Cross-sex hormone therapy in transgender persons affects total body weight, body fat and lean body mass: a meta-analysis

The intersection of the laboratory and transgender care

Transgender and gender diverse (TGD) individuals seeking gender affirming treatment are an increasing demographic in today's society; such treatments include hormonal and surgical interventions aimed at alleviating gender dysphoria and increasing quality of life. A number of diagnostic pathology tests are provided to medical professionals with sex specific reference intervals (RIs) for interpretation, due to sex specific physiological differences, organ size and hormone levels for example. These tests may be reported with RIs that are not appropriate, and interpretation for the medical professional can be challenging. From the laboratory perspective, there are limitations in Laboratory Information Management Systems (LIMS) and the ability of these databases to record both sex and gender identifiers, as well as the reporting of appropriate RIs. The use of RIs derived from the transgender population is complex, studies generally have a low sample size and include adults with long established hormonal treatments. The age of an individual undergoing gender affirming therapy has decreased, and the use of Gonadotrophin Releasing Hormone analogues adds complexity. In this review, we will discuss the current challenges and perspectives regarding the reporting of reference intervals in the TGD population, the derivation of personalized or transgender specific RIs and interpretation of specific diagnostic tests.

Early body composition changes in trans women on low-dose estradiol: comparing oral vs sublingual administration using dual energy absorptiometry and bioelectrical impedance analysis

BACKGROUND

Low-dose sublingual estradiol gender-affirming hormone therapy (GAHT) in treatment-naive transgender women effectively suppresses testosterone and initiates breast development, comparable to oral estradiol with cyproterone acetate; however, its impact on body composition remains unstudied.

AIM

To assess early body composition changes with low-dose estradiol, compare sublingual versus oral administration efficacy, and evaluate bioelectrical impedance analysis (BIA) and dual-energy X-ray absorptiometry (DXA) agreement in transgender women undergoing GAHT.

METHODS

In this 6-month prospective study, 22 treatment-naïve transgender women received either 2 mg/day sublingual estradiol (SLE) or combined oral (CO)-2 mg/day oral estradiol plus 10 mg/day cyproterone acetate. Body composition was assessed using DXA and BIA at baseline and after 6 months.

OUTCOMES

Changes in body composition, including lean body mass, fat mass, visceral fat area, waist-to-hip ratio, and android-to-gynoid fat ratio.

RESULTS

BIA and DXA measurements showed good agreement. Both groups experienced decreased lean body mass and increased fat mass. The SLE group showed less increase in total and segmental body fat, and visceral fat area compared to CO. Both treatments decreased waist-to-hip ratio and android-to-gynoid fat ratio, indicating early achievement of a more feminine body shape.

CLINICAL IMPLICATIONS

These findings may help optimize GAHT protocols, improve patient satisfaction with treatment, and enable monitoring outcome assessment in transgender women.

STRENGTHS AND LIMITATIONS

This study provides valuable insights into early body composition changes with low-dose estradiol administration via different administration routes and validates BIA as an alternative to DXA. However, the sample size was relatively small, the study arm allocation was not randomized, and the study duration was only 6 months.

CONCLUSION

Low-dose estradiol induces significant feminizing body composition changes within 6 months of GAHT, with sublingual administration potentially limiting fat accumulation while achieving a feminine body shape.

STUDY REGISTRATION

ISRCTN15726488 Entire data set found at:  https://doi.org/10.17605/OSF.IO/VNC54.

Treatment of Cardiovascular Manifestations in Transgender Individuals

The transgender population has been steadily increasing, with more individuals seeking gender-affirming care to align their physical characteristics with their gender identity. Despite advances in healthcare, transgender individuals face significant barriers to accessing culturally competent care, resulting in heightened cardiovascular risks and disparities. Cardiovascular disease prevalence among transgender individuals is influenced by a combination of physiological, psychological, and social factors, including the impacts of gender-affirming hormone therapy, surgical interventions, and minority stress. This review examines the cardiovascular risks associated with estrogen therapy in transfeminine individuals and testosterone therapy in transmasculine individuals, highlighting their effects on lipid profiles, thromboembolic risks, and metabolic parameters. Furthermore, it explores the implications of gender-affirming surgeries and the role of psychosocial stress in cardiovascular outcomes. Current evidence underscores the need for tailored risk assessment, proactive management strategies, and lifestyle interventions to optimize cardiovascular health in this population. Significant research gaps remain regarding the long-term cardiovascular effects of gender-affirming care. Large-scale, prospective studies and the development of transgender-specific cardiovascular care guidelines are crucial to address these gaps. This review advocates for a multidisciplinary, patient-centered approach to mitigate cardiovascular risks and improve outcomes for transgender individuals.

Gender-affirming hormone therapy and its impact on myocardial mass and cardiac function: a prospective magnetic resonance cohort study on transgender men and women

OBJECTIVE

Differences in cardiac parameters such as myocardial mass, left ventricular ejection fraction (LVEF), cardiac output, and brain natriuretic peptide (NT-proBNP) levels between cisgender men and women are well established. No evidence exists regarding changes in myocardial mass or cardiac function parameters in transgender individuals undergoing gender-affirming hormone therapy (GAHT).

DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOMES

A prospective study enrolling transgender individuals under GAHT (20 individuals assigned female at birth [AFAB] and 15 assigned male at birth [AMAB]) was conducted at the Medical University of Vienna from 2019 to 2022. A 3-Tesla electrocardiogram-gated magnetic resonance imaging measured myocardial mass, LVEF, and other cardiac function parameters before GAHT and at 6-month follow-up. Myocardial lipid content was quantified using magnetic resonance spectroscopy.

RESULTS

In AFAB, myocardial mass increased significantly after 6 months of GAHT from mean (±SD) 48 (±8) g/m2 at baseline to 54 (±7) g/m2 at follow-up (P = .011). Individuals assigned male at birth showed a nonsignificant decrease of 4 (±14) g/m2 in myocardial mass. In both groups, no significant changes were noted in LVEF, stroke volume, cardiac output, or peak filling rate. Neither testosterone (AFAB: r = -0.127, P = .679; AMAB: r = -0.127, P = .679) nor estradiol levels (AFAB: r = -0.154, P = .616; AMAB: r = -0.154, P = .616) nor body mass index was related to myocardial mass at follow-up. Brain natriuretic peptide levels in AFAB were significantly reduced at follow-up (from median [IQR] 41 [26-57] to 19 [12-34] pg/mL).

CONCLUSIONS

Myocardial mass increased, while NT-proBNP levels decreased significantly in AFAB after 6 months of GAHT. However, no significant changes in cardiac function were noted in AMAB and AFAB.

REGISTRATION

ClinicalTrials.gov: NCT06245681 (registered 07 February 2024, https://classic.clinicaltrials.gov/ct2/show/NCT06245681).

Inclusivity in Epilepsy Care: Navigating the Complex Nature of Seizure Disorders in People Undergoing Gender-Affirming Care

There is a paucity of information to rely on when caring for transgender and gender diverse (TGD) individuals with epilepsy. Clinicians must be aware of the mechanisms of antiseizure medications, potential unique side effects, and medication interactions that require monitoring. This principle is central to the clinical care of the TGD population, specifically for those pursuing gender-affirming care via hormone treatment and/or surgical interventions. This resource aims to support the delivery of quality healthcare with a comprehensive approach for TGD individuals living with epilepsy. This article discusses diverse topics, including antiseizure medications, drug-drug interactions, surgical and neuromodulation techniques, as well as general considerations for managing complex cases of medication-resistant epilepsy in TGD individuals. It also aims to make neurologists familiar with the basics of medical and surgical care for the same population and highlight potential reciprocal effects between comprehensive gender-affirming and epilepsy care.

The effects of gender-affirming hormone therapy on myocardial, hepatic, pancreatic lipid content, body fat distribution and other cardiometabolic risk factors: A magnetic resonance-based study in transgender individuals

Purpose

We aimed to assess the changes in body fat distribution, intraorgan lipid accumulation, and cardiometabolic risk factors after 6 months of gender-affirming hormone therapy (GAHT) in transgender men (TM) and transgender women (TW).

Methods

Conducted at the Medical University of Vienna between 2019 and 2022, the study included 15 TW and 20 TM. We conducted magnetic resonance imaging and spectroscopy to determine the visceral (VAT) and subcutaneous adipose tissue (SAT) amounts, the VAT/SAT ratio, and the intraorgan lipid content (liver, pancreas, myocardium), bloodwork, and an oral glucose tolerance test at baseline and after 6 months of GAHT.

Results

Pancreatic, hepatic, and intramyocardial lipid contents did not significantly change in either group after 6 months of GAHT. In TW, VAT/SAT ratio decreased significantly from baseline 0,930 (IQR 0,649-1,287) to 0,758 (IQR 0,424-0,900; p = 0,011) after 6 months of GAHT. The updated homeostatic model assessment for insulin sensitivity (HOMA2-%S) significantly decreased from 83,03 % (±31,11) to 64,27 % (±18,01; p = 0,047), indicating decreased insulin sensitivity, while the updated homeostatic model assessment for β-cell function (HOMA2-%β) increased (from 128,11 % (±35,80) to 156,80 % (±39,49); p = 0,020) in TW after 6 months of GAHT. In TM, there were no changes in glucose metabolism parameters except for an increase in HbA1c (5,1% (±0,3) vs 5,3% (±0,4), p = 0,001).

Conclusions

6 months of GAHT were not associated with statistically significant changes in myocardial, hepatic, or pancreatic lipid content. Short-term GAHT led to a marked body fat redistribution with a significant decrease in the VAT/SAT ratio in TW.

Longitudinal changes in regional fat and muscle composition and cardiometabolic biomarkers over 5 years of hormone therapy in transgender individuals

BACKGROUND

Longitudinal studies investigating hormone therapy in transgender individuals are rare and often limited to 1- to 2-year follow-up periods.

