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Krishnamurthy N, Slack DJ, Kyweluk M, Cullen O, Kirkley J, Safer JD. Erythrocytosis Is Rare With Exogenous Testosterone in Gender-Affirming Hormone Therapy. J Clin Endocrinol Metab 2024; 109:1285-1290. [PMID: 38011684 DOI: 10.1210/clinem/dgad651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Indexed: 11/29/2023]
Abstract
CONTEXT Studies have found a variable incidence of erythrocytosis among people using testosterone as part of gender-affirming hormone therapy (GAHT). OBJECTIVE To examine the effect of using exogenous testosterone as GAHT on hematocrit in a large North American cohort. METHODS We conducted a cross-sectional analysis of testosterone and hematocrit laboratory values in 6670 patients who were prescribed testosterone through Plume, a national provider of GAHT. The prevalence of erythrocytosis, the mean hematocrit at predetermined testosterone thresholds and with varying routes of testosterone administration were assessed. RESULTS Among 6670 individuals, 560 (8.4%) had a hematocrit ≥50%, 182 ≥ 52% (2.7%), and 60 ≥ 54% (0.9%). There was significant variation (P < .001) in hematocrit between different clinically relevant testosterone thresholds (T < 50 vs T 50-299 vs T 300-999 vs T ≥ 1000 ng/dL) and when comparing serum testosterone in increments of 50 ng/dL within the target range for males (300-1000 ng/dL) (P < .001). Mean hematocrit ranged from 41.84% (T < 50 ng/dL) to 45.68% (T 900-949 ng/dL). Patients on intramuscular testosterone had a higher mean hematocrit than those on transdermal testosterone (44.96% vs 43.41%, P < .001). Both route of administration (P < .001) and testosterone level (P < .001) had statistically significant associations with hematocrit when controlling for each other. CONCLUSION While the magnitude of change in hematocrit with serum level and route of administration of testosterone was statistically significant, the absolute levels were within the normal range, unlikely to be clinically meaningful. These findings, along with the low prevalence of erythrocytosis, should help allay concerns about the use of testosterone as GAHT.
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Affiliation(s)
| | - Daniel J Slack
- Division of Endocrinology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574, USA
| | - Moira Kyweluk
- Clinical Research Division, Plume Health, Denver, CO 80209, USA
| | - Olivia Cullen
- Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574, USA
| | - Jerrica Kirkley
- Clinical Research Division, Plume Health, Denver, CO 80209, USA
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY 10029-6574, USA
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2
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Yau M, Malhotra NR, Steever J, Baldisserotto E, Lin C, Fader R, Oransky M, Safer JD. Pubertal Status at the Time of Fertility Preservation in Transgender Girls. Endocr Pract 2024; 30:356-359. [PMID: 38242354 DOI: 10.1016/j.eprac.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND Puberty blockade and gender-affirming hormone therapy can impair fertility. Counseling on fertility preservation is important before initiation of therapy. Our study aimed to assess Tanner staging and the presence of virilizing secondary sex characteristics at the time of sperm collection and correlate the viability of sperm with the Tanner staging and degree of virilization. METHODS A retrospective chart review of 23 transgender girls referred to pediatric urology at our academic pediatric transgender clinic for fertility preservation counseling was performed. At the initial visit before treatment, pubertal staging along with the assessment of virilizing secondary characteristics was performed. The semen analyses were evaluated for volume, sperm concentration, total sperm count, motility, and total motile count. RESULTS Of the first 23 transgender girls evaluated and counseled, 8 transgender females successfully produced a sperm sample for cryopreservation. The average testicular volume was 18.5 ml and ranged from 12 ml to 20 ml. The median semen parameters were at or above the 2021 World Health Organization threshold. The 8 transgender females who successfully underwent fertility preservation presented with at least 1 secondary sex characteristic. In 1 subject with Tanner stage 3 pubic hair development and a testicular volume of 12 ml, only voice change was reported. Facial hair and laryngeal prominence were not present on examination. CONCLUSION More than a third of our patients who accepted a referral to pediatric urology agreed to produce a sperm sample for cryopreservation. All of these patients successfully preserved sperm. With counseling and early referral to pediatric urology, a high percentage of fertility preservation in transgender girls was achieved.
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Affiliation(s)
- Mabel Yau
- Mount Sinai Center for Transgender Medicine and Surgery, New York, New York; Division of Pediatric Endocrinology, Mount Sinai Kravis Children's Hospital, New York, New York.
| | - Neha R Malhotra
- Division of Pediatric Urology, Mount Sinai Kravis Children's Hospital, New York, New York
| | - John Steever
- Division of Adolescent Medicine, Mount Sinai Kravis Children's Hospital, New York, New York
| | - Eva Baldisserotto
- Division of Pediatric Urology, Mount Sinai Kravis Children's Hospital, New York, New York
| | - Cathy Lin
- Division of Pediatric Endocrinology, Mount Sinai Kravis Children's Hospital, New York, New York
| | - Ralph Fader
- Mount Sinai Center for Transgender Medicine and Surgery, New York, New York; Department of Psychiatry, Mount Sinai Hospital, New York, New York
| | - Matthew Oransky
- Mount Sinai Center for Transgender Medicine and Surgery, New York, New York
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, New York, New York; Division of Endocrinology, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
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3
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Weinand JD, Safer JD. Corrigendum to "Hormone therapy in transgender adults is safe with provider supervision; A review of hormone therapy sequelae for transgender individuals" [J. JCTE 2 (2015) 55-60]. J Clin Transl Endocrinol 2024; 35:100334. [PMID: 38567202 PMCID: PMC10985022 DOI: 10.1016/j.jcte.2024.100334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
[This corrects the article DOI: 10.1016/j.jcte.2015.02.003.].
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Affiliation(s)
- Jamie D. Weinand
- Transgender Medicine Research Group, Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA
| | - Joshua D. Safer
- Transgender Medicine Research Group, Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA
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Fisher AD, Marconi M, Castellini G, Safer JD, D'Arienzo S, Levi M, Brogonzoli L, Iardino R, Cocchetti C, Romani A, Mazzoli F, Matarrese P, Ricca V, Vignozzi L, Maggi M, Pierdominici M, Ristori J. Estimate and needs of the transgender adult population: the SPoT study. J Endocrinol Invest 2024:10.1007/s40618-023-02251-9. [PMID: 38372939 DOI: 10.1007/s40618-023-02251-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/17/2023] [Indexed: 02/20/2024]
Abstract
BACKGROUND Despite the increasing interest in transgender health research, to date little is known about the size of the transgender and gender diverse (TGD) population. METHODS A web-based questionnaire survey was developed, including a collection of socio-demographic characteristics and disseminated online through social media. Gender incongruence was evaluated by using a 2-item approach assessing gender recorded at birth and gender identity. The primary objective of the present population-based study was to estimate the proportion of TGD people across ages among a large sample of people who answered a web-based survey. The secondary endpoints were to identify gender-affirming needs and possible barriers to healthcare access. RESULTS A total of 19,572 individuals participated in the survey, of whom 7.7% reported a gender identity different from the sex recorded at birth. A significantly higher proportion of TGD people was observed in the youngest group of participants compared with older ones. Among TGD people who participated in the study, 58.4% were nonbinary, and 49.1% experienced discrimination in accessing health care services. Nonbinary TGD participants reported both the need for legal name and gender change, along with hormonal and surgical interventions less frequently compared to binary persons. CONCLUSIONS Being TGD is not a marginal condition In Italy. A large proportion of TGD persons may not need medical and surgical treatments. TGD people often experience barriers to healthcare access relating to gender identity.
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Affiliation(s)
- A D Fisher
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, University of Florence, Florence, Italy.
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy.
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Careggi University Hospital, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.
| | - M Marconi
- Reference Centre for Gender Medicine, Italian National Institute of Health, Rome, Italy
| | - G Castellini
- Psychiatric Unit, University of Florence, Florence, Italy
| | - J D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, New York City, NY, USA
- Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - S D'Arienzo
- Azienda USL Toscana Centro SOC Monitoraggio e Programmazione Performance Clinico-Assistenziale Pistoia, Prato ed Empoli e Relazioni con Agenzie Esterne, Florence, Italy
| | - M Levi
- UFC Epidemiologia, Dipartimento di Prevenzione Azienda USL Toscana Centro, Florence, Italy
| | | | | | - C Cocchetti
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, University of Florence, Florence, Italy
| | - A Romani
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, University of Florence, Florence, Italy
| | - F Mazzoli
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, University of Florence, Florence, Italy
| | - P Matarrese
- Reference Centre for Gender Medicine, Italian National Institute of Health, Rome, Italy
| | - V Ricca
- Psychiatric Unit, University of Florence, Florence, Italy
| | - L Vignozzi
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, University of Florence, Florence, Italy
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - M Maggi
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - M Pierdominici
- Reference Centre for Gender Medicine, Italian National Institute of Health, Rome, Italy
| | - J Ristori
- Andrology, Women's Endocrinology and Gender Incongruence Unit, Florence University Hospital, University of Florence, Florence, Italy
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5
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Harty R, Safer JD. Gender-affirming care and endocrine-related cancers. Endocr Relat Cancer 2024; 31:e230214. [PMID: 38054816 DOI: 10.1530/erc-23-0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 12/06/2023] [Indexed: 12/07/2023]
Abstract
Graphical abstract Abstract With the increasing number of transgender and gender diverse (TGD) individuals who are seeking gender-affirming care, there is a clear need for the development and collection of evidence-based data to establish guidelines for patient care. TGD individuals are estimated to represent 0.3 to 4.5% of the world population. Gender-affirming care that includes hormone therapy helps to align the body of a transgender person with their gender identity. Hormone therapy requires monitoring for both safety and efficacy. The extent to which gender-affirming hormone therapy alters cancer risk remains unknown. Because of a lack of comprehensive data collection pertaining to this patient population, endocrine cancer data including incidence and outcomes is limited. Dedicated research is needed to help address the gap in knowledge pertaining to the risk of cancer in the TGD population.
