1
|
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.
Collapse
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
| |
Collapse
|
2
|
Eitel KB, Zenno A, Di Blasi C, Fechner PY, Hodax JK. Gender-Diverse Youth with Turner Syndrome: Special Management Considerations. JCEM CASE REPORTS 2024; 2:luae076. [PMID: 38707656 PMCID: PMC11066912 DOI: 10.1210/jcemcr/luae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Indexed: 05/07/2024]
Abstract
Turner syndrome (TS) is a sex chromosome abnormality characterized by short stature and primary hypogonadism with increased risk for cardiovascular disease, osteopenia, metabolic syndrome, diabetes mellitus, abnormal liver enzymes, and impairment of nonverbal learning skills. Gender-diverse youth include youth who have a gender identity that is different from their sex assigned at birth. They have an increased risk of suicidality, which is decreased in those who receive gender-affirming care. There have been no prior reports on the association or management of gender-diverse youth with TS. We describe 3 cases of gender-diverse youth with TS that highlight the importance of discussing gender identity in patients with hypogonadism in need of sex hormone replacement. Goals of care should be discussed to determine whether estrogen or testosterone replacement aligns best with gender identity. If a patient chooses to start testosterone, special considerations of risks such as erythrocytosis, osteopenia, and cardiovascular disease should be discussed in relation to their TS.
Collapse
Affiliation(s)
- Kelsey B Eitel
- Department of Pediatrics, University of Washington, Seattle, WA 98105, USA
| | - Anna Zenno
- Department of Pediatrics, University of Washington, Seattle, WA 98105, USA
- Department of Internal Medicine, University of Washington, Seattle, WA 98105, USA
| | - Carolina Di Blasi
- Department of Pediatrics, University of Washington, Seattle, WA 98105, USA
| | - Patricia Y Fechner
- Department of Pediatrics, University of Washington, Seattle, WA 98105, USA
| | - Juanita K Hodax
- Department of Pediatrics, University of Washington, Seattle, WA 98105, USA
| |
Collapse
|
3
|
Calcaterra V, Tornese G, Zuccotti G, Staiano A, Cherubini V, Gaudino R, Fazzi EM, Barbi E, Chiarelli F, Corsello G, Esposito SMR, Ferrara P, Iughetti L, Laforgia N, Maghnie M, Marseglia G, Perilongo G, Pettoello-Mantovani M, Ruggieri M, Russo G, Salerno M, Striano P, Valerio G, Wasniewska M. Adolescent gender dysphoria management: position paper from the Italian Academy of Pediatrics, the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, the Italian Society of Adolescent Medicine and the Italian Society of Child and Adolescent Neuropsychiatry. Ital J Pediatr 2024; 50:73. [PMID: 38637868 PMCID: PMC11025175 DOI: 10.1186/s13052-024-01644-7] [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: 02/28/2024] [Accepted: 04/05/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND In response to the imperative need for standardized support for adolescent Gender Dysphoria (GD), the Italian Academy of Pediatrics, in collaboration with the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, Italian Society of Adolescent Medicine and Italian Society of Child and Adolescent Neuropsychiatry is drafting a position paper. The purpose of this paper is to convey the author's opinion on the topic, offering foundational information on potential aspects of gender-affirming care and emphasizing the care and protection of children and adolescents with GD. MAIN BODY Recognizing that adolescents may choose interventions based on their unique needs and goals and understanding that every individual within this group has a distinct trajectory, it is crucial to ensure that each one is welcomed and supported. The approach to managing individuals with GD is a multi-stage process involving a multidisciplinary team throughout all phases. Decisions regarding treatment should be reached collaboratively by healthcare professionals and the family, while considering the unique needs and circumstances of the individual and be guided by scientific evidence rather than biases or ideologies. Politicians and high court judges should address discrimination based on gender identity in legislation and support service development that aligns with the needs of young people. It is essential to establish accredited multidisciplinary centers equipped with the requisite skills and experience to effectively manage adolescents with GD, thereby ensuring the delivery of high-quality care. CONCLUSION Maintaining an evidence-based approach is essential to safeguard the well-being of transgender and gender diverse adolescents.
Collapse
Affiliation(s)
- Valeria Calcaterra
- Pediatric Department, Buzzi Children's Hospital, Milano, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Gianluca Tornese
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
- Department of Pediatrics, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Gianvincenzo Zuccotti
- Pediatric Department, Buzzi Children's Hospital, Milano, Italy.
- Department of Biomedical and Clinical Sciences, University of Milan, Via GB Grassi, n.74, Milano, 20157, Italy.
| | - Annamaria Staiano
- Department of Translational Medical Sciences, Section of Pediatrics, University Federico II of Naples, Naples, Italy
| | - Valentino Cherubini
- Department of Women's and Children's Health, Azienda Ospedaliero-Universitaria delle Marche, Ospedali Riuniti di Ancona, "G. Salesi Hospital", Ancona, Italy
| | - Rossella Gaudino
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Elisa Maria Fazzi
- Unit of Child Neurology and Psychiatry, ASST Spedali Civili of Brescia, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Egidio Barbi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
- Department of Pediatrics, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | | | - Giovanni Corsello
- Division of Pediatrics, "A.R.N.A.S." Civic Hospital, Di Cristina Benfratelli, University of Palermo, Palermo, Italy
| | - Susanna Maria Roberta Esposito
- Pediatric Clinic, Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Pietro Ferrara
- Department of Medicine and Surgery, Università Campus Bio-Medico, Roma, Italy
- Operative Research Unit of Pediatrics, Fondazione Policlinico Universitario Campus Bio-Medico, Roma, Italy
| | - Lorenzo Iughetti
- Paediatric Unit, Department of Medical and Surgical Sciences of Mothers, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Laforgia
- Section of Neonatology and Neonatal Intensive Care Unit, Interdisciplinary Department of Medicine (DIM), University of Bari "Aldo Moro", Bari, Italy
| | - Mohamad Maghnie
- IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Gianluigi Marseglia
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, Pediatric Unit, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giorgio Perilongo
- Department of Rare Diseases, University Hospital of Padua, Padua, Italy
- Division of Pediatrics, Department of Woman's & Child's Health, University Hospital of Padua, Padua, Italy
| | | | - Martino Ruggieri
- Unit of Pediatric Clinic, Centre for Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Giovanna Russo
- Pediatric Hematology and Oncology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Mariacarolina Salerno
- Department of Translational Medical Sciences, Paediatric Endocrinology Unit, University "Federico II", Naples, Italy
| | - Pasquale Striano
- IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
| | - Giuliana Valerio
- Department of Medical, Movement and Wellbeing studies, University of Napoli "Parthenope", Napoli, Italy
| | - Malgorzata Wasniewska
- Department of Human Pathology in Adulthood and Childhood, University of Messina, Messina, Italy
| |
Collapse
|
4
|
Persky RW, Apple D, Dowshen N, Pine E, Whitehead J, Barrera E, Roberts SA, Carswell J, Stone D, Diez S, Bost J, Dwivedi P, Gomez-Lobo V. Pubertal Suppression in Early Puberty Followed by Testosterone Mildly Increases Final Height in Transmasculine Youth. J Endocr Soc 2024; 8:bvae089. [PMID: 38752206 PMCID: PMC11094470 DOI: 10.1210/jendso/bvae089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Indexed: 05/18/2024] Open
Abstract
Context Treatment for transmasculine youth (TMY) can involve testosterone treatment and is sometimes preceded by gonadotropin-releasing hormone agonist (GnRHa) treatment for puberty blockade. GnRHas can increase final height in birth-assigned females with central precocious puberty. Maximizing final adult height (FAH) is an important outcome for many TMY. Objective Our objective was to determine how GnRHa treatment before testosterone impacts FAH. Methods Retrospective cohort study at 5 US transgender health clinics. Participants were 32 TMY treated with GnRHas in early to midpuberty before testosterone (GnRHa + T group) and 62 late/postpubertal TMY treated with testosterone only (T-only group). Results The difference between FAH minus midparental target height (MPTH) was +2.3 ± 5.7 cm and -2.2 ± 5.6 cm in the GnRHa + T and T-only groups, respectively (P < .01). In the GnRHa + T group, FAH was 1.8 ± 3.4 cm greater than predicted adult height (PAH) (P < .05) and FAH vs initial height (IH) z-score was 0.5 ± 1.2 vs 0.16 ± 1.0 (P < .05). After adjusting for patient characteristics, each additional month of GnRHa monotherapy increased FAH by 0.59 cm (95% CI 0.31, 0.9 cm), stage 3 breast development at start of GnRHa was associated with 6.5 cm lower FAH compared with stage 2 (95% CI -10.43, -2.55), and FAH was 7.95 cm greater in the GnRHa + T group than in T-only group (95% CI -10.85, -5.06). Conclusion Treatment with GnRHa in TMY in early puberty before testosterone increases FAH compared with MPTH, PAH, IH, and TMY who only received testosterone in late/postpuberty. TMY considering GnRHas should be counseled that GnRHas may mildly increase their FAH if started early.
Collapse
Affiliation(s)
- Rebecca W Persky
- Division of Endocrinology, Children's National Hospital, Washington, DC 20010, USA
| | - Danielle Apple
- Craig-Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19178, USA
| | - Nadia Dowshen
- Craig-Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19178, USA
| | - Elyse Pine
- Division of Pediatric Endocrinology, Chase Brexton Health Care, Baltimore, MD 21201, USA
| | - Jax Whitehead
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Ellis Barrera
- Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA
| | - Stephanie A Roberts
- Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA
| | - Jeremi Carswell
- Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA
| | - Dana Stone
- Division of Endocrinology, Children's National Hospital, Washington, DC 20010, USA
| | - Sandra Diez
- Georgetown University School of Medicine, Washington, DC 20007, USA
- Division of Gynecology, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - James Bost
- Division of Biostatistics, Children's National Hospital, Washington, DC 20010, USA
| | - Pallavi Dwivedi
- Division of Biostatistics, Children's National Hospital, Washington, DC 20010, USA
| | - Veronica Gomez-Lobo
- Division of Gynecology, MedStar Washington Hospital Center, Washington, DC 20010, USA
- Divison of Pediatric and Adolescent Gynecology, Children's National Hospital, Washington, DC 20010, USA
- Section on Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| |
Collapse
|
5
|
Zepf FD, König L, Kaiser A, Ligges C, Ligges M, Roessner V, Banaschewski T, Holtmann M. [Beyond NICE: Updated Systematic Review on the Current Evidence of Using Puberty Blocking Pharmacological Agents and Cross-Sex-Hormones in Minors with Gender Dysphoria]. ZEITSCHRIFT FUR KINDER- UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2024; 52:167-187. [PMID: 38410090 DOI: 10.1024/1422-4917/a000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Beyond NICE: Updated Systematic Review on the Current Evidence of Using Puberty Blocking Pharmacological Agents and Cross-Sex-Hormones in Minors with Gender Dysphoria Abstract: Objective: The suppression of physiological puberty using puberty-blocking pharmacological agents (PB) and prescribing cross-sex hormones (CSH) to minors with gender dysphoria (GD) is a current matter of discussion, and in some cases, PB and CSH are used in clinical practice for this particular population. Two systematic reviews (one on PB, one on CSH treatment) by the British National Institute for Clinical Excellence (NICE) from 2020 indicated no clear clinical benefit of such treatments regarding critical outcome variables. In particular, these two systematic NICE reviews on the use of PB and CSH in minors with GD detected no clear improvements of GD symptoms. Moreover, the overall scientific quality of the available evidence, as discussed within the above-mentioned two NICE reviews, was classified as "very low certainty" regarding modified GRADE criteria. Method: The present systematic review presents an updated literature search on this particular topic (use of PB and CSH in minors with GD) following NICE principles and PICO criteria for all relevant new original research studies published since the release of the two above-mentioned NICE reviews (updated literature search period was July 2020-August 2023). Results: The newly conducted literature search revealed no newly published original studies targeting NICE-defined critical and important outcomes and the related use of PB in minors with GD following PICO criteria. For CSH treatment, we found two new studies that met PICO criteria, but these particular two studies had low participant numbers, yielded no significant additional clear evidence for specific and clearly beneficial effects of CSH in minors with GD, and could be classified as "low certainty" tfollowing modified GRADE criteria. Conclusions: The currently available studies on the use of PB and CSH in minors with GD have significant conceptual and methodological flaws. The available evidence on the use of PB and CSH in minors with GD is very limited and based on only a few studies with small numbers, and these studies have problematic methodology and quality. There also is a lack of adequate and meaningful long-term studies. Current evidence doesn't suggest that GD symptoms and mental health significantly improve when PB or CSH are used in minors with GD. Psychotherapeutic interventions to address and reduce the experienced burden can become relevant in children and adolescents with GD. If the decision to use PB and/or CSH is made on an individual case-by-case basis and after a complete and thorough mental health assessment, potential treatment of possibly co-occurring mental health problems as well as after a thoroughly conducted and carefully executed individual risk-benefit evaluation, doing so as part of clinical studies or research projects, as currently done in England, can be of value in terms of generation of new research data. The electronic supplement (ESM) 1 is an adapted and abreviated English version of this work.