OBJECTIVES AND METHODS

We examined changes in body composition, muscle volumes, and fat distribution as well as muscle strength, arterial stiffness, and cardiometabolic biomarkers in both transgender men (TM; n = 17, age 25 ± 5 years) and transgender women (TW; n = 16, age 28 ± 5 years) at baseline and after 1 and 5-6 years of hormone therapy in a longitudinal prospective cohort design. Whole-body and regional fat and muscle volumes were analyzed using magnetic resonance imaging, and blood samples were taken.

RESULTS

Skeletal muscle size increased in TM (21% after 6 years) and decreased in TW (7% after 5 years). Muscle strength increased 18% after 6 years in TM (p = 0.003) but was statistically unchanged in TW. Muscle fat infiltration changed (p < 0.05) almost completely toward the affirmed sex phenotype after 1 year of therapy in both TM and TW. The most notable changes in fat volume distribution were that TW increased total adiposity but decreased visceral fat volume, whereas TM showed increased visceral fat (70%) and liver fat but relatively stable total adipose tissue levels. Although arterial stiffness and blood pressure did not change, there was a significant increase in triglyceride and LDL cholesterol levels and a decrease in HDL levels in TM after 6 years.

CONCLUSION

These unique longitudinal data underscore the importance of continued clinical monitoring of the long-term health effects of gender-affirming hormone therapy in both TW and, perhaps especially, TM.

Trans men can achieve adequate muscular development through low-dose testosterone therapy: A long-term study on body composition changes

BACKGROUND

Transgender individuals undergo the gender-affirming hormone therapy (GAHT) to achieve physical changes consistent with their gender identity. Few studies are available on the long-term safety and efficacy of GAHT.

OBJECTIVES

To investigate the long-term physical effects and the safety of the testosterone therapy for trans men and to assess the impact of differential hormone dose.

MATERIALS AND METHODS

Trans men who initiated GAHT between May 2000 and December 2021 were included in this retrospective analysis. Physical findings (body mass index, body fat percentage (BFP), lean body mass (LBM), and grip strength), blood testing results (hemoglobin, hematocrit, uric acid, creatinine, total cholesterol, triglycerides, and total testosterone), and menstrual cessation were recorded. We assessed the effects of testosterone on body composition changes and laboratory parameters, comparing a low-dose group (≤ 62.5 mg/wk) to a high-dose group (> 62.5 mg/wk).

RESULTS

Of 291 participants, 188 patients (64.6%) were in the low-dose group and 103 (35.4%) in the high-dose group. Cumulative menstrual cessation rates up to 12 months were not significantly different between groups. Both groups showed a decrease in BFP and an increase in LBM during the first year of therapy, followed by a slight increase in both over the long term. The high-dose group exhibited greater LBM gains during the first year. Higher hormone doses and lower initial LBM values were associated with LBM increases at 3 and 6 months (3 mo, P = 0.006, P < 0.001; 6 mo, P = 0.015, P < 0.001). There were no long-term, dose-dependent side effects such as polycythemia or dyslipidemia.

CONCLUSION

Long-term GAHT for trans men is safe and effective. Low-dose testosterone administration is sufficient to increase LBM in trans men. Higher testosterone doses can lead to an earlier increase in muscle mass.

Differences in cardiorespiratory fitness by gonadotropin-releasing hormone agonist treatment before and after testosterone in transgender adolescents

There are known sex differences in cardiorespiratory fitness (CRF). Little is known about the impact of pubertal blockade with a gonadotropin-releasing hormone agonist (GnRHa) followed by hormone therapy on CRF for transgender adolescents. We aimed to 1) determine the effect of GnRHa monotherapy on CRF and mitochondrial function and associations with metabolomic profiles and 2) evaluate changes after 1 and 12 mo of testosterone therapy among transgender adolescents. Participants assigned female at birth (n = 19, baseline age of 15.0 ± 1.0 yr) from two groups: GnRHa+ (n = 8) and GnRHa- (n = 11) were examined at baseline and 1- and 12-mo post-testosterone therapy in a longitudinal observational study to assess cardiorespiratory fitness, mitochondrial respiration, and metabolic profile. Fasted morning labs included assessment of metabolomics and peripheral blood mononuclear cell mitochondrial respiration and degree of mitochondrial coupling (respiratory control ratio, RCR). A graded cycle ergometer test was performed. Baseline differences were evaluated between groups. Changes were compared with mixed linear regression models evaluating time (baseline, 1 mo, and 12 mo), group (GnRHa treatment yes/no), and their interaction. At baseline GnRHa+ individuals had higher relative V̇o2peak (30.1 ± 4.83 vs. 25.24 ± 4.47 mL/kg/min, P = 0.042) than GnRHa- individuals. In regression models, GnRHa+ individuals had a significant increase in peak watts (P = 0.011) and total exercise time (P = 0.005) after 12 mo of testosterone (P = 0.012) but not GnRHa- individuals. GnRHa+ individuals have significantly higher RCR under carbohydrate (P = 0.0007) and lipid (P = 0.0002) conditions than GnRHa+ individuals. Pretreatment with GnRHa positively influences peak CRF and mitochondrial respiration in adolescent transgender males undergoing testosterone therapy.NEW & NOTEWORTHY This study demonstrates differences in exercise capacity and mitochondrial respiration at baseline based on whether or not individuals had feminizing puberty blocked. Individuals who had puberty blocked had greater improvements in cardiopulmonary exercise testing parameters after 12 mo of testosterone than those who went through feminizing puberty.

