and other treatments for transgender males and non-binary trans masculine individuals. Best Pract Res Clin Endocrinol Metab 2024:101908. [PMID: 38997938 DOI: 10.1016/j.beem.2024.101908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2024]
Abstract
Testosterone therapy is the main hormonal treatment offered in transmen to alleviate somatic gender dysphoria. Testosterone can be administered via topical or injectable preparations to achieve physical changes resulting in masculinisation and improve quality of life for the treated individuals. The aim of our paper is to outline methods for testosterone replacement, their impact on main body systems of transmen, potential associated health risks and long term follow up. Androgen use in transgender medicine is safe with appropriate endocrine guidance and monitoring. Studies with longer follow-up period, including those who may prefer low dose testosterone, interested in pregnancy or older people may further improve the management of female-to-male transgender persons.
Collapse
Affiliation(s)
- A Dimakopoulou
- Department of Endocrinology, Gender Identity Clinic, Tavistock & Portman NHS Foundation Trust, London, UK
| | - L J Seal
- Department of Endocrinology, Gender Identity Clinic, Tavistock & Portman NHS Foundation Trust, London, UK; St George's University of London Medical School, UK.
| |
Collapse
|
11
|
Gosiker B, Moutchia J, Nguyen N, Getahun D, Goodman M. Changes in Blood Lipids Following Initiation of Gender Affirming Hormone Therapy: A Systematic Review and Meta-Analysis. J Clin Transl Endocrinol 2024; 36:100349. [PMID: 38737626 PMCID: PMC11087959 DOI: 10.1016/j.jcte.2024.100349] [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: 12/11/2023] [Revised: 03/08/2024] [Accepted: 04/29/2024] [Indexed: 05/14/2024] Open
Abstract
Aim The aim of this study was to conduct a systematic review and meta-analysis of changes in low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), total cholesterol, and triglycerides following initiation of feminizing or masculinizing gender affirming hormone therapy (GAHT). Methods A search of Ovid MEDLINE, Embase, Web of Science, SCOPUS, and CINAHL databases identified potentially relevant articles published from 1990 through 2024. Both observational and randomized trials of adults receiving feminizing or masculinizing GAHT with baseline and follow-up measures were included. Articles were reviewed for eligibility using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. The risk of bias in each study was quantified using the NHLBI Study Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group. Random effects models were used to compute the before-and-after meta-differences in mean values for each parameter along with the I2 statistic to assess heterogeneity of results. Results Thirty-five studies met the criteria for inclusion in the meta-analysis. Masculinizing GAHT was associated with significant changes in serum lipids from baseline up through the 60-month timepoint with meta-difference of means (95% CI) estimates of 26.2mg/dL (23.3,29.0) for LDL-C, 26.1mg/dL (22.8,29.4) for total cholesterol, 30.7mg/dL (6.9,54.6) for triglycerides and -9.4mg/dL (-12.1, -6.7) for HDL-C. Studies evaluating the effects of feminizing GAHT on balance demonstrated no notable changes in HDL-C or triglycerides while the results for LDL-C and total cholesterol were inconsistent. Heterogeneity of results ranged from minimal (I2 = 0%) to substantial (I2 = 90%). Conclusions While the results for transfeminine individuals on GAHT appear somewhat reassuring, transmasculine patients receiving testosterone may benefit from closer monitoring of lipid profiles.
Collapse
Affiliation(s)
- Bennett Gosiker
- Kaiser Permanente Bernard J. Tyson School of Medicine, United States
| | - Jude Moutchia
- Penn Medicine, University of Pennsylvania, United States
| | - Nghiem Nguyen
- Kaiser Permanente Bernard J. Tyson School of Medicine, United States
| | - Darios Getahun
- Kaiser Permanente Southern California, Department of Research and Evaluation, Southern California Permanente Medical Group, United States
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, United States
| | - Michael Goodman
- Department of Epidemiology, Rollins School of Public Health, Emory University, United States
| |
Collapse
|
12
|
Ong C, Monita M, Liu M. Gender-affirming hormone therapy and cardiovascular health in transgender adults. Climacteric 2024; 27:227-235. [PMID: 38597210 DOI: 10.1080/13697137.2024.2310518] [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: 11/13/2023] [Accepted: 01/20/2024] [Indexed: 04/11/2024]
Abstract
A growing number of people identify as transgender and gender non-binary in the USA and worldwide. Concomitantly, an increasing number of patients are receiving gender-affirming hormone therapy (GAHT) to achieve gender congruence. GAHT has far-ranging effects on clinical and subclinical markers of cardiovascular risk. Transgender patients also appear to be at higher risk for cardiovascular diseases compared to their cisgender peers and the impact of gender-affirming therapy on cardiovascular health is unclear. Studies on the effect of GAHT on cardiovascular outcomes are confounded by differences in GAHT regimens and methodological challenges in a diverse and historically hard-to-reach population. Current cardiovascular guidelines do not incorporate gender identity and hormone status into risk stratification and clinical decision-making. In this review, we provide an overview on the cardiometabolic impact and clinical considerations of GAHT for cardiovascular risk in transgender patients.
Collapse
Affiliation(s)
- Caroline Ong
- Division of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Monique Monita
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Minghao Liu
- Department of Endocrinology, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| |
Collapse
|
13
|
Iwamoto SJ, Rice JD, Moreau KL, Cornier MA, Wierman ME, Mancuso MP, Gebregzabheir A, Hammond DB, Rothman MS. The association of gender-affirming hormone therapy duration and body mass index on bone mineral density in gender diverse adults. J Clin Transl Endocrinol 2024; 36:100348. [PMID: 38756206 PMCID: PMC11096741 DOI: 10.1016/j.jcte.2024.100348] [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: 01/30/2024] [Revised: 03/23/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction Feminizing and masculinizing gender-affirming hormone therapy (fGAHT, mGAHT) results in bone mineral density (BMD) maintenance or improvement over time in transgender and gender diverse (TGD) adults. Mostly European TGD studies have explored GAHT's impact on BMD, but the association of BMI and BMD in TGD adults deserves further study. Objective To determine whether GAHT duration or BMI are associated with BMD and Z-scores among TGD young adults. Methods Cross-sectional study of nonsmoking TGD adults aged 18-40 years without prior gonadectomy or gonadotropin-releasing hormone agonist (GnRHa) therapy taking GAHT for > 1 year. BMD and Z-scores were collected from dual-energy x-ray absorptiometry. Associations between femoral neck, total hip, and lumbar spine BMDs and Z-scores and the predictors, GAHT duration and BMI, were estimated using linear regression. Results Among 15 fGAHT and 15 mGAHT, mean BMIs were 27.6 +/- standard deviation (SD) 6.4 kg/m2 and 25.3 +/- 5.9 kg/m2, respectively. Both groups had mean BMDs and Z-scores within expected male and female reference ranges at all three sites. Higher BMI among mGAHT was associated with higher femoral neck and total hip BMDs (femoral neck: β = 0.019 +/- standard error [SE] 0.007 g/cm2, total hip: β = 0.017 +/- 0.006 g/cm2; both p < 0.05) and Z-scores using male and female references. GAHT duration was not associated with BMDs or Z-scores for either group. Conclusions Z-scores in young, nonsmoking TGD adults taking GAHT for > 1 year, without prior gonadectomy or GnRHa, and with mean BMIs in the overweight range, were reassuringly within the expected ranges for age based on male and female references. Higher BMI, but not longer GAHT duration, was associated with higher femoral neck and total hip BMDs and Z-scores among mGAHT. Larger, prospective studies are needed to understand how body composition changes, normal or low BMIs, and gonadectomy affect bone density in TGD adults.
Collapse
Affiliation(s)
- Sean J. Iwamoto
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, 12801 E 17th Ave, 7103, Aurora, CO 80045, USA
- Endocrinology, Medicine and Research Services, Rocky Mountain Regional VA Medical Center, 1700 N Wheeling St, 111H, Aurora, CO 80045, USA
- UCHealth Integrated Transgender Program, University of Colorado Hospital, 1635 Aurora Court, Anschutz Outpatient Pavilion, 6th floor, Aurora, CO 80045, USA
| | - John D. Rice
- Department of Biostatistics, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, USA
| | - Kerrie L. Moreau
- Division of Geriatrics, Department of Medicine, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, 12631 E 17th Ave, 8111, Aurora, CO 80045, USA
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Rocky Mountain Regional VA Medical Center, 1700 N Wheeling St, Aurora, CO 80045, USA
| | - Marc-André Cornier
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas St, CSB 822, Charleston, SC 29425, USA
| | - Margaret E. Wierman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, 12801 E 17th Ave, 7103, Aurora, CO 80045, USA
- Endocrinology, Medicine and Research Services, Rocky Mountain Regional VA Medical Center, 1700 N Wheeling St, 111H, Aurora, CO 80045, USA
| | - Mary P. Mancuso
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, 12631 E 17th Ave, Aurora, CO, 80045, USA
| | - Amanuail Gebregzabheir
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, 12801 E 17th Ave, 7103, Aurora, CO 80045, USA
| | - Daniel B. Hammond
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, 12801 E 17th Ave, 7103, Aurora, CO 80045, USA
- UCHealth Integrated Transgender Program, University of Colorado Hospital, 1635 Aurora Court, Anschutz Outpatient Pavilion, 6th floor, Aurora, CO 80045, USA
| | - Micol S. Rothman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, 12801 E 17th Ave, 7103, Aurora, CO 80045, USA
- UCHealth Integrated Transgender Program, University of Colorado Hospital, 1635 Aurora Court, Anschutz Outpatient Pavilion, 6th floor, Aurora, CO 80045, USA
| |
Collapse
|
14
|
Drobnič Radobuljac M, Grošelj U, Kaltiala R, Vermeiren R, Crommen S, Kotsis K, Danese A, Hoekstra PJ, Fegert JM. ESCAP statement on the care for children and adolescents with gender dysphoria: an urgent need for safeguarding clinical, scientific, and ethical standards. Eur Child Adolesc Psychiatry 2024; 33:2011-2016. [PMID: 38678135 DOI: 10.1007/s00787-024-02440-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Affiliation(s)
- Maja Drobnič Radobuljac
- Department of Psychiaty, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
- Centre for Mental Health, University Psychiatric Clinic Ljubljana, Ljubljana, Slovenia.