Collapse
Affiliation(s)
- Florian D Zepf
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- German Center for Mental Health (DZPG), Site Jena-Magdeburg-Halle, Jena, Germany
| | - Laura König
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- German Center for Mental Health (DZPG), Site Jena-Magdeburg-Halle, Jena, Germany
| | - Anna Kaiser
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Carolin Ligges
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- German Center for Mental Health (DZPG), Site Jena-Magdeburg-Halle, Jena, Germany
| | - Marc Ligges
- Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- German Center for Mental Health (DZPG), Site Jena-Magdeburg-Halle, Jena, Germany
| | - Veit Roessner
- Department of Child and Adolescent Psychiatry, TU Dresden, Dresden, Germany
- German Center for Child and Adolescent Health (DZJK), partner site Leipzig-Dresden, Germany
| | - Tobias Banaschewski
- Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
- German Center for Mental Health (DZPG), partner site Mannheim-Heidelberg-Ulm, Germany
| | - Martin Holtmann
- LWL-Universitätsklinik Hamm der Ruhr-Universität Bochum, Hamm, Germany
| |
Collapse
|
6
|
Nie T, Venkatesh VS, Golub S, Stok KS, Hemmatian H, Desai R, Handelsman DJ, Zajac JD, Grossmann M, Davey RA. Estradiol increases cortical and trabecular bone accrual and bone strength in an adolescent male-to-female mouse model of gender-affirming hormone therapy. Bone Res 2024; 12:1. [PMID: 38212599 PMCID: PMC10784310 DOI: 10.1038/s41413-023-00308-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/28/2023] [Accepted: 12/05/2023] [Indexed: 01/13/2024] Open
Abstract
The effects of gender-affirming hormone therapy on the skeletal integrity and fracture risk in transitioning adolescent trans girls are unknown. To address this knowledge gap, we developed a mouse model to simulate male-to-female transition in human adolescents in whom puberty is first arrested by using gonadotrophin-releasing hormone analogs with subsequent estradiol treatment. Puberty was suppressed by orchidectomy in male mice at 5 weeks of age. At 3 weeks post-surgery, male-to-female mice were treated with a high dose of estradiol (~0.85 mg) by intraperitoneal silastic implantation for 12 weeks. Controls included intact and orchidectomized males at 3 weeks post-surgery, vehicle-treated intact males, intact females and orchidectomized males at 12 weeks post-treatment. Compared to male controls, orchidectomized males exhibited decreased peak bone mass accrual and a decreased maximal force the bone could withstand prior to fracture. Estradiol treatment in orchidectomized male-to-female mice compared to mice in all control groups was associated with an increased cortical thickness in the mid-diaphysis, while the periosteal circumference increased to a level that was intermediate between intact male and female controls, resulting in increased maximal force and stiffness. In trabecular bone, estradiol treatment increased newly formed trabeculae arising from the growth plate as well as mineralizing surface/bone surface and bone formation rate, consistent with the anabolic action of estradiol on osteoblast proliferation. These data support the concept that skeletal integrity can be preserved and that long-term fractures may be prevented in trans girls treated with GnRHa and a sufficiently high dose of GAHT. Further study is needed to identify an optimal dose of estradiol that protects the bone without adverse side effects.
Collapse
Affiliation(s)
- Tian Nie
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, VIC, 3084, Australia
| | - Varun S Venkatesh
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, VIC, 3084, Australia
| | - Suzanne Golub
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, VIC, 3084, Australia
| | - Kathryn S Stok
- Department of Biomedical Engineering, University of Melbourne, Parkville, VIC, 3010, Australia
| | - Haniyeh Hemmatian
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, VIC, 3084, Australia
| | - Reena Desai
- ANZAC Research Institute, University of Sydney and Andrology, Concord Repatriation General Hospital, Concord, NSW, 2137, Australia
| | - David J Handelsman
- ANZAC Research Institute, University of Sydney and Andrology, Concord Repatriation General Hospital, Concord, NSW, 2137, Australia
| | - Jeffrey D Zajac
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, VIC, 3084, Australia
| | - Mathis Grossmann
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, VIC, 3084, Australia
| | - Rachel A Davey
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, VIC, 3084, Australia.
| |
Collapse
|
7
|
van der Loos MATC, Vlot MC, Klink DT, Hannema SE, den Heijer M, Wiepjes CM. Bone Mineral Density in Transgender Adolescents Treated With Puberty Suppression and Subsequent Gender-Affirming Hormones. JAMA Pediatr 2023; 177:1332-1341. [PMID: 37902760 PMCID: PMC10616766 DOI: 10.1001/jamapediatrics.2023.4588] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 08/30/2023] [Indexed: 10/31/2023]
Abstract
Importance Bone mineral density (BMD) z scores in transgender adolescents decrease during puberty suppression with a gonadotropin-releasing hormone (GnRH) agonist. Previous research found that after short-term use of gender-affirming hormones (GAH), pretreatment z scores were not restored. Long-term follow-up studies are lacking. Objective To assess BMD after long-term GAH treatment in transgender adults who used puberty suppression in adolescence. Design, Setting, and Participants This single-center cohort study with follow-up duration of 15 years selected participants from a database containing all people visiting a gender identity clinic at an academic hospital in the Netherlands between 1972 and December 31, 2018. Recruitment occurred from March 1, 2020, to August 31, 2021. A total of 75 participants diagnosed with gender dysphoria who had used puberty suppression before age 18 years prior to receiving at least 9 years of long-term GAH were included. Exposures Puberty suppression with a GnRH agonist followed by GAH treatment. Main Outcomes and Measures Lumbar spine, total hip, and femoral neck BMD and z scores before the start of puberty suppression, at start of GAH, and at short- and long-term follow-up. Results Among 75 participants, 25 were assigned male at birth, and 50 were assigned female at birth. At long-term follow-up, the median (IQR) age was 28.2 (27.0-30.8) years in participants assigned male at birth and 28.2 (26.6-30.6) years in participants assigned female at birth. The median (IQR) duration of GAH treatment was 11.6 (10.1-14.7) years among those assigned male at birth and 11.9 (10.2-13.8) years among those assigned female at birth. The z scores decreased during puberty suppression. In individuals assigned male at birth, the mean (SD) z score after long-term GAH use was -1.34 (1.16; change from start of GnRH agonist: -0.87; 95% CI, -1.15 to -0.59) at the lumbar spine, -0.66 (0.75; change from start of GnRH agonist: -0.12; 95% CI, -0.31 to 0.07) at the total hip, and -0.54 (0.84; change from start of GnRH agonist: 0.01; 95% CI, -0.20 to 0.22) at the femoral neck. In individuals assigned female at birth, after long-term GAH use, the mean (SD) z score was 0.20 (1.05; change from start of GnRH agonist: 0.09; 95% CI, -0.09 to 0.27) at the lumbar spine, 0.07 (0.91; change from start of GnRH agonist: 0.10; 95% CI, -0.06 to 0.26) at the total hip, and -0.19 (0.94; change from start of GnRH agonist: -0.20; 95% CI, -0.26 to 0.06) at the femoral neck. Conclusions and Relevance In this cohort study, after long-term use of GAH, z scores in individuals treated with puberty suppression caught up with pretreatment levels, except for the lumbar spine in participants assigned male at birth, which might have been due to low estradiol concentrations. These findings suggest that treatment with GnRH agonists followed by long-term GAH is safe with regard to bone health in transgender persons receiving testosterone, but bone health in transgender persons receiving estrogen requires extra attention and further study. Estrogen treatment should be optimized and lifestyle counseling provided to maximize bone development in individuals assigned male at birth.
Collapse
Affiliation(s)
- Maria Anna Theodora Catharina van der Loos
- Department of Endocrinology and Metabolism, Amsterdam University Medical Center (UMC) at Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC at Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Mariska Caroline Vlot
- Department of Internal Medicine, Hospital St Jansdal, Harderwijk/Lelystad, the Netherlands
| | - Daniel Tatting Klink
- Division of Pediatric Endocrinology, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Sabine Elisabeth Hannema
- Center of Expertise on Gender Dysphoria, Amsterdam UMC at Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Pediatrics, Amsterdam UMC at Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Martin den Heijer
- Department of Endocrinology and Metabolism, Amsterdam University Medical Center (UMC) at Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC at Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Chantal Maria Wiepjes
- Department of Endocrinology and Metabolism, Amsterdam University Medical Center (UMC) at Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC at Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
8
|
Venkatesh VS, Nie T, Zajac JD, Grossmann M, Davey RA. The Utility of Preclinical Models in Understanding the Bone Health of Transgender Individuals Undergoing Gender-Affirming Hormone Therapy. Curr Osteoporos Rep 2023; 21:825-841. [PMID: 37707757 PMCID: PMC10724092 DOI: 10.1007/s11914-023-00818-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 09/15/2023]
Abstract
PURPOSE OF REVIEW To summarise the evidence regarding the effects of gender-affirming hormone therapy (GAHT) on bone health in transgender people, to identify key knowledge gaps and how these gaps can be addressed using preclinical rodent models. RECENT FINDINGS Sex hormones play a critical role in bone physiology, yet there is a paucity of research regarding the effects of GAHT on bone microstructure and fracture risk in transgender individuals. The controlled clinical studies required to yield fracture data are unethical to conduct making clinically translatable preclinical research of the utmost importance. Novel genetic and surgical preclinical models have yielded significant mechanistic insight into the roles of sex steroids on skeletal integrity. Preclinical models of GAHT have the potential inform clinical approaches to preserve skeletal integrity and prevent fractures in transgender people undergoing GAHT. This review highlights the key considerations required to ensure the information gained from preclinical models of GAHT are informative.