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Affiliation(s)
- Roger Harty
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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6
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Ghofranian A, Aharon D, Friedenthal J, Hanley WJ, Lee JA, Daneyko M, Rodriguez Z, Safer JD, Copperman AB. Family Building in Transgender Patients: Modern Strategies with Assisted Reproductive Technology Treatment. Transgend Health 2024; 9:76-82. [PMID: 38312448 PMCID: PMC10835155 DOI: 10.1089/trgh.2021.0210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose Transgender and gender diverse (TGD) individuals continue to face adversity, stigma, and inequality, especially in health care. This study aimed to characterize the experience of TGD people and partners of TGD people with regard to fertility treatment. Methods All TGD patients presenting to a single academic center between 2013 and 2021 were included. Baseline demographics collected included patient age, body mass index, anti-Mullerian hormone, basal antral follicle count, history of gender-affirming surgery, and/or gender-affirming hormone therapy. Outcomes included total patients who progressed to treatment, cycle type(s), and clinical outcomes. Results In total, 82 patients who identified as TGD or had a partner who identified as TGD presented to care seeking fertility treatment. Of the 141 planned cycles, 106 (75.2%) progressed to treatment. Of the 15 in vitro fertilization (IVF) and co-IVF cycles, 12 achieved live birth. Of the 76 intrauterine inseminations 7 patients were discharged with ongoing pregnancies and one achieved live birth. Conclusion These findings reaffirm that TGD individuals utilize the entire array of fertility services. With recent advances in access to care and modern medicine, assisted reproductive technology treatment has the power to support TGD patients in building contemporary family structures.
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Affiliation(s)
- Atoosa Ghofranian
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Devora Aharon
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Reproductive Medicine Associates of New York, New York, New York, USA
| | - Jenna Friedenthal
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Reproductive Medicine Associates of New York, New York, New York, USA
| | - William J. Hanley
- Reproductive Medicine Associates of New York, New York, New York, USA
| | - Joseph A. Lee
- Reproductive Medicine Associates of New York, New York, New York, USA
| | - Margaret Daneyko
- Reproductive Medicine Associates of New York, New York, New York, USA
| | - Zoe Rodriguez
- Mount Sinai Center for Transgender Medicine and Surgery, New York, New York, USA
| | - Joshua D. Safer
- Mount Sinai Center for Transgender Medicine and Surgery, New York, New York, USA
| | - Alan B. Copperman
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Reproductive Medicine Associates of New York, New York, New York, USA
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7
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Yau M, Safer JD. In a Modest Transgender Cohort Following Guidelines, Few Discontinued Treatment and Regret Was not Observed. J Clin Endocrinol Metab 2024; 109:e862-e863. [PMID: 37493070 DOI: 10.1210/clinem/dgad439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/07/2023] [Accepted: 07/24/2023] [Indexed: 07/27/2023]
Affiliation(s)
- Mabel Yau
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY 10029, USA
- Division of Pediatric Endocrinology, Mount Sinai Kravis Children's Hospital, New York, NY 10029, USA
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY 10029, USA
- Division of Endocrinology, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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8
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Diaz-Thomas AM, Golden SH, Dabelea DM, Grimberg A, Magge SN, Safer JD, Shumer DE, Stanford FC. Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement. J Clin Endocrinol Metab 2023; 108:1533-1584. [PMID: 37191578 PMCID: PMC10653187 DOI: 10.1210/clinem/dgad124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Indexed: 05/17/2023]
Abstract
Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.
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Affiliation(s)
- Alicia M Diaz-Thomas
- Department of Pediatrics, Division of Endocrinology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Sherita Hill Golden
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Dana M Dabelea
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Adda Grimberg
- Department of Pediatrics, Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Sheela N Magge
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Joshua D Safer
- Department of Medicine, Division of Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10001, USA
| | - Daniel E Shumer
- Department of Pediatric Endocrinology, C.S. Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
| | - Fatima Cody Stanford
- Massachusetts General Hospital, Department of Medicine-Division of Endocrinology-Neuroendocrine, Department of Pediatrics-Division of Endocrinology, Nutrition Obesity Research Center at Harvard (NORCH), Boston, MA 02114, USA
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9
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Tesfamariam R, Safer JD. How Should a Transgender Patient's History of Deep Vein Thrombosis and Smoking Influence Gender-Affirming Health Decision Sharing? AMA J Ethics 2023; 25:E386-390. [PMID: 37285291 DOI: 10.1001/amajethics.2023.386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This commentary on a case considers a transgender patient's mental health and risk for deep vein thrombosis (DVT) in ethical decision making about feminizing gender-affirming hormone therapy (GAHT). Key considerations when beginning GAHT include recognizing that venous thromboembolism risk may only be modest and can be easily mitigated and that a transgender patient's mental health status should not weigh in a treatment decision about hormone therapy any more than it would for someone who is not transgender. Because the DVT risk of the case patient, who has a history of smoking and DVT, will only be increased modestly if at all by estrogen therapy and can be decreased through smoking cessation along with other DVT prevention methods, the patient should receive gender-affirming hormone therapy.
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Affiliation(s)
- Rebkah Tesfamariam
- Second-year student at Touro College of Osteopathic Medicine in Harlem, New York City
| | - Joshua D Safer
- Executive director of the Mount Sinai Center for Transgender Medicine and Surgery and a professor of medicine at the Icahn School of Medicine in New York City
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10
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Dickstein DR, Edwards CR, Lehrer EJ, Tarras ES, Gallitto M, Sfakianos J, Galsky MD, Stock R, Safer JD, Rosser BRS, Marshall DC. Sexual health and treatment-related sexual dysfunction in sexual and gender minorities with prostate cancer. Nat Rev Urol 2023; 20:332-355. [PMID: 37217695 PMCID: PMC10389287 DOI: 10.1038/s41585-023-00778-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 05/24/2023]
Abstract
Prostate cancer treatment has substantial effects on sexual health and function. Sexual function is a vital aspect of human health and a critical component of cancer survivorship, and understanding the potential effects of different treatment modalities on sexual health is crucial. Existing research has extensively described the effects of treatment on male erectile tissues necessary for heterosexual intercourse; however, evidence regarding their effects on sexual health and function in sexual and gender minority populations is minimal. These groups include sexual minority - gay and bisexual - men, and transgender women or trans feminine people in general. Such unique effects in these groups might include altered sexual function in relation to receptive anal and neovaginal intercourse and changes to patients' role-in-sex. Sexual dysfunctions following prostate cancer treatment affecting quality of life in sexual minority men include climacturia, anejaculation, decreased penile length, erectile dysfunction, and problematic receptive anal intercourse, including anodyspareunia and altered pleasurable sensation. Notably, clinical trials investigating sexual outcomes after prostate cancer treatment do not collect sexual orientation and gender identity demographic data or outcomes specific to members of these populations, which perpetuates the uncertainty regarding optimal management. Providing clinicians with a solid evidence base is essential to communicate recommendations and tailor interventions for sexual and gender minority patients with prostate cancer.
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Affiliation(s)
- Daniel R Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Collin R Edwards
- Department of Radiology, Vagelos College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elizabeth S Tarras
- Department of Pulmonology, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew Gallitto
- Department of Radiation Oncology, Vagelos College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - John Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew D Galsky
- Department of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard Stock
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - B R Simon Rosser
- Division of Epidemiology and Community Health, School of Public Health at University of Minnesota, Minneapolis, MN, USA
| | - Deborah C Marshall
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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11
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Ahmed SB, Beach LB, Safer JD, Veale JF, Whitley CT. Considerations in the care of transgender persons. Nat Rev Nephrol 2023; 19:360-365. [PMID: 37069283 DOI: 10.1038/s41581-023-00713-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/19/2023]
Affiliation(s)
- Sofia B Ahmed
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
- O'Brien Institute for Public Health, Calgary, Alberta, Canada.
- Alberta Kidney Disease Network, Calgary, Alberta, Canada.
| | - Lauren B Beach
- Department of Medical Social Sciences, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
- Department of Preventive Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
- ADVOCATE SGM Health Program, Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA.
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA.
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Jaimie F Veale
- Te Kura Whatu Oho Mauri School of Psychology, University of Waikato, Hamilton, Aotearoa New Zealand.
| | - Cameron T Whitley
- Department of Sociology, Western Washington University, Bellingham, WA, USA.
