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Roberge S, Roberge T, Corathers S, Nasomyont N. Determinants of Bone Mass Accrual in Transgender and Gender Diverse Youth Undergoing Pubertal Suppression Therapy. J Clin Densitom 2024; 27:101505. [PMID: 38936233 DOI: 10.1016/j.jocd.2024.101505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 06/10/2024] [Accepted: 06/10/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION/BACKGROUND Gender-affirming care for gender diverse and transgender (GDTG) youth includes puberty suppression with gonadotropin-releasing hormone agonists (GnRHa). Puberty is a critical period of bone mass accrual, and pubertal suppression may impact bone health. Previous studies have shown a decrease in areal bone mineral density (aBMD) Z-score while on puberty suppression. However, the rate of bone mass accrual and its determinants during GnRHa therapy are not known. METHODOLOGY This is a retrospective chart review of GDTG youth with aBMD assessment within six months of starting GnRHa monotherapy at Cincinnati Children's Hospital Medical Center between 01/2011 and 12/2022. In individuals with follow-up aBMD assessment, we calculated their aBMD velocity and generated Z-scores using reference data from the Bone Mineral Density in Childhood Study. The determinants of baseline height-adjusted aBMD and aBMD velocity Z-scores were assessed with multiple linear regression models. RESULTS Thirty-six participants (36% assigned female at birth (AFAB), mean age at first aBMD assessment 12 ± 1.1 years) had baseline height-adjusted aBMD Z-score of -0.053 ± 0.79. Among 16 participants with follow-up aBMD assessment, the mean aBMD velocity Z-score was -0.42 ± 1.13 (-0.27 ± 0.79 in AFAB vs -0.52 ± 1.32 in assigned male at birth, p = 0.965). Baseline aBMD Z-scores significantly correlated with age at the first aBMD assessment (adjusted R2 0.124, p = 0.02) with combined modeling including age at first aBMD assessment and BMI Z-score being most significant (adjusted R2 0.21, p = 0.008). Only BMI Z-scores were positively associated with the aBMD-velocity Z-scores (adjusted R2 0.255, p = 0.046). CONCLUSIONS GDTG youth undergoing GnRHa therapy appeared to have below-average aBMD velocity Z-scores. A lower BMI Z-score was a determinant of lower baseline height-adjusted aBMD and aBMD velocity Z-scores. Building on previous studies, our study highlights aBMD velocity as a novel technique for bone health surveillance in GDTG youth.
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Affiliation(s)
- Samantha Roberge
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Taylor Roberge
- Department of Science and Health, University of Cincinnati Clermont College, Batavia, OH, USA
| | - Sarah Corathers
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nat Nasomyont
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Nokoff NJ, Bothwell S, Rice JD, Cree MG, Kelsey MM, Moreau KL, Zeitler P, Nadeau KJ. Insulin sensitivity, body composition and bone mineral density after testosterone treatment in transgender youth with and without prior GnRH agonist therapy. J Clin Transl Endocrinol 2024; 36:100356. [PMID: 38948245 PMCID: PMC11214195 DOI: 10.1016/j.jcte.2024.100356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 05/14/2024] [Accepted: 05/31/2024] [Indexed: 07/02/2024] Open
Abstract
Background 1.8% of youth identify as transgender; a growing proportion are transgender male (female sex, male gender identity). Many receive gonadotropin releasing hormone agonist (GnRHa) therapy to suppress endogenous puberty and/or will start testosterone to induce secondary sex characteristics that align with gender identity. Objectives To determine the effects of 12 months of testosterone on cardiometabolic health among transgender youth, including insulin sensitivity, body composition, and bone mineral density and whether changes in outcomes differ based on prior GnRHa treatment. Methods Participants (n = 19, baseline age 15.0 ± 1.0 years) were examined prior to and 12 months after testosterone therapy in a longitudinal observational study. Fasted morning blood draw, a 2-hour 75-gram oral glucose tolerance test, body composition and bone mineral density (dual-energy X-ray absorptiometry) were assessed at baseline and 12 months. Insulin sensitivity was estimated by HOMA-IR and Matsuda index. Changes were compared with mixed linear regression models evaluating time (baseline, 12 months), group (GnRHa treatment yes/no), and their interaction. Results In