Collapse
Affiliation(s)
- Varun S Venkatesh
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, 3084, Australia
| | - Tian Nie
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, 3084, Australia
| | - Jeffrey D Zajac
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, 3084, Australia
| | - Mathis Grossmann
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, 3084, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, 3084, Australia
| | - Rachel A Davey
- Department of Medicine, Austin Health, The University of Melbourne, Heidelberg, Victoria, 3084, Australia.
| |
Collapse
|
9
|
Ludvigsson JF, Adolfsson J, Höistad M, Rydelius PA, Kriström B, Landén M. A systematic review of hormone treatment for children with gender dysphoria and recommendations for research. Acta Paediatr 2023; 112:2279-2292. [PMID: 37069492 DOI: 10.1111/apa.16791] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/05/2023] [Accepted: 04/17/2023] [Indexed: 04/19/2023]
Abstract
AIM The aim of this systematic review was to assess the effects on psychosocial and mental health, cognition, body composition, and metabolic markers of hormone treatment in children with gender dysphoria. METHODS Systematic review essentially follows PRISMA. We searched PubMed, EMBASE and thirteen other databases until 9 November 2021 for English-language studies of hormone therapy in children with gender dysphoria. Of 9934 potential studies identified with abstracts reviewed, 195 were assessed in full text, and 24 were relevant. RESULTS In 21 studies, adolescents were given gonadotropin-releasing hormone analogues (GnRHa) treatment. In three studies, cross-sex hormone treatment (CSHT) was given without previous GnRHa treatment. No randomised controlled trials were identified. The few longitudinal observational studies were hampered by small numbers and high attrition rates. Hence, the long-term effects of hormone therapy on psychosocial health could not be evaluated. Concerning bone health, GnRHa treatment delays bone maturation and bone mineral density gain, which, however, was found to partially recover during CSHT when studied at age 22 years. CONCLUSION Evidence to assess the effects of hormone treatment on the above fields in children with gender dysphoria is insufficient. To improve future research, we present the GENDHOR checklist, a checklist for studies in gender dysphoria.
Collapse
Affiliation(s)
- Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
- Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Jan Adolfsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- The Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Malin Höistad
- The Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Per-Anders Rydelius
- Department of Women's and Children's health, Karolinska Institutet, Stockholm, Sweden
| | - Berit Kriström
- Department of Clinical Sciences/Paediatrics, Umeå University, Umeå, Sweden
| | - Mikael Landén
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
10
|
Hodax JK, Brady C, DiVall S, Ahrens KR, Carlin K, Khalatbari H, Parisi MT, Salehi P. Low Pretreatment Bone Mineral Density in Gender Diverse Youth. Transgend Health 2023; 8:467-471. [PMID: 37810939 PMCID: PMC10551758 DOI: 10.1089/trgh.2021.0183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Gender diverse adolescents have low pretreatment bone mineral density (BMD), with variable changes in BMD after initiation of gender-affirming treatment. We aimed to assess factors associated with low BMD in gender diverse youth. Sixty-four patients were included in our analysis (73% assigned male at birth). Subtotal whole-body BMD Z-scores were low in 30% of patients, and total lumbar spine BMD Z-scores low in 14%. There was a positive association with body mass index, and no association with vitamin D level. Male sex assigned at birth was associated with lower pretreatment BMD, with lower average BMD Z-scores compared to previous studies.
Collapse
Affiliation(s)
- Juanita K. Hodax
- Division of Pediatric Endocrinology, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Charles Brady
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Sara DiVall
- Division of Pediatric Endocrinology, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Kym R. Ahrens
- University of Washington School of Medicine, Seattle, Washington, USA
- Division of Adolescent Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kristen Carlin
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Hedieh Khalatbari
- University of Washington School of Medicine, Seattle, Washington, USA
- Division of Radiology, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Marguerite T. Parisi
- University of Washington School of Medicine, Seattle, Washington, USA
- Division of Radiology, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - Parisa Salehi
- Division of Pediatric Endocrinology, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
- University of Washington School of Medicine, Seattle, Washington, USA
| |
Collapse
|
11
|
Tang GT, Zwickl S, Sinclair R, Zajac JD, Cheung AS. Effect of gender-affirming hormone therapy on hair growth: a systematic review of the literature. Clin Exp Dermatol 2023; 48:1117-1127. [PMID: 37311161 DOI: 10.1093/ced/llad203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/04/2023] [Indexed: 06/15/2023]
Abstract
Gender-affirming hormone therapy (GAHT) leads to changes in body composition, secondary sex characteristics and in the distribution and pattern of hair growth. Transgender individuals undergoing GAHT may experience altered hair growth patterns that may be affirming and desirable, or undesirable with a subsequent impact on their quality of life. Given increasing numbers of transgender individuals commencing GAHT worldwide and the clinical relevance of the impact of GAHT on hair growth, we systematically reviewed the existing literature on the impact of GAHT on hair changes and androgenic alopecia (AGA). The majority of studies used grading schemes or subjective measures of hair changes based on patient or investigator's examination. Very few studies used objective quantitative measures of hair parameters but demonstrated statistically significant changes in hair growth length, diameter and density. Feminizing GAHT with estradiol and/or antiandrogens in transgender women may reduce facial and body hair growth and also can improve AGA. Masculinizing GAHT with testosterone in transgender men may increase facial and body hair growth as well as induce or accelerate AGA. The impact of GAHT on hair growth may not align with a transgender person's hair growth goals and specific treatment for AGA and/or hirsutism may be sought. Further research on how GAHT affects hair growth is required.
Collapse
Affiliation(s)
- Gia Toan Tang
- Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
| | - Sav Zwickl
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, VIC, Australia
| | | | - Jeffrey D Zajac
- Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, VIC, Australia
| | - Ada S Cheung
- Department of Endocrinology, Austin Health, Heidelberg, VIC, Australia
- Trans Health Research Group, Department of Medicine (Austin Health), The University of Melbourne, VIC, Australia
| |
Collapse
|
12
|
Thompson L, Sarovic D, Wilson P, Irwin L, Visnitchi D, Sämfjord A, Gillberg C. A PRISMA systematic review of adolescent gender dysphoria literature: 3) treatment. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001478. [PMID: 37552651 PMCID: PMC10409298 DOI: 10.1371/journal.pgph.0001478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 06/29/2023] [Indexed: 08/10/2023]
Abstract
It is unclear whether the literature on adolescent gender dysphoria (GD) provides evidence to inform clinical decision making adequately. In the final of a series of three papers, we sought to review published evidence systematically regarding the types of treatment being implemented among adolescents with GD, the age when different treatment types are instigated, and any outcomes measured within adolescence. Having searched PROSPERO and the Cochrane library for existing systematic reviews (and finding none at that time), we searched Ovid Medline 1946 -October week 4 2020, Embase 1947-present (updated daily), CINAHL 1983-2020, and PsycInfo 1914-2020. The final search was carried out on 2nd November 2020 using a core strategy including search terms for 'adolescence' and 'gender dysphoria' which was adapted according to the structure of each database. Papers were excluded if they did not clearly report on clinically-likely gender dysphoria, if they were focused on adult populations, if they did not include original data (epidemiological, clinical, or survey) on adolescents (aged at least 12 and under 18 years), or if they were not peer-reviewed journal publications. From 6202 potentially relevant articles (post deduplication), 19 papers from 6 countries representing between 835 and 1354 participants were included in our final sample. All studies were observational cohort studies, usually using retrospective record review (14); all were published in the previous 11 years (median 2018). There was significant overlap of study samples (accounted for in our quantitative synthesis). All papers were rated by two reviewers using the Crowe Critical Appraisal Tool v1·4 (CCAT). The CCAT quality ratings ranged from 71% to 95%, with a mean of 82%. Puberty suppression (PS) was generally induced with Gonadotropin Releasing Hormone analogues (GnRHa), and at a pooled mean age of 14.5 (±1.0) years. Cross Sex Hormone (CSH) therapy was initiated at a pooled mean of 16.2 (±1.0) years. Twenty-five participants from 2 samples were reported to have received surgical intervention (24 mastectomy, one vaginoplasty). Most changes to health parameters were inconclusive, except an observed decrease in bone density z-scores with puberty suppression, which then increased with hormone treatment. There may also be a risk for increased obesity. Some improvements were observed in global functioning and depressive symptoms once treatment was started. The most common side effects observed were acne, fatigue, changes in appetite, headaches, and mood swings. Adolescents presenting for GD intervention were usually offered puberty suppression or cross-sex hormones, but rarely surgical intervention. Reporting centres broadly followed established international guidance regarding age of treatment and treatments used. The evidence base for the outcomes of gender dysphoria treatment in adolescents is lacking. It is impossible from the included data to draw definitive conclusions regarding the safety of treatment. There remain areas of concern, particularly changes to bone density caused by puberty suppression, which may not be fully resolved with hormone treatment.
Collapse
Affiliation(s)
- Lucy Thompson
- Gillberg Neuropsychiatry Centre (GNC), University of Gothenburg, Göteborg, Sweden
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
- Institute of Applied Health Science, University of Aberdeen, Inverness, United Kingdom
| | - Darko Sarovic
- Gillberg Neuropsychiatry Centre (GNC), University of Gothenburg, Göteborg, Sweden
| | - Philip Wilson
- Institute of Applied Health Science, University of Aberdeen, Inverness, United Kingdom
| | - Louis Irwin
- Institute of Applied Health Science, University of Aberdeen, Inverness, United Kingdom
| | - Dana Visnitchi
- Institute of Applied Health Science, University of Aberdeen, Inverness, United Kingdom
| | - Angela Sämfjord
- The Child and Adolescent Psychiatric Clinic, The Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Christopher Gillberg
- Gillberg Neuropsychiatry Centre (GNC), University of Gothenburg, Göteborg, Sweden
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| |
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the scientific evidence on bone health in transgender and gender diverse (TGD) youth. RECENT FINDINGS Gender-affirming medical therapies may be introduced during a key window of skeletal development in TGD adolescents. Before treatment, low bone density for age is more prevalent than expected in TGD youth. Bone mineral density Z-scores decrease with gonadotropin-releasing hormone agonists and differentially respond to subsequent estradiol or testosterone. Risk factors for low bone density in this population include low body mass index, low physical activity, male sex designated at birth, and vitamin D deficiency. Peak bone mass attainment and implications for future fracture risk are not yet known. TGD youth have higher than expected rates of low bone density prior to initiation of gender-affirming medical therapy. More studies are needed to understand the skeletal trajectories of TGD youth receiving medical interventions during puberty.