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12
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Rose AJ, Hughto JM, Dunbar MS, Quinn EK, Deutsch M, Feldman J, Radix A, Safer JD, Shipherd JC, Thompson J, Jasuja GK. Trends in Feminizing Hormone Therapy for Transgender Patients, 2006-2017. Transgend Health 2023; 8:188-194. [PMID: 37013092 PMCID: PMC10066771 DOI: 10.1089/trgh.2021.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Combination therapy with estrogen and spironolactone may help some transgender women achieve desired results. We used two databases, OptumLabs® Data Warehouse (OLDW) and Veterans Health Administration (VHA), to examine trends in feminizing therapy. We included 3368 transgender patients from OLDW and 3527 from VHA, all of whom received estrogen, spironolactone, or both between 2006 and 2017. In OLDW, the proportion receiving combination therapy increased from 47% to 75% during this period. Similarly, in VHA, the proportion increased from 39% to 69% during this period. We conclude that the use of combination hormone therapy has become much more common over the past decade.
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Affiliation(s)
- Adam J. Rose
- Hebrew University School of Public Health, Jerusalem, Israel
| | - Jaclyn M.W. Hughto
- Brown University School of Public Health, Providence, Rhode Island, USA
- Fenway Health, Boston, Massachusetts, USA
| | | | - Emily K. Quinn
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - Madeline Deutsch
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Jamie Feldman
- University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Asa Radix
- Callen-Lorde Community Health Center, New York, New York, USA
| | - Joshua D. Safer
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jillian C. Shipherd
- Lesbian, Gay, Bisexual, Transgender, Queer, and Questioning (LGBTQ+) Health Program, Veterans Health Administration, Washington, District of Columbia, USA
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - Guneet K. Jasuja
- Boston University School of Medicine, Boston, Massachusetts, USA
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Memorial Veterans Hospital, Bedford VA Medical Center, Bedford, Massachusetts, USA
- OptumLabs Visiting Scholar, OptumLabs, Eden Prairie, Minnesota, USA
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13
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Leone AG, Trapani D, Schabath MB, Safer JD, Scout NFN, Lambertini M, Berardi R, Marsoni S, Perrone F, Cinieri S, Miceli R, Morano F, Pietrantonio F. Cancer in Transgender and Gender-Diverse Persons: A Review. JAMA Oncol 2023; 9:556-563. [PMID: 36757703 DOI: 10.1001/jamaoncol.2022.7173] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Importance Transgender and gender-diverse individuals face unique challenges, including barriers to health care access and inequities in treatment, that may influence cancer risk and outcomes. Observations In this narrative review, a scoping review was conducted focusing on primary and secondary prevention and epidemiology of cancer, barriers to health care services, and health care practitioners' knowledge about specific issues pertaining to transgender and gender-diverse individuals. PubMed, the Cochrane Library, and Embase, were reviewed for citations from their inception to December 31, 2021. This review revealed that transgender and gender-diverse people had a high prevalence of tobacco consumption and alcohol use and high rates of infection with human papillomavirus (HPV) and HIV. Transgender and gender-diverse individuals were less likely to adhere to cancer screening programs and had a higher incidence of HIV- and HPV-associated cancers. Social and economic determinants seemed to drive these disparities in risk factors and outcomes. A lack of knowledge about gender minorities' health needs among health care practitioners was evidenced, and it represented a major hurdle to cancer prevention, care, and survivorship for transgender and gender-diverse individuals. Discrimination, discomfort caused by gender-labeled oncological services, stigma, and lack of cultural sensitivity of health care practitioners were other barriers met by transgender and gender-diverse persons in the oncology setting. Conclusions and Relevance The findings suggest that transgender and gender-diverse peoples' needs in the cancer care continuum are not optimally addressed. Effective solutions are needed to offer the best care to every patient in a person-centric and gender diversity-sensitive environment.
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Affiliation(s)
| | - Dario Trapani
- European Institute of Oncology, IRCCS, Milan, Italy.,Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | | - Joshua D Safer
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York, New York.,Mount Sinai Center for Transgender Medicine and Surgery, New York, New York
| | - N F N Scout
- National LGBT Cancer Network, Providence, Rhode Island
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties, School of Medicine, University of Genova, Genova, Italy.,Department of Medical Oncology, Unità Operativa Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Rossana Berardi
- Oncology Clinic, Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Ancona, Italy
| | - Silvia Marsoni
- IFOM, FIRC Institute of Molecular Oncology, Milan, Italy
| | - Francesco Perrone
- Clinical Trial Unit, Istituto Nazionale Tumori, IRCCS, Fondazione G. Pascale, Napoli, Italy
| | - Saverio Cinieri
- Medical Oncology Unit, Ospedale di Summa A. Perrino, Brindisi, Italy
| | - Rosalba Miceli
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Federica Morano
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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14
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Ramsay A, Safer JD. Update in Adult Transgender Medicine. Annu Rev Med 2023; 74:117-124. [PMID: 36322979 DOI: 10.1146/annurev-med-020222-121106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Transgender people often face barriers in health care due to lack of access to care, lack of knowledgeable healthcare professionals, discrimination, and gaps in medical and mental health research. Existing research on transgender health has focused heavily on mental health, HIV/AIDS, sexually transmitted diseases/infections, and substance abuse. Gender-affirming hormone therapy and/or surgery allows for some alignment of biology and gender identity. Gender-affirming care may offer quality-of-life benefits, which may outweigh modest concerns related to exogenous hormone therapy. The Endocrine Society treatment guidelines were revised in 2017, and this article reviews recent data that might inform a future guideline revision. Future longitudinal research is needed to close the gap in knowledge in the field of transgender medicine.
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Affiliation(s)
- Alyxandra Ramsay
- Mount Sinai Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA; ,
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA; ,
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15
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Yau M, Safer JD. The return of spermatogenesis in transgender women ceasing gender-affirming hormone therapy. Cell Rep Med 2023; 4:100835. [PMID: 36652904 PMCID: PMC9873818 DOI: 10.1016/j.xcrm.2022.100835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Fertility has become a priority in transgender health research. In this issue of Cell Reports Medicine, a study by de Nie et al.1 of nine transgender women demonstrates sperm production after the cessation of gender-affirming hormone therapy (GAHT). Their results suggest the transient nature of gonadal suppression by GAHT.
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Affiliation(s)
- Mabel Yau
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA; Division of Pediatric Endocrinology, Mount Sinai Kravis Children's Hospital, New York, NY, USA.
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA; Division of Endocrinology, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY, USA
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16
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Reisman T, Safer JD. Are adrenal androgens altered by gender affirming hormone therapy? J Clin Endocrinol Metab 2022; 108:e191-e192. [PMID: 36580563 DOI: 10.1210/clinem/dgac757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/19/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Tamar Reisman
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Endocrinology, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Endocrinology, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY, USA
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17
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Riddle MC, Safer JD. Medical considerations in the care of transgender and gender diverse patients with eating disorders. J Eat Disord 2022; 10:178. [PMID: 36414965 PMCID: PMC9682795 DOI: 10.1186/s40337-022-00699-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/09/2022] [Indexed: 11/24/2022] Open
Abstract
Transgender and gender diverse (TGD) individuals are at increased risk for the development of eating disorders, but very little has been published with regards to the unique aspects of their medical care in eating disorder treatment. Providing gender affirming care is a critical component of culturally competent eating disorder treatment. This includes knowledge of gender affirming medical and surgical interventions and how such interventions may be impacted by eating disordered behaviors, as well as the role of such interventions in eating disorder treatment and recovery. TGD individuals face barriers to care, and one of these can be provider knowledge. By better understanding these needs, clinicians can actively reduce barriers and ensure TGD individuals are provided with appropriate care. This review synthesizes the available literature regarding the medical care of TGD patients and those of patients with eating disorders and highlights areas for further research.
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Affiliation(s)
- Megan C Riddle
- Eating Recovery Center, 1231 116Th Ave NE, Bellevue, WA, 98004, USA. .,Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Box 356560, Seattle, WA, 98195-6560, USA.
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, 275 7Th Ave 12Th Floor, New York, NY, 10001, USA
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18
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Shin SJ, Pang JH, Tiersten L, Jorge N, Hirschmann J, Kutsy P, Ashley K, Stein L, Safer JD, Barnett B. The Mount Sinai Interdisciplinary Approach to Perioperative Care Improved the Patient Experience for Transgender Individuals. Transgend Health 2022; 7:449-452. [PMID: 36644486 PMCID: PMC9829120 DOI: 10.1089/trgh.2020.0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Purpose Although medical care for transgender and gender nonbinary (TGNB) individuals is rapidly expanding, numerous gaps in the organization of quality care for TGNB individuals remain. In 2018, the Mount Sinai Center for Transgender Medicine and Surgery (CTMS) expanded its unified care approach to integrate services with an interdisciplinary inpatient team for surgical patients as part of the program. The inpatient team connected with the existing interdisciplinary ambulatory team with all pertinent medical and psychosocial information shared between the teams. The format enabled the hospital team to better prepare in advance of a patient's arrival and facilitated discharge planning as well. We sought to assess patient satisfaction with inpatient care after implementation of the interdisciplinary operation. Methods The standard Press Ganey survey tool used by the Mount Sinai Health System to measure patient satisfaction with care was queried before and after implementation of the interdisciplinary inpatient care team. Results Patient ratings of inpatient care rose dramatically. Relative to other institutions nationally, Press Ganey scores rose into the 98th or 99th percentiles across all domains. The new scores represented a rise of 25% for communication with nurses, 3% for hospital environment, 25% for care transition, and 100% for willingness to recommend. The discharge information score represented a 30-fold improvement. Conclusion An interdisciplinary inpatient health care team can significantly improve patient satisfaction for TGNB patients. Such an approach might be considered for other TGNB health care programs along with health care delivery in other areas of medicine.