Evaluating changes in body composition, bone mass, and metabolic profile in an animal model undergoing transfeminine hormone therapy and physical exercise

BACKGROUND & AIMS

Gender-affirming hormone therapy (GAHT) is essential for transgender individuals seeking body modifications. For transfeminine people assigned male at birth, GAHT typically involves a combination of antiandrogens and estrogens. Despite its importance, the scientific literature presents inconsistencies regarding the effects of these hormones on nutritional status, body composition, and biochemical markers. This study aims to evaluate the impact of estradiol enanthate and dihydroxyprogesterone acetophenide (E2EN/DHPA) hormonal treatment, in conjunction with resistive physical exercise, on body composition and metabolic profiles.

METHODS

Twenty-eight male rats were divided into three groups: MO (control group, n = 8), receiving sesame oil vehicle; MH (n = 11), receiving E2EN/DHPA; and MEH (n = 9), receiving E2EN/DHPA along with physical exercise. The hormonal treatment was administered every ten days for two months, while the exercise regimen involved stair climbing with progressively increasing weights, performed five times weekly for seven weeks. Evaluated parameters included body mass index (BMI), body composition (fat and lean mass), bone mineral density (BMD), and lipid profile (triglycerides, HDL-C, LDL-C).

RESULTS

The rats that received E2EN/DHPA showed significant changes in body composition and BMI, regardless of exercise. The MH group had increased body fat, while both the MH and MEH groups had decreased bone area and mineral content. However, BMD remained the same across all groups. Elevated triglyceride levels were observed, and the MEH group also had reduced LDL-C levels. HDL-C levels did not show significant variation.

CONCLUSION

The study's findings show similarities to changes seen in transfeminine individuals undergoing GAHT with estrogen and antiandrogens. These changes include decreased muscle mass, increased body fat, preserved bone mineral density, and elevated triglycerides. The study also found that resistance exercise positively impacted lipid profiles, particularly in reducing LDL-C. These results highlight the need for further research and comparative trials on hormone therapy regimens.

Assessing the Influence of Long-Term Gender-Affirming Hormone Therapy on Cardiovascular Risk in Transgender Men through Carotid Intima-Media Thickness

Background: Transgender men use exogenous androgen for male pattern virilization. Hysterectomy and bilateral salpingo-oophorectomy (HBSO) is performed to stop the endogenous estrogen secretion. Cardiovascular disease (CVD) risk has been shown to increase with long-term use of androgens and the removal of estrogen. We aimed to investigate the CVD risk in these individuals by measuring internal and common carotid artery intima-media thicknesses (CIMT). Methods: In this cohort study, data were collected from transgender men who had undergone HBSO and used androgens for at least two years (median treatment duration was 5 years in our research). Cisgender women in the same age range were selected as the control group. Demographics, vital signs, and hematological values of transgender patients and cisgender women subjects in the control group were noted. CVD markers were compared with sonographically measured CIMT values. Results: The mean age and body mass index (BMI) of the study group were 32.6 and 25.3, respectively. Weight, systolic-diastolic blood pressure, hemoglobin, hematocrit, low-density lipoprotein (LDL), serum triglyceride (TG), HbA1c levels, internal CIMT, and common CIMT values of the study group were higher, while the high-density lipoprotein (HDL) level was significantly lower compared the control group (p1 = 0.025, p2 = 0.010, p3 = 0.002, p4 = 0.001, p5 = 0.001, p6 = 0.012, p7 = 0.008, p8 = 0.007, p9 = 0.013, and p10 = 0.001). There was also an increase in the body weight, BMI, LDL, and TG levels of the study group after the testosterone treatment (p1 = 0.025, p2 = 0.019, p3 = 0.001, p4 = 0.001, and p5 = 0.001). Conclusions: We demonstrated that the use of testosterone therapy in transgender men is associated with higher CIMT values. While further investigation is needed to assess morbidity and mortality rates, we recommend that regular clinical and radiological examinations be performed in these individuals to accurately evaluate the risk of CVD.

Association Between Body Mass Index and Clinical Outcomes of Gender-Affirming Masculinizing Chest Reconstruction

INTRODUCTION

Body mass index (BMI) is often used in surgical settings to determine patients' risk of complications. In the context of gender-affirming care, BMI requirements for surgery can limit access to necessary care for larger-bodied people. There is a critical need to understand the association between BMI and postoperative outcomes for this population.

METHODS

A retrospective chart review was conducted using the first 250 consecutive gender-affirming masculinizing chest reconstructions performed between 2017 and 2021 at a large academic medical institution. The relationships between BMI, preoperative factors, and common postsurgical outcomes were assessed.