Collapse
Affiliation(s)
- Janet Y Lee
- Department of Pediatrics, Division of Pediatric Endocrinology, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Department of Medicine, Division of Endocrinology & Metabolism, University of California, San Francisco, San Francisco, CA, 94143, USA.
- Endocrine and Metabolism Section, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.
| |
Collapse
|
14
|
Conflitti AC, Spaziani M, Pallotti F, Tarsitano MG, Di Nisio A, Paoli D, Lombardo F. Update on bioethical, medical and fertility issues in gender incongruence during transition age. J Endocrinol Invest 2023:10.1007/s40618-023-02077-5. [PMID: 37071372 PMCID: PMC10371879 DOI: 10.1007/s40618-023-02077-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/22/2023] [Indexed: 04/19/2023]
Abstract
PURPOSE Many issues still remain unresolved in the management of pubertal patients with gender incongruence (GI). The aim of this review is to discuss the main aspects of the treatment of these patients to provide a practical approach for clinicians. METHODS A comprehensive literature search within PubMed was performed to provide updates of available evidence regarding the impact on bioethical, medical and fertility issues in gender incongruence during transition age. RESULTS Gender Affirming Hormone Treatment (GAHT) and Gender Affirming Surgery (GAS) can induce unsatisfaction with change, future regrets, and the risk of infertility. This raises ethical issues especially in the management of pubertal patients that remain unresolved. Therapy with GnRH analogues (GnRHa) is intended to delay puberty, so as to give the adolescent a longer period of time to decide whether to continue with the treatments. At the level of physical changes, this therapy may have an effect on bone mineralization and body composition; however, long-term longitudinal data are not yet available. An important feature related to the use of GnRHa is the risk of fertility. Gamete cryopreservation is the most established method of fertility preservation (FP) and should be counselled to transgender adolescents. However, these patients are not always interested in having biological children. CONCLUSION Based on the current evidence, there is a need to conduct further research to clarify certain issues and to standardize clinical practice and improve counselling in transgender adolescent decision making and avoid regrets in the future.
Collapse
Affiliation(s)
- A C Conflitti
- Laboratory of Seminology-Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - M Spaziani
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Viale del Policlinico 155, 00161, Rome, Italy
| | - F Pallotti
- Laboratory of Seminology-Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - M G Tarsitano
- Department of Medical and Surgical Science, University Magna Graecia, Catanzaro, Italy
| | - A Di Nisio
- Department of Medicine, Operative Unit of Andrology and Medicine of Human Reproduction, University of Padova, Padua, Italy
| | - D Paoli
- Laboratory of Seminology-Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - F Lombardo
- Laboratory of Seminology-Sperm Bank "Loredana Gandini", Department of Experimental Medicine, "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| |
Collapse
|
15
|
Abstract
Increasing numbers of transgender and gender-diverse (TGD) youth, from early puberty through late adolescence, are seeking medical services to bring their physical sex characteristics into alignment with their gender identity-their inner sense of self as male or female or elsewhere on the gender spectrum. Numerous studies, primarily of short- and medium-term duration (up to 6 years), demonstrate the clearly beneficial-even lifesaving-mental health impact of gender-affirming medical care in TGD youth. However, there are significant gaps in knowledge and challenges to such care. Long-term safety and efficacy studies are needed to optimize medical care for TGD youth.
Collapse
Affiliation(s)
- Janet Y Lee
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California, San Francisco, California, USA; ,
- Division of Endocrinology & Metabolism, Department of Medicine, University of California, San Francisco, California, USA
- Endocrine and Metabolism Section, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Stephen M Rosenthal
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California, San Francisco, California, USA; ,
| |
Collapse
|
16
|
Willemsen LA, Boogers LS, Wiepjes CM, Klink DT, van Trotsenburg ASP, den Heijer M, Hannema SE. Just as Tall on Testosterone; a Neutral to Positive Effect on Adult Height of GnRHa and Testosterone in Trans Boys. J Clin Endocrinol Metab 2023; 108:414-421. [PMID: 36190924 PMCID: PMC9844962 DOI: 10.1210/clinem/dgac571] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/15/2022] [Indexed: 01/22/2023]
Abstract
CONTEXT Growth is an important topic for many transgender boys. However, few studies have investigated the impact of puberty suppression (PS) and gender-affirming hormone treatment (GAHT) on growth and adult height. OBJECTIVE To evaluate the effect of PS and GAHT on growth and adult height. DESIGN Retrospective cohort study. SETTING Specialized gender identity clinic. PARTICIPANTS A total of 146 transgender boys treated with GnRH analogues and testosterone who reached adult height. MAIN OUTCOME MEASURES Growth, bone age (BA), adult height, and difference between adult height and predicted adult height (PAH) and midparental height. RESULTS In those with BA ≤14 years at start (n = 61), a decrease in growth velocity and bone maturation during PS was followed by an increase during GAHT. Adult height was 172.0 ± 6.9 cm; height SD score was similar to baseline (0.1; 95% CI, -0.2 to 0.4). Adult height was 3.9 ± 6.0 cm above midparental height and 3.0 ± 3.6 cm above PAH at start of PS. A younger BA at start PS was associated with an adult height significantly further above PAH. CONCLUSION During PS, growth decelerated followed by an acceleration during GAHT. Although adult height SD score was similar to baseline, adult height was taller than predicted based on BA at baseline, especially in those who started treatment at a younger BA. It is reassuring that PS and GAHT do not have a negative impact on adult height in transgender boys and might even lead to a slightly taller adult height, especially in those who start at a younger age.
Collapse
Affiliation(s)
| | | | - Chantal Maria Wiepjes
- Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, 1081 HV Amsterdam, the Netherlands
- Department of Endocrinology, Amsterdam UMC location Vrije Universiteit Amsterdam, 1081 HV Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, 1105 BK Amsterdam, the Netherlands
| | - Daniel Tatting Klink
- Division of Pediatric Endocrinology, Department of Pediatrics, Ghent University Hospital, Ghent, Oost-Vlaanderen 9000, Belgium
| | - Adrianus Sarinus Paulus van Trotsenburg
- Department of Pediatric Endocrinology, Amsterdam UMC location University of Amsterdam, 1105 AZ Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, 1105 BK Amsterdam, the Netherlands
| | - Martin den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, 1081 HV Amsterdam, the Netherlands
- Department of Endocrinology, Amsterdam UMC location Vrije Universiteit Amsterdam, 1081 HV Amsterdam, the Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, 1105 BK Amsterdam, the Netherlands
| | - Sabine Elisabeth Hannema
- Correspondence: Sabine Elisabeth Hannema, MD PhD, Department of Pediatrics, Section Endocrinology, Amsterdam University Medical Centers, Amsterdam, the Netherlands, PO Box 7057, 1007 MB Amsterdam.
| |
Collapse
|
17
|
Biggs M. The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence. JOURNAL OF SEX & MARITAL THERAPY 2023; 49:348-368. [PMID: 36120756 DOI: 10.1080/0092623x.2022.2121238] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
It has been a quarter of a century since Dutch clinicians proposed puberty suppression as an intervention for "juvenile transsexuals," which became the international standard for treating gender dysphoria. This paper reviews the history of this intervention and scrutinizes the evidence adduced to support it. The intervention was justified by claims that it was reversible and that it was a tool for diagnosis, but these claims are increasingly implausible. The main evidence for the Dutch protocol came from a longitudinal study of 70 adolescents who had been subjected to puberty suppression followed by cross-sex hormones and surgery. Their outcomes shortly after surgery appeared positive, except for the one patient who died, but these findings rested on a small number of observations and incommensurable measures of gender dysphoria. A replication study conducted in Britain found no improvement. While some effects of puberty suppression have been carefully studied, such as on bone density, others have been ignored, like on sexual functioning.
Collapse
Affiliation(s)
- Michael Biggs
- Department of Sociology, University of Oxford, Oxford, UK
| |
Collapse
|
18
|
Williams DR, Chaves E, Greenwood NE, Kushner J, Chelvakumar G, Swaringen SE, Leibowitz SF. Care of Gender Diverse Youth with Obesity. Curr Obes Rep 2022; 11:215-226. [PMID: 36050541 DOI: 10.1007/s13679-022-00480-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The relationships between gender identity, body image, and gender expression are complex, requiring a gender affirming approach to address weight management. This purpose of this review is to describe the essentials to caring for gender diverse youth, as well as the differences and intersections among those with obesity. RECENT FINDINGS Gender-affirming hormone therapy may lead to abnormal weight gain and increased body mass index, or worsen obesity and exacerbate weight-related complications. Moreover, given the high prevalence of victimization, marginalization, and stigmatization among gender diverse people and youth with obesity, care guidelines and treatment goals should also include reducing the negative impact of social-related complications. Despite the overlap in clinical care and lived experiences that impact the health of gender diverse youth with obesity, there is very little research to help guide clinicians. Careful attention to medical and behavioral comorbidities, barriers to care, and health disparities can inform clinical practice. Future research that specifically addresses nuances to care for gender diverse youth with obesity can help to establish standards of care to address their unmet needs and further support clinicians, patients and their families.
Collapse
Affiliation(s)
- Dominique R Williams
- Center for Healthy Weight and Nutrition, Nationwide Children's Hospital, Columbus, USA.
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, 43210, USA.
| | - Eileen Chaves
- Center for Healthy Weight and Nutrition, Nationwide Children's Hospital, Columbus, USA
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, 43210, USA
- Division of Pediatric Neuropsychology and Psychology, Nationwide Children's Hospital, Columbus, USA
| | - Nicole E Greenwood
- Center for Healthy Weight and Nutrition, Nationwide Children's Hospital, Columbus, USA
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | - Jennifer Kushner
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- THRIVE Gender Development Program, Nationwide Children's Hospital, Columbus, USA
- Division of Endocrinology, Nationwide Children's Hospital, Columbus, USA
| | - Gayathri Chelvakumar
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, 43210, USA
- THRIVE Gender Development Program, Nationwide Children's Hospital, Columbus, USA
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, USA
| | - Shanna E Swaringen
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, 43210, USA
- THRIVE Gender Development Program, Nationwide Children's Hospital, Columbus, USA
- Division of Psychiatry and Behavioral Health, Nationwide Children's Hospital, Columbus, USA
| | - Scott F Leibowitz
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, 43210, USA
- THRIVE Gender Development Program, Nationwide Children's Hospital, Columbus, USA
- Division of Psychiatry and Behavioral Health, Nationwide Children's Hospital, Columbus, USA
| |
Collapse
|
19
|
Moussaoui D, Elder CV, O’Connell MA, Mclean A, Grover SR, Pang KC. Pelvic pain in transmasculine adolescents receiving testosterone therapy. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 25:10-18. [PMID: 38323021 PMCID: PMC9869722 DOI: 10.1080/26895269.2022.2147118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Background: Pelvic pain is a common complaint among individuals assigned female at birth. However, few studies have explored pelvic pain among transmasculine patients on gender-affirming testosterone treatment, and most of these were performed in adult populations. Aims: The aim of our study was to investigate the prevalence, risk factors, nature and treatment of pelvic pain among trans adolescents on testosterone. Methods: A retrospective cohort study was performed on all trans adolescents started on gender-affirming testosterone treatment at our institution between 2007 and 2020. Results: Among 158 trans adolescents who were started on testosterone therapy and followed-up for at least six months, 37 (23.4%) reported pelvic pain, with a median interval between testosterone initiation and reported onset of pain of 1.6 months (range 0.3-6.4). The prevalence of pelvic pain was higher in patients who were receiving menstrual suppression (n = 36, 26.3%) compared to those who were not (n = 1, 4.8%), giving a risk difference of 21.5% (95% CI 9.8% to 33.2%, p = 0.028). The most common descriptive terms were "cramps" (n = 17, 45.9%) and "similar to previous period pain" (n = 8, 21.6%). A range of different pharmacological strategies were employed, including paracetamol, NSAIDs, danazol, norethisterone, medroxyprogesterone, etonogestrel implant, intra-uterine device, goserelin and pelvic floor physiotherapy, with variable outcomes. Conclusion: In conclusion, we report here - in what is to our knowledge the first time - the prevalence rate of pelvic pain in trans adolescents on gender-affirming testosterone treatment, and observe that a quarter of them described pelvic pain. Limitations of our study include its retrospective nature, which is likely to be associated with under-reporting of pelvic pain, and the limited documentation of the nature and likely causes of this pain within the medical records. Prospective longitudinal studies to better understand the nature, etiology and optimal management of testosterone-associated pelvic pain are therefore warranted.