| | - Urh Grošelj
- Department of Endocrinology, Diabetes and Metabolism, UMC - University Children's Hospital Ljubljana, Ljubljana, Slovenia
- Department of Pediatrics, University of Ljubljana, Ljubljana, Slovenia
- Department of Medical Ethics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- National Medical Ethics Committee of Slovenia, Ljubljana, Slovenia
| | - Riittakerttu Kaltiala
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Adolescent Psychiatry, Tampere University Hospital, Tampere, Finland
- Vanha Vaasa Hospital, Vaasa, Finland
| | - Robert Vermeiren
- Department of Child and Adolescent Psychiatry, Curium-Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Konstantinos Kotsis
- Community CAMHS, and Department of Psychiatry, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Andrea Danese
- Department of Child and Adolescent Psychiatry and Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
- National and Specialist CAMHS Clinic for Trauma, Anxiety, and Depression, South London and Maudsley NHS Foundation Trust, London, UK
| | - Pieter J Hoekstra
- Department of Child and Adolescent Psychiatry, University of Groningen; and University Medical Center Groningen, Groningen, The Netherlands
| | - Jörg M Fegert
- Department of Child and Adolescent Psychiatry/Psychotherapy, University Hospital Ulm, Ulm, Germany
| |
Collapse
|
15
|
Nikzad N, Fisher AR, Pillai A, Targownik LE, Te HS, Aronsohn A, Paul S. Considerations in gender-affirming hormone therapy in transgender and gender diverse patients undergoing liver transplantation. Am J Transplant 2024:S1600-6135(24)00296-X. [PMID: 38729612 DOI: 10.1016/j.ajt.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/26/2024] [Accepted: 05/06/2024] [Indexed: 05/12/2024]
Abstract
Liver transplantation is lifesaving for patients with end-stage liver disease. Similar to the role of transplantation for patients with end-stage liver disease, gender-affirming hormone therapy (GAHT) can be lifesaving for transgender and gender diverse (TGGD) patients who experience gender dysphoria. However, management of such hormone therapy during the perioperative period is unknown and without clear guidelines. Profound strides can be made in improving care for TGGD patients through gender-affirming care and appropriate management of GAHT in liver transplantation. In this article, we call for the transplant community to acknowledge the integral role of GAHT in the care of TGGD liver transplant candidates and recipients. We review the current literature and describe how the transplant community is ethically obligated to address this health care gap. We suggest tangible steps that clinicians may take to improve health outcomes for this minoritized patient population.
Collapse
Affiliation(s)
- Newsha Nikzad
- Department of Internal Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Andrew R Fisher
- Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, Illinois, USA
| | - Anjana Pillai
- Department of Gastroenterology, Hepatology & Nutrition, Center for Liver Disease, University of Chicago Medicine, Chicago, Illinois, USA
| | - Laura E Targownik
- Department of Gastroenterology and Hepatology, University of Toronto, Toronto, Ontario, Canada
| | - Helen S Te
- Department of Gastroenterology, Hepatology & Nutrition, Center for Liver Disease, University of Chicago Medicine, Chicago, Illinois, USA
| | - Andrew Aronsohn
- Department of Gastroenterology, Hepatology & Nutrition, Center for Liver Disease, University of Chicago Medicine, Chicago, Illinois, USA
| | - Sonali Paul
- Department of Gastroenterology, Hepatology & Nutrition, Center for Liver Disease, University of Chicago Medicine, Chicago, Illinois, USA.
| |
Collapse
|
16
|
Dix C, Moloney M, Tran HA, McFadyen JD. Venous Thromboembolism and Estrogen-Containing Gender-Affirming Hormone Therapy. Thromb Haemost 2024; 124:387-398. [PMID: 37816389 DOI: 10.1055/a-2188-8898] [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: 10/12/2023]
Abstract
Gender-affirming therapy involves the use of hormones to develop the physical characteristics of the identified gender and suppressing endogenous sex hormone production. Venous thromboembolism (VTE) is a known risk of exogenous estrogen therapy, and while evidence of VTE risk among transgender women using modern gender-affirming hormone therapy (GAHT) is still emerging, it is thought to affect up to 5% of transgender women. Historically, GAHT was associated with a high risk of VTE; however, modern preparations are less thrombogenic mainly due to significantly lower doses used as well as different preparations. This review presents the available literature regarding the following four topics: (1) risk of VTE among transgender women receiving estradiol GAHT, (2) how the route of administration of estradiol affects the VTE risk, (3) perioperative management of GAHT, (4) VTE risk among adolescents on GAHT. There is a need for large, longitudinal studies of transgender women using GAHT to further characterize VTE risk and how this is affected by factors such as patient age, duration of GAHT use, tobacco use, body mass index, and comorbidities. Future studies in these areas could inform the development of clinical guidelines to improve the care of transgender people.
Collapse
Affiliation(s)
- Caroline Dix
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
| | - Mollie Moloney
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
| | - Huyen A Tran
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
| | - James D McFadyen
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia
- Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Australia
- Atherothrombosis and Vascular Biology Program, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| |
Collapse
|
17
|
Volpe SG, Ahmad J, Patel RA, Rosendale N. Neurological care for LGBT+ people. Nat Rev Neurol 2024; 20:288-297. [PMID: 38499761 DOI: 10.1038/s41582-024-00944-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2024] [Indexed: 03/20/2024]
Abstract
Sexual and gender minority (LGBT+) people face unique health disparities that must be considered by health-care providers to ensure equitable and inclusive care. Although traditionally LGBT+ health has not been integrated into neurology training, sexual orientation and gender identity have direct relevance to neurological health, driven by both systemic and interpersonal factors. In this Review, we summarize the evidence for associations between sexual orientation and gender identity with the prevalence and outcomes of various neurological conditions, including neurodegenerative diseases, epilepsy, stroke and neurodevelopmental disorders, among others. We describe important clinical considerations pertaining to LGBT+ people and recommend language and practices to promote inclusive care, as well as highlight gaps in need of further research and possible strategies to minimize these, including systematic collection of sexual orientation and gender identity and use of inclusive language.
Collapse
Affiliation(s)
| | - Joya Ahmad
- College of Medicine, SUNY Downstate Health Sciences University, New York City, NY, USA
| | - Roshni Abee Patel
- Neurology Service, Jesse Brown VA Medical Center, Chicago, IL, USA
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Nicole Rosendale
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA.
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA.
| |
Collapse
|
18
|
Tolley P, Susarla S, Ettinger RE. Gender-Affirming Facial Surgery: Lower Third of the Face. Oral Maxillofac Surg Clin North Am 2024; 36:207-219. [PMID: 38272781 DOI: 10.1016/j.coms.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
This article is intended to give the reader an overview of facial gender-affirming procedures applicable to the lower face and neck. A review of facial analysis in the context of masculine versus feminine facial features and the contributions of both soft tissue and bone to this anatomy is provided. The use of systematic facial evaluation and patient-driven concerns as a guide for presurgical planning is reviewed. Detailed descriptions of the unique surgical interventions to feminize the soft tissues and the skeletal framework of the lower face and neck are provided.
Collapse
Affiliation(s)
- Phil Tolley
- Division of Plastic Surgery, Department of Surgery, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359796, Seattle, WA 98104, USA
| | - Srinivas Susarla
- Division of Plastic Surgery, Department of Surgery, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359796, Seattle, WA 98104, USA; Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children's Hospital
| | - Russell E Ettinger
- Division of Plastic Surgery, Department of Surgery, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359796, Seattle, WA 98104, USA; Division of Craniofacial and Plastic Surgery, Department of Surgery, Seattle Children's Hospital.
| |
Collapse
|
19
|
Yang KJ, Kerr C, Rumps MV, Mulcahey M. Musculoskeletal and cardiovascular considerations for transgender athletes. PHYSICIAN SPORTSMED 2024:1-7. [PMID: 38605534 DOI: 10.1080/00913847.2024.2342230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/09/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Participation in athletics is essential for the overall well-being of transgender athletes and should be included as part of gender-affirming care. Surveys show physicians and athletic trainers want to provide appropriate care for transgender athletes but lack the proper knowledge and training to do so. Gender Affirming Hormone Therapy (GAHT) is part of gender-affirming care, yet the effects of GAHT on the cardiovascular and musculoskeletal health of transgender athletes is not well-understood. The purpose of this review was to discuss important musculoskeletal and cardiovascular considerations unique to transgender athletes and improve physician understanding in caring for transgender athletes. METHODS A representative selection of literature on the effects of GAHT on cardiovascular and musculoskeletal health was included in this review. RESULTS Estrogen therapy may increase the risk of venous thromboembolism (VTE) and stroke, and decrease blood pressure levels among transgender women, while studies on lipid profile are inconsistent among both transgender men and women. Transgender women receiving GAHT may also be at greater risk for bone fracture and ligamentous injuries. CONCLUSION Exercise is essential for the well-being of transgender individuals and special considerations regarding the cardiovascular and musculoskeletal health of transgender athletes should be incorporated into standard medical education. Educational programs for transgender patients and their support team should focus on preventative measures that can be taken to reduce the risk of adverse musculoskeletal and cardiovascular events. The PPE is an invaluable tool available to physicians to monitor the health and safety of transgender athletes and should be regularly updated as research on the health of transgender individuals continues to grow. Longitudinal and prospective studies should examine the effects of GAHT on the musculoskeletal and cardiovascular health of transgender athletes. Lastly, health care providers play an important role in the advancement of gender-neutral policies.