RESULTS

Average BMI at surgery was 27.5 ± 6.7 kg/m2. Increases in BMI were associated with longer drain stays, larger volume of tissue resected, higher likelihood of nipple grafts, and lower likelihood of periareolar surgery (all P < 0.0001). Simple logistic regression revealed that BMI increases were significantly related to the likelihood of experiencing dog ears in the intermediate term (P = 0.002). Multivariate logistic regression adjusted for common covariates (age, ethnicity, smoking status, asthma, autoimmune disorders, cardiovascular conditions, and mental health disorders) did not reveal any significant relationships between BMI and the likelihood of experiencing complications at any study point.

CONCLUSIONS

Masculinizing chest reconstruction is safe and satisfactory for young adult patients across the range of BMI, with significant differences in outcomes found only for esthetic complications (i.e., dog ears). Surgeons should inform patients with higher BMIs about what outcomes to expect but higher BMI should not preclude surgery access.

Relationship between Food Habits, Nutritional Status, and Hormone Therapy among Transgender Adults: A Systematic Review

Background/Objectives: The current gender-specific nutritional assessment methods for the transgender population may not cover the unique physiological characteristics of the gender transition process. Considering the potential effects of hormone therapy (HT), it has become relevant to review current evidence on the nutritional status of the transgender population. This systematic review aims to provide an updated report of the characteristics of the nutritional status, including food habits, and eating disorders in transgender individuals undergoing HT. Methods: Five databases were researched (PubMed, Web of Science, Scopus, Scielo, and Cochrane Library) from database inception to May 2024. The PRISMA 2020 statement was used. Studies focusing on adult transgender individuals (18 to 65 years old) that included outcomes related to nutritional status, HT, and food habits were considered for this review. The NOS and NIH tools were chosen to perform the risk of bias and quality assessment. Results: A total of 122 studies were identified, and 27 were included in this review. These studies comprised sixteen cohorts, seven cross-sectional, and four case studies, with a combined number of 8827 participants. BMI was the most referenced parameter, varying between low weight and overweight. High food insecurity frequency, restricted eating behaviors, high fat intake, and low levels of vegetable, grain, and fruit consumption were also observed. Conclusions: While nutritional status was perceived as a relevant factor when administering HT, the relationship between HT with both nutritional status and food habits has been insufficiently explored and warrants further research.

Metabolic and cardiovascular risks of hormone treatment for transgender individuals

Identifying metabolic and cardiovascular risks of gender-affirming hormone therapy (GAHT) is challenging due to other confounding variables that affect patient outcomes and the diversity of treatment regimes. Masculinising hormone therapy produces atherogenic lipid profiles, while effects on other metabolic parameters are not consistent. There is insufficient evidence to conclude if cardiovascular disease risk among transmen is increased. The effects of feminising hormone therapy on metabolic parameters do not demonstrate a consistent pattern in the available literature. However, the risk of venous thromboembolism is greater in transwomen than in cis-gender men and women with a possible increase in cardiovascular disease risk. It is recommended to discuss the potential effects of GAHT on cardiovascular health and encourage patients seeking GAHT to adopt a healthy lifestyle. Performing baseline and periodic assessments of cardiovascular risk factors would enable early identification and interventions. In high-risk individuals, the cardiovascular effects of hormonal regimes might impact the treatment decision.

Gender-affirming hormone treatment modalities for transfemale & non-binary transfeminine individuals: A UK perspective

Gender incongruence and the number of people seeking gender affirming hormone treatment has dramatically risen in the last two decades. In the UK, transgender women and non-binary transfeminine individuals are typically treated with simultaneous suppression of endogenous testosterone production through anti-androgens and exogenous oestradiol replacement. Oestrogen replacement comes in different forms and is primarily given as transdermal (gel or patch) or oral preparations in the UK. Decisions around preparation choice are based on a combination of individual preference and/or mitigating the chance of complications based on individual risk profiles. Time frames to achieve female physical changes are largely predictable and managing expectations of individuals prior to commencing treatment is highly important. Common complications include venous thromboembolism, liver dysfunction and effects on fertility, thus individuals should be thoroughly counselled prior to commencing treatment. This article provides an overview of the management and considerations of gender-affirming hormone treatment in transgender women and non-binary transfeminine individuals.

Prevalence of cardiovascular events among transgender adults with obesity: A population-based analysis

INTRODUCTION

Although obesity and its impact on cardiovascular (CV) events have been extensively studied in the cisgender population, little is known about its impact on CV events in transgender individuals. Our study aimed to establish the prevalence of obesity and CV events in transgender adults.

METHODS

We conducted a retrospective cohort comparative study utilizing the U.S. National Inpatient Sample 2020 database. We identified admissions of transgender patients with administrative codes. Later, these patients were divided into obesity and non-obesity cohorts. Multivariable regression analysis was then performed for in-hospital all-cause mortality, acute myocardial infarction, acute ischemic stroke, cardiac arrest, pulmonary embolism and, major adverse cardiovascular and cerebrovascular events (MACCE).