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Affiliation(s)
- Sangyoon J. Shin
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Henry Pang
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Linda Tiersten
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Noemy Jorge
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jo Hirschmann
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Polina Kutsy
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kenneth Ashley
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura Stein
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua D. Safer
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Barbara Barnett
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
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19
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health 2022; 23:S1-S259. [PMID: 36238954 PMCID: PMC9553112 DOI: 10.1080/26895269.2022.2100644] [Citation(s) in RCA: 455] [Impact Index Per Article: 227.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
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Affiliation(s)
- E Coleman
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A E Radix
- Callen-Lorde Community Health Center, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - W P Bouman
- Nottingham Centre for Transgender Health, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - G R Brown
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- James H. Quillen VAMC, Johnson City, TN, USA
| | - A L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M B Deutsch
- Department of Family & Community Medicine, University of California-San Francisco, San Francisco, CA, USA
- UCSF Gender Affirming Health Program, San Francisco, CA, USA
| | - R Ettner
- New Health Foundation Worldwide, Evanston, IL, USA
- Weiss Memorial Hospital, Chicago, IL, USA
| | - L Fraser
- Independent Practice, San Francisco, CA, USA
| | - M Goodman
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Green
- Independent Scholar, Vancouver, WA, USA
| | - A B Hancock
- The George Washington University, Washington, DC, USA
| | - T W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - D H Karasic
- University of California San Francisco, San Francisco, CA, USA
- Independent Practice at dankarasic.com
| | - G A Knudson
- University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health, Vancouver, Canada
| | - S F Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - H F L Meyer-Bahlburg
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | - J Motmans
- Transgender Infopunt, Ghent University Hospital, Gent, Belgium
- Centre for Research on Culture and Gender, Ghent University, Gent, Belgium
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T O Nieder
- University Medical Center Hamburg-Eppendorf, Interdisciplinary Transgender Health Care Center Hamburg, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - S L Reisner
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - C Richards
- Regents University London, UK
- Tavistock and Portman NHS Foundation Trust, London, UK
| | | | - V Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - A C Tishelman
- Boston College, Department of Psychology and Neuroscience, Chestnut Hill, MA, USA
| | - M A A Van Trotsenburg
- Bureau GenderPRO, Vienna, Austria
- University Hospital Lilienfeld-St. Pölten, St. Pölten, Austria
| | - S Winter
- School of Population Health, Curtin University, Perth, WA, Australia
| | - K Ducheny
- Howard Brown Health, Chicago, IL, USA
| | - N J Adams
- University of Toronto, Ontario Institute for Studies in Education, Toronto, Canada
- Transgender Professional Association for Transgender Health (TPATH)
| | - T M Adrián
- Asamblea Nacional de Venezuela, Caracas, Venezuela
- Diverlex Diversidad e Igualdad a Través de la Ley, Caracas, Venezuela
| | - L R Allen
- University of Nevada, Las Vegas, NV, USA
| | - D Azul
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - H Bagga
- Monash Health Gender Clinic, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - K Başar
- Department of Psychiatry, Hacettepe University, Ankara, Turkey
| | - D S Bathory
- Independent Practice at Bathory International PLLC, Winston-Salem, NC, USA
| | - J J Belinky
- Durand Hospital, Guemes Clinic and Urological Center, Buenos Aires, Argentina
| | - D R Berg
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J U Berli
- Oregon Health & Science University, Portland, OR, USA
| | - R O Bluebond-Langner
- NYU Langone Health, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York, NY, USA
| | - M-B Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Plastic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - M L Bowers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - P J Brassard
- GrS Montreal, Complexe CMC, Montreal, Quebec, Canada
- Université de Montreal, Quebec, Canada
| | - J Byrne
- University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - L Capitán
- The Facialteam Group, Marbella International Hospital, Marbella, Spain
| | | | - J M Carswell
- Harvard Medical School, Boston, MA, USA
- Boston's Children's Hospital, Boston, MA, USA
| | - S C Chang
- Independent Practice, Oakland, CA, USA
| | - G Chelvakumar
- Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University, College of Medicine, Columbus, OH, USA
| | - T Corneil
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K B Dalke
- Penn State Health, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - G De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - E de Vries
- Nelson Mandela University, Gqeberha, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - A H Devor
- University of Victoria, Victoria, BC, Canada
| | - C Dhejne
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - A D'Marco
- UCTRANS-United Caribbean Trans Network, Nassau, The Bahamas
- D M A R C O Organization, Nassau, The Bahamas
| | - E K Edmiston
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Edwards-Leeper
- Pacific University, Hillsboro, OR, USA
- Independent Practice, Beaverton, OR, USA
| | - R Ehrbar
- Whitman Walker Health, Washington, DC, USA
- Independent Practice, Maryland, USA
| | - D Ehrensaft
- University of California San Francisco, San Francisco, CA, USA
| | - J Eisfeld
- Transvisie, Utrecht, The Netherlands
| | - E Elaut
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Clinical Experimental and Health Psychology, Ghent University, Gent, Belgium
| | - L Erickson-Schroth
- The Jed Foundation, New York, NY, USA
- Hetrick-Martin Institute, New York, NY, USA
| | - J L Feldman
- Institute for Sexual and Gender Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A D Fisher
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | - M M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA, USA
| | - L Gijs
- Institute of Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | - B P Hall
- Duke University Medical Center, Durham, NC, USA
- Duke Adult Gender Medicine Clinic, Durham, NC, USA
| | - T L D Hardy
- Alberta Health Services, Edmonton, Alberta, Canada
- MacEwan University, Edmonton, Alberta, Canada
| | - M S Irwig
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - A C Janssen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- RMIT University, Melbourne, Australia
- University of Brighton, Brighton, UK
| | - D T Klink
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, Gent, Belgium
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children's Hospital, Antwerp, Belgium
| | - B P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - L E Kuper
- Department of Psychiatry, Southwestern Medical Center, University of Texas, Dallas, TX, USA
- Department of Endocrinology, Children's Health, Dallas, TX, USA
| | - E J Kvach
- Denver Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M A Malouf
- Malouf Counseling and Consulting, Baltimore, MD, USA
| | - R Massey
- WPATH Global Education Institute
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - T Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - C McLachlan
- Professional Association for Transgender Health, South Africa
- Gender DynamiX, Cape Town, South Africa
| | - S D Morrison
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - S W Mosser
- Gender Confirmation Center, San Francisco, CA, USA
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - P M Neira
- Johns Hopkins Center for Transgender Health, Baltimore, MD, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, MD, USA
| | - U Nygren
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Speech and Language Pathology, Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - J M Oates
- La Trobe University, Melbourne, Australia
- Melbourne Voice Analysis Centre, East Melbourne, Australia
| | - J Obedin-Maliver
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford, CA, USA
| | - G Pagkalos
- Independent PracticeThessaloniki, Greece
- Military Community Mental Health Center, 424 General Military Training Hospital, Thessaloniki, Greece
| | - J Patton
- Talkspace, New York, NY, USA
- CytiPsychological LLC, San Diego, CA, USA
| | - N Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - K Rachlin
- Independent Practice, New York, NY, USA
| | - T Reed
- Gender Identity Research and Education Society, Leatherhead, UK
| | - G N Rider
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Ristori
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | | | - S A Roberts
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Boston's Children's Hospital, Boston, MA, USA
| | - K A Rodriguez-Wallberg
- Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - S M Rosenthal
- Division of Pediatric Endocrinology, UCSF, San Francisco, CA, USA
- UCSF Child and Adolescent Gender Center
| | - K Sabir
- FtM Phoenix Group, Krasnodar Krai, Russia
| | - J D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
| | - A I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - L J Seal
- Tavistock and Portman NHS Foundation Trust, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - K Spencer
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - C St Amand
- University of Houston, Houston, TX, USA
- Mayo Clinic, Rochester, MN, USA
| | - T D Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - J F Strang
- Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | - G B Taylor
- Atrium Health Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charlotte, NC, USA
| | - K Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - G G T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - L N Vala
- Independent Practice, Campbell, CA, USA
| | - N M Van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J F Veale
- School of Psychology, University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - J A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - B Vincent
- Trans Learning Partnership at https://spectra-london.org.uk/trans-learning-partnership, UK
| | - L M Wesp
- College of Nursing, University of Wisconsin MilwaukeeMilwaukee, WI, USA
- Health Connections Inc., Glendale, WI, USA
| | - M A West
- North Memorial Health Hospital, Robbinsdale, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - J Arcelus
- School of Medicine, University of Nottingham, Nottingham, UK
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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20
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Alpert AB, Scout NFN, Schabath MB, Adams S, Obedin-Maliver J, Safer JD. Gender- and Sexual Orientation- Based Inequities: Promoting Inclusion, Visibility, and Data Accuracy in Oncology. Am Soc Clin Oncol Educ Book 2022; 42:1-17. [PMID: 35658501 DOI: 10.1200/edbk_350175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Sexual and gender minority (SGM) people, including agender, asexual, bisexual, gay, gender diverse, genderqueer, genderfluid, intersex, lesbian, nonbinary, pansexual, queer, and transgender people, comprise approximately 10% or more of the U.S. population. Thus, most oncologists see SGM patients whether they know it or not. SGM people experience stigma and structural discrimination that lead to cancer disparities. Because of the lack of systematic and comprehensive data collection, data regarding SGM cancer incidence, outcomes, and treatment responses are limited. Collection of data regarding sexual orientation, gender identity, transgender identity and/or experience, anatomy, and serum hormone concentrations in oncology settings would drastically increase collective knowledge about the impact of stigma and biologic markers on cancer outcomes. Increasing the safety of oncology settings for SGM people will require individual, institutional, and systems changes that will likely improve oncologic care for all patients.