Collapse
Affiliation(s)
- Kailynn J Yang
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Canaan Kerr
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Mia V Rumps
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| | - Mary Mulcahey
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, IL, USA
| |
Collapse
|
20
|
Trout AL, McLouth CJ, Westberry JM, Sengoku T, Wilson ME. Estrogen's sex-specific effects on ischemic cell death and estrogen receptor mRNA expression in rat cortical organotypic explants. AGING BRAIN 2024; 5:100117. [PMID: 38650743 PMCID: PMC11033203 DOI: 10.1016/j.nbas.2024.100117] [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: 10/19/2023] [Revised: 02/14/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024] Open
Abstract
Estrogens, such as the biologically active 17-β estradiol (E2), regulate not only reproductive behaviors in adults, but also influence neurodevelopment and neuroprotection in both females and males. E2, contingent upon the timing and concentration of the therapy, is neuroprotective in female and male rodent models of stroke. In Vivo studies suggest that E2 may partially mediate this neuroprotection, particularly in the cortex, via ERα. In Vitro studies, utilizing a chemically induced ischemic injury in cortical explants from both sexes, suggest that ERα or ERβ signaling is needed to mediate the E2 protection. Since we know that the timing and concentration of E2 therapy may be sex-specific, we examined if E2 (1 nM) mediates neuroprotection when female and male cortical explants are separately isolated from postnatal day (PND) 3-4 rat. Changes in basal levels ERα, ERβ, and AR mRNA expression are compared across early post-natal development in the intact cortex and the corresponding days in vitro (DIV) for cortical explants. Following ischemic injury at 7 DIV, cell death and ERα, ERβ and AR mRNA expression was compared in female and male cortical explants. We provide evidence that E2-mediated protection is maintained in isolated cortical explants from females, but not male rats. In female cortical explants, the E2-mediated protection at 24 h occurs secondarily to a blunted transient increase in ERα mRNA at 12 h. These results suggest that cortical E2-mediated protection is influenced by sex and supports data to differentially treat females and males following ischemic injury.
Collapse
Affiliation(s)
- Amanda L. Trout
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA
- Department of Neurosurgery, University of Kentucky, Lexington, KY 40536, USA
| | - Christopher J McLouth
- Department of Neurology, University of Kentucky, Lexington, KY, 40536, USA
- Department of Biostatistics, University of Kentucky, Lexington, KY, 40536, USA
| | - Jenne M. Westberry
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA
| | - Tomoko Sengoku
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA
| | - Melinda E. Wilson
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA
| |
Collapse
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Waters J, Linsenmeyer W. The impact of gender-affirming hormone therapy on nutrition-relevant biochemical measures. Front Nutr 2024; 11:1339311. [PMID: 38646103 PMCID: PMC11026707 DOI: 10.3389/fnut.2024.1339311] [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: 11/15/2023] [Accepted: 03/21/2024] [Indexed: 04/23/2024] Open
Abstract
Gender-affirming hormone therapy carries the potential risk for shifts in biochemical markers that may impact cardiometabolic, hematologic, hepatic, and renal health. The critical evaluation of biochemical data is an integral part of a comprehensive nutrition assessment; therefore, nutrition professionals should be aware of shifts that are expected during the course of masculinizing and feminizing hormone therapy. Changes in important biochemical values along with binary sex-specific standards for interpreting laboratory data can pose significant challenges for nutrition professionals working with transgender and gender-diverse patients who receive gender-affirming hormone therapy. Overall, research on the biochemical impact of masculinizing and feminizing hormone therapy is nascent and limited. Methodologies and outcomes measured are heterogenous across studies, introducing complexities that impede researchers from drawing definitive conclusions. In light of these limitations, this narrative review aims to describe the potential implications of masculinizing and feminizing hormone therapy regimens on biochemical measures that may influence nutrition strategies and interventions to promote optimal health.
Collapse
Affiliation(s)
- Jennifer Waters
- School of Health Studies, Northern Illinois University, Dekalb, IL, United States
| | - Whitney Linsenmeyer
- Department of Nutrition and Dietetics, Saint Louis University, Saint Louis, MO, United States
| |
Collapse
|
23
|
de Barros VIPVL, de Oliveira ALML, do Nascimento DJ, Zlotnik E, Teruchkin MM, Marques MA, Margarido PFR. Use of hormones and risk of venous thromboembolism. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2024; 46:e-FPS02. [PMID: 38765519 PMCID: PMC11075397 DOI: 10.61622/rbgo/2024fps02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
•The risk of venous thromboembolism (VTE) is not increased in women using long-acting reversible contraceptive methods (LARCs) with progestogens. •Oral contraceptives with levonorgestrel or norgestimate confer half the risk of VTE compared to oral contraceptives containing desogestrel, gestodene or drospirenone. •Progestogen-only pills do not confer an increased risk of VTE. •Women using transdermal contraceptive patches and combined oral contraceptives (COCs) are at an approximately eight times greater risk of VTE than non-users of hormonal contraceptives (HCs), corresponding to 9.7 events per 10,000 women/years. •Vaginal rings increase the risk of VTE by 6.5 times compared to not using HC, corresponding to 7.8 events per 10,000 women/years. •Several studies have demonstrated an increased risk of VTE in transgender individuals receiving hormone therapy (HT). •Hormone therapy during menopause increases the risk of VTE by approximately two times, and this risk is increased by obesity, thrombophilia, age over 60 years, surgery and immobilization. •The route of estrogen administration, the dosage and type of progestogen associated with estrogen may affect the risk of VTE in the climacteric. •Combined estrogen-progesterone therapy increases the risk of VTE compared to estrogen monotherapy. •Postmenopausal HT increases the risk of thrombosis at atypical sites.
Collapse
Affiliation(s)
- Venina Isabel Poço Viana Leme de Barros
- Clínica Obstétrica Hospital das Clínicas Universidade de São Paulo São PauloSP Brasil Clínica Obstétrica, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - André Luiz Malavasi Longo de Oliveira
- Clínica Obstétrica Hospital das Clínicas Universidade de São Paulo São PauloSP Brasil Clínica Obstétrica, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Denis Jose do Nascimento
- Departamento de Obstetrícia e Ginecologia Faculdade de Medicina Universidade Federal do Paraná CuritibaPR Brasil Departamento de Obstetrícia e Ginecologia, Faculdade de Medicina, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Eduardo Zlotnik
- Hospital Israelita Albert Einstein São PauloSP Brasil Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
| | - Marcelo Melzer Teruchkin
- Hospital Moinhos de Vento Porto AlegreRS Brasil Hospital Moinhos de Vento, Porto Alegre, RS, Brasil
| | - Marcos Arêas Marques
- Universidade do Estado do Rio de Janeiro Rio de JaneiroRJ Brasil Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
- Universidade Federal do Estado do Rio de Janeiro Rio de JaneiroRJ Brasil Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Paulo Francisco Ramos Margarido
- Hospital Universitário Universidade de São Paulo São PauloSP Brasil Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brasil
| |
Collapse
|
24
|
Oğuz SH, Boyraz BS, Ertürk B, Yıldız BO. The prevalence, phenotype and cardiometabolic risk of polycystic ovary syndrome in treatment-naïve transgender people assigned female at birth. Endocrine 2024; 84:287-292. [PMID: 38141060 DOI: 10.1007/s12020-023-03648-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023]
Abstract
PURPOSE Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age. We aimed to investigate the prevalence and phenotypic characteristics of PCOS in testosterone treatment-naïve transgender people assigned female at birth (AFAB), as well as to determine whether cardiometabolic risk factors vary based on the presence of PCOS and its components. METHODS Evaluation of 112 testosterone treatment-naïve transgender adults AFAB for PCOS and its individual components, including androgen excess, ovulatory dysfunction and polycystic ovarian morphology (PCOM). RESULTS In our cohort, 79.5% of transgender individuals AFAB had at least one component of PCOS. The prevalence of PCOS was 38.4% (43/112). Phenotype C was the most common phenotype (17.8%), followed by phenotype B (10.7%). Transgender individuals AFAB with at least one component of PCOS had higher blood pressure (BP) measurements and higher fasting plasma glucose levels compared to those with none. Sixty-one subjects (54%) had hyperandrogenism (HA), with 20 (17.9%) having HA without other components of PCOS. When compared to those without HA, transgender individuals AFAB with HA had higher body mass index (BMI), BP, triglyceride and lower HDL-cholesterol levels. CONCLUSION PCOS and androgen excess appear to be prevalent among transgender people AFAB. Transgender individuals AFAB with HA or PCOS may exhibit an unfavorable cardiometabolic risk profile compared to those without any PCOS component. Assessment of androgen excess and the specific components of PCOS at baseline could inform long-term management.
Collapse
Affiliation(s)
- Seda Hanife Oğuz
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Beyza Seda Boyraz
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Banu Ertürk
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Bülent Okan Yıldız
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.
| |
Collapse
|
25
|
Simmasalam R, Zuniga MC, Hinson HE. Neurological Health in Sexual and Gender Minority Individuals. Semin Neurol 2024; 44:193-204. [PMID: 38485126 DOI: 10.1055/s-0043-1778637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Despite representing a significant proportion of the U.S. population, there is a paucity of population-based research on the health status and health needs of sexual and gender minority (SGM) individuals in neurology. Compared with heterosexual peers, some SGM populations have a higher burden of chronic health conditions. In parallel, SGM individuals are more likely to experience stigma and discrimination producing psychological distress, which may contribute to and be compounded by reduced health care access and utilization. In this narrative review, we summarize the existing literature on common neurological health conditions such as stroke, headache, epilepsy, movement disorders, and traumatic brain injury through the lens of intersection of SGM identity. Special focus is attuned to social determinants of health and gender-affirming hormonal therapy. Given the limitations in the available literature, there is an urgent unmet need for datasets that include sexual orientation and gender identity information, as well as funding for research that will characterize the prevalence of neurological conditions, unique risk factors, and health outcomes in SGM populations. In the health care community, providers should address deficiencies in their professional training and integrate inclusive language into their clinical skillset to build trust with SGM patients. There is an opportunity in neurology to proactively engage SGM communities, collaborate to remove barriers to care, promote resilience, and develop targeted interventions to ensure high-quality, culturally competent care for SGM populations to improve neurological health for all.