RESULTS

In 2020, 19,345 transgender patients were admitted; 16,390 (84.7 %) had no obesity, and 2,955 (15.3 %) had obesity. The median age was 31 years in the non-obesity cohort and 37 years in the obesity cohort. Transgender men comprised 54.5 % of the non-obesity cohort and 47.9 % of the obesity cohort. Common baseline conditions in the non-obesity and obesity cohorts, respectively, included hypertension (20.7 % vs. 43.5 %), diabetes (10.2 % vs. 32.5 %), chronic pulmonary disease (18.9 % vs. 27.7 %), and hyperlipidemia (11.5 % vs. 25 %). MACCE was observed in 2.3 % of the non-obesity cohort compared to 5.4 % in the obesity cohort, and cardiac arrest occurred in 0.2 % of the non-obesity cohort versus 1.2 % in the obesity cohort. A statistically significant association was found in MACCE [odds ratio (OR) 2.1, 95 % confidence interval (CI) 1.24-3.55, p = 0.006] and cardiac arrest [OR 3.92, 95 % CI 1.11-12.63, p = 0.022] among transgender patients with obesity.

CONCLUSION

We observed increased odds of MACCE and cardiac arrest in transgender patients with obesity, possibly due to obesity and CV risk factors like hypertension, diabetes, and hyperlipidemia. Further large-scale comparative studies are needed to better understand obesity's impact on CV outcomes in the transgender population.

Persistent vaginal bleeding during gender-affirming hormone therapy in transgender men

PURPOSE

While it is common for menstrual cycles to cease within the initial 6 months of treatment, there are instances where some transgender men may not experience this cessation. We analyzed transgender men undergoing gender-affirming hormone therapy (GAHT) with testosterone who experienced breakthrough bleeding in order to identify the factors associated with this condition.

METHODS

In this case-control study, 24 transgender men in the case group and 48 in the control group were assessed for clinical, sociodemographic, hormonal, and body composition variables using dual-energy X-ray absorptiometry. All participants had been on GATH for at least 6 months.

RESULTS

A few transgender men experienced persistent breakthrough bleeding, which was associated with decreased testosterone levels and free androgen index (FAI) compared with controls (p = 0.002 and p = 0.008, respectively). Among individuals with breakthrough bleeding, 50% had testosterone levels below the lowest tertile calculated for the sample, compared with 18.8% on controls (p = 0.007). After therapy adjustment, testosterone levels increased compared with the values obtained in the initial bleeding episode (p = 0.031). Eight transgender men required the addition of an oral progestogen to achieve amenorrhea, and these individuals had higher BMI than those in whom the adjustment of the parenteral testosterone dose was adequate (p = 0.026). A univariate prevalence ratio analysis revealed a negative association of persistent bleeding with testosterone levels (p = 0.028) and FAI levels (p = 0.019).

CONCLUSION

Higher BMI and lower levels of testosterone and FAI were the main factors associated with breakthrough bleeding in transgender men.

Body composition and risk for sarcopenia in transgender women

OBJECTIVES

Body composition and strength of cisgender (cis) individuals are well established. However, those for transgender women (trans women) undergoing gender-affirming hormone therapy remain unclear. This study aimed to detect possible body composition and strength variations related to sarcopenia.

METHODS

This was a cross-sectional comparative study of 37 trans women, 34 cis men, and 34 cis women. Body composition was measured in all individuals by bioelectrical impedance analysis; prehensile strength by dynamometry was studied in trans women.

RESULTS

In this study, trans women had higher body mass index values than cis individuals (P < 0.01). Fat mass was 41% higher for trans women than cis men. Muscle mass (MM) was lower in trans women than cis men (-10%), and higher than cis women (24%). Bone mass was lower in trans women than cis men and higher in cis women (P < 0.01). Trans women's prehensile strengths were 25.26 kg for the right hand and 24.8 kg for the left. Appendicular skeletal muscle mass was 23.63 kg, and appendicular skeletal muscle mass index was 8.14 kg.

CONCLUSION

Trans women undergoing gender-affirming hormone therapy show a tendency to adapt body compartments to those of cis women with increased fat mass and reduced muscle mass. Prehensile strength in trans women was close to the cutoff points for sarcopenia risk. Nutrition, physical activity, strength, and body composition are important to avoid the possible risk for sarcopenia. More studies along these lines are necessary, especially in older adults.

Insulin sensitivity, body composition and bone mineral density after testosterone treatment in transgender youth with and without prior GnRH agonist therapy

Background

1.8% of youth identify as transgender; a growing proportion are transgender male (female sex, male gender identity). Many receive gonadotropin releasing hormone agonist (GnRHa) therapy to suppress endogenous puberty and/or will start testosterone to induce secondary sex characteristics that align with gender identity.

Objectives

To determine the effects of 12 months of testosterone on cardiometabolic health among transgender youth, including insulin sensitivity, body composition, and bone mineral density and whether changes in outcomes differ based on prior GnRHa treatment.

Methods

Participants (n = 19, baseline age 15.0 ± 1.0 years) were examined prior to and 12 months after testosterone therapy in a longitudinal observational study. Fasted morning blood draw, a 2-hour 75-gram oral glucose tolerance test, body composition and bone mineral density (dual-energy X-ray absorptiometry) were assessed at baseline and 12 months. Insulin sensitivity was estimated by HOMA-IR and Matsuda index. Changes were compared with mixed linear regression models evaluating time (baseline, 12 months), group (GnRHa treatment yes/no), and their interaction.