the entire cohort, fasted insulin decreased (median [25,75 %ile]: -3 [-5, 0] mIU/L, p = 0.044) and 2-hour glucose increased (mean ± standard deviation): +18.5 ± 28.9 mg/dL, p = 0.013 from baseline after 12 months of testosterone therapy. There were no significant changes in HOMA-IR (p = 0.062) or Matsuda index (p = 0.096), nor by GnRHa status. Absolute (+6.2 [4.7, 7.5] kg, p = 0.016) and percent fat-free mass increased (+7.3 [5.4, 9.1] %, p = 0.003) and percent fat mass declined (-7.4 [-9.3, 5.3]%, p = 0.005) for the entire cohort. There were time*group interactions for absolute (p = 0.0007) and percent fat-free mass (p = 0.033). There were time*group interactions for bone mineral content (p = 0.006). Conclusions Twelve months of testosterone in transgender adolescents resulted in changes in body composition and bone mineral density, with baseline differences between the +/-GnRHa group and convergence after 12 months. There were no changes in insulin sensitivity over time or between groups.
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Affiliation(s)
- Natalie J. Nokoff
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
- Ludeman Family Center for Women’s Health Research, USA
| | - Samantha Bothwell
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
| | - John D. Rice
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
- University of Michigan, Department of Biostatistics, USA
| | - Melanie G. Cree
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
- Ludeman Family Center for Women’s Health Research, USA
| | - Megan M. Kelsey
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
- Ludeman Family Center for Women’s Health Research, USA
| | - Kerrie L. Moreau
- Ludeman Family Center for Women’s Health Research, USA
- University of Colorado Anschutz Medical Campus, Department of Medicine, USA
| | - Philip Zeitler
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
| | - Kristen J. Nadeau
- University of Colorado Anschutz Medical Campus, Department of Pediatrics, 13123 E 16 Ave, Aurora, CO 80045, USA
- Ludeman Family Center for Women’s Health Research, USA
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Jorgensen SCJ, Athéa N, Masson C. Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:1941-1956. [PMID: 38565790 PMCID: PMC11106199 DOI: 10.1007/s10508-024-02850-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024]
Abstract
In this essay, we consider the clinical and ethical implications of puberty blockers for pediatric gender dysphoria through the lens of "the child's right to an open future," which refers to rights that children do not have the capacity to exercise as minors, but that must be protected, so they can exercise them in the future as autonomous adults. We contrast the open future principle with the beliefs underpinning the gender affirming care model and discuss implications for consent. We evaluate claims that puberty blockers are reversible, discuss the scientific uncertainty about long-term benefits and harms, summarize international developments, and examine how suicide has been used to frame puberty suppression as a medically necessary, lifesaving treatment. In discussing these issues, we include relevant empirical evidence and raise questions for clinicians and researchers. We conclude that treatment pathways that delay decisions about medical transition until the child has had the chance to grow and mature into an autonomous adulthood would be most consistent with the open future principle.
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Affiliation(s)
- Sarah C J Jorgensen
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada.
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | | | - Céline Masson
- Département de Psychologie, Université de Picardie Jules-Verne, Amiens, France
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Jacobson AR, Blaszczak J, Ahn J, Viglianti BL. DEXA Screening for Transgender and Gender Diverse Patients: An Overview of Current Guidance and Call for Improved Protocols. Acad Radiol 2024; 31:2159-2163. [PMID: 37977892 DOI: 10.1016/j.acra.2023.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/16/2023] [Accepted: 10/22/2023] [Indexed: 11/19/2023]
Affiliation(s)
| | - Julie Blaszczak
- Department of Family Medicine, University of Michigan, Ann Arbor, MI (J.B.).
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor MI (J.A.).
| | - Benjamin L Viglianti
- Department of Radiology, Division of Nuclear Medicine, University of Michigan, Ann Arbor, MI (B.L.V.).