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Affiliation(s)
- Ash B Alpert
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI.,Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | - N F N Scout
- National LGBT Cancer Network, Providence, RI
| | - Matthew B Schabath
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Spencer Adams
- School of Interdisciplinary Health Programs, Western Michigan University, Kalamazoo, MI
| | - Juno Obedin-Maliver
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, CA
| | - Joshua D Safer
- Division of Endocrinology, Icahn School of Medicine at Mount Sinai, New York, NY.,Mount Sinai Center for Transgender Medicine and Surgery, New York, NY
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21
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Dunbar MS, Hughto JMW, Jasuja GK, Quinn EK, Deutsch M, Radix A, Feldman J, Abbott J, Safer JD, Thompson J, Rose AJ. Considering Quality Measures for the Care of Transgender Patients: Preliminary Findings from a Technical Expert Panel. LGBT Health 2022; 9:264-275. [PMID: 35363052 DOI: 10.1089/lgbt.2021.0279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Transgender (TG) individuals are a historically understudied and underserved patient population. Although clinical guidelines for the care of TG patients exist, quality measures (QMs) specific to this population are lacking. The goal of this study was to obtain expert input on aspects of care for which quality measurement may be appropriate and describe feedback on candidate QMs. Methods: We convened a virtual technical expert panel in September 2020 with six experts in TG medical care. Experts participated in a guided discussion and provided numeric ratings on dimensions of measure suitability (importance, validity/reliability, feasibility, and ease of understanding) for eight candidate QMs spanning multiple care domains (e.g., laboratory testing/monitoring, cancer screening, and sexually transmitted infection screening). Results: Panelists acknowledged high importance and potential to improve care for some candidate QMs, particularly those related to laboratory testing before initiating and during hormone therapy. Numeric ratings of QMs varied but tended to be higher for testing-focused QMs. Experts raised concerns about overly prescriptive language for some QMs and emphasized the importance of considering more flexible specifications to accommodate diverse care scenarios-including care provided to nonbinary individuals-and align with the individualized nature of gender-affirming care. Conclusion: These preliminary findings support a potential role for QMs in improving quality of care for TG patients. Measures related to laboratory testing/monitoring for patients who receive or plan to initiate hormone therapy may be feasible and promising to explore in the future. Additional larger-scale efforts are needed to develop and test QMs for the care of TG individuals.
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Affiliation(s)
- Michael S Dunbar
- Health Care Division, RAND Corporation, Pittsburgh, Pennsylvania, USA
| | - Jaclyn M W Hughto
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA.,Center for Health Promotion and Health Equity, Brown University, Providence, Rhode Island, USA.,The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Memorial Veterans Hospital, Bedford VA Medical Center, Bedford, Massachusetts, USA.,Boston University School of Medicine, Boston, Massachusetts, USA
| | - Emily K Quinn
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Madeline Deutsch
- UCSF Transgender Care, University of California, San Francisco, San Francisco, California, USA.,Department of Family & Community Medicine, UCSF School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Asa Radix
- Callen-Lorde Community Health Center, New York, New York, USA
| | - Jamie Feldman
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jennifer Abbott
- Western North Carolina Community Health Services, Asheville, North Carolina, USA
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Adam J Rose
- Department of Health Policy, School of Public Health, Hebrew University, Jerusalem, Israel.,OptumLabs, Eden Prairie, Minnesota, USA
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22
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Safer JD. Fairness for Transgender People in Sport. J Endocr Soc 2022; 6:bvac035. [PMID: 35350392 PMCID: PMC8944319 DOI: 10.1210/jendso/bvac035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Indexed: 12/02/2022] Open
Abstract
Increasingly visible participation by transgender people in athletic competition has resulted in efforts to include transgender women in the women’s categories while addressing possible advantage they might have from exposure to typically male levels of testosterone. There does not seem to be any reason to expect advantage for transgender people prior to puberty of or for transgender people whose gender-affirming treatment begins at the onset of puberty. To date, the only established driver of athletic advantage in men over women is testosterone. Further, the existing literature suggests that treatment to lower testosterone may be sufficient to erase that advantage in at least some athletic activities. Whether other aspects of puberty are advantages or disadvantages in certain sports remains to be established. There is need for more research on the topic. In addition, there is a need to prioritize the need to motivate people to participate in sport for better health.
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Affiliation(s)
- Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Endocrinology, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY, USA
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23
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Abstract
In this commentary, we describe the way in which science has been used to constrain transgender peoples’ access to gender-affirming care. The required diagnosis of gender dysphoria is rooted in both the historical assumption that psychological distress is an inherent aspect of being transgender and the incorrect notion that gender-affirming care is a panacea for the mental health issues that transgender people may experience, regardless of whether these mental health issues are related to their being transgender. We provide recommendations for how to address these barriers to care moving forward.
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Affiliation(s)
- Anish Kumar
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Joshua D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
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24
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Hirschmann J, Kozato A, Sharma V, Villagra C, Wetmore J, Jandorf L, Pang JH, Reynolds M, Dodge L, Mejía S, Safer JD. An Analysis of Chaplains' Narrative Chart Notes Describing Spiritual Care Visits with Gender Affirmation Surgical Patients. Transgend Health 2022; 7:92-100. [PMID: 36644021 PMCID: PMC9829152 DOI: 10.1089/trgh.2020.0030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Purpose The benefit of spiritual care for patients is well described, but little is known about the role of spiritual care in transgender and nonbinary patients recovering from gender affirming surgeries (GASs). Methods A single-center retrospective chart review was performed on patients who underwent GAS in 2017. Demographic information, surgery type, and chaplains' narrative notes were examined. Results A total of 145 chaplain visits were identified in 103 inpatient stays among 98 patients at the Mount Sinai Center for Transgender Medicine and Surgery in New York. Analysis was performed on narrative notes authored by a single chaplain, which included 132 visits among 78 transfeminine and 11 transmasculine patients. Fifty-four patients (61%) expressed gratitude for the chaplain visit and/or hospital experience overall. Seven patients (8%) described movement between religious denominations over the course of their lives, and 7 (8%) described supportive belief systems. Fifty-seven patients (64%) had a family member or friend present during the perioperative process, 13 (15%) described support systems, and 9 (10%) described supportive practices, activities, and/or coping methods. Twenty-one patients (24%) expressed concerns about current symptoms or the recovery process, and 32 (36%) received a prayer or blessing from the chaplain. Fifty-two patients (58%) consented to a follow-up call. Conclusion Almost 50% of patients expressed gratitude for the chaplain's visit and more than half consented to a follow-up call from the chaplain, suggesting a chaplain can provide a welcome layer of support to postoperative GAS patients. The authors recommend integrating spiritual care into perioperative care.