Collapse
Affiliation(s)
- Rubinee Simmasalam
- Department of Neurology, University of California, San Francisco, California
| | - Mary C Zuniga
- Department of Neurology, University of California, San Francisco, California
| | - H E Hinson
- Department of Neurology, University of California, San Francisco, California
| |
Collapse
|
26
|
Saposnik G, Bushnell C, Coutinho JM, Field TS, Furie KL, Galadanci N, Kam W, Kirkham FC, McNair ND, Singhal AB, Thijs V, Yang VXD. Diagnosis and Management of Cerebral Venous Thrombosis: A Scientific Statement From the American Heart Association. Stroke 2024; 55:e77-e90. [PMID: 38284265 DOI: 10.1161/str.0000000000000456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
Cerebral venous thrombosis accounts for 0.5% to 3% of all strokes. The most vulnerable populations include young individuals, women of reproductive age, and patients with a prothrombotic state. The clinical presentation of cerebral venous thrombosis is diverse (eg, headaches, seizures), requiring a high level of clinical suspicion. Its diagnosis is based primarily on magnetic resonance imaging/magnetic resonance venography or computed tomography/computed tomographic venography. The clinical course of cerebral venous thrombosis may be difficult to predict. Death or dependence occurs in 10% to 15% of patients despite intensive medical treatment. This scientific statement provides an update of the 2011 American Heart Association scientific statement for the diagnosis and management of cerebral venous thrombosis. Our focus is on advances in the diagnosis and management decisions of patients with suspected cerebral venous thrombosis. We discuss evidence for the use of anticoagulation and endovascular therapies and considerations for craniectomy. We also provide an algorithm to optimize the management of patients with cerebral venous thrombosis and those with progressive neurological deterioration or thrombus propagation despite maximal medical therapy.
Collapse
|
27
|
Lam K, Kraft WK, Zhan T, Lam E. Bidirectional pharmacokinetics of doravirine, tenofovir, and feminizing hormones in transgender women (IDentify): A randomized crossover trial. Clin Transl Sci 2024; 17:e13721. [PMID: 38421210 PMCID: PMC10903328 DOI: 10.1111/cts.13721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/18/2023] [Accepted: 12/22/2023] [Indexed: 03/02/2024] Open
Abstract
Transgender women may have concerns of drug interactions between feminizing hormone therapy (FHT) and antiretrovirals, leading to nonadherence. This randomized, three-period crossover, open-label, phase I trial assessed the effects of doravirine (DOR) and tenofovir disoproxil fumarate (TDF) on the pharmacokinetics (PKs) of estradiol, spironolactone, and total testosterone and vice versa in healthy transgender women. Volunteers were randomized 1:1 into two sequences containing three treatment groups (DOR, lamivudine [3TC], and TDF alone; estradiol, spironolactone, and placebo; and DOR/3TC/TDF, estradiol, and spironolactone). Eight subjects enrolled in the study and six had completed all study periods. The geometric mean ratios for DOR area under the concentration-time curve from zero to last measured concentration (AUC0-last ), maximum concentration (Cmax ), and concentration at 24 h (C24 ) were similar. However, tenofovir (TFV) AUC0-last , Cmax , and C24 moderately increased by 14%-38%. Last, estradiol AUC0-last , Cmax , and C24 were increased by 10%-13%. Whereas most 90% confidence intervals did not meet the bioequivalence bounds of 80%-125%, the point estimates fell within the intervals. Log-transformed DOR, TFV, and estradiol PK parameters computed with and without co-administration were not statistically different (p > 0.05). There were no serious adverse events. There is not a clinically significant impact of FHT on DOR/TFV PKs. Similarly, there is no observed impact on estradiol PKs and total testosterone following use of DOR/3TC/TDF.
Collapse
Affiliation(s)
- Kevin Lam
- Department of Pharmacology, Physiology, and Cancer BiologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Walter K. Kraft
- Department of Pharmacology, Physiology, and Cancer BiologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Tingting Zhan
- Department of Pharmacology, Physiology, and Cancer BiologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Edwin Lam
- Clinical Pharmacokinetics Research LabNational Institutes of HealthBethesdaMarylandUSA
| |
Collapse
|
28
|
Wolfe HL, Fix GM, Hughto JMW, Hughes LD, Operario D, Hadland SE, Siegel J, Drainoni ML. Understanding how primary care providers report discussing substance use with transgender and gender diverse patients. PATIENT EDUCATION AND COUNSELING 2024; 120:108101. [PMID: 38103396 PMCID: PMC10842839 DOI: 10.1016/j.pec.2023.108101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/28/2023] [Accepted: 12/09/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVES To explore how primary care providers report discussing substance use with transgender and gender diverse (TGD) adult patients within the context of discussing gender-affirming interventions. METHODS Between March and April 2022, in-depth, semi-structured qualitative interviews were conducted with 15 primary care providers who care for TGD patients in the Northeastern US. Thematic analysis was used to analyze interview data and identify themes. RESULTS Two primary themes emerged among providers: 1) placing a focus on harm reduction, emphasizing reducing negative consequences of substance use, and 2) using access to gender-affirming interventions as an incentive for patients to change their substance use patterns. CONCLUSIONS Focusing on harm reduction can emphasize reducing potential adverse outcomes while working with TGD patients towards their gender-affirmation goals. Future research should explore varying approaches to how substance use is discussed with TGD patients, as well as the interpretation of gender-affirming clinical guidelines. PRACTICE IMPLICATIONS Findings from this study indicate a need for enhancing provider knowledge around the appropriate application of gender-affirming care guidelines. Investing in training efforts to improve gender-affirming care is critical for encouraging approaches that prioritize harm reduction and do not unnecessarily prevent access to gender-affirming interventions.
Collapse
Affiliation(s)
- Hill L Wolfe
- Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, USA; Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, USA.
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, USA; Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, USA
| | - Jaclyn M W Hughto
- Center for Health Promotion and Health Equity, Brown University School of Public Health, Providence, USA; Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, USA; Department of Epidemiology, Brown University School of Public Health, Providence, USA; The Fenway Institute, Fenway Health, Boston, USA
| | - Landon D Hughes
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Don Operario
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, USA
| | - Scott E Hadland
- Division of Adolescent and Young Adult Medicine, Mass General for Children, Boston, USA; Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Jennifer Siegel
- Division of General Internal Medicine, Transgender Health Program, Massachusetts General Hospital, Boston, USA; Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
| | - Mari-Lynn Drainoni
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, USA; Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA; Evans Center for Implementation and Improvement Sciences, Boston University, Boston, USA
| |
Collapse
|
29
|
Harrison DJ, Prada F, Nokoff NJ, Iwamoto SJ, Pastor T, Jacobsen RM, Yeung E. Considerations for Gender-Affirming Hormonal and Surgical Care Among Transgender and Gender Diverse Adolescents and Adults With Congenital Heart Disease. J Am Heart Assoc 2024; 13:e031004. [PMID: 38293963 PMCID: PMC11056179 DOI: 10.1161/jaha.123.031004] [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: 05/17/2023] [Accepted: 12/05/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Transgender and gender diverse (TGD) individuals and long-term survivors with adult congenital heart disease (ACHD) are both growing populations with specialized needs. No studies assess temporal trends or evaluate the care of TGD individuals with ACHD. METHODS AND RESULTS Meetings between congenital cardiology and gender-affirming care specialists identified unique considerations in TGD individuals with ACHD. A retrospective chart review was then performed to describe patient factors and outpatient trends in those with an ACHD diagnosis undergoing gender-affirming hormonal or surgical care (GAHT/S) at 1 adult and 1 pediatric tertiary care center. Thirty-three TGD individuals with ACHD were identified, 21 with a history of GAHT/S. Fourteen (66%) had moderate or complex ACHD, 8 (38%) identified as transgender male, 9 (43%) transgender female, and 4 (19%) other gender identities. Three had undergone gender-affirming surgery. There were zero occurrences of the composite end point of unplanned hospitalization or thrombotic event over 71.1 person-years of gender-affirming care. Median age at first gender-affirming appointment was 16.8 years [interquartile range 14.8-21.5]. The most common treatment modification was changing estradiol administration from oral to transdermal to reduce thrombotic risk (n=3). An increasing trend was observed from zero TGD patients with ACHD attending a gender diversity appointment in 2012 to 14 patients in 2022. CONCLUSIONS There is a growing population of TGD patients with ACHD and unique medical and psychosocial needs. Future studies must fully evaluate the reassuring safety profile observed in this small cohort. We share 10 actionable care considerations for providers with a goal of overseeing a safe and fulfilling gender transition across all TGD patients with ACHD.