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Roy MK, Bothwell S, Kelsey MM, Ma NS, Moreau KL, Nadeau KJ, Rothman MS, Nokoff NJ. Bone Density in Transgender Youth on Gender-Affirming Hormone Therapy. J Endocr Soc 2024; 8:bvae045. [PMID: 38562129 PMCID: PMC10983072 DOI: 10.1210/jendso/bvae045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Indexed: 04/04/2024] Open
Abstract
Some transgender youth are treated with gonadotropin-releasing hormone agonists (GnRHa) followed by testosterone or estradiol, which may impact bone mineral density (BMD). This cross-sectional study of transgender youth (n = 56, aged 10.4-19.8 years, 53% assigned female at birth [AFAB]) utilized total body dual-energy x-ray absorptiometry to evaluate BMD Z-scores, and associations between GnRHa duration, body mass index (BMI), and BMD. Participants on GnRHa alone (n = 19, 14 assigned male at birth [AMAB], 5 AFAB) at the time of the study visit were 13.8 [12.8, 15.3] (median [IQR]) years old, had been on GnRHa for 10 [5.5, 19.5] months, and began GnRHa at age 12 [10.4, 12.6] years. Total body BMD Z-score for individuals on GnRHa monotherapy was -0.10 [-0.8, 0.4] (AFAB, female norms) and -0.65 [-1.4, 0.22] (AMAB, male norms). AFAB participants (n = 21) on testosterone were age 16.7 [15.9, 17.8] years, had been on testosterone for 11 [7.3, 14.5] months, and started testosterone at age 16 [14.8, 16.8] years; total body BMD Z-score -0.2 [-0.5, 0] (male norms) and 0.4 [-0.2, 0.7] (female norms). AMAB participants (n = 16) were age 16.2 [15.1, 17.4] years, had been on estradiol for 11 [5.6, 13.7] months, and started estradiol at age 16 [14.4, 16.7] years; total body BMD Z-score -0.4 [-1.1, 0.3] (male norms) and -0.2 [-0.7, 0.6] (female norms). BMD Z-score was negatively correlated with GnRHa duration (male norms: r = -0.5, P = .005; female norms: r = -0.4, P = .029) and positively correlated with BMI (male norms: r = 0.4, P = .003; female norms: r = 0.4, P = .004). In this cross-sectional cohort, total body BMD Z-scores were slightly below average, but lowest in the AMAB group on GnRHa monotherapy.
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Affiliation(s)
- Micaela K Roy
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Samantha Bothwell
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Megan M Kelsey
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Nina S Ma
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Kerrie L Moreau
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Geriatric Research Education and Clinical Center, Veterans Affairs Eastern Colorado, Aurora, CO 80045, USA
| | - Kristen J Nadeau
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Micol S Rothman
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Natalie J Nokoff
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
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Lee JY. Puberty Assessment and Consideration of Gonadotropin-Releasing Hormone Agonists in Transgender and Gender-Diverse Youth. Pediatr Ann 2023; 52:e462-e466. [PMID: 38049185 PMCID: PMC11045295 DOI: 10.3928/19382359-20231016-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
Transgender and gender-diverse (TGD) youth may pursue gender-affirming medical therapy in the form of gonadotropin-releasing hormone analogues (GnRHa), or "puberty blockers," if pubertal changes result in the development or worsening of gender dysphoria. GnRHa monotherapy can allow TGD youth to explore gender without the distress of unwanted secondary sexual characteristics. However, given the potential effects of GnRHa on growth, skeletal development, neurodevelopment, fertility, and future surgical outcomes, it is critical to accurately assess pubertal status to facilitate fully informed conversations with TGD youth and families about risks, benefits, and unknown consequences of GnRHa monotherapy. The focus of this discussion will be on the approach to puberty assessment in TGD youth as well as the different effects of GnRHa monotherapy that may be important to TGD youth and their families. [Pediatr Ann. 2023;52(12):e462-e466.].
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