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Affiliation(s)
- Jo Hirschmann
- Mount Sinai Center for Transgender Medicine and Surgery, Center for Spirituality and Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Address correspondence to: Jo Hirschmann, MAHL, Mount Sinai Center for Transgender Medicine and Surgery, Center for Spirituality and Health, Icahn School of Medicine at Mount Sinai, 10 Nathan D. Perlman Place, New York, NY 10003, USA,
| | - Aki Kozato
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vansh Sharma
- Department of Psychiatry, Center for Spirituality and Health, Center for Stress, Resilience and Personal Growth, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Cristina Villagra
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Wetmore
- Mount Sinai Health System, New York, New York, USA
| | - Lina Jandorf
- Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Henry Pang
- Mount Sinai Center for Transgender Medicine and Surgery, Department of Surgery, Division of Plastic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Leanne Dodge
- Department of Spiritual Care and Education, Mount Sinai Beth Israel, New York, New York, USA
| | - Silvia Mejía
- Department of Spiritual Care and Education, Mount Sinai Beth Israel, New York, New York, USA
| | - Joshua D. Safer
- Mount Sinai Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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25
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Kozato A, Karim S, Chennareddy S, Amakiri UO, Ting J, Avanessian BK, Safer JD, Eckert J, Kent M, Pang JH. Neovaginal Stenosis in Transfeminine Patients after Gender-Affirming Vaginoplasty Operation. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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26
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Kozato A, Safer JD, Pang JH. Response to Letter to the Editor from Blasdel et al: "No Venous Thromboembolism Increase Among Transgender Female Patients Remaining on Estrogen for Gender Affirming Surgery". J Clin Endocrinol Metab 2021; 106:e3791. [PMID: 33846741 DOI: 10.1210/clinem/dgab245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Aki Kozato
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| | - John Henry Pang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
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27
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Walch A, Davidge-Pitts C, Lopez X, Tangpricha V, Iwamoto SJ, Safer JD. Response to Letter to the Editor from Malone: "Proper Care of Transgender and Gender Diverse Persons in the Setting of Proposed Discrimination: A Policy Perspective". J Clin Endocrinol Metab 2021; 106:e3295-e3296. [PMID: 33772302 DOI: 10.1210/clinem/dgab206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Abby Walch
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California San Francisco, Benioff Children's Hospital, San Francisco, California 94143, USA
| | - Caroline Davidge-Pitts
- Division of Endocrinology, Diabetes, Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Ximena Lopez
- Division of Pediatric Endocrinology, University of Texas Southwestern Medical Center, Dallas, Texas 75390, USA
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30322, USA
- Atlanta VA Medical Center, Decatur, Georgia 30300, USA
| | - Sean J Iwamoto
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado 80045, USA
- Division of Endocrinology, Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Health Care System, Aurora, Colorado 80045, USA
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, New York, New York 10001, USA
- Icahn School of Medicine at Mount Sinai, New York, New York 10029, USA
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28
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Reisman T, Safer JD. New Data to Challenge Gender-affirming Hormone Therapy Prescribing Practice. J Clin Endocrinol Metab 2021; 106:e2365-e2366. [PMID: 33524111 DOI: 10.1210/clinem/dgab006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Tamar Reisman
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Division of Endocrinology, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Division of Endocrinology, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
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29
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Zucker R, Reisman T, Safer JD. Minimizing Venous Thromboembolism in Feminizing Hormone Therapy: Applying Lessons From Cisgender Women and Previous Data. Endocr Pract 2021; 27:621-625. [PMID: 33819637 DOI: 10.1016/j.eprac.2021.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To review he impact of estrogen-containing feminizing hormone regimens on transgender individuals' risk for VTE. METHODS We evaluated VTE risk by screening 1170 relevant studies published from 1994 to 2020, focusing on meta-analysis data. RESULTS The type of oral estrogen, route of administration, patient demographics, and comorbidities may affect the risk of VTE. Venous thrombosis is the most common vascular complication associated with HT. CONCLUSION Conjugated equine estrogens and 17-β estradiol appear to be safer than oral ethinyl estradiol. Transdermal estrogen formulations appear to be the least thrombogenic estrogens. Estrogens used concomitantly with progestins increase the risk of VTE compared to estrogens alone. To date, there are no data to demonstrate the benefit of holding HT prior to vaginoplasty or other gender affirming surgeries. For most young, healthy transgender women, there is little risk of VTE with HT, while older patients with risk factors should be discussed case by case.
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Affiliation(s)
- Roy Zucker
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tamar Reisman
- Icahn School of Medicine at Mount Sinai, New York, New York; Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, New York
| | - Joshua D Safer
- Icahn School of Medicine at Mount Sinai, New York, New York; Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, New York.
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30
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Kozato A, Fox GWC, Yong PC, Shin SJ, Avanessian BK, Ting J, Ling Y, Karim S, Safer JD, Pang JH. No Venous Thromboembolism Increase Among Transgender Female Patients Remaining on Estrogen for Gender-Affirming Surgery. J Clin Endocrinol Metab 2021; 106:e1586-e1590. [PMID: 33417686 DOI: 10.1210/clinem/dgaa966] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Both surgery and exogenous estrogen use are associated with increased risk of venous thromboembolism (VTE). However, it is not known whether estrogen hormone therapy (HT) exacerbates the surgery-associated risk among transgender and gender nonbinary (TGNB) individuals. The lack of published data has contributed to heterogeneity in perioperative protocols regarding estrogen HT administration for TGNB patients undergoing gender-affirming surgery. METHODS A single-center retrospective chart review was performed on all TGNB patients who underwent gender-affirming surgery between November 2015 and August 2019. Surgery type, preoperative HT regimen, perioperative HT regimen, VTE prophylaxis management, outcomes, and demographic data were recorded. RESULTS A total of 919 TGNB patients underwent 1858 surgical procedures representing 1396 unique cases, of which 407 cases were transfeminine patients undergoing primary vaginoplasty. Of the latter, 190 cases were performed with estrogen suspended for 1 week prior to surgery, and 212 cases were performed with HT continued throughout. Of all cases, 1 patient presented with VTE, from the cohort of transfeminine patients whose estrogen HT was suspended prior to surgery. No VTE events were noted among those who continued HT. Mean postoperative follow-up was 285 days. CONCLUSIONS Perioperative VTE was not a significant risk in a large, homogenously treated cohort of TGNB patients independent of whether HT was suspended or not prior to surgery.
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Affiliation(s)
- Aki Kozato
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - G W Conner Fox
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patrick C Yong
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sangyoon J Shin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| | - Bella K Avanessian
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| | - Jess Ting
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| | - Yiwei Ling
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| | - Subha Karim
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| | - Joshua D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
| | - John Henry Pang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA
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31
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Gorbea E, Gidumal S, Kozato A, Pang JH, Safer JD, Rosenberg J. Insurance Coverage of Facial Gender Affirmation Surgery: A Review of Medicaid and Commercial Insurance. Otolaryngol Head Neck Surg 2021; 165:791-797. [PMID: 33722109 DOI: 10.1177/0194599821997734] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To provide a portrait of gender affirmation surgery (GAS) insurance coverage across the United States, with attention to procedures of the head and neck. STUDY DESIGN Systematic review. SETTING Policy review of US medical insurance companies. METHODS State policies on transgender care for Medicaid insurance providers were collected for all 50 states. Each state's policy on GAS and facial gender affirmation surgery (FGAS) was examined. The largest medical insurance companies in the United States were identified using the National Association of Insurance Commissioners Market Share report. Policies of the top 49 primary commercial medical insurance companies were examined. RESULTS Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17%). Thirteen states prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender-affirming medical care coverage policy. Ninety-two percent of commercial medical insurance providers had a published policy on GAS coverage. Genital reconstruction was described as a medically necessary aspect of transgender care in 100% of the commercial policies reviewed. Ninety-three percent discussed coverage of FGAS, but 51% considered these procedures cosmetic. Thyroid chondroplasty (20%) was the most commonly covered FGAS procedure. Mandibular and frontal bone contouring, rhinoplasty, blepharoplasty, and facial rhytidectomy were each covered by 13% of the medical policies reviewed. CONCLUSION While certain surgical aspects of gender-affirming medical care are nearly ubiquitously covered by commercial insurance providers, FGAS is considered cosmetic by most Medicaid and commercial insurance providers, potentially limiting patient access. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Enrique Gorbea
- Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sunder Gidumal
- Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aki Kozato
- Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Henry Pang
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Surgery, Division of Plastic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua Rosenberg
- Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Pang JH, Safer JD. An Opportunity to Better Assess Breast Development in Transgender Women. J Clin Endocrinol Metab 2021; 106:e1453-e1454. [PMID: 33332566 DOI: 10.1210/clinem/dgaa934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Indexed: 11/19/2022]
Affiliation(s)
- John Henry Pang
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Plastic Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Endocrinology, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Abstract
With the growing number of transgender and gender-nonbinary individuals who are becoming visible, it is clear that there is a need to develop a rigorous evidence base to inform care practice. Transgender health research is often limited to HIV/AIDS or mental health research and is typically subsumed in larger studies with general LGBTQ focus. Although the number of knowledgeable health care providers remains modest, the model for the medical approach to transgender health is shifting owing to growing social awareness and an appreciation of a biological component. Gender-affirming medicine facilitates aligning the body of the transgender person with the gender identity; typical treatment regimens include hormone therapy and/or surgical interventions. While broadly safe, hormone treatments require some monitoring for safety. Exogenous estrogens are associated with a dose-dependent increase in venous thromboembolic risk, and androgens stimulate erythropoiesis. The degree to which progressing gender-affirming hormone treatment changes cancer risk, cardiac heart disease risk, and/or bone health remains unknown. Guidelines referencing the potential exacerbation of cancer, heart disease, or other disease risk often rely on physiology models, because conclusive clinical data do not exist. Dedicated research infrastructure and funding are needed to address the knowledge gap in the field.
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Safer JD. Using Evidence to Fill Gaps in the Care of Transgender People. Endocr Pract 2021; 26:1387-1388. [PMID: 33471668 DOI: 10.4158/ep-2020-0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Joshua D Safer
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York..
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Safer JD, Tangpricha V. Guidance For Collecting Sex/Gender Data In Research. Endocr Pract 2021; 26:1225-1226. [PMID: 33471722 DOI: 10.4158/ep-2020-0356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 06/14/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Joshua D Safer
- From the Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Vin Tangpricha
- the Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, and the Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
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Walch A, Davidge-Pitts C, Safer JD, Lopez X, Tangpricha V, Iwamoto SJ. Proper Care of Transgender and Gender Diverse Persons in the Setting of Proposed Discrimination: A Policy Perspective. J Clin Endocrinol Metab 2021; 106:305-308. [PMID: 33326028 PMCID: PMC7823304 DOI: 10.1210/clinem/dgaa816] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Indexed: 12/20/2022]
Abstract
Transgender and gender diverse (TGD) individuals face significant barriers to accessing health care. Recent introductions of regulatory policies at state and federal levels raise concerns over the politicization of gender-affirming health care, the risks of further restricting access to quality care, and the potential criminalization of healthcare professionals who care for TGD patients. The Endocrine Society and the Pediatric Endocrine Society have published several news articles and comments in the last couple of years supporting safe and effective gender-affirming interventions as outlined in the 2017 Endocrine Society's Clinical Practice Guidelines. The Endocrine Society Position Statement on Transgender Health also acknowledges the rapid expansion in understanding the biological underpinning of gender identity and the need for increased funding to help close gaps in knowledge about the optimal care of TGD individuals. This Policy Perspective affirms these principles in the context of pending and future legislation attempting to discriminate against TGD patients while also stressing the need for science and health care experts to inform health policies.