Collapse
Affiliation(s)
- David J. Harrison
- Colorado Adult and Teen Congenital Heart (C.A.T.C.H.) ProgramUniversity of Colorado School of Medicine, UCHealth Hospital System and Children’s Hospital ColoradoAuroraCOUSA
| | - Francisco Prada
- Division of Adolescent MedicineChildren’s Hospital ColoradoAuroraCOUSA
| | | | - Sean J. Iwamoto
- UCHealth Integrated Transgender Program, Division of Endocrinology, Metabolism and DiabetesUniversity of Colorado School of Medicine, Rocky Mountain Regional VA Medical CenterAuroraCOUSA
| | - Tony Pastor
- Division of Cardiology, Yale New Haven HospitalNew HavenCTUSA
| | - Roni M. Jacobsen
- Colorado Adult and Teen Congenital Heart (C.A.T.C.H.) ProgramUniversity of Colorado School of Medicine, UCHealth Hospital System and Children’s Hospital ColoradoAuroraCOUSA
| | - Elizabeth Yeung
- Colorado Adult and Teen Congenital Heart (C.A.T.C.H.) ProgramUniversity of Colorado School of Medicine, UCHealth Hospital System and Children’s Hospital ColoradoAuroraCOUSA
| |
Collapse
|
30
|
van Zijverden LM, Wiepjes CM, van Diemen JJK, Thijs A, den Heijer M. Cardiovascular disease in transgender people: a systematic review and meta-analysis. Eur J Endocrinol 2024; 190:S13-S24. [PMID: 38302717 DOI: 10.1093/ejendo/lvad170] [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: 05/19/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE Hormone therapy in transgender people might be associated with an increased risk of cardiovascular disease (CVD). We aimed to investigate whether the risk of CVD is increased in transgender people compared with people of the same birth sex. DESIGN AND METHODS PubMed, Cochrane, Embase, and Google Scholar were searched until July 2022. Studies evaluating cardiovascular events in transgender women or men were included. Primary outcomes were stroke, myocardial infarction (MI), and venous thromboembolism (VTE). The risk for transgender women versus cisgender men and for transgender men versus cisgender women was analysed through random-effects meta-analysis. RESULTS Twenty-two studies involving 19 893 transgender women, 14 840 transgender men, 371 547 cisgender men, and 434 700 cisgender women were included. The meta-analysis included 10 studies (79% of transgender women and 76% of transgender men). In transgender women, incidence of stroke was 1.8%, which is 1.3 (95% confidence interval [CI], 1.0-1.8) times higher than in cisgender men. Incidence of MI was 1.2%, with a pooled relative risk of 1.0 (95% CI, 0.8-1.2). Venous thromboembolism incidence was 1.6%, which is 2.2 (95% CI, 1.1-4.5) times higher. Stroke occurred in 0.8% of transgender men, which is 1.3 (95% CI, 1.0-1.6) times higher compared with cisgender women. Incidence of MI was 0.6%, with a pooled relative risk of 1.7 (95% CI, 0.8-3.6). For VTE, this was 0.7%, being 1.4 (95% CI, 1.0-2.0) times higher. CONCLUSIONS Transgender people have a 40% higher risk of CVD compared with cisgender people of the same birth sex. This emphasizes the importance of cardiovascular risk management. Future studies should assess the potential influence of socio-economic and lifestyle factors.
Collapse
Affiliation(s)
- Lieve Mees van Zijverden
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam,De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
| | - Chantal Maria Wiepjes
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam,De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
| | - Jeske Joanna Katarina van Diemen
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
| | - Abel Thijs
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
| | - Martin den Heijer
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam,De Boelelaan 1117, Amsterdam 1081HV, The Netherlands
| |
Collapse
|
31
|
Kanuri B, Biswas P, Dahdah A, Murphy AJ, Nagareddy PR. Impact of age and sex on myelopoiesis and inflammation during myocardial infarction. J Mol Cell Cardiol 2024; 187:80-89. [PMID: 38163742 PMCID: PMC10922716 DOI: 10.1016/j.yjmcc.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024]
Abstract
Of all the different risk factors known to cause cardiovascular disease (CVD), age and sex are considered to play a crucial role. Aging follows a continuum from birth to death, and therefore it inevitably acts as a risk for CVD. Along with age, sex differences have also been shown to demonstrate variations in immune system responses to pathological insults. It has been widely perceived that females are protected against myocardial infarction (MI) and the protection is quite apparent in young vs. old women. Acute MI leads to changes in the population of myeloid and lymphoid cells at the injury site with myeloid bias being observed in the initial inflammation and the lymphoid in the late-resolution phases of the pathology. Multiple evidence demonstrates that aging enhances damage to various cellular processes through inflamm-aging, an inflammatory process identified to increase pro-inflammatory markers in circulation and tissues. Following MI, marked changes were observed in different sub-sets of major myeloid cell types viz., neutrophils, monocytes, and macrophages. There is a paucity of information regarding the tissue and site-specific functions of these sub-sets. In this review, we highlight the importance of age and sex as crucial risk factors by discussing their role during MI-induced myelopoiesis while emphasizing the current status of myeloid cell sub-sets. We further put forth the need for designing and executing age and sex interaction studies aimed to determine the appropriate age and sex to develop personalized therapeutic strategies post-MI.
Collapse
Affiliation(s)
- Babunageswararao Kanuri
- Department of Internal Medicine, Section of Cardiovascular Diseases, University of Oklahoma Health Sciences Center (OUHSC), Oklahoma City, OK, USA
| | - Priosmita Biswas
- Department of Internal Medicine, Section of Cardiovascular Diseases, University of Oklahoma Health Sciences Center (OUHSC), Oklahoma City, OK, USA
| | - Albert Dahdah
- Department of Internal Medicine, Section of Cardiovascular Diseases, University of Oklahoma Health Sciences Center (OUHSC), Oklahoma City, OK, USA
| | - Andrew J Murphy
- Baker Heart and Diabetes Institute, Division of Immunometabolism, Melbourne, Australia
| | - Prabhakara R Nagareddy
- Department of Internal Medicine, Section of Cardiovascular Diseases, University of Oklahoma Health Sciences Center (OUHSC), Oklahoma City, OK, USA.
| |
Collapse
|
32
|
Iwamoto SJ, Rothman MS, T’Sjoen G, Defreyne J. Approach to the Patient: Hormonal Therapy in Transgender Adults With Complex Medical Histories. J Clin Endocrinol Metab 2024; 109:592-602. [PMID: 37683089 PMCID: PMC10795931 DOI: 10.1210/clinem/dgad536] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/02/2023] [Accepted: 09/06/2023] [Indexed: 09/10/2023]
Abstract
While endocrinologists continue to initiate gender-affirming hormone therapy (GAHT) in healthy transgender and gender diverse (TGD) patients, they may also encounter more TGD patients in their clinics with complex medical histories that influence the patient-provider shared decision-making process for initiating or continuing GAHT. The purpose of this Approach to the Patient article is to describe management considerations in 2 adults with thromboembolic disease and 2 adults with low bone mineral density in the setting of feminizing and masculinizing GAHT.
Collapse
Affiliation(s)
- Sean J Iwamoto
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
- Endocrinology Service, Medicine Service, Rocky Mountain Regional Veterans Affairs Medical Center, Eastern Colorado Health Care System, Aurora, CO 80045, USA
- UCHealth Integrated Transgender Program, University of Colorado Hospital, Aurora, CO 80045, USA
| | - Micol S Rothman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA
- UCHealth Integrated Transgender Program, University of Colorado Hospital, Aurora, CO 80045, USA
| | - Guy T’Sjoen
- Department of Endocrinology and Center for Sexology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Justine Defreyne
- Department of Endocrinology and Center for Sexology, Ghent University Hospital, 9000 Ghent, Belgium
| |
Collapse
|
33
|
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.
Collapse
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
| |
Collapse
|
34
|
Douglas M, White RT, Sankey K, Gallegos Aragon K. Pharmacist guide for providing gender-affirming care: dispensing and beyond. J Am Pharm Assoc (2003) 2024; 64:212-217. [PMID: 37839698 DOI: 10.1016/j.japh.2023.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/17/2023]
|
35
|
Connelly PJ, Osmanska J, Lee MMY, Delles C, McEntegart MB, Byrne J. A case report of myocardial infarction in a young transgender man with testosterone therapy: raising awareness on healthcare issues in the transgender community and a call for further research. Eur Heart J Case Rep 2023; 7:ytad562. [PMID: 38093823 PMCID: PMC10716680 DOI: 10.1093/ehjcr/ytad562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 10/30/2023] [Accepted: 11/10/2023] [Indexed: 03/07/2024]
Abstract
Background People who are transgender may utilize masculinizing or feminizing gender-affirming hormonal therapy. Testosterone and oestrogen receptors are expressed throughout the cardiovascular system, yet the effects of these therapies on cardiovascular risk and outcomes are largely unknown. We report the case of a young transgender man with no discernible cardiovascular risk factors presenting with an acute coronary syndrome. Case summary A 31-year-old transgender man utilizing intramuscular testosterone masculinizing gender-affirming hormonal therapy presented with central chest pain radiating to the left arm. He had no past medical history of hypertension, dyslipidaemia, diabetes, or smoking. Electrocardiography demonstrated infero-septal ST depression, and high-sensitivity troponin-I was elevated and increased to 19 686 ng/L. He was diagnosed with a non-ST-segment elevation myocardial infarction. Inpatient coronary angiography confirmed a critical focal lesion in the mid right coronary artery, which was managed with two drug-eluting stents. Medical management (i.e. aspirin, ticagrelor, atorvastatin, ramipril, and bisoprolol) and surveillance of residual plaque disease evident in the long tubular left main stem, proximal left anterior descending, and proximal circumflex vessels was undertaken. The masculinizing gender-affirming hormonal therapy was continued. Discussion Despite a greater awareness of the potential risk of increased cardiovascular disease in transgender people, the fundamental lack of data regarding cardiovascular outcomes in transgender people may be contributing to healthcare inequalities in this population. We must implement better training, awareness, and research into transgender cardiovascular health to facilitate equitable and evidence-based outcomes.