Collapse
Affiliation(s)
- Dehlia Moussaoui
- Department of Paediatric and Adolescent Gynaecology, The Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
| | - Charlotte V. Elder
- Department of Paediatric and Adolescent Gynaecology, The Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Michele A. O’Connell
- Department of Endocrinology and Diabetes, The Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
| | - Ashleigh Mclean
- Department of Endocrinology and Diabetes, The Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
| | - Sonia R. Grover
- Department of Paediatric and Adolescent Gynaecology, The Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Ken C. Pang
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Adolescent Medicine, The Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
20
|
Ciancia S, Dubois V, Cools M. Impact of gender-affirming treatment on bone health in transgender and gender diverse youth. Endocr Connect 2022; 11:e220280. [PMID: 36048500 PMCID: PMC9578106 DOI: 10.1530/ec-22-0280] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022]
Abstract
Both in the United States and Europe, the number of minors who present at transgender healthcare services before the onset of puberty is rapidly expanding. Many of those who will have persistent gender dysphoria at the onset of puberty will pursue long-term puberty suppression before reaching the appropriate age to start using gender-affirming hormones. Exposure to pubertal sex steroids is thus significantly deferred in these individuals. Puberty is a critical period for bone development: increasing concentrations of estrogens and androgens (directly or after aromatization to estrogens) promote progressive bone growth and mineralization and induce sexually dimorphic skeletal changes. As a consequence, safety concerns regarding bone development and increased future fracture risk in transgender youth have been raised. We here review published data on bone development in transgender adolescents, focusing in particular on differences in age and pubertal stage at the start of puberty suppression, chosen strategy to block puberty progression, duration of puberty suppression, and the timing of re-evaluation after estradiol or testosterone administration. Results consistently indicate a negative impact of long-term puberty suppression on bone mineral density, especially at the lumbar spine, which is only partially restored after sex steroid administration. Trans girls are more vulnerable than trans boys for compromised bone health. Behavioral health measures that can promote bone mineralization, such as weight-bearing exercise and calcium and vitamin D supplementation, are strongly recommended in transgender youth, during the phase of puberty suppression and thereafter.
Collapse
Affiliation(s)
- Silvia Ciancia
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Vanessa Dubois
- Basic and Translational Endocrinology (BaTE), Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Martine Cools
- Department of Internal Medicine and Pediatrics, Ghent University, Pediatric Endocrinology Service, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
21
|
Huang C, Gold S, Radi R, Amos S, Yeung H. Managing Dermatologic Effects of Gender-Affirming Therapy in Transgender Adolescents. Adolesc Health Med Ther 2022; 13:93-106. [PMID: 36237602 PMCID: PMC9552673 DOI: 10.2147/ahmt.s344078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 09/14/2022] [Indexed: 11/05/2022] Open
Abstract
Transgender adolescents seek gender-affirming medical care to address gender identity and incongruence. Improved understanding of the dermatologic impact of gender-affirming medical care such as pubertal suppression, hormone therapy, and surgeries can enhance patient outcome. Pubertal suppression treats dysphoria associated with development of secondary sex characteristics, including androgen-driven acne. Gender-affirming hormone therapy influences acne and hair development in transgender adolescents. Dermatologists can help manage skin effects associated with chest binding and gender-affirming hormone therapy and surgery. Provision of patient-centered gender-affirming care in dermatologic and multidisciplinary settings is essential to improve skin and overall outcomes of gender-affirming therapy.
Collapse
Affiliation(s)
- Christina Huang
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Sarah Gold
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Rakan Radi
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Seth Amos
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Howa Yeung
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA,Clinical Resource Hub, Veterans Affairs Southeast Network Veterans Integrated Service Network 7, Decatur, GA, USA,Correspondence: Howa Yeung, Department of Dermatology, Emory University School of Medicine, 1525 Clifton Road NE Suite 100, Atlanta, GA, 30322, USA, Tel +1 (404) 727-9838, Fax +1 (404) 727-5878, Email
| |
Collapse
|
22
|
Dimakopoulou A, Millar OD, Moschonas D, Jayasena CN. The role of androgens in transgender medicine. Best Pract Res Clin Endocrinol Metab 2022; 36:101617. [PMID: 35120800 DOI: 10.1016/j.beem.2022.101617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Androgen therapy is the mainstay of treatment in female to male (FtM) transgender persons to increase testosterone levels, suppress oestrogens and treat gender dysphoria. Testosterone is widely used for male hypogonadism, but is comparatively under-investigated in FtM transgender persons. The aim of our study was to identify treatment and safety outcomes associated with testosterone use in transgender medicine. Androgens in FtM transgender persons are effective to lower voice frequency, increase facial hair-growth, and increase hematocrit and hemoglobin levels to adult male reference ranges. A 1.2-fold-3.7-fold higher rate of myocardial infarction has been reported retrospectively, compared to cisgender women. Blood pressure, glycaemic control and body mass index remained unchanged in FtM transgender persons. Androgens in FtM transgender persons have important cardio-metabolic implications. Randomised control trials, longer follow-up periods and studies involving older persons may further improve the management of FtM transgender persons.
Collapse
Affiliation(s)
| | - Ophelia D Millar
- Department of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, W12 0NN, UK
| | | | - Channa N Jayasena
- Department of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, W12 0NN, UK.
| |
Collapse
|
23
|
Marwa A, Misra M, Lopez X. Determinants of Bone Mineral Density in Transgender Youth. Transgend Health 2022; 7:213-218. [PMID: 36643057 PMCID: PMC9831245 DOI: 10.1089/trgh.2020.0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Purpose We aimed to study determinants of bone health in transgender youth in anticipation of or shortly after initiating puberty suppression and/or gender-affirming hormone therapy. Methods This was a retrospective review of records of transgender adolescents in our institution between June 2014 and June 2019. Dual energy X-ray absorptiometry was used to assess bone mineral density (BMD). Baseline characteristics were collected and included in a multilinear regression model to assess determinants of lumbar spine (LS) BMD Z-scores adjusted for age and height and accounting for race. Welch's t-test was used to compare characteristics across genders. Results One hundred nineteen patient records were analyzed. Forty-six patients (38.7%) were assigned male at birth (AMAB) and 73 patients (61.3%) were assigned female at birth (AFAB). Mean (±standard deviation [SD]) age (years) was 14.7±2.6 for AMAB and 15.0±2.2 for AFAB. The adjusted LS BMD Z-score was lower in the AMAB population with a mean (+SD) of -0.605±1.42 compared with 0.043±1.09 in AFAB (p=0.010). In a multivariate model, AMAB gender, vitamin D deficiency, and lower body mass index (BMI) z-scores were determinants of lower LS BMD Z-scores (R 2=0.206). Age, race, ethnicity, insurance status, and Tanner stage were not determinants of BMD. However, post hoc analysis did show that pubertal status modified the results. Conclusion AMAB transgender adolescents have lower BMD compared with AFAB patients, before or shortly after starting puberty suppression and/or gender-affirming hormone therapy. Lower BMI and vitamin D deficiency were determinants of lower BMD. Further studies are needed to explore etiology for bone health discrepancy in this population.
Collapse
Affiliation(s)
- Albara Marwa
- Division of Pediatric Endocrinology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Madhusmita Misra
- Division of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ximena Lopez
- Division of Pediatric Endocrinology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
24
|
Verroken C, Collet S, Lapauw B, T'Sjoen G. Osteoporosis and Bone Health in Transgender Individuals. Calcif Tissue Int 2022; 110:615-623. [PMID: 35366693 DOI: 10.1007/s00223-022-00972-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/15/2022] [Indexed: 12/22/2022]
Abstract
This review discusses the changes in bone mass, structure, and metabolism that occur upon gender-affirming hormonal treatment (GAHT) in transgender adults and adolescents, as well as their clinical relevance. In general, available evidence shows that GAHT in transgender adults is not associated with major bone loss. In transgender adolescents, pubertal suppression with gonadotropin-releasing hormone agonist monotherapy impairs bone development, but at least partial recovery is observed after GAHT initiation. Nevertheless, a research gap remains concerning fracture risk and determinants of bone strength other than bone mineral density. Attention for bone health is warranted especially in adult as well as adolescent trans women, given the relatively high prevalence of low bone mass both before the start of treatment and after long-term GAHT in this population. Strategies to optimize bone health include monitoring of treatment compliance and ensuring adequate exposure to administered sex steroids, in addition to general bone health measures such as adequate physical activity, adequate vitamin D and calcium intake, and a healthy lifestyle. When risk factors for osteoporosis exist the threshold to perform DXA should be low, and treatment decisions should be based on the same guidelines as the general population.
Collapse
Affiliation(s)
- Charlotte Verroken
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium.
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium.
| | - Sarah Collet
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Bruno Lapauw
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Guy T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| |
Collapse
|
25
|
D'hoore L, T'Sjoen G. Gender-affirming hormone therapy: An updated literature review with an eye on the future. J Intern Med 2022; 291:574-592. [PMID: 34982475 DOI: 10.1111/joim.13441] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
In line with increasing numbers of transgender (trans) and gender nonbinary people requesting hormone treatment, the body of available research is expanding. More clinical research groups are presenting data, and the numbers of participants in these studies are rising. Many previous review papers have focused on all available data, as these were scarce, but a more recent literature review is timely. Hormonal regimens have changed over time, and older data may be less relevant for today's practice. In recent literature, we have found that even though mental health problems are more prevalent in trans people compared to cisgender people, less psychological difficulties occur, and life satisfaction increases with gender-affirming hormone treatment (GAHT) for those who feel this is a necessity. With GAHT, body composition and contours change towards the affirmed sex. Studies in bone health are reassuring, but special attention is needed for adolescent and adult trans women, aiming at adequate dosage of hormonal supplementation and stimulating therapy compliance. Existing epidemiological data suggest that the use of (certain) estrogens in trans women induces an increased risk of myocardial infarction and stroke, the reason that lifestyle management can be an integral part of trans health care. The observed cancer risk in trans people does not exceed the known cancer-risk differences between men and women. Now it is time to integrate the mostly reassuring data, to leave the overly cautious approach behind, to not copy the same research questions repeatedly, and to focus on longer follow-up data with larger cohorts.