Results

In the entire cohort, fasted insulin decreased (median [25,75 %ile]: -3 [-5, 0] mIU/L, p = 0.044) and 2-hour glucose increased (mean ± standard deviation): +18.5 ± 28.9 mg/dL, p = 0.013 from baseline after 12 months of testosterone therapy. There were no significant changes in HOMA-IR (p = 0.062) or Matsuda index (p = 0.096), nor by GnRHa status. Absolute (+6.2 [4.7, 7.5] kg, p = 0.016) and percent fat-free mass increased (+7.3 [5.4, 9.1] %, p = 0.003) and percent fat mass declined (-7.4 [-9.3, 5.3]%, p = 0.005) for the entire cohort. There were time*group interactions for absolute (p = 0.0007) and percent fat-free mass (p = 0.033). There were time*group interactions for bone mineral content (p = 0.006).

Conclusions

Twelve months of testosterone in transgender adolescents resulted in changes in body composition and bone mineral density, with baseline differences between the +/-GnRHa group and convergence after 12 months. There were no changes in insulin sensitivity over time or between groups.

Medical Management of Gender Diversity

This article provides context on the experiences and medical care of individuals who experience gender dysphoria for the benefit of oral and maxillofacial surgeons. The mechanism of action, effects, and side effects of medical therapies used for gender-affirming care are reviewed. Specific guidance for anesthetic care is given. Trauma-informed tools for care of transgender and gender-diverse patients are offered.

Nutrition research and practice with transgender and gender non-conforming populations

The purpose of the present article is to describe the current state of sex and gender data collection in nutrition science research, discuss the effects of flawed data collection practices, highlight considerations for transgender and gender non-conforming populations and propose a sex- and gender-informed approach to human subjects research. Sex and gender are separate constructs that are often conflated in nutrition research and practice. Current nutrition surveillance programmes in the United States, United Kingdom and Ireland do not accurately capture sex and gender data, which undermines the accuracy of the analyses and excludes gender minorities. Transgender and gender non-conforming populations have distinct clinical and psychosocial nutrition considerations that require further research to inform nutrition policy and practice, such as anthropometric and biochemical changes with hormone therapy, eating disorders, food insecurity and nutrition as a source of empowerment or expression of gender identity. Researchers can apply a sex- and gender-informed approach to human subjects research by treating sex and gender as separate, relevant demographic data, appreciating gender as a fluid construct, and approaching data collection on gender minorities with sensitivity to privacy and confidentiality.

Disordered eating in transgender and gender non-conforming youth: A comparison to community-based and clinical samples

OBJECTIVE

This study investigates eating pathology in transgender and gender non-conforming (TGNC) youth compared to a community-based sample and individuals with eating disorders (EDs).

METHOD

Participants (ages 13-21 years) included TGNC youth from a paediatric gender clinic (N = 97), a demographically matched community-based sample of cisgender males (N = 97) and cisgender females (N = 97), and treatment-seeking patients with EDs (N = 112). The Eating Disorder Examination Questionnaire (EDE-Q) was used to assess ED cognitions and behaviours.

RESULTS

Transgender and gender non-conforming participants reported significantly higher EDE-Q global scores compared to the cisgender samples, but significantly lower than the ED sample. Transgender and gender non-conforming individuals reported a higher likelihood of objective binge episodes (OBEs) than the cisgender groups, albeit lower than youth with EDs. A substantial proportion of TGNC participants scored in elevated ranges on the EDE-Q global score (35% ≥ score of 3, 17% ≥ score of 4), significantly higher than cisgender males (0% ≥ score of 3, 0% ≥ score of 4) and females (9% ≥ score of 3, 3% ≥ score of 4).

CONCLUSIONS

Findings indicate that TGNC youth exhibit increased ED cognitions and OBEs compared to cisgender samples, highlighting the need for screening and addressing ED symptoms in this population.

Obesity: a gender-view

PURPOSE

There is a growing awareness of the importance of understanding gender differences in obesity. The aim of this short review was to revise the current evidence on anthropometric characteristics and nutritional and pharmacological aspects of obesity from a gender perspective.

METHODS

A literature search within PubMed was performed. Selected publications related to obesity and gender differences were reviewed.

RESULTS

The prevalence of obesity among men is higher than in women, but women have a higher percentage of body fat content compared to men, and gender appears to be an important factor in the manifestation of central (android) or peripheral (gynoid) obesity. In addition, while in most clinical trials, women are still underrepresented, in clinical registration trials of anti-obesity drugs, women are commonly up-represented and gender-specific analysis is uncommon. Considering that adipose tissue is one of the factors affecting the volume of distribution of many drugs, mainly lipophilic drugs, gender differences might be expected in the pharmacokinetics and pharmacodynamics of anti-obesity drugs. Indeed, although Liraglutide 3 mg, a long-acting glucagon-like peptide-1 receptor agonist, and naltrexone/bupropion display lipophilic properties, currently, a gender-dose adjustment for both these drugs administration is not recommended. In addition, despite that predicted responders to treatment offer substantial opportunities for efficient use, especially of expensive new therapies, such as anti-obesity drugs, data on gender differences to identify early responders to both these have not yet been investigated. Finally, bariatric surgery gender disparity reflects healthcare practices. Weight loss similar, but differing effects: women need more correction and face psychology challenges; men have worse physiology and fewer comorbidity improvements.