Collapse
Affiliation(s)
- Paul J Connelly
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Endocrinology and Diabetes, Queen Elizabeth University Hospital, Glasgow, UK
| | - Joanna Osmanska
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Endocrinology and Diabetes, Queen Elizabeth University Hospital, Glasgow, UK
| | - Matthew M Y Lee
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Endocrinology and Diabetes, Queen Elizabeth University Hospital, Glasgow, UK
| | - Christian Delles
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Endocrinology and Diabetes, Queen Elizabeth University Hospital, Glasgow, UK
| | - Margaret B McEntegart
- Department of Endocrinology and Diabetes, Queen Elizabeth University Hospital, Glasgow, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
- Department of Cardiology, Columbia University Medical Center, New York, USA
| | - John Byrne
- Department of Endocrinology and Diabetes, Queen Elizabeth University Hospital, Glasgow, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| |
Collapse
|
36
|
Moustakli E, Tsonis O. Exploring Hormone Therapy Effects on Reproduction and Health in Transgender Individuals. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2094. [PMID: 38138197 PMCID: PMC10744413 DOI: 10.3390/medicina59122094] [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: 10/29/2023] [Revised: 11/17/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023]
Abstract
Transgender individuals often face elevated mental health challenges due to gender dysphoria, but gender-affirming treatments such as surgery and hormone therapy have been linked to significant improvements in mental well-being. The potential influence of time and circadian rhythms on these treatments is prevalent. The intricate interplay between hormones, clock genes, and fertility is profound, acknowledging the complexity of reproductive health in transgender individuals. Furthermore, risks associated with gender-affirming hormonal therapy and potential complications of puberty suppression emphasize the importance of ongoing surveillance for these patients and the need of fertility preservation and family-building options for transgender individuals. This narrative review delves into the intricate landscape of hormone therapy for transgender individuals, shedding light on its impact on bone, cardiovascular, and overall health. It explores how hormone therapy affects bone maintenance and cardiovascular risk factors, outlining the complex interplay of testosterone and estrogen. It also underscores the necessity for further research, especially regarding the long-term effects of transgender hormones. This project emphasizes the critical role of healthcare providers, particularly obstetricians and gynecologists, in providing affirming care, calling for comprehensive understanding and integration of transgender treatments. This review will contribute to a better understanding of the impact of hormone therapy on reproductive health and overall well-being in transgender individuals. It will provide valuable insights for healthcare providers, policymakers, and transgender individuals themselves, informing decision-making regarding hormone therapy and fertility preservation options. Additionally, by identifying research gaps, this review will guide future studies to address the evolving healthcare needs of transgender individuals. This project represents a critical step toward addressing the complex healthcare needs of this population. By synthesizing existing knowledge and highlighting areas for further investigation, this review aims to improve the quality of care and support provided to transgender individuals, ultimately enhancing their reproductive health and overall well-being.
Collapse
Affiliation(s)
- Efthalia Moustakli
- Laboratory of Medical Genetics, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece;
| | - Orestis Tsonis
- Fertility Preservation Service, Assisted Conception Unit, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK
| |
Collapse
|
37
|
Wright ME, Murphy K. A mini-review of the evidence for cerebrovascular changes following gender-affirming hormone replacement therapy and a call for increased focus on cerebrovascular transgender health. Front Hum Neurosci 2023; 17:1303871. [PMID: 38077183 PMCID: PMC10702528 DOI: 10.3389/fnhum.2023.1303871] [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: 09/28/2023] [Accepted: 10/31/2023] [Indexed: 02/12/2024] Open
Abstract
Gender-affirming hormone replacement therapy (gaHRT) is an important step for many in the gender diverse community, associated with increased quality-of-life and lower self-reported scores of depression and anxiety. However, considering the interactions that the involved sex hormones have on vasculature (with oestrogen and testosterone demonstrating vasodilatory and vasoconstricting properties, respectively), it is important for transgender healthcare research to examine how the manipulation of these hormones interact with cerebrovascular structure and functioning. There is a stark lack of research in this area. This mini-review outlines the research suggesting a vascular impact of these sex hormones using evidence from a range of cohorts (e.g., menopause, polycystic ovary syndrome) and discusses the work that has been done into cerebrovascular changes following gaHRT. Finally, recommendations for future research into cerebrovascular health in transgender cohorts following gaHRT are outlined.
Collapse
Affiliation(s)
- Melissa Emily Wright
- Cardiff University Brain Research Imaging Centre (CUBRIC), School of Psychology, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | | |
Collapse
|
38
|
Pataky MW, Dasari S, Michie KL, Sevits KJ, Kumar AA, Klaus KA, Heppelmann CJ, Robinson MM, Carter RE, Lanza IR, Nair KS. Impact of biological sex and sex hormones on molecular signatures of skeletal muscle at rest and in response to distinct exercise training modes. Cell Metab 2023; 35:1996-2010.e6. [PMID: 37939659 PMCID: PMC10659143 DOI: 10.1016/j.cmet.2023.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 05/09/2023] [Accepted: 10/13/2023] [Indexed: 11/10/2023]
Abstract
Substantial divergence in cardio-metabolic risk, muscle size, and performance exists between men and women. Considering the pivotal role of skeletal muscle in human physiology, we investigated and found, based on RNA sequencing (RNA-seq), that differences in the muscle transcriptome between men and women are largely related to testosterone and estradiol and much less related to genes located on the Y chromosome. We demonstrate inherent unique, sex-dependent differences in muscle transcriptional responses to aerobic, resistance, and combined exercise training in young and older cohorts. The hormonal changes with age likely explain age-related differential expression of transcripts. Furthermore, in primary human myotubes we demonstrate the profound but distinct effects of testosterone and estradiol on amino acid incorporation to multiple individual proteins with specific functions. These results clearly highlight the potential of designing exercise programs tailored specifically to men and women and have implications for people who change gender by altering their hormone profile.
Collapse
Affiliation(s)
- Mark W Pataky
- Division of Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Surendra Dasari
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Kelly L Michie
- Division of Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Kyle J Sevits
- Division of Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - A Aneesh Kumar
- Division of Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Katherine A Klaus
- Division of Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
| | | | - Matthew M Robinson
- School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Rickey E Carter
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Ian R Lanza
- Division of Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - K Sreekumaran Nair
- Division of Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
39
|
Martinez CA, Rikhi R, Fonseca Nogueira N, Pester MS, Salazar AS, Ashinne B, Aguilar N, Melara A, Porras V, Parker M, Mendez A, Cyrus E, De Santis JP, Jones DL, Brown TT, Hurwitz BE, Alcaide ML. Estrogen-Based Gender-Affirming Hormone Therapy and Subclinical Cardiovascular Disease in Transgender Women with HIV. LGBT Health 2023; 10:576-585. [PMID: 37459150 PMCID: PMC10712365 DOI: 10.1089/lgbt.2023.0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
Purpose: Transgender women (TW) are disproportionately affected by HIV infection and cardiovascular disease (CVD). This study evaluated whether estrogen-based gender-affirming hormone therapy (GAHT) in TW with HIV (TWH-GAHT) is associated with indices of subclinical CVD. Methods: Of the 40 HIV-seropositive persons enrolled, 20-60 years of age, on antiretroviral treatment with undetectable viral load, assessments were performed on 15 TWH; of these persons, 11 were GAHT treated. These TWH-GAHT were matched with HIV+ cisgender men and women based on age, ethnicity/race, body mass index, and antihypertensive medication use. Sex hormones, and cardiometabolic (waist circumference, blood pressure, insulin resistance, lipid profile, and C-reactive protein), vascular (flow-mediated dilation [FMD] and arterial stiffness), and proinflammatory measures were obtained. Results: TWH-GAHT displayed elevated estradiol and suppressed testosterone levels relative to normative ranges. Analyses indicated the TWH-GAHT displayed lower low-density lipoprotein compared with cisgender groups (p < 0.05). Although no difference was seen on FMD, the central augmentation index of aortic stiffness was higher in cisgender HIV+ women than cisgender HIV+ men (p < 0.05). No other group difference on subclinical CVD markers was observed. For TWH, partial correlations indicated associations of certain sex hormones with selected cardiometabolic outcomes and the inflammatory cytokine, interleukin-8. Conclusion: When well matched to HIV+ cisgender men and women, subclinical CVD pathophysiology did not appear elevated in TWH-GAHT, although tendencies emerged suggesting that some subclinical CVD indices may be higher, but others lower than cisgender groups. Longitudinal studies of TWH are needed to more precisely evaluate the moderating effect of GAHT on cardiometabolic pathophysiology.
Collapse
Affiliation(s)
- Claudia A. Martinez
- Division of Cardiovascular Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rishi Rikhi
- Division of Cardiology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicholas Fonseca Nogueira
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mollie S. Pester
- Behavioral Medicine Research Center and Department of Psychology, University of Miami, Miami/Coral Gables, Florida, USA
| | - Ana S. Salazar
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Beteal Ashinne
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Natalie Aguilar
- Division of Cardiovascular Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Abraham Melara
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Valeria Porras
- Division of Cardiovascular Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Meela Parker
- Behavioral Medicine Research Center and Department of Psychology, University of Miami, Miami/Coral Gables, Florida, USA
| | - Armando Mendez
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Elena Cyrus
- Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Joseph P. De Santis
- School of Nursing and Health Studies, University of Miami, Miami, Florida, USA
| | - Deborah L. Jones
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
- Behavioral Medicine Research Center and Department of Psychology, University of Miami, Miami/Coral Gables, Florida, USA
| | - Todd T. Brown
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Barry E. Hurwitz
- Behavioral Medicine Research Center and Department of Psychology, University of Miami, Miami/Coral Gables, Florida, USA
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Maria L. Alcaide
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| |
Collapse
|
40
|
Murphy CN, Delles C, Davies E, Connelly PJ. Cardiovascular disease in transgender individuals. Atherosclerosis 2023; 384:117282. [PMID: 37821271 DOI: 10.1016/j.atherosclerosis.2023.117282] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/23/2023] [Accepted: 09/05/2023] [Indexed: 10/13/2023]
Abstract
The population of people identifying as transgender has grown rapidly in recent years, resulting in a substantive increase in individuals obtaining gender-affirming medical care to align their secondary sex characteristics with their gender identity. This has established benefits for patients including improvements in gender dysphoria and psychosocial functioning, while reducing adverse mental health outcomes. Despite these potential advantages, recent evidence has suggested that gender-affirming hormone therapy (GAHT) may increase the risk of cardiovascular disease. However, owing to a paucity of research, the mechanisms underpinning these increased risks are poorly understood. Moreover, previous research has been limited by heterogenous methodologies, being underpowered, and lacking appropriate control populations. Consequently, the need for evidence regarding cardiovascular health in LGBTQ + individuals has been recognised as a critical area for future research to facilitate better healthcare and guidance. Recent research investigating the effect of transmasculine (testosterone) GAHT on cardiovascular disease risk points to testosterone effecting the nitric oxide pathway, triggering inflammation, and promoting endothelial dysfunction. Equivalent studies focussing on transfeminine (oestrogen) GAHT are required, representing a crucial area of future research. Furthermore, when examining the effects of GAHT on the vasculature, it cannot be ignored that there are multiple factors that may increase the burden of cardiovascular disease in the transgender population. Such stressors include major psychological stress; increased adverse health behaviours, such as smoking; discrimination; and lowered socioeconomic status; all of which undoubtedly impact upon cardiovascular disease risk and offers the opportunity for intervention.