Collapse
Affiliation(s)
- Laurens D'hoore
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Guy T'Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium.,Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
26
|
Valentine A, Nokoff N, Bonny A, Chelvakumar G, Indyk J, Leibowitz S, Nahata L. Cardiometabolic Parameters Among Transgender Adolescent Males on Testosterone Therapy and Body Mass Index-Matched Cisgender Females. Transgend Health 2022; 6:369-373. [PMID: 34993308 DOI: 10.1089/trgh.2020.0052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Limited data are available on changes in metabolic parameters in transgender youth on testosterone therapy in comparison with cisgender females. Data from 42 transgender males on testosterone therapy were retrospectively analyzed. Body mass index (BMI) and lipid profile changes were compared with BMI-matched females. There was a significant increase in BMI over time in the transgender males as compared with the cisgender females, and a decrease in high-density lipoprotein in the transgender males after starting testosterone therapy. Longitudinal prospective studies with cisgender controls are needed to better define effects of testosterone therapy in adolescents.
Collapse
Affiliation(s)
- Anna Valentine
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, Division of Endocrinology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Natalie Nokoff
- Department of Pediatrics, Division of Endocrinology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Andrea Bonny
- The Ohio State University College of Medicine, Columbus, Ohio, USA.,Divisions of Adolescent Medicine and Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Gayathri Chelvakumar
- The Ohio State University College of Medicine, Columbus, Ohio, USA.,Divisions of Adolescent Medicine and Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Justin Indyk
- The Ohio State University College of Medicine, Columbus, Ohio, USA.,Divisions of Endocrinology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Scott Leibowitz
- The Ohio State University College of Medicine, Columbus, Ohio, USA.,Department of Psychiatry, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Leena Nahata
- The Ohio State University College of Medicine, Columbus, Ohio, USA.,Divisions of Endocrinology, Nationwide Children's Hospital, Columbus, Ohio, USA.,Center for Biobehavioral Health, Abigail Wexner Research Institute, Columbus, Ohio, USA
| |
Collapse
|
27
|
O’Connell MA, Nguyen TP, Ahler A, Skinner SR, Pang KC. Approach to the Patient: Pharmacological Management of Trans and Gender-Diverse Adolescents. J Clin Endocrinol Metab 2022; 107:241-257. [PMID: 34476487 PMCID: PMC8684462 DOI: 10.1210/clinem/dgab634] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Indexed: 11/24/2022]
Abstract
Internationally, increasing numbers of children and adolescents with gender dysphoria are presenting for care. In response, gender-affirming therapeutic interventions that seek to align bodily characteristics with an individual's gender identity are more commonly being used. Depending on a young person's circumstances and goals, hormonal interventions may aim to achieve full pubertal suppression, modulation of endogenous pubertal sex hormone effects, and/or development of secondary sex characteristics congruent with their affirmed gender. This is a relatively novel therapeutic area and, although short-term outcomes are encouraging, longer term data from prospective longitudinal adolescent cohorts are still lacking, which may create clinical and ethical decision-making challenges. Here, we review current treatment options, reported outcomes, and clinical challenges in the pharmacological management of trans and gender-diverse adolescents.
Collapse
Affiliation(s)
- Michele A O’Connell
- Department of Endocrinology and Diabetes, The Royal Children’s Hospital Melbourne, Parkville, VIC 3052, Australia
- Department of Adolescent Medicine, The Royal Children’s Hospital Melbourne, Parkville, VIC 3052, Australia
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3010, Australia
- Correspondence: Michele A. O’Connell, FRACP, MD, Department of Endocrinology and Diabetes, The Royal Children’s Hospital, 50 Flemington Road, Parkville, VIC 3052, Australia.
| | - Thomas P Nguyen
- School of Medicine, Western Sydney University, Sydney, NSW 2560, Australia
| | - Astrid Ahler
- Reproductive Medicine and Gynecological Endocrinology (RME), University Hospital Basel, Basel, Switzerland
| | - S Rachel Skinner
- Speciality of Child and Adolescent Health, Faculty of Medicine and Health, Sydney University, Children’s Hospital Westmead, NSW 2145, Australia
| | - Ken C Pang
- Department of Adolescent Medicine, The Royal Children’s Hospital Melbourne, Parkville, VIC 3052, Australia
- Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC 3010, Australia
- Walter and Eliza Hall Institute for Medical Research, Parkville, VIC 3052, Australia
| |
Collapse
|
28
|
Nahon RL, Silva APSD, Muniz-Santos R, Novaes RCTD, Pedroso LSPL. SPORTS AND PERFORMANCE IN THE TRANSGENDER POPULATION: A SYSTEMATIC REVIEW AND META-ANALYSIS. REV BRAS MED ESPORTE 2021. [DOI: 10.1590/1517-8692202127062021_0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Introduction: The debate surrounding the regulations on the participation of transgender individuals in sports is not recent, but it is still ongoing. Some sports organizations are more flexible in this regard, while others are more conservative. Objective: Through a systematic review and meta-analysis, this study summarizes the scientific evidence of the effects of cross-sex hormone therapy on muscle strength, hematocrit, and hemoglobin measurements, parameters that seem to be linked to sports performance. Methods: We conducted electronic searches for manuscripts published before November 20th, 2020. Studies published in three different databases (PubMed, SciELO, and Lilacs) were included, without any time or language restriction, and using keywords such as “transgender”, “gender dysphoria”, “strength”, “hematocrit”, and “hemoglobin”. The PRISMA systematization was used for the elaboration of this review, while a meta-analysis was conducted to mathematically evidence the results. The meta-analysis was performed using the random effect model, to find the pooled estimate effect of cross-sex hormone therapy on the parameters analyzed. Results: The electronic search retrieved 21 articles that were eligible for inclusion. Cross-sex hormone therapy influenced the three parameters analyzed in almost all the studies. Overall, there was a significant increase in muscle strength in female-to-males (FtMs), per muscle group analyzed: +17.7% (95% confidence interval [CI]14.9;20.6). In male-to-females (MtFs) the results of the muscle strength analysis were more controversial, but the pooled estimate effect showed a decrease: −3.6% (95% confidence interval [CI] −6.6; −0.6). Conclusion: Muscle strength, hematocrit, and hemoglobin were altered as a result of cross-sex hormone therapy in both FtMs and MtFs. However, there was a lack of studies comparing the transgender individuals to the population of the same desired gender. Such studies are needed, to better infer rules for the participation of transgender athletes in Olympic sports. Level of Evidence I; Systematic Review and Meta-analysis.
Collapse
|
29
|
Motosko CC, Tosti A. Dermatologic Care of Hair in Transgender Patients: A Systematic Review of Literature. Dermatol Ther (Heidelb) 2021; 11:1457-1468. [PMID: 34235628 PMCID: PMC8484383 DOI: 10.1007/s13555-021-00574-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 06/25/2021] [Indexed: 10/26/2022] Open
Abstract
Transgender patients on masculinizing and feminizing hormonal therapy undergo myriad physical and psychologic changes. Dermatologists are uniquely qualified to guide patients in the gender-affirming process, especially as it relates to hair. Given the paucity of literature guiding dermatologists in this process, a systematic review was performed to better understand the physiologic changes of hair in patients on masculinizing and feminizing hormonal therapy as well as the variety of treatment options that exist to help transgender patients to attain their desired hair growth pattern. This review reports findings and treatment options supported by the performed literature review as well as treatment recommendations based on the authors' own experiences treating this unique patient population.
Collapse
Affiliation(s)
- Catherine C Motosko
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, FL, USA
| | - Antonella Tosti
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, Miami, FL, USA.
| |
Collapse
|
30
|
Rosenthal SM. Challenges in the care of transgender and gender-diverse youth: an endocrinologist's view. Nat Rev Endocrinol 2021; 17:581-591. [PMID: 34376826 DOI: 10.1038/s41574-021-00535-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 02/07/2023]
Abstract
An increasing number of transgender and gender-diverse (TGD) youth (early pubertal through to late adolescent, typically 9-10 through to 18 years of age) are seeking medical services to bring their physical sex characteristics into alignment with their gender identity - their inner sense of self as male or female or somewhere on the gender spectrum. Compelling research has demonstrated the clear mental health - even life-saving - benefits of gender-affirming care, but current clinical practice guidelines and standards of care are based on only several short-term and a few medium-term outcomes studies complemented by expert opinion. Nevertheless, although the relative paucity of outcomes data raises concerns, the stance of not intervening until more is known is not a neutral option, and large observational studies evaluating current models of care are necessary and are now underway. This Review highlights key advances in our understanding of transgender and gender-diverse youth, the challenges of providing gender-affirming care, gaps in knowledge and priorities for research.
Collapse
Affiliation(s)
- Stephen M Rosenthal
- Department of Pediatrics, Division of Pediatric Endocrinology, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA.
| |
Collapse
|
31
|
Biggs M. Revisiting the effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria. J Pediatr Endocrinol Metab 2021; 34:937-939. [PMID: 33894110 DOI: 10.1515/jpem-2021-0180] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 03/24/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Michael Biggs
- Department of Sociology, University of Oxford, Oxford, UK
| |
Collapse
|
32
|
Knight EP. Gender and Cardiovascular Disease Risk: Beyond the Binary. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
33
|
Kothmann KH, Jacobsen V, Laffitte E, Bromfield C, Grizzaffi M, Jarboe M, Braundmeier-Fleming AG, Bahr JM, Nowak RA, Newell-Fugate AE. Virilizing doses of testosterone decrease circulating insulin levels and differentially regulate insulin signaling in liver and adipose tissue of females. Am J Physiol Endocrinol Metab 2021; 320:E1107-E1118. [PMID: 33900852 PMCID: PMC8285596 DOI: 10.1152/ajpendo.00281.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Transgender men undergoing hormone therapy are at risk for insulin resistance. However, how virilizing testosterone therapy affects serum insulin and peripheral insulin sensitivity in transgender men is unknown. This study assessed the effect of acute, virilizing testosterone on serum insulin concentrations and insulin signaling in liver, skeletal muscle, and white adipose tissue (WAT) of female pigs as a translational model for transgender men. Females received three doses of intramuscular testosterone cypionate (TEST females; 50 mg/day/pig) or corn oil (control) spaced 6 days apart starting on the day of estrus (D0). Fasting blood was collected on D0, D3, D5, D11, and D13, and females were euthanized on D13. On D13, TEST females had virilizing concentrations of serum testosterone with normal concentrations of serum estradiol. Virilizing serum testosterone concentrations (D13) were associated with decreased serum insulin and C-peptide concentrations. Blood glucose and serum glycerol concentrations were not altered by testosterone. Virilizing concentrations of testosterone downregulated AR and ESR1 in subcutaneous (sc) WAT and upregulated transcript levels of insulin-signaling pathway components in WAT and liver. At the protein level, virilizing testosterone concentrations were associated with increased PI3K 110α in liver and increased insulin receptor (INSR) and phospho(Ser256)-FOXO1 in visceral (v) WAT but decreased phospho(Ser473)-AKT in vWAT and scWAT. These results suggest that acute exposure to virilizing concentrations of testosterone suppresses circulating insulin levels and results in increased abundance of proteins in the insulin-signaling pathway in liver and altered phosphorylation of key proteins in control of insulin sensitivity in WAT.NEW & NOTEWORTHY Acute virilizing doses of testosterone administered to females suppress circulating insulin levels, upregulate components of the insulin-signaling pathway in liver, and suppress insulin signaling in white adipose tissue. These results suggest that insulin resistance in transgender men may be due to suppression of the insulin-signaling pathway and decreased insulin sensitivity in white adipose tissue.
