Care of Transgender Persons

Providing Care for Transgender Persons With Kidney Disease: A Narrative Review

Purpose of review

Nephrologists are increasingly providing care to transgender individuals with chronic kidney disease (CKD). However, they may lack familiarity with this patient population that faces unique challenges. The purpose of this review is to discuss the care of transgender persons and what nephrologists should be aware of when providing care to their transgender patients.

Sources of information

Original research articles were identified from MEDLINE and Google Scholar using the search terms "transgender," "gender," "sex," "chronic kidney disease," "end stage kidney disease," "dialysis," "transplant," and "nephrology."

Methods

A focused review and critical appraisal of existing literature regarding the provision of care to transgender men and women with CKD including dialysis and transplant to identify specific issues related to gender-affirming therapy and chronic disease management in transgender persons.

Key findings

Transgender persons are at an increased risk of adverse outcomes compared with the cisgender population including mental health, cardiovascular disease, malignancy, sexually transmitted infections, and mortality. Individuals with CKD have a degree of hypogonadotropic hypogonadism and decreased levels of endogenous sex hormones; therefore, transgender persons with CKD may require reduced exogenous sex hormone dosing. Exogenous estradiol therapy increases the risk of venous thromboembolism and cardiovascular disease which may be further increased in CKD. Exogenous testosterone therapy increases the risk of polycythemia which should be closely monitored. The impact of gender-affirming hormone therapy on glomerular filtration rate (GFR) trajectory in CKD is unclear. Gender-affirming hormone therapy with testosterone, estradiol, and anti-androgen therapies changes body composition and lean body mass which influences creatinine generation and the performance for estimated glomerular filtration rate (eGFR) equations in transgender persons. Confirmation of eGFR with measured GFR is reasonable if an accurate knowledge of GFR is needed for clinical decision-making.

Limitations

There are limited studies regarding the intersection of transgender persons and kidney disease and those that exist are mostly case reports. Randomized controlled trials and observational studies in nephrology do not routinely differentiate between cisgender and transgender participants.

Implications

This review highlights important considerations for providing care to transgender persons with kidney disease. Additional research is needed to evaluate the performance of eGFR equations in transgender persons, the effects of gender-affirming hormone therapy, and the impact of being transgender on outcomes in persons with kidney disease.

Physical and Psychological Effects of Gender-Affirming Hormonal Treatment Using Intramuscular Testosterone Enanthate in Japanese Transgender Men

INTRODUCTION

The evidence on gender-affirming hormonal treatment (HT) for transgender persons is still insufficient.

AIM

To characterize the physical and psychological effects of HT using testosterone enanthate in transgender men, and to validate the safety of this treatment.

METHODS

A total of 85 Japanese transgender men who were followed up for at least 1 year at our gender clinic from 2004 to 2017 were included in this study. All self-reported effects that they recognized and regularly acquired laboratory data were investigated after initiation of HT.

MAIN OUTCOME MEASURE

HT mainly using testosterone enanthate 250 mg every 2 weeks caused the most desired physical effects to appear promptly and effectively, whereas small but not negligible numbers of undesired physical and psychological effects were also confirmed.

RESULTS

The initial dose of testosterone enanthate was 250 mg for 72 (84.7%) subjects, and the injection interval was maintained every 2 weeks for 70 (82.3%). Most physical effects appeared within 6 months. A deepened voice (87.1%), cessation of menses (78.8%), acne (69.4%), and facial (52.9%)/body (37.6%) hair growth occurred within 3 months. Although recognition of psychological effects was rare, emotional instability (9.4%) and increased libido (7.1%) appeared in the relatively early phase after beginning HT. The mean values for red blood cells, hemoglobin, uric acid, and alkaline phosphatase were significantly increased for 2 year. During the observation period, there were no life-threatening adverse effects in any subjects.

CONCLUSION

The present HT strategy is effective and safe for Japanese transgender men. The information from self-reported effects and objective data from blood tests can help both physicians and transgender men to understand testosterone HT. Kirisawa T, Ichihara K, Sakai Y, et al. Physical and Psychological Effects of Gender-Affirming Hormonal Treatment Using Intramuscular Testosterone Enanthate in Japanese Transgender Men. Sex Med 2021;9:100306.