CONCLUSION

Gender differences exist in obesity prevalence and phenotype, body fat distribution, drug efficacy, clinical trial representation, and different secondary effects of bariatric surgery. Gender is an important variable in obesity analysis.

Approach to the Patient: Hormonal Therapy in Transgender Adults With Complex Medical Histories

While endocrinologists continue to initiate gender-affirming hormone therapy (GAHT) in healthy transgender and gender diverse (TGD) patients, they may also encounter more TGD patients in their clinics with complex medical histories that influence the patient-provider shared decision-making process for initiating or continuing GAHT. The purpose of this Approach to the Patient article is to describe management considerations in 2 adults with thromboembolic disease and 2 adults with low bone mineral density in the setting of feminizing and masculinizing GAHT.

Risk assessment of transgender people: implementation of a demasculinizing-feminizing rodent model including the evaluation of thyroid homeostasis

BACKGROUND

Individuals whose gender identity differs from the biological sex and the social norms are defined as transgender. Sometimes transgender undergo gender affirming hormone therapy, which lasts for the entire life making essential to evaluate its potential long-term effects. Moreover, transgender can represent a susceptible sub-group of population and specific attention is needed in risk assessment, including the development of targeted animal models. Aim of the study is the implementation of a rodent demasculinizing-feminizing model through the setting of appropriate dose of hormone therapy and the selection of specific biomarkers to evaluate the sex transition. Specific attention is paid to thyroid homeostasis due to the close link with reproductive functions. Four male adult rats/group were subcutaneously exposed to three doses plus control of β-estradiol valerate plus cyproterone acetate at: 0.045 + 0.2 (low), 0.09 + 0.2 (medium) and 0.18 + 0.2 (high) mg/dose, five times/week. The doses were selected considering the most recent recommendations for transgender woman. Sperm count, histopathological analysis (testis, liver, thyroid), testosterone, estradiol, triiodothyronine and thyroid-stimulating hormone serum levels and gene expression of sex dimorphic CYP450 were evaluated.

RESULTS

The doses induced feminizing-demasculinizing effects: decreased testosterone serum levels at the corresponding cisgender, increased estradiol, impairment of male reproductive function and reversal of sex-specific CYP liver expression. However, the medium and high doses induced marked liver toxicity and the low dose is considered the best choice, also for long-term studies in risk assessment. The alterations of thyroid indicated follicular cell hypertrophy supported by increased thyroid-stimulating hormone serum levels at the higher doses.

CONCLUSIONS

The implementation of animal models that mimic the effects of gender affirming hormone therapy is essential for supporting clinical studies in transgender people and filling data gap in order to ensure an appropriate risk assessment and a more accurate, personalized care for transgender people.

Gender-Affirming Nutrition: An Overview of Eating Disorders in the Transgender Population

PURPOSE OF REVIEW

Transgender individuals are vulnerable to many nutrition-related conditions, especially eating disorders due to gender dysphoria. This review aims to summarize the current literature on eating disorders in transgender individuals. The issues that should be considered in nutrition care for the transgender population are discussed regarding public health.

RECENT FINDINGS

Transgender individuals can exhibit disordered eating behaviors to overcome the stress they experience due to stigma, discrimination, social exclusion, and abuse. Recent studies showed that disordered eating and clinical eating disorders are more prevalent among transgender than cisgender people. It is very important for a multidisciplinary team working in the clinic to understand the epidemiology, etiology, diagnostic criteria, and treatment of eating disorders in the transgender population. However, multidisciplinary nutritional care is limited due to the lack of transgender-specific nutrition guidelines. It is safe to say that adhering to a generally healthy nutritional pattern and using standardized nutrition guidelines. We recommend that health professionals working with patients/clients with eating disorders receive continuing education in transgender health, be empowering and inclusive, address patients/clients with their gender identity nouns and pronouns, and develop nutritional treatment plans that are not gender-specific. Eating disorders are a significant public health problem in the transgender population. Therefore, clinical screening and early intervention are necessary to identify and treat eating disorders in transgender people. Eating disorders in the transgender population should be monitored routinely, and gender-affirming care should be provided as well as treatment of eating disorders.

Cystatin C-Based eGFR Changes during Gender-Affirming Hormone Therapy in Transgender Individuals

BACKGROUND

Men with CKD tend to experience a faster eGFR decline than women, potentially because of sex hormones. Limited research exists regarding the effect of gender-affirming hormone therapy (GAHT) on kidney function. Furthermore, monitoring kidney function during GAHT is challenging because serum creatinine is confounded by body composition. To investigate the relationship between sex hormones and kidney function, we studied the changes of serum creatinine and serum cystatin C, a filtration marker less affected by sex, during 1 year of GAHT.

METHODS

As part of the European Network for the Investigation of Gender Incongruence study, we measured serum creatinine and serum cystatin C in 260 transgender women and 285 transgender men before and