Collapse
Affiliation(s)
- Kadden H Kothmann
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas
| | - Victoria Jacobsen
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas
| | - Emily Laffitte
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas
| | - Corinne Bromfield
- Agricultural Animal Care and Use Program, Office of the Vice Chancellor for Research, University of Illinois Urbana-Champaign, Urbana, Illinois
| | - Matthew Grizzaffi
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas
| | - Monica Jarboe
- Department of Medical Microbiology, Immunology and Cell Biology, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Andrea G Braundmeier-Fleming
- Department of Medical Microbiology, Immunology and Cell Biology, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Janice M Bahr
- Department of Animal Sciences, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Romana A Nowak
- Department of Animal Sciences, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Annie E Newell-Fugate
- Department of Veterinary Physiology and Pharmacology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas
| |
Collapse
|
34
|
Tüten A, Hamzaoğlu K, Gönen B, Tüten N, Uçar D. Does exogenous androgen use affect the retinal blood flow: An OCTA study in transgender men. Eur J Ophthalmol 2021; 32:1570-1576. [PMID: 34053312 DOI: 10.1177/11206721211020639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE This study aims to investigate the effect of using exogenous androgen on retinal microvascular structures in transgender men. METHODS Retinal microvascular structures of transgender men and healthy women in the control group were visualized with optical coherence tomography angiography (OCTA). Foveal avascular zone (FAZ), superficial capillary vascular density (sCVD), deep capillary vascular density (dCVD), and radial peripapillary capillary (RPC) vascular density were evaluated. RESULTS Thirty transgender men and 30 healthy women were included in the study. There were no significant differences between transgender men and the control group in terms of FAZ, central macular thickness, parafoveal, and perifoveal retinal thicknesses (p = 0.859, 0.288, 0.561, and 0.719; respectively). sCVD were found to be low in transgender men in the whole image, parafoveal, and perifoveal zones (p = 0.006, 0.025, and 0.005; respectively). Although there were low values of dCVD of the whole image, parafoveal, and perifoveal zones in transgender men, the difference was not statistically significant (p = 0.295, 0.085, and 0.270; respectively). RPC vessel densities in the whole image, peripapillary zone, and the inferior of the optic disc were found to be significantly low in transgender men (p = 0.003, 0.005, and 0.003; respectively). CONCLUSION In this study, a decrease in vessel density in the superficial retinal layers and around the optic disc was detected in transgender men. These findings suggest that routine ophthalmological examination may be important in individuals who use exogenous androgens.
Collapse
Affiliation(s)
- Abdullah Tüten
- Department of Gynecology and Obstetrics, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Kübra Hamzaoğlu
- Department of Gynecology and Obstetrics, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Busenur Gönen
- Department of Ophthalmology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Nevin Tüten
- Department of Gynecology and Obstetrics, Kanuni Sultan Süleyman Education and Research Hospital, Istanbul, Turkey
| | - Didar Uçar
- Department of Ophthalmology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| |
Collapse
|
35
|
Millington K, Finlayson C, Olson-Kennedy J, Garofalo R, Rosenthal SM, Chan YM. Association of High-Density Lipoprotein Cholesterol With Sex Steroid Treatment in Transgender and Gender-Diverse Youth. JAMA Pediatr 2021; 175:520-521. [PMID: 33587098 PMCID: PMC7885095 DOI: 10.1001/jamapediatrics.2020.5620] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This cohort study analyzes the association of sex steroids with cholesterol in different sex-chromosome contexts.
Collapse
Affiliation(s)
- Kate Millington
- Division of Endocrinology, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | - Courtney Finlayson
- Division of Endocrinology, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
| | | | - Robert Garofalo
- Division of Adolescent Medicine, Lurie Children’s Hospital, Chicago, Illinois
| | - Stephen M. Rosenthal
- Division of Pediatric Endocrinology, Benioff Children’s Hospital, University of California, San Francisco, San Francisco
| | - Yee-Ming Chan
- Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts
| |
Collapse
|
36
|
Hu T, Wei Z, Ju Q, Chen W. Sexualhormone und Akne: Aktueller Stand. J Dtsch Dermatol Ges 2021; 19:509-516. [PMID: 33861017 DOI: 10.1111/ddg.14426_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/10/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Tingting Hu
- Abteilung Dermatologie, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, PR China
| | - Ziyu Wei
- Abteilung Dermatologie, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, PR China
| | - Qiang Ju
- Abteilung Dermatologie, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, PR China
| | - WenChieh Chen
- Abteilung Dermatologie und Allergologie, Technische Universität München, München, Germany
| |
Collapse
|
37
|
Hu T, Wei Z, Ju Q, Chen W. Sex hormones and acne: State of the art. J Dtsch Dermatol Ges 2021; 19:509-515. [PMID: 33576151 DOI: 10.1111/ddg.14426] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/10/2020] [Indexed: 01/13/2023]
Abstract
Acne is an androgen-dependent inflammatory disease of sebaceous follicles. Herein, we reviewed and discussed the underlying pathways of androgen biosynthesis and metabolism, non-genomic regulation of androgen receptor expression and function, posttranslational regulation of androgen excess in acne and acne-associated syndromes, such as polycystic ovary syndrome, and congenital adrenal hyperplasia. We provide insights into the involvement of sex hormones, particularly androgens, in skin homeostasis and acne pathogenesis, including comedogenesis, lipogenesis, microbiota, and inflammation. Advanced understanding of the action mechanisms of classical acne treatment and new development of antiandrogens, both topical and systemic, are also highlighted.
Collapse
Affiliation(s)
- Tingting Hu
- Department of Dermatology, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ziyu Wei
- Department of Dermatology, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qiang Ju
- Department of Dermatology, South Campus, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Department of Dermatology, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - WenChieh Chen
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
| |
Collapse
|
38
|
Connelly PJ, Clark A, Touyz RM, Delles C. Transgender adults, gender-affirming hormone therapy and blood pressure: a systematic review. J Hypertens 2021; 39:223-230. [PMID: 32809982 PMCID: PMC7810409 DOI: 10.1097/hjh.0000000000002632] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/20/2020] [Accepted: 07/28/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Gender-affirming hormone therapy (GHT) is utilized by people who are transgender to align their secondary sex characteristics with their gender identity. Data relating to cardiovascular outcomes in this population are limited. We aimed to review the impact of GHT on the blood pressure (BP) of transgender individuals. METHODS We searched PubMed/MEDLINE, SCOPUS and Cochrane Library databases for articles published relating to the BP of transgender adults commencing GHT. Methodological quality was assessed via the 'Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group'. RESULTS Six hundred articles were screened, of which 14 studies were included in this systematic review encompassing 1309 individuals (∼50% transgender men and women) treated with GHT between 1989 and 2019. These articles were all pre-post observational studies without control groups. Mean ages ranged between 23.0-36.7 years (transgender men) and 25.2-34.8 years (transgender women). Interventions were diverse and included oral, transdermal and injectable hormonal preparations with 4 months to 5 years follow-up. Most studies in transgender men did not demonstrate a change in BP, whereas transgender women on GHT demonstrated both increases and decreases in SBP. These studies were heterogenous with significant methodological limitations and only two were determined to have a good quality rating. CONCLUSION There is currently insufficient data to advise the impact of GHT on BP in transgender individuals. Better quality research is essential to elucidate whether exogenous sex hormones modulate BP in transgender people and whether this putative alteration infers poorer cardiovascular outcomes.
Collapse
Affiliation(s)
- Paul J Connelly
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | | | | |
Collapse
|
39
|
Yang R, Liu C, Li Q, Wang W, Wu B, Chen A, Wang B, Li W, Chen J. Artificial intelligence based identification of the functional role of hirudin in diabetic erectile dysfunction treatment. Pharmacol Res 2021; 163:105244. [PMID: 33053440 DOI: 10.1016/j.phrs.2020.105244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/28/2020] [Accepted: 10/06/2020] [Indexed: 12/15/2022]
Abstract
Diabetic erectile dysfunction (DED) hugely affected the patients' sexual life quality. However, there are no satisfactory therapeutic methods and intervention targets for this subtype of erectile dysfunction (ED). Inspired by the clinical practice of traditional Chinese medicine (TCM), we found that hirudin, the main active ingredient in the leech, could ameliorate the ED symptoms of the DED mouse model. To further reveal the underlying mechanism of hirudin, we designed a novel strategy to discover potential targets based on the diagnostic system of TCM, and found that myeloperoxidase (MPO) was a promising target of hirudin. Hirudin directly interacts with MPO and inhibits its activity, thus further decreases the content of oxidized low-density lipoprotein (ox-LDL) in serum. Our results demonstrated that the hirudin could ameliorate the symptoms of DED, and revealed the underlying mechanism of hirudin in regulating the activity of MPO.
Collapse
Affiliation(s)
- Ruocong Yang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, 100029, China
| | - Chao Liu
- State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, 100101, China
| | - Qianqian Li
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, 100029, China
| | - Weilu Wang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, 100029, China
| | - Bingbing Wu
- State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, 100101, China
| | - Aiping Chen
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, 100029, China
| | - Bin Wang
- Department of Andrology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, China.
| | - Wei Li
- State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, 100101, China.
| | - Jianxin Chen
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, 100029, China.
| |
Collapse
|
40
|
Stancampiano MR, Lucas-Herald AK, Bryce J, Russo G, Barera G, Balsamo A, Baronio F, Bertelloni S, Valiani M, Cools M, Tack LJW, Darendeliler F, Poyrazoglu S, Globa E, Grinspon R, Hannema SE, Hughes IA, Tadokoro-Cuccaro R, Thankamony A, Iotova V, Mladenov V, Konrad D, Mazen I, Niedziela M, Kolesinska Z, Nordenström A, Ahmed SF. Testosterone Therapy and Its Monitoring in Adolescent Boys with Hypogonadism: Results of an International Survey from the I-DSD Registry. Sex Dev 2021; 15:236-243. [PMID: 34350903 DOI: 10.1159/000516784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/15/2021] [Indexed: 11/19/2022] Open
Abstract
It is unclear whether testosterone replacement therapy (TRT) in adolescent boys, affected by a range of endocrine diseases that may be associated with hypogonadism, is particularly common. The aim of this study was to assess the contemporary practice of TRT in boys included in the I-DSD Registry. All participating centres in the I-DSD Registry that had boys between 10 and 18 years of age and with a condition that could be associated with hypogonadism were invited to provide further information in 2019. Information on 162 boys was collected from 15 centres that had a median (range) number of 6 boys per centre (1.35). Of these, 30 (19%) from 9 centres were receiving TRT and the median (range) age at the start was 12.6 years (10.8-16.2), with 6 boys (20%) starting at <12 years. Median (range) age of boys not on TRT was 11.7 years (10.7-17.7), and 69 out of 132 (52%) were <12 years. TRT had been initiated in 20 of 71 (28%) boys with a disorder of gonadal development, 3 of 14 (21%) with a disorder of androgen synthesis, and all 7 (100%) boys with hypogonadotropic hypogonadism. The remainder who did not have TRT included 15 boys with partial androgen insensitivity, 52 with non-specific XY DSD, and 3 with persistent Müllerian duct syndrome. Before starting TRT, liver function and blood count were checked in 19 (68%) and 18 boys (64%), respectively, a bone age assessment was performed in 23 (82%) and bone mineral density assessment in 12 boys (43%). This snapshot of contemporary practice reveals that TRT in boys included in the I-DSD Registry is not very common, whilst the variation in starting and monitoring therapy is quite marked. Standardisation of practice may lead to more effective assessment of treatment outcomes.