Imaging in Gender Affirmation Surgery

Purpose of Review

This review summarizes recent developments in gender affirmation surgery, imaging findings in patients undergoing these surgeries, focusing on common postoperative radiologic appearances, complications, and pitfalls in interpretation.

Recent Findings

The imaging workup of masculinizing and feminizing genitourinary surgeries uses multiple modalities in presurgical planning and within the immediate and long-term postoperative period. CT and MRI can help identify immediate and remote postoperative complications. Fluoroscopic examinations can diagnose postoperative urethral complications after gender affirmation surgeries. Lastly, the patients can undergo imaging for unrelated acute and chronic pathology, and knowledge of these imaging findings can be very helpful.

Summary

Imaging plays a significant role in the care of transgender patients and, particularly, in those pursuing gender affirmation surgery. As insurance coverage expands for these surgical procedures, radiologists should be prepared to encounter, understand, and interpret pre and postoperative findings.

Classification of Transgender Man's Breast for Optimizing Chest Masculinizing Gender-affirming Surgery

The purpose of mastectomy for the female-to-male transgender patient is to produce a masculine appearance of the chest. A number of algorithms have been proposed for selecting the surgical technique; these have generally been based on the degree of breast ptosis and the quality and elasticity of the skin. We present a series of subcutaneous mastectomies operated on by 1 surgeon during the last 2 decades. Based on our experience, we suggest a classification system for selecting surgical technique.

SERUM HORMONE CONCENTRATIONS IN TRANSGENDER INDIVIDUALS RECEIVING GENDER-AFFIRMING HORMONE THERAPY: A LONGITUDINAL RETROSPECTIVE COHORT STUDY

OBJECTIVE

To examine the association of various gender-affirming hormone therapy regimens with blood sex hormone concentrations in transgender individuals.

METHODS

This retrospective study included transgender people receiving gender-affirming hormone therapy between January 2000 and September 2018. Data on patient demographics, laboratory values, and hormone dose and frequency were collected. Nonparametric tests and linear regression analyses were used to identify factors associated with serum hormone concentrations.

RESULTS

Overall, 196 subjects (134 transgender women and 62 transgender men), with a total of 941 clinical visits, were included in this study. Transgender men receiving transdermal testosterone had a significantly lower median concentration of serum total testosterone when compared with those receiving injectable preparations (326.0 ng/dL vs 524.5 ng/dL, respectively, P = .018). Serum total estradiol concentrations in the transgender women were higher in those receiving intramuscular estrogen compared with those receiving oral and transdermal estrogen (366.0 pg/mL vs 102.0 pg/mL vs 70.8 pg/mL, respectively, P < .001). A dose-dependent increase in the hormone levels was observed for oral estradiol (P < .001) and injectable testosterone (P = .018) but not for intramuscular and transdermal estradiol. Older age and a history of gonadectomy in both the transgender men and women were associated with significantly higher concentrations of serum gender-affirming sex hormones.

CONCLUSION

In the transgender men, all routes and formulations of testosterone appeared to be equally effective in achieving concentrations in the male range. The intramuscular injections of estradiol resulted in the highest serum concentrations of estradiol, whereas transdermal estradiol resulted in the lowest concentration. There was positive relationship between both oral estradiol and injectable testosterone dose and serum sex hormone concentrations in transgender people receiving GAHT.

Providing Care for Transgender Persons With Kidney Disease: A Narrative Review

Purpose of review:

Nephrologists are increasingly providing care to transgender individuals with chronic kidney disease (CKD). However, they may lack familiarity with this patient population that faces unique challenges. The purpose of this review is to discuss the care of transgender persons and what nephrologists should be aware of when providing care to their transgender patients.

Sources of information:

Original research articles were identified from MEDLINE and Google Scholar using the search terms “transgender,” “gender,” “sex,” “chronic kidney disease,” “end stage kidney disease,” “dialysis,” “transplant,” and “nephrology.”

Methods:

A focused review and critical appraisal of existing literature regarding the provision of care to transgender men and women with CKD including dialysis and transplant to identify specific issues related to gender-affirming therapy and chronic disease management in transgender persons.