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Affiliation(s)
- Abby Walch
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California San Francisco, Benioff Children’s Hospital, San Francisco, California, USA
- Correspondence and Reprint Requests: Abby Walch, Division of Pediatric Endocrinology, Department of Pediatrics, University of California San Francisco, Benioff Children’s Hospital, San Francisco, California 94143, USA.
| | - Caroline Davidge-Pitts
- Division of Endocrinology, Diabetes, Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, New York, New York, USA
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ximena Lopez
- Division of Pediatric Endocrinology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Atlanta VA Medical Center, Decatur, Georgia, USA
| | - Sean J Iwamoto
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Endocrinology, Rocky Mountain Regional VA Medical Center, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
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Abstract
OBJECTIVE To review screening guidelines for cardiometabolic disease in aging patients and review literature describing the effect of hormone therapy (HT) on several key cardiometabolic processes to inform providers caring for older transgender individuals. METHODS A traditional literature review was performed using PubMed and Google Scholar databases. RESULTS The risk of cardiovascular disease increases with age. Exogenous sex hormones may interact with hormone-dependent metabolic pathways and affect some biochemical assays, but they do not necessarily impact clinical outcomes. While long-term HT is associated with an increased risk of some adverse cardiovascular outcomes, modern treatment regimens minimize this risk. CONCLUSION Screening for cardiometabolic derangements and risk reduction are important for all aging individuals. Currently, there is insufficient evidence to propose separate screening recommendations for transgender individuals on long-term HT. Aging transgender men and women should be monitored for cardiovascular disease in much the same way as their cisgender counterparts.
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Affiliation(s)
- Daniel J Slack
- Mount Sinai Center for Transgender Medicine, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York.
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Abstract
INTRODUCTION This review summarizes gender affirming medical and surgical care available to transgender individuals, along with proposals to improve medically and culturally appropriate care. AREAS COVERED Transgender individuals are those whose gender identity differs from that recorded at birth (usually based on visualization of external sexual anatomy). In order to align the body with the patient's gender identity, clinicians can provide hormone therapy (HT) to bring sex hormone levels to the range associated with the patient's gender identity. At steady state, monitoring for maintenance of levels, as well as for known risks and complications, is required. Treating clinicians should have knowledge of trans assessment criteria, hormone therapy, surgical options, primary care, and mental health needs of transgender patients. A narrative literature review was conducted using Pubmed and EMBASE with articles then selected for relevance. The initial search terms were: androgen suppression, antiandrogen, breast development, chest reconstruction, cisgender, estrogen, fertility preservation, gender-affirming surgery, gender identity, gender incongruence, genital reconstruction, hormone replacement, hyperlipidemia, orchiectomy, prolactin, prostate atrophy, spermatogenesis, spironolactone, testosterone, thrombogenesis, transgender, and virilization. EXPERT OPINION Although guidelines exist and examples of training are available, systematic formal training must be implemented to truly mainstream high-quality gender-affirming health care .
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Affiliation(s)
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai , New York, NY, USA
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Lichtenstein M, Stein L, Connolly E, Goldstein ZG, Martinson T, Tiersten L, Shin SJ, Pang JH, Safer JD. The Mount Sinai Patient-Centered Preoperative Criteria Meant to Optimize Outcomes Are Less of a Barrier to Care Than WPATH SOC 7 Criteria Before Transgender-Specific Surgery. Transgend Health 2020; 5:166-172. [PMID: 33644310 DOI: 10.1089/trgh.2019.0066] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objectives: With expanding coverage of gender-affirming care in the United States, many insurers default to the World Professional Association for Transgender Health (WPATH) Standards of Care 7 (SOC 7) to establish eligibility requirements for surgery coverage. Informed by bariatric and transplant surgery evaluation models, the Mount Sinai Center for Transgender Medicine and Surgery (CTMS) developed patient-centered criteria to assess readiness for surgery, focusing on concerns that could impair recovery. To make recommendations for the next version of the WPATH SOC, SOC 8, we compared Mount Sinai patient-centered surgical readiness criteria with the WPATH SOC 7 criteria. Methods: Data were extracted from a deidentified data set developed as part the quality dashboard for CTMS. The data set included all patients seeking vaginoplasty who were evaluated by a single mental health provider, from July 2016 through August 2018, and who completed the full CTMS assessment. The number of patients eligible for surgery based on the Mount Sinai CTMS criteria was compared with the number of patients eligible for surgery according to WPATH SOC 7 criteria. Results: Of 139 patients identified, 63 (45%) were ready for surgery immediately based on the Mount Sinai patient-centered model. By contrast, only 21 (15%) out of the 139 met criteria for surgery based on WPATH SOC 7. Fifty patients (40%) were ready for surgery as per Mount Sinai patient-centered readiness review but not WPATH criteria. Conclusion: An assessment designed to better prepare patients for surgery may also result in fewer barriers to care than existing criteria used by insurance companies in the United States.
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Affiliation(s)
- Max Lichtenstein
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura Stein
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erin Connolly
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zil G Goldstein
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tyler Martinson
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Linda Tiersten
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sangyoon J Shin
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Henry Pang
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Hassett MJ, Somerfield MR, Baker ER, Cardoso F, Kansal KJ, Kwait DC, Plichta JK, Ricker C, Roshal A, Ruddy KJ, Safer JD, Van Poznak C, Yung RL, Giordano SH. Management of Male Breast Cancer: ASCO Guideline. J Clin Oncol 2020; 38:1849-1863. [PMID: 32058842 DOI: 10.1200/jco.19.03120] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To develop recommendations concerning the management of male breast cancer. METHODS ASCO convened an Expert Panel to develop recommendations based on a systematic review and a formal consensus process. RESULTS Twenty-six descriptive reports or observational studies met eligibility criteria and formed the evidentiary basis for the recommendations. RECOMMENDATIONS Many of the management approaches used for men with breast cancer are like those used for women. Men with hormone receptor-positive breast cancer who are candidates for adjuvant endocrine therapy should be offered tamoxifen for an initial duration of five years; those with a contraindication to tamoxifen may be offered a gonadotropin-releasing hormone agonist/antagonist plus aromatase inhibitor. Men who have completed five years of tamoxifen, have tolerated therapy, and still have a high risk of recurrence may be offered an additional five years of therapy. Men with early-stage disease should not be treated with bone-modifying agents to prevent recurrence, but could still receive these agents to prevent or treat osteoporosis. Men with advanced or metastatic disease should be offered endocrine therapy as first-line therapy, except in cases of visceral crisis or rapidly progressive disease. Targeted systemic therapy may be used to treat advanced or metastatic cancer using the same indications and combinations offered to women. Ipsilateral annual mammogram should be offered to men with a history of breast cancer treated with lumpectomy regardless of genetic predisposition; contralateral annual mammogram may be offered to men with a history of breast cancer and a genetic predisposing mutation. Breast magnetic resonance imaging is not recommended routinely. Genetic counseling and germline genetic testing of cancer predisposition genes should be offered to all men with breast cancer.
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Affiliation(s)
| | | | | | - Fatima Cardoso
- Champalimaud Clinical Centre/Champalimaud Foundation, Lisbon, Portugal
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Goldstein Z, Martinson T, Ramachandran S, Lindner R, Safer JD. Improved Rates of Cervical Cancer Screening Among Transmasculine Patients Through Self-Collected Swabs for High-Risk Human Papillomavirus DNA Testing. Transgend Health 2020; 5:10-17. [PMID: 32322684 PMCID: PMC7173695 DOI: 10.1089/trgh.2019.0019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Introduction: Nearly all cervical cancer cases are caused by one of several high-risk strains of the human papillomavirus (hr-HPV). Transmasculine (TM) individuals (persons who have a masculine spectrum gender identity, but were recorded female at birth) have low adherence to standard cervical cancer screening modalities. Introduction of self-collected vaginal swabs for hr-HPV DNA testing may promote initiation and adherence to cervical cancer screening among TM individuals to narrow screening disparities. The purpose of this study was to assess the rate of cervical cancer screening among TM individuals following the introduction of self-collected swabbing for hr-HPV DNA testing in comparison to clinician-administered cervical specimen collection. Methods: Rates of uptake and adherence to cervical cancer screening among TM individuals were assessed before and after the clinical introduction of self-collected swab testing in October 2017. Rates were compared with the rates of cervical cancer screening among cisgender women at a colocated Comprehensive Health Program during the time period of review. Results: Of the 121 TM patients seen for primary care in the 6-month baseline period before the October 2017 introduction of self-collected swabbing for hr-HPV DNA testing, 30 (25%) had cervical cancer screening documented in the electronic medical record. Following the implementation of self-swabbing, of 193 patients, 98 (51%) had a documented cervical cancer screening, a two-fold increase in the rates of adherence to cervical cancer screening (p<0.001). Conclusion: Self-collected swab testing for hr-HPV can increase rates of adherence to screening recommendations among an otherwise under-screened population.