Collapse
Affiliation(s)
- Charlotte N Murphy
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom
| | - Christian Delles
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom
| | - Eleanor Davies
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom
| | - Paul J Connelly
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom.
| |
Collapse
|
41
|
Mercer J, Bandy S, Tang H, Wenger B, Ryan L, Lee G, Lipscomb J. Gender-affirming pharmacotherapy and additional health considerations: A contemporary review. J Am Pharm Assoc (2003) 2023; 63:1669-1676.e1. [PMID: 37619851 DOI: 10.1016/j.japh.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/10/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Transgender and gender-diverse (TGD) individuals in the United States face health care disparities compounded with discrimination and limited access to necessary medical services. Gender-affirming interventions have been shown to mitigate gender dysphoria and psychiatric comorbidities, yet United States legislation limiting such interventions has increased. As medication experts, pharmacists can facilitate access to care and appropriate use of gender-affirming hormone therapy (GAHT) and educate other health care providers on best practices for caring for TGD individuals in a variety of settings. OBJECTIVES To provide pharmacists with a contemporary review of GAHT and associated medication-related concerns. METHODS We searched PubMed for articles published until December 2022. MeSH terms such as transgender, transsexual, gender diverse, gender variant, or gender nonconforming in combination with phrases like gender-affirming care, treatment, pharmacotherapy, or hormone therapy were used to capture desired articles. RESULTS Feminizing hormone therapy (FHT), such as estrogen and antiandrogen agents, increases female secondary sex characteristics while suppressing male secondary sex characteristics. Masculinizing hormone therapy (MHT) achieves male secondary sex characteristics and minimizes female secondary sex characteristics using testosterone. For both FHT and MHT, the choice of therapy and formulation ultimately involves the patient's treatment goals, preferences, and tolerability. GAHT has additional health considerations pertaining to renal drug dosing, fertility, cardiovascular, and cancer risks. Pharmacists may provide crucial guidance and education to both patients and health care providers regarding risks associated with GAHT. CONCLUSION Many pharmacists feel unprepared to help provide, manage, and optimize GAHT. For many TGD individuals, GAHT is medically necessary and a life-saving treatment. Therefore, pharmacists should be provided tools to close knowledge gaps and improve their ability to care for these patients. By offering a thorough updated overview of GAHT, pharmacists can gain confidence to provide appropriate care for this increasingly visible population.
Collapse
|
42
|
Gupta P, Patterson BC, Chu L, Gold S, Amos S, Yeung H, Goodman M, Tangpricha V. Adherence to Gender Affirming Hormone Therapy in Transgender Adolescents and Adults: A Retrospective Cohort Study. J Clin Endocrinol Metab 2023; 108:e1236-e1244. [PMID: 37246711 PMCID: PMC10583985 DOI: 10.1210/clinem/dgad306] [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: 04/20/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 05/30/2023]
Abstract
CONTEXT Transgender and gender diverse (TGD) individuals often seek gender-affirming hormone therapy (GAHT). While receipt of GAHT has been associated with improved well-being, the risk of GAHT discontinuation and its reasons are not well known. OBJECTIVE There were two main objectives: (1) To investigate the proportion of TGD individuals who discontinue therapy after an average of 4 years (maximum 19 years) since GAHT initiation; and (2) to explore reasons for GAHT discontinuation. This was a retrospective cohort study at academic centers providing care to TGD adolescents and adults. TGD individuals prescribed estradiol or testosterone between January 1, 2000, and January 1, 2019, were included. GAHT continuation was ascertained using a 2-phase process. In phase 1, Kaplan-Meier survival analyses were used to examine likelihood of GAHT discontinuation and compare discontinuation rates by age and sex assigned at birth. In phase 2, reasons for stopping GAHT were investigated by reviewing records and by contacting study participants who discontinued therapy. The main outcome measures were incidence and determinants of GAHT discontinuation. RESULTS Among 385 eligible participants, 231 (60%) were assigned male at birth and 154 (40%) were assigned female at birth. Less than one-third of participants (n = 121) initiated GAHT prior to their 18th birthday, constituting the pediatric cohort (mean age 15 years), and the remaining 264 were included in the adult cohort (mean age 32 years). In phase 1, 6 participants (1.6%) discontinued GAHT during follow-up, and of those only 2 discontinued GAHT permanently (phase 2). CONCLUSION GAHT discontinuation is uncommon when therapy follows Endocrine Society guidelines. Future research should include prospective studies with long-term follow-up of individuals receiving GAHT.
Collapse
Affiliation(s)
- Pranav Gupta
- Department of Pediatrics, Division of Endocrinology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Pediatrics, Division of Endocrinology, Children's Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Briana C Patterson
- Department of Pediatrics, Division of Endocrinology, Emory University School of Medicine, Atlanta, GA 30322, USA
- Department of Pediatrics, Division of Endocrinology, Children's Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Lena Chu
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Sarah Gold
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Seth Amos
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Howa Yeung
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Michael Goodman
- Rollin's School of Public Health, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Vin Tangpricha
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA 30322, USA
- Atlanta VA Medical Center, Decatur, GA 30300, USA
| |
Collapse
|
43
|
Garland K, Mullins E, Bercovitz RS, Rodriguez V, Connors J, Sokkary N. Hemostatic considerations for gender affirming care. Thromb Res 2023; 230:126-132. [PMID: 37717369 DOI: 10.1016/j.thromres.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/24/2023] [Accepted: 09/08/2023] [Indexed: 09/19/2023]
Abstract
Gender dysphoria or gender incongruence is defined as "persons that are not satisfied with their designated gender" [1]. The awareness and evidence-based treatment options available to this population have grown immensely over the last two decades. Protocols now include an Endocrine Society Clinical Practice Guideline [1] as well as the World Professional Association of Transgender Health Standards of Care (WPATH SOC) [2]. Hematologic manifestations, most notably thrombosis, are one of the most recognized adverse reactions to the hormones used for gender-affirming care. Therefore, hematologists are frequently consulted prior to initiation of hormonal therapy to help guide safe treatment. This review will focus on the scientific evidence related to hemostatic considerations for various gender-affirming therapies and serve as a resource to assist in medical decision-making among providers and patients.
Collapse
Affiliation(s)
- Kathleen Garland
- Children's Minnesota, Minneapolis, MN 55404, United States of America.
| | - Eric Mullins
- Cincinnati Children's Hospital Medical Center and University of Cincinnati-College of Medicine, Cincinnati, OH 45229, United States of America
| | - Rachel S Bercovitz
- Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, IL 60611, United States of America
| | - Vilmarie Rodriguez
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH 43205, United States of America
| | - Jean Connors
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA 02115, United States of America
| | - Nancy Sokkary
- Children's Healthcare of Atlanta, Atlanta, GA 30308, United States of America
| |
Collapse
|
44
|
Veale JF. Transgender-related stigma and gender minority stress-related health disparities in Aotearoa New Zealand: hypercholesterolemia, hypertension, myocardial infarction, stroke, diabetes, and general health. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 39:100816. [PMID: 37927998 PMCID: PMC10624989 DOI: 10.1016/j.lanwpc.2023.100816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/07/2023] [Accepted: 05/23/2023] [Indexed: 11/07/2023]
Abstract
Background Research has found that transgender-related enacted stigma-including discrimination, harassment, violence, cyberbullying, community rejection, and conversion efforts-is associated with negative mental health among transgender people. Transgender people also experience physical health disparities that could be due to chronic gender minority stress caused by stigma and prejudice. Methods We compared a large New Zealand national survey of transgender participants with the New Zealand Health Survey (NZHS) with age and ethnicity weightings on stress-related health conditions and indicators. We conducted multivariate logistic regression to test associations between transgender-related enacted stigma and physical health conditions and indicators, controlling for age, gender, ethnicity, gender affirming hormone use, and alcohol and tobacco use. Findings Transgender participants had a greater likelihood of ever having hypertension (63%, 95% CI 41%-89%), a myocardial infarction (98%, 6%-271%), a stroke (104%, 2%-311%), hypercholesteremia 148% (114%-188%), and current poor or fair general health (128%, 107%-151%). There were no significant differences for diabetes. Compared with those scoring at the 10th percentile on transgender-related enacted stigma, those at the 90th percentile were more likely to have had hypertension (81%, 36%-140%), hypercholesteremia (54%, 20%-98), and poor/fair health (75%, 45%-110%). Interpretation We found large disparities for stress-related physical health conditions and indicators, and transgender people who experienced higher transgender-related enacted stigma had a significantly increased prevalence of these negative outcomes. Our findings highlight the need for health professionals to consider gender minority stress and for interventions and policy/law reforms to address transgender-related stigma. Funding The Health Research Council of New Zealand and Rule Foundation.
Collapse
Affiliation(s)
- Jaimie F Veale
- Trans Health Research Lab, Te Kura Whatu Oho Mauri/School of Psychology, University of Waikato, Aotearoa/New Zealand
| |
Collapse
|
45
|
Birnbaum A, Karamitopoulos M, Carter CW. Musculoskeletal health considerations for the transgender athlete. PHYSICIAN SPORTSMED 2023; 51:387-393. [PMID: 35373697 DOI: 10.1080/00913847.2022.2057787] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND In addition to the familiar sports-related injuries and conditions experienced by cisgender athletes, transgender athletes may also face unique challenges to maintaining their musculoskeletal health. Encouraging sports medicine professionals to become familiar with accepted nomenclature and terminology related to transgender athletes will enable open communication on the field, in the athletic training facility, and office. OBJECTIVE Understanding contemporary medical and surgical gender-affirming treatments and the unique ways in which the musculoskeletal system might be affected by each - such as impairments in bone health, changes in ligamentous function and the potential increased risk for deep venous thromboembolism - is essential for provision of optimal musculoskeletal care to transgender athletes. Knowledge of the existing participation policies for transgender athletes is also key for enabling sports medicine professionals to effectively counsel athletes about the need for specialized protective equipment. Additionally, this knowledge is important for appropriately managing therapeutic use exemptions in the competitive sports setting. CONCLUSION This article provides an overview of the current accepted nomenclature, common gender-affirming medical and surgical treatments, unique musculoskeletal health considerations, and participation policies for transgender athletes.
Collapse
Affiliation(s)
- Amy Birnbaum
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | | | - Cordelia W Carter
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| |
Collapse
|
46
|
Vena W, Paschou SA. Cardiovascular health in gender dysphoric adults. Hormones (Athens) 2023; 22:357-358. [PMID: 37138181 DOI: 10.1007/s42000-023-00450-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/19/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Walter Vena
- Diabetes Center, Humanitas Gavazzeni Institute, Via M. Gavazzeni 21, 24100, Bergamo, Italy.
| | - Stavroula A Paschou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
47
|
Vaccaro CJ, Karageuzian SA, McFadden E. The Importance of Safely Prescribing Hormones in the Transgender Community. Cureus 2023; 15:e44639. [PMID: 37799231 PMCID: PMC10548402 DOI: 10.7759/cureus.44639] [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: 09/04/2023] [Indexed: 10/07/2023] Open
Abstract
The transgender community is rapidly growing, necessitating further education and understanding of their unique healthcare needs. Gender affirmation is a multistep process, which generally begins with transgender individuals socially transitioning by adopting a new name, pronouns, and appearance changes, such as hair and clothing, to express themselves. Additional gender affirmation treatment can be achieved through medical therapy with hormones and surgical intervention. Here, we report the case of an 18-year-old transgender man who presented to his primary care provider for a referral to initiate a medical transition with testosterone therapy. The patient practiced penetrative vaginal sex without contraception. The patient presented to the clinic eight months later with amenorrhea, thick coarse facial and body hair, oily skin, irritable moods, and a 20-lb weight gain. A pregnancy test revealed a positive result. A healthy baby girl was delivered at 40 weeks' gestation. This case demonstrates the importance of addressing contraception during the masculinization process in individuals who continue to practice vaginal intercourse. Healthcare providers should seek to establish a clinical environment free of discrimination and stigma to allow patients to feel comfortable describing potential triggers of gender dysphoria. We encourage medical practitioners to discuss all methods of birth control with transgender male patients and choose the contraceptive that best allows for a seamless medical transition.
Collapse
Affiliation(s)
| | - Sergio A Karageuzian
- School of Osteopathic Medicine, A.T. Still University of Health Sciences, Mesa, USA
| | - Erin McFadden
- Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, USA
| |
Collapse
|
48
|
Alsaloum M, Zilinyi RS, Madhavan M, Snyder DJ, Saleem D, Burton JB, Rosenzweig EB, Takeda K, Brodie D, Agerstrand C, Eisenberger A, Kirtane AJ, Parikh SA, Sethi SS. Gender Disparities in Presentation, Management, and Outcomes of Acute Pulmonary Embolism. Am J Cardiol 2023; 202:67-73. [PMID: 37421732 DOI: 10.1016/j.amjcard.2023.06.012] [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: 03/21/2023] [Revised: 05/29/2023] [Accepted: 06/05/2023] [Indexed: 07/10/2023]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death; however, gender disparities in PE remain understudied. All PE cases at a single institution between January 2013 and June 2019 were retrospectively reviewed. The clinical presentation, treatment modalities, and outcomes were compared between men and women using univariate and multivariate analyses adjusting for differences in baseline characteristics. A total of 1,345 patients were diagnosed with acute PE, of whom 56.3% were women (n = 757). Women had a significantly higher mean body mass index (29.4 vs 28.4) and a higher frequency of hypertension (53% vs 46%) and hormone use (6.6% vs 0%; all p <0.02). Men had a higher frequency of smoking (45% vs 33%, p <0.0001). Women had significantly lower PE severity index classifications (p = 0.0009). The rates of intensive care unit admission, vasopressor requirements, extracorporeal membrane oxygenation cannulation, and mechanical ventilation were similar between the genders. There was no significant difference in the treatment modality used between the genders. Although the risk factors and PE severity index class differed between the genders, there was no significant difference in resource utilization or treatment modality. Gender was also not a significant predictor of in-hospital mortality, moderate or severe bleeding, increased length of stay, or readmission in the study population.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine
| | - Cara Agerstrand
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine
| | - Andrew Eisenberger
- Division of Hematology and Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | | | | | | |
Collapse
|
49
|
Doan D, Sharma Y, Veneros DL, Caceres BA. Caring for Sexual and Gender Minority Adults with Cardiovascular Disease. Nurs Clin North Am 2023; 58:461-473. [PMID: 37536792 DOI: 10.1016/j.cnur.2023.05.010] [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: 08/05/2023]
Abstract
This article summarizes existing evidence on cardiovascular disease (CVD) risk and CVD diagnoses among sexual and gender minority adults and provides recommendations for providing nursing care to sexual and gender minority adults with CVD. More research is needed to develop evidence-based strategies to care for sexual and gender minority adults with CVD.
Collapse
Affiliation(s)
- Danny Doan
- Center for Sexual and Gender Minority Health Research, Columbia University School of Nursing, 560 West 168th Street, New York, NY 10032, USA
| | - Yashika Sharma
- Center for Sexual and Gender Minority Health Research, Columbia University School of Nursing, 560 West 168th Street, New York, NY 10032, USA
| | - David López Veneros
- Center for Sexual and Gender Minority Health Research, Columbia University School of Nursing, 560 West 168th Street, New York, NY 10032, USA
| | - Billy A Caceres
- Center for Sexual and Gender Minority Health Research, Columbia University School of Nursing, 560 West 168th Street, New York, NY 10032, USA.
| |
Collapse
|
50
|
Shawky NM, Reckelhoff JF, Alexander BT, Cardozo LLY. Insights Into the Cardiomodulatory Effects of Sex Hormones: Implications in Transgender Care. Hypertension 2023; 80:1810-1820. [PMID: 37462057 PMCID: PMC10530189 DOI: 10.1161/hypertensionaha.123.19501] [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] [Indexed: 07/29/2023]
Abstract
Transgender individuals that undergo gender-affirming hormone therapy may experience discrimination in the health care setting with a lack of access to medical personnel competent in transgender medicine. Recent evidence suggests that gender-affirming hormone therapy is associated with an increased risk of cardiovascular diseases and cardiovascular risk factors. A recent statement from the American Heart Association reinforces the importance of cardiovascular-focused clinical management and the necessity for more research into the impact of gender-affirming hormone therapy. With this in mind, this review will highlight the known cardiovascular risk factors associated with gender-affirming hormone therapy and identify potential molecular mechanisms determined from the limited animal studies that explore the role of cross-sex steroids on cardiovascular risk. The lack of data in this understudied population requires future clinical and basic research studies to inform and educate clinicians and their transgender patient population to promote precision medicine for their care to improve their quality of life.
Collapse
Affiliation(s)
- Noha M. Shawky
- Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, MS
- Mississippi Center of Excellence in Perinatal Research, University of Mississippi Medical Center, Jackson, MS
- Women’s Health Research Center, University of Mississippi Medical Center, Jackson, MS
- Cardiovascular Renal Research Center, University of Mississippi Medical Center, Jackson, MS
| | - Jane F. Reckelhoff
- Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, MS
- Mississippi Center of Excellence in Perinatal Research, University of Mississippi Medical Center, Jackson, MS
- Women’s Health Research Center, University of Mississippi Medical Center, Jackson, MS
- Cardiovascular Renal Research Center, University of Mississippi Medical Center, Jackson, MS
| | - Barbara T. Alexander
- Department of Physiology, University of Mississippi Medical Center, Jackson, MS
- Mississippi Center of Excellence in Perinatal Research, University of Mississippi Medical Center, Jackson, MS
- Women’s Health Research Center, University of Mississippi Medical Center, Jackson, MS
- Cardiovascular Renal Research Center, University of Mississippi Medical Center, Jackson, MS
| | - Licy L. Yanes Cardozo
- Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, MS
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
- Department of Physiology, University of Mississippi Medical Center, Jackson, MS
- Mississippi Center of Excellence in Perinatal Research, University of Mississippi Medical Center, Jackson, MS
- Women’s Health Research Center, University of Mississippi Medical Center, Jackson, MS
- Cardiovascular Renal Research Center, University of Mississippi Medical Center, Jackson, MS
| |
Collapse
|