Collapse
Affiliation(s)
- Marianna R Stancampiano
- Department of Paediatrics, Endocrine Unit, Scientific Institute San Raffaele, Milan, Italy,
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom,
| | - Angela K Lucas-Herald
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
| | - Jillian Bryce
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
| | - Gianni Russo
- Department of Paediatrics, Endocrine Unit, Scientific Institute San Raffaele, Milan, Italy
| | - Graziano Barera
- Department of Paediatrics, Endocrine Unit, Scientific Institute San Raffaele, Milan, Italy
| | - Antonio Balsamo
- Department of Medical and Surgical Sciences, Paediatric Unit, Endo-ERN Center IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Baronio
- Department of Medical and Surgical Sciences, Paediatric Unit, Endo-ERN Center IT11, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Silvano Bertelloni
- Paediatric and Adolescent Endocrinology, Department of Obstetrics, Gynecology and Paediatrics, Azienda Ospedaliero, Universitaria Pisana, Pisa, Italy
| | - Margherita Valiani
- Paediatric and Adolescent Endocrinology, Department of Obstetrics, Gynecology and Paediatrics, Azienda Ospedaliero, Universitaria Pisana, Pisa, Italy
| | - Martine Cools
- Department of Internal Medicine and Paediatrics, Ghent University and Department of Paediatric Endocrinology, University Hospital Ghent, Ghent, Belgium
| | - Lloyd J W Tack
- Department of Internal Medicine and Paediatrics, Ghent University and Department of Paediatric Endocrinology, University Hospital Ghent, Ghent, Belgium
| | - Feyza Darendeliler
- Paediatric Endocrinology Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sukran Poyrazoglu
- Paediatric Endocrinology Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Evgenia Globa
- Department of Pediatric Endocrinology, Ukrainian Scientific Center of Endocrine Surgery, Endocrine Organs and Tissue Transplantation, MoH of Ukraine, Kyiv, Ukraine
| | - Romina Grinspon
- Centro de Investigaciones Endocrinológicas 'Dr. César Bergadá' (CEDIE), CONICET - FEI, División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Centre, Amsterdam, The Netherlands
| | - Ieuan A Hughes
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | | | - Ajay Thankamony
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Violeta Iotova
- Department of Paediatrics - UMHAT 'Sv.Marina', Medical University of Varna, Varna, Bulgaria
| | - Vilhelm Mladenov
- Department of Paediatrics - UMHAT 'Sv.Marina', Medical University of Varna, Varna, Bulgaria
| | - Daniel Konrad
- Division of Paediatric Endocrinology and Diabetology, University Children's Hospital, Zurich, Switzerland
| | - Inas Mazen
- Department of Clinical Genetics, National Research Center, Cairo, Egypt
| | - Marek Niedziela
- Department of Paediatric Endocrinology and Rheumatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Zofia Kolesinska
- Department of Paediatric Endocrinology and Rheumatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Paediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
| |
Collapse
|
41
|
Rozga M, Linsenmeyer W, Cantwell Wood J, Darst V, Gradwell E. Hormone therapy, health outcomes and the role of nutrition in transgender individuals: A scoping review. Clin Nutr ESPEN 2020; 40:42-56. [DOI: 10.1016/j.clnesp.2020.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/21/2020] [Accepted: 08/22/2020] [Indexed: 02/06/2023]
|
42
|
Schagen SEE, Wouters FM, Cohen-Kettenis PT, Gooren LJ, Hannema SE. Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones. J Clin Endocrinol Metab 2020; 105:5903559. [PMID: 32909025 PMCID: PMC7524308 DOI: 10.1210/clinem/dgaa604] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 09/08/2020] [Indexed: 12/30/2022]
Abstract
CONTEXT Hormonal interventions in adolescents with gender dysphoria may have adverse effects, such as reduced bone mineral accrual. OBJECTIVE To describe bone mass development in adolescents with gender dysphoria treated with gonadotropin-releasing hormone analogues (GnRHa), subsequently combined with gender-affirming hormones. DESIGN Observational prospective study. SUBJECTS 51 transgirls and 70 transboys receiving GnRHa and 36 transgirls and 42 transboys receiving GnRHa and gender-affirming hormones, subdivided into early- and late-pubertal groups. MAIN OUTCOME MEASURES Bone mineral apparent density (BMAD), age- and sex-specific BMAD z-scores, and serum bone markers. RESULTS At the start of GnRHa treatment, mean areal bone mineral density (aBMD) and BMAD values were within the normal range in all groups. In transgirls, the mean z-scores were well below the population mean. During 2 years of GnRHa treatment, BMAD stabilized or showed a small decrease, whereas z-scores decreased in all groups. During 3 years of combined administration of GnRHa and gender-affirming hormones, a significant increase of BMAD was found. Z-scores normalized in transboys but remained below zero in transgirls. In transgirls and early pubertal transboys, all bone markers decreased during GnRHa treatment. CONCLUSIONS BMAD z-scores decreased during GnRHa treatment and increased during gender-affirming hormone treatment. Transboys had normal z-scores at baseline and at the end of the study. However, transgirls had relatively low z-scores, both at baseline and after 3 years of estrogen treatment. It is currently unclear whether this results in adverse outcomes, such as increased fracture risk, in transgirls as they grow older.
Collapse
Affiliation(s)
- Sebastian E E Schagen
- Department of Pediatric Endocrinology, VU University Medical Center, 1081 HV Amsterdam, & Leiden University Medical Center, ZA Leiden, the Netherlands
| | - Femke M Wouters
- Department of Pediatric Endocrinology, VU University Medical Center, HV Amsterdam, the Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology, Amsterdam UMC, VU University, HV Amsterdam, the Netherlands
| | - Louis J Gooren
- Department of Endocrinology, VU University Medical Center, HV Amsterdam, the Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Willem-Alexander Children Hospital, Leiden University Medical Center, ZA Leiden, the Netherlands
- Department of Pediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Centre, CN Rotterdam, Netherlands
| |
Collapse
|
43
|
Abstract
Many children with chronic disease are now surviving into adulthood. As a result, there is a growing interest in optimizing bone health early in the disease course with the dual goals of improving quality of life during childhood and reducing life-long fracture risk. Risk factors for impaired bone health in these children include immobility, nutritional deficiency, exposure to bone toxic therapies, hormonal deficiencies affecting growth and pubertal development, and chronic inflammation. This review focuses on the chronic diseases of childhood most commonly associated with impaired bone health. Recent research findings and clinical practice recommendations, when available, for specific disorders are summarized.
Collapse
Affiliation(s)
- David R Weber
- Department of Pediatrics - Endocrinology, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA.
| |
Collapse
|
44
|
Lee JY, Finlayson C, Olson-Kennedy J, Garofalo R, Chan YM, Glidden DV, Rosenthal SM. Low Bone Mineral Density in Early Pubertal Transgender/Gender Diverse Youth: Findings From the Trans Youth Care Study. J Endocr Soc 2020; 4:bvaa065. [PMID: 32832823 PMCID: PMC7433770 DOI: 10.1210/jendso/bvaa065] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/29/2020] [Indexed: 11/29/2022] Open
Abstract
Context Transgender youth may initiate GnRH agonists (GnRHa) to suppress puberty, a critical period for bone-mass accrual. Low bone mineral density (BMD) has been reported in late-pubertal transgender girls before gender-affirming therapy, but little is known about BMD in early-pubertal transgender youth. Objective To describe BMD in early-pubertal transgender youth. Design Cross-sectional analysis of the prospective, observational, longitudinal Trans Youth Care Study cohort. Setting Four multidisciplinary academic pediatric gender centers in the United States. Participants Early-pubertal transgender youth initiating GnRHa. Main Outcome Measures Areal and volumetric BMD Z-scores. Results Designated males at birth (DMAB) had below-average BMD Z-scores when compared with male reference standards, and designated females at birth (DFAB) had below-average BMD Z-scores when compared with female reference standards except at hip sites. At least 1 BMD Z-score was < -2 in 30% of DMAB and 13% of DFAB. Youth with low BMD scored lower on the Physical Activity Questionnaire for Older Children than youth with normal BMD, 2.32 ± 0.71 vs. 2.76 ± 0.61 (P = 0.01). There were no significant deficiencies in vitamin D, but dietary calcium intake was suboptimal in all youth. Conclusions In early-pubertal transgender youth, BMD was lower than reference standards for sex designated at birth. This lower BMD may be explained, in part, by suboptimal calcium intake and decreased physical activity–potential targets for intervention. Our results suggest a potential need for assessment of BMD in prepubertal gender-diverse youth and continued monitoring of BMD throughout the pubertal period of gender-affirming therapy.
Collapse
Affiliation(s)
- Janet Y Lee
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California, San Francisco, San Francisco, California.,Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Courtney Finlayson
- Division of Endocrinology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Johanna Olson-Kennedy
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Robert Garofalo
- Division of Adolescent Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yee-Ming Chan
- Division of Endocrinology, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Stephen M Rosenthal
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California, San Francisco, San Francisco, California
| |
Collapse
|
45
|
Venous Thromboembolism in a Transgender Adolescent on Testosterone Therapy: A Case Report and Literature Review. J Pediatr Hematol Oncol 2020; 42:e352-e354. [PMID: 32079984 DOI: 10.1097/mph.0000000000001755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of pediatric venous thromboembolism (VTE) has been increasing in the past few decades and can be associated with significant mortality and morbidity. There are known risk factors associated with VTE, including estrogen therapy. However, the relationship between testosterone and VTE remains unclear. Here, we present a 17-year-old female-to-male transgender patient without a history of inherited thrombophilia, who developed pulmonary embolism while receiving testosterone injections for gender dysphoria. Despite the limited data on testosterone and the risk of VTE, health care providers should counsel patients and family about the possible increased risk of VTE when starting testosterone.
Collapse
|