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Affiliation(s)
- Zil Goldstein
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tyler Martinson
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shruti Ramachandran
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rebecca Lindner
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
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Pang JH, Safer JD. A Beginning in the Investigation of the Metabolic Consequences of Transgender Hormone Treatment on Young People. J Clin Endocrinol Metab 2020; 105:5658514. [PMID: 31803926 DOI: 10.1210/clinem/dgz249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/04/2019] [Indexed: 11/19/2022]
Affiliation(s)
- John Henry Pang
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY
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43
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Libman H, Safer JD, Siegel JR, Reynolds EE. Caring for the Transgender Patient: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2020; 172:202-209. [PMID: 32016334 DOI: 10.7326/m19-3813] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The term transgender refers to persons whose gender identity is different from that recorded at birth. Similar to other marginalized populations, transgender patients commonly experience discrimination in the health care setting, and they may not have access to medical professionals who can provide competent care. In addition to primary medical and preventive health care, transgender patients need access to gender-affirming interventions, including hormone therapy and surgeries. In 2017, the Endocrine Society updated its clinical practice guideline for the care of transgender persons on the basis of the best available evidence from systematic reviews and individual studies. Among its general requirements for adolescents and recommendations for adults were the following: Involvement of a mental health professional who is knowledgeable about the diagnostic criteria for gender dysphoria and criteria for gender-affirming treatment, has training and experience in assessing psychopathology, and is willing to participate in ongoing care. Hormone therapy should be offered to transgender adult patients, with levels maintained within the normal range for gender identity and treatment appropriately monitored. Clinicians involved in the care of transgender adult patients should be knowledgeable about diagnostic criteria for gender dysphoria/gender incongruence, the use of medical and surgical gender-affirming interventions, and appropriate monitoring for reproductive organ cancer risk. Here, 2 clinicians with expertise in this area debate whether psychological evaluation is warranted in a transgender patient requesting gender-affirming hormones or surgery, the potential risks and benefits of estrogen therapy, and the role of the primary care practitioner in the care of transgender persons.
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Affiliation(s)
- Howard Libman
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (H.L., E.E.R.)
| | | | - Jennifer R Siegel
- Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts (J.R.S.)
| | - Eileen E Reynolds
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (H.L., E.E.R.)
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Affiliation(s)
- Joshua D Safer
- From the Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York (J.D.S.); and the Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, and the Atlanta Veterans Affairs Medical Center - both in Atlanta (V.T.)
| | - Vin Tangpricha
- From the Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York (J.D.S.); and the Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, and the Atlanta Veterans Affairs Medical Center - both in Atlanta (V.T.)
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45
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Affiliation(s)
- Joshua D Safer
- Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York (J.D.S.)
| | - Vin Tangpricha
- Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, Georgia (V.T.)
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46
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Rosenthal SM, Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Safer JD, Tangpricha V, T'Sjoen GG. Response to Letter to the Editor: "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab 2019; 104:5102-5103. [PMID: 31046093 DOI: 10.1210/jc.2019-00930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 04/26/2019] [Indexed: 02/13/2023]
Affiliation(s)
- Stephen M Rosenthal
- University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Wylie C Hembree
- New York Presbyterian Hospital, Columbia University Medical Center, New York, New York
| | | | - Louis Gooren
- VU University Medical Center, Amsterdam, Netherlands
| | | | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minnesota
| | - Joshua D Safer
- Ichan School of Medicine at Mount Sinai, New York, New York
| | - Vin Tangpricha
- Emory University School of Medicine, Atlanta, Georgia
- The Atlanta VA Medical Center, Atlanta, Georgia
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47
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Safer JD. The prevalence of sexually transmissible infections in transgender people. Med J Aust 2019; 211:401. [PMID: 31595513 DOI: 10.5694/mja2.50369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Joshua D Safer
- Mount Sinai Center for Transgender Medicine and Surgery, New York, New York, United States of America
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48
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Rosen HN, Hamnvik OPR, Jaisamrarn U, Malabanan AO, Safer JD, Tangpricha V, Wattanachanya L, Yeap SS. Bone Densitometry in Transgender and Gender Non-Conforming (TGNC) Individuals: 2019 ISCD Official Position. J Clin Densitom 2019; 22:544-553. [PMID: 31327665 DOI: 10.1016/j.jocd.2019.07.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/08/2019] [Indexed: 01/20/2023]
Abstract
The indications for initial and follow-up bone mineral density (BMD) in transgender and gender nonconforming (TGNC) individuals are poorly defined, and the choice of which gender database to use to calculate Z-scores is unclear. Herein, the findings of the Task Force are presented after a detailed review of the literature. As long as a TGNC individual is on standard gender-affirming hormone treatment, BMD should remain stable to increasing, so there is no indication to monitor for bone loss or osteoporosis strictly on the basis of TGNC status. TGNC individuals who experience substantial periods of hypogonadism (>1 yr) might experience bone loss or failure of bone accrual during that time, and should be considered for baseline measurement of BMD. To the extent that this hypogonadism continues over time, follow-up measurements can be appropriate. TGNC individuals who have adequate levels of endogenous or exogenous sex steroids can, of course, suffer from other illnesses that can cause osteoporosis and bone loss, such as hyperparathyroidism and steroid use; they should have measurement of BMD as would be done in the cisgender population. There are no data that TGNC individuals have a fracture risk different from that of cisgender individuals, nor any data to suggest that BMD predicts their fracture risk less well than in the cisgender population. The Z-score in transgender individuals should be calculated using the reference data (mean and standard deviation) of the gender conforming with the individual's gender identity. In gender nonconforming individuals, the reference data for the sex recorded at birth should be used. If the referring provider or the individual requests, a set of "male" and "female" Z-scores can be provided, calculating the Z-score against male and female reference data, respectively.
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Affiliation(s)
- Harold N Rosen
- Division of Endocrinology and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Ole-Petter R Hamnvik
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Unnop Jaisamrarn
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Alan O Malabanan
- Division of Endocrinology and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Joshua D Safer
- Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, Center for Transgender Medicine and Surgery, New York, NY, USA
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA
| | - Lalita Wattanachanya
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Swan S Yeap
- Department of Medicine, Subang Jaya Medical Centre, Subang Jaya, Selangor, Malaysia
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Iwamoto SJ, T'Sjoen G, Safer JD, Davidge-Pitts CJ, Wierman ME, Glodowski MB, Rothman MS. Letter to the Editor: "Progesterone Is Important for Transgender Women's Therapy-Applying Evidence for the Benefits of Progesterone in Ciswomen". J Clin Endocrinol Metab 2019; 104:3127-3128. [PMID: 30860591 DOI: 10.1210/jc.2019-00249] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/06/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Sean J Iwamoto
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Division of Endocrinology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
- UCHealth Integrated Transgender Program, UCHealth University of Colorado Hospital, Aurora, Colorado
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Caroline J Davidge-Pitts
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Margaret E Wierman
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Division of Endocrinology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Michele B Glodowski
- Division of Endocrinology, Diabetes and Metabolism, New York University School of Medicine, New York, New York
| | - Micol S Rothman
- Division of Endocrinology, Metabolism & Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- UCHealth Integrated Transgender Program, UCHealth University of Colorado Hospital, Aurora, Colorado
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Goldstein Z, Khan M, Reisman T, Safer JD. Managing the risk of venous thromboembolism in transgender adults undergoing hormone therapy. J Blood Med 2019; 10:209-216. [PMID: 31372078 PMCID: PMC6628137 DOI: 10.2147/jbm.s166780] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/26/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction: Venous thromboembolism (VTE) is a potential risk of estrogen therapy. However, data show an improvement in the quality of life for transgender people who use feminizing hormone therapy. With few transgender-specific data, guidance may be drawn from cisgender (nontransgender) data, with a focus on hormonal birth control and postmenopausal hormone replacement therapy (HRT). The aim of this review is to examine the degree to which routes of administration, patient comorbidities, and type of hormone utilized affect the safety of estrogen therapy. Methods: We identified 6,349 studies by searching PubMed with the terms "transgender", "estrogen", "VTE", and "HRT". Of these, there were only 13 studies between 1989 and 2018 that investigated the effects of hormone therapy, including types of estrogens used, in transgender women and men. Results: The data suggest that the route of hormone administration, patient demographics, and patient comorbidities all affect estrogen's link with VTE. For example, avoiding ethinyl estradiol might make the use of hormone therapy in trans feminine individuals safer than oral birth control. Data from both cis and trans groups suggest additional VTE risk associated with the use of progestins. While transdermal estrogens dosed up to 0.1 mg/day or below appear lower risk for VTE than other forms of estrogen, it is unclear whether this is related to the delivery method or a dose effect. Finally, even if the risk from exogenous estrogen use remains significant statistically, the absolute clinical risk remains low. Conclusion: Clinicians should avoid the use of ethinyl estradiol. Additionally, data suggest that progestins should be avoided for transgender individuals. Further study of the relationship between estrogen use and the risk of VTE will serve to inform the safest care strategies for transgender individuals.
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Affiliation(s)
- Zil Goldstein
- Center for Transgender Medicine and Surgery at Mount Sinai, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | | | - Tamar Reisman
- Center for Transgender Medicine and Surgery at Mount Sinai, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery at Mount Sinai, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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