Key findings:

Transgender persons are at an increased risk of adverse outcomes compared with the cisgender population including mental health, cardiovascular disease, malignancy, sexually transmitted infections, and mortality. Individuals with CKD have a degree of hypogonadotropic hypogonadism and decreased levels of endogenous sex hormones; therefore, transgender persons with CKD may require reduced exogenous sex hormone dosing. Exogenous estradiol therapy increases the risk of venous thromboembolism and cardiovascular disease which may be further increased in CKD. Exogenous testosterone therapy increases the risk of polycythemia which should be closely monitored. The impact of gender-affirming hormone therapy on glomerular filtration rate (GFR) trajectory in CKD is unclear. Gender-affirming hormone therapy with testosterone, estradiol, and anti-androgen therapies changes body composition and lean body mass which influences creatinine generation and the performance for estimated glomerular filtration rate (eGFR) equations in transgender persons. Confirmation of eGFR with measured GFR is reasonable if an accurate knowledge of GFR is needed for clinical decision-making.

Limitations:

There are limited studies regarding the intersection of transgender persons and kidney disease and those that exist are mostly case reports. Randomized controlled trials and observational studies in nephrology do not routinely differentiate between cisgender and transgender participants.

Implications:

This review highlights important considerations for providing care to transgender persons with kidney disease. Additional research is needed to evaluate the performance of eGFR equations in transgender persons, the effects of gender-affirming hormone therapy, and the impact of being transgender on outcomes in persons with kidney disease.

Reproductive desires in transgender and gender diverse adults: A cross-sectional study in Thailand

Objective: To explore the desires and barriers to fertility preservation among transgender women and gender diverse people assigned male at birth in Thailand. Material and methods: This study is a cross-sectional study in clinic-based setting. The data was obtained from a questionnaire. Three hundred and three participants visiting the Gender Care Clinic at Chiang Mai University Hospital and Mplus clinics between April 2019 and December 2019 were included. Of these, 199 were transgender women and 104 were gender diverse people assigned male at birth. Results: The overall parental desire was 30.4% which was similar across the 2 groups (p = 0.897). A genetically related child was preferred in 40.9% of transgender women and 50.5% of gender diverse group (p = 0.115). Factors impacting a parental desire were a good relationship with family (OR 2.905, 95%CI 1.315-6.420, p = 0.008), being in a stable relationship (OR 4.183, 95%CI 1.738-10.069, p < 0.001) and belief in a positive attitude of society toward LGBTQ parenting (OR 2.572, 95%CI 1.207-5.479, p = 0.014). Access to fertility preservation services was low. The majority of transgender women (75.3%) and gender diverse people (95.2%) never received a consultation regarding fertility. The utilization rate of fertility treatments was 5.3% in our study. Conclusion: Transgender women and gender diverse people assigned male at birth have parental desires for a genetically related child. However, access to reproductive information, consultation and services were very limited. Social support along with competent health services might increase access to reproductive services in transgender and gender diverse populations.

CARDIOVASCULAR HEALTH MAINTENANCE IN AGING INDIVIDUALS: THE IMPLICATIONS FOR TRANSGENDER MEN AND WOMEN ON HORMONE THERAPY

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.

Predicting outcomes of cross-sex hormone therapy in transgender individuals with gender incongruence based on pre-therapy resting-state brain connectivity

Individuals with gender incongruence (GI) experience serious distress due to incongruence between their gender identity and birth-assigned sex. Sociological, cultural, interpersonal, and biological factors are likely contributory, and for some individuals medical treatment such as cross-sex hormone therapy and gender-affirming surgery can be helpful. Cross-sex hormone therapy can be effective for reducing body incongruence, but responses vary, and there is no reliable way to predict therapeutic outcomes. We used clinical and MRI data before cross-sex hormone therapy as features to train a machine learning model to predict individuals' post-therapy body congruence (the degree to which photos of their bodies match their self-identities). Twenty-five trans women and trans men with gender incongruence participated. The model significantly predicted post-therapy body congruence, with the highest predictive features coming from the cingulo-opercular (R2 = 0.41) and fronto-parietal (R2 = 0.30) networks. This study provides evidence that hormone therapy efficacy can be predicted from information collected before therapy, and that patterns of functional brain connectivity may provide insights into body-brain effects of hormones, affecting one's sense of body congruence. Results could help identify the need for personalized therapies in individuals predicted to have low body-self congruence after standard therapy.

Transgender patients: considerations for routine gynecologic care and cancer screening

In the last several years, demand for transgender care from gynecologists has increased significantly. Transgender people comprise a diverse group who do not identify with the sex they were assigned at birth. Worldwide, it is estimated that 25 million people identify as transgender. Some undergo hormonal and/or surgical treatment aiming to feminize or masculinize their bodies. Cross-sex hormone treatment for transgender women-individuals assigned as male at birth who identify themselves as women-includes exogenous estrogen and/or progestin administration in combination with anti-androgens, whereas testosterone is used for transgender men-individuals whose natal sex is women but identify themselves as men. Although it is usually rare, hormone-sensitive malignancies may arise, and long-term effects remain unknown. In addition, reconstructive surgeries may include breast augmentation and vaginoplasty (creation of a vagina) for transgender women, and chest masculinization surgery (bilateral mastectomy) and metoidioplasty (lengthening of the clitoris to create a microphallus) or phalloplasty (creation of a phallus) for transgender men. Evidence relating to breast and reproductive tract cancers in the trans population is limited and insufficient to estimate cancer prevalence, and recommendations for screening and preventive care depend on the patients' hormonal and surgical status. Even less information exists regarding the sub-set of individuals with genetic predisposition for these malignancies. In this review, we aimed to summarize current recommendations for gynecologists and gynecologic oncologists regarding cancer screening and personalized cancer-risk assessment in transgender people.

Genome-Wide Sex and Gender Differences in Cancer

Despite their known importance in clinical medicine, differences based on sex and gender are among the least studied factors affecting cancer susceptibility, progression, survival, and therapeutic response. In particular, the molecular mechanisms driving sex differences are poorly understood and so most approaches to precision medicine use mutational or other genomic data to assign therapy without considering how the sex of the individual might influence therapeutic efficacy. The mandate by the National Institutes of Health that research studies include sex as a biological variable has begun to expand our understanding on its importance. Sex differences in cancer may arise due to a combination of environmental, genetic, and epigenetic factors, as well as differences in gene regulation, and expression. Extensive sex differences occur genome-wide, and ultimately influence cancer biology and outcomes. In this review, we summarize the current state of knowledge about sex-specific genetic and genome-wide influences in cancer, describe how differences in response to environmental exposures and genetic and epigenetic alterations alter the trajectory of the disease, and provide insights into the importance of integrative analyses in understanding the interplay of sex and genomics in cancer. In particular, we will explore some of the emerging analytical approaches, such as the use of network methods, that are providing a deeper understanding of the drivers of differences based on sex and gender. Better understanding these complex factors and their interactions will improve cancer prevention, treatment, and outcomes for all individuals.

Longitudinal Changes in Hematologic Parameters Among Transgender People Receiving Hormone Therapy

CONTEXT

The effect of gender-affirming hormone therapy (HT) on erythropoiesis is an area of priority in transgender health research.

OBJECTIVE

To compare changes in hematologic parameters and rates of erythrocytosis and anemia among transgender people to those of cisgender controls.

DESIGN

Longitudinal observational study.

PARTICIPANTS AND SETTING

We compared 559 transfeminine (TF) and 424 transmasculine (TM) people enrolled in 3 integrated health care systems to matched cisgender referents.

INTERVENTIONS AND OUTCOME

Hormone therapy receipt was ascertained from filled prescriptions. Hemoglobin (Hb) and hematocrit (Hct) levels were examined from the first blood test to HT initiation, and from the start of HT to the most recent blood test. Rates of erythrocytosis and anemia in transgender participants and referents were compared by calculating adjusted hazard ratios and 95% confidence intervals (CI).

RESULTS

In the TF group, there was a downward trend for both Hb and Hct. The corresponding changes in the TM cohort were in the opposite direction. TM study participants experienced a 7-fold higher rate (95% CI: 4.1-13.4) of erythrocytosis relative to matched cisgender males, and an 83-fold higher rate (95% CI: 36.1-191.2) compared to cisgender females. The corresponding rates for anemia were elevated in TF subjects but primarily relative to cisgender males (hazard ratio 5.9; 95% CI: 4.6-7.5).

CONCLUSIONS

Our results support previous recommendations that hematological parameters of transgender people receiving HT should be interpreted based on their affirmed gender, rather than their sex documented at birth. The clinical significance of erythrocytosis following testosterone therapy, as well as anemia following feminizing HT, requires further investigation.

Endocrine treatment of transgender individuals: current guidelines and strategies

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Case Report of Transgender Patient with Gonadotropic Dysfunction Secondary to Craniopharyngioma: Toward Improving Understanding of Biopsychosocial Dynamics of Gender Identity in Neurosurgical Care

BACKGROUND

There is a paucity of information in the literature linking possible neuroendocrinologic repercussions of anterior pituitary insufficiency from tumor-associated mass effect with gender identity in transindividuals. The authors present the case of a 26-year-old transgender woman who was found to have a sellar/suprasellar neoplasm after reporting loss of vision in a bitemporal distribution.

CASE DESCRIPTION

Magnetic resonance imaging demonstrated a 2.6-cm complex cystic and solid sellar/suprasellar mass, suggestive of craniopharyngioma, intimately associated with the pituitary stalk. Importantly, this radiographic diagnosis was made 2 years following the initiation of gender-affirming hormone therapy (HT). Laboratory testing following radiographic diagnosis demonstrated evidence of diffuse anterior pituitary insufficiency with decreased morning cortisol, free thyroxine, insulin-like growth factor-1, and testosterone. Following optimization with the endocrinology team, the patient was taken to the operating room for expanded endonasal resection of tumor with lumbar drain insertion and nasoseptal flap coverage. Gross total resection was achieved with marked improvement in vision noted following surgery. The patient continued her HT following surgery.

CONCLUSIONS

In hindsight, the neuroendocrinologic manifestations of the craniopharyngioma may have influenced distressing pubertal experiences that distanced her from her assigned male sex, as well as the desired effects of feminization HT in this patient, ultimately delaying her presentation to the neurosurgery service and diagnosis of craniopharyngioma. As the first report of the neurosurgical evaluation and treatment of a transgender patient with anterior pituitary insufficiency secondary to craniopharyngioma, this case examines the biopsychosocial interplay between the development of gender identity and the neuroendocrinologic manifestations of craniopharyngioma.

Kidney transplantation and donation in the transgender population: A single-institution case series

The medical needs of the transgender population are increasingly recognized within the US health care system. Hormone therapy and gender-affirming surgery present distinct anatomic, hormonal, infectious, and psychosocial issues among transgender kidney transplant donors and recipients. We present the first reported experience with kidney transplantation and donation in transgender patients. A single-center case series (January 2014-December 2018) comprising 4 transgender kidney transplant recipients and 2 transgender living donors was constructed and analyzed. Experts in transplant surgery, transplant psychiatry, transplant infectious disease, pharmacy, and endocrinology were consulted to discuss aspects of care for these patients. Four transgender patients identified as male-to-female and 2 as female-to-male. Three of 6 had gender-affirming surgeries prior to transplant surgery, 1 of whom had further procedures posttransplant. Additionally, 4 patients were on hormone therapy. All 6 had psychiatric comorbidities. The 4 grafts have done well, with an average serum creatinine of 1.45 mg/dL at 2 years (range 1.01-1.85 mg/dL). However, patients encountered various postoperative complications, 1 of which was attributable to modified anatomy. Thus, transgender kidney transplant patients can present novel challenges in regard to surgical considerations as well as pre- and posttransplant care. Dedicated expertise is needed to optimize outcomes for this population.

Fertility Options for the Transgender and Gender Nonbinary Patient

Comprehensive care for transgender and gender nonbinary patients has been a priority established by the World Professional Association for Transgender Health. Because pubertal suppression, gender-affirming hormone therapy, and antiandrogen therapy used alone or in combination during medical transition can affect gonadal function, understanding the effects these treatments have on fertility potential is important for practitioners caring for transgender and gender nonbinary patients. In this review, we outline the impacts of gender-affirming treatments on fertility potential and discuss the counseling and the treatment approach for fertility preservation and/or family building in transgender and gender nonbinary individuals.

The effect of early puberty suppression on treatment options and outcomes in transgender patients

In the past 10-15 years, paediatric transgender care has emerged at the forefront of several general practice and subspecialty guidelines and is the topic of continuing medical education for various medical disciplines. Providers in specialties ranging from family medicine, paediatrics and adolescent medicine to endocrinology, gynaecology and urology are caring for transgender patients in increasing numbers. Current and evolving national and international best practice guidelines recommend offering a halt of endogenous puberty for patients with early gender dysphoria, in whom impending puberty is unacceptable for their psychosocial health and wellness. Pubertal blockade has implications for fertility preservation, transgender surgical care and psychosocial health, all of which must be considered and discussed with the patient and their family and/or legal guardian before initiation.

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

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.

Visual Conformity With Affirmed Gender or "Passing": Its Distribution and Association With Depression and Anxiety in a Cohort of Transgender People

BACKGROUND

Visual conformity with affirmed gender (VCAG) or "passing" is thought to be an important, but poorly understood, determinant of well-being in transgender people. VCAG is a subjective measure that is different from having an inner sense of being congruent with one's gender identity.

AIM

We examined the frequency and determinants of VCAG and explored its association with mental health outcomes in a cohort of transgender adults.

METHODS

The "Study of Transition, Outcomes & Gender (STRONG)" is a cohort of transgender individuals recruited from 3 Kaiser Permanente health plans located in Georgia, Northern California and Southern California. A subset of cohort members completed a survey between 2015 and 2017. VCAG was assessed as the difference between 2 scales: scale 1 reflecting the person's sense of how they are perceived by others, and scale 2 reflecting the person's desire to be perceived. Participants were considered to have achieved VCAG when their scale 1 scores were equal to or exceeded their scale 2 scores. The frequency of VCAG and their independent associations with anxiety and depression symptoms were explored using data from 620 survey respondents including 309 transwomen and 311 transmen. Based on self-described gender identity, none of the participants identified as nonbinary or gender fluid.

OUTCOMES

VCAG, depression, and anxiety.

RESULTS

VCAG was achieved in 28% of transwomen and 62% of transmen and was more common in persons who reported greater sense of acceptance and pride in their gender identity as measured on the Transgender Congruence Scale. Another factor associated with greater likelihood of VCAG was receipt of gender-affirming surgery, but the association was only evident among transmen. Participants who achieved VCAG had a lower likelihood of depression and anxiety with prevalence ratios (95% confidence intervals) of 0.79 (0.65, 0.96) and 0.67 (0.46, 0.98), respectively.

CLINICAL IMPLICATIONS

VCAG may serve as an important outcome measure after gender-affirming therapy.

STRENGTHS AND LIMITATIONS

Strengths of this study include a well-defined sampling frame and use of a novel patient-centered outcome of interest. Cross-sectional design and uncertain generalizability of results are the limitations.

CONCLUSION

These results, once confirmed by prospective studies, may help better characterize the determinants of well-being in the transgender community, facilitating the design of interventions to improve the well-being and quality of life of this vulnerable population. To M, Zhang Q, Bradlyn A, et al. Visual Conformity With Affirmed Gender or "Passing": Its Distribution and Association With Depression and Anxiety in a Cohort of Transgender People. J Sex Med 2020;17:2084-2092.

[Transsexualism and transgender medicine - what every internal specialist should know about]

The authors present current findings on transsexualism and its treatment. According to the ICD-10, transsexualism is defined as the "desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex." Synonyms of transsexualism are terms such as gender dysphoria reflecting the distress that persons feel due to a mismatch between their gender identity and their sex assigned at birth.The prevalence of transsexualism is estimated to be about 0,6 %. The diagnosis of transsexualism is made by psychiatrists, but at least five more medical specialties (endocrinologist, surgeon, ear, nose and throat specialist, speech therapist and dermatologist) are involved when treating transsexual persons. Hormonal therapy is a very important element of the treatment process; due to the complexity of transsexualism it should be undertaken by endocrinologists with experience and expertise in this field.

Effects of gender affirming hormone therapy on body mass index in transgender individuals: A longitudinal cohort study

Introduction

Many transgender people take hormone therapy to affirm their gender identity. One potential long-term consequence of gender affirming hormone therapy is increased body mass index (BMI), which may be associated with metabolic syndrome, cardiovascular disease and higher mortality. Only a few published studies explored changes in BMI in transgender people taking gender affirming hormone therapy (GAHT).

Objective

To examine the changes in BMI longitudinally in response to GAHT in transgender women and men.

Methods

We conducted a retrospective cohort study of transgender individuals who received GAHT from the endocrinology clinic between January 1, 2000 and September 6, 2018. Subjects who sought GAHT were included if they had two separate measurements of BMI and were excluded if they had a BMI greater than 35 kg/m² or were missing demographic data at entry. We used a linear mixed model to analyze the longitudinal change in BMI.

Results

There were a total of 227 subjects included in this cohort. Among subjects already on GAHT, transgender women were receiving GAHT longer than transgender men (6.59 ± 9.35 vs 3.67 ± 3.43 years, p-value = 0.04). Over the period of 7 years, there was a significant increase in BMI in transwomen who newly initiated GAHT (p-value 0.004). There were no changes in BMI in transgender men and women already on GAHT or in transgender men who newly initiated GAHT in the study.

Conclusion

We conclude that BMI significantly increases in transwomen but not in transmen after initiation of GAHT in a single center based in the United States. In transwomen and transmen, BMI appears to be stable following 3 to 6 years of GAHT. Future investigations should examine the causes for increased BMI in transgender women including type of GAHT, diet and lifestyle, and association with risk of metabolic syndrome and cardiovascular disease.

Knowledge and practice of induction of lactation in trans women among professionals working in trans health

BACKGROUND

Breastfeeding is emerging as an important reproductive rights issue in the care of trans and gender nonconforming people. This study sought to understand the tools available to professionals working in the field of trans health to help trans women induce lactation and explore the concept of unmet need.

METHODS

In November 2018, we conducted a cross-sectional study which surveyed attendees at the World Professional Association for Transgender Health (WPATH) symposium in Buenos Aires, Argentina. Eligible participants were 18 + years old, had professional experience with transgender populations, were able to complete a survey in English, and were conference attendees. Descriptive data were collected using a 14-item written survey encompassing demographic characteristics, experience in transgender health, and lactation induction in trans women.

RESULTS

We surveyed 82 respondents (response rate 10.5%), the majority of whom were healthcare professionals (84%). Average age of respondents was 42.3 years old. They represented 11 countries and averaged 8.8 years of work at 21.3 h/week with trans populations. Healthcare professionals in this sample primarily specialized in general/internal medicine, psychology, endocrinology, and obstetrics/gynecology. One-third of respondents (34%) stated that they have met trans women who expressed interest in inducing lactation. Seventeen respondents (21%) knew of providers, clinics, or programs that facilitated the induction of lactation through medication or other means. Seven respondents (9%) have helped trans women induce lactation with an average of 1.9 trans women in the previous year. Two protocols for lactation induction were mentioned in free text responses and 91% believe there is a need for specialized protocols for trans women.

CONCLUSION

This exploratory study demonstrates healthcare professionals' interest in breastfeeding protocols for lactation induction in trans women. Additional studies are needed to capture insights from breastfeeding specialists, e.g. lactation consultants and peripartum nurses, and to understand patients' perspectives on this service.

Unmasked Testicular Seminoma During Use of Hormonal Transgender Woman Therapy: A Hidden hCG-Secreting Tumor

Management of gender-affirming hormone therapy (HT) in transgender women includes surveillance of testosterone (T) levels. Failure of T to suppress, despite adherence to therapy, warrants additional investigations for unexpected sources of T or factors stimulating T secretion. Possible causes include T or gonadotropin production by an occult neoplasm. Testicular cancer is the most common malignancy affecting biological men aged between 15 and 35 years. Patients may be asymptomatic until tumor burden is high and/or metastatic. Hormone-producing tumors have rarely been reported in treated transgender women. Routine screening tests are recommended in a gender-incongruent person as per the 2017 Endocrine Society guidelines with measurement of T levels every 3 months initially to reach a goal of less than 50 ng/dL. Expectations should be discussed in detail with the transgender person since anticipated physical changes may not be notable for 6 to 18 months. We herein describe a case of a transgender woman who underwent standard HT including gonadotropin suppression with a gonadotropin-releasing hormone agonist, whose total T level failed to suppress. Testing revealed an elevated serum level of the beta subunit of human chorionic gonadotropin (β-hCG), diagnostic of an hCG-secreting testicular seminoma, as the underlying cause of unexpected T production. This case illustrates how easily a testicular cancer can remain unnoticed because it can be asymptomatic and the necessity to be alert to, and act on, anomalous laboratory results during treatment of a transgender person.

Improved Rates of Cervical Cancer Screening Among Transmasculine Patients Through Self-Collected Swabs for High-Risk Human Papillomavirus DNA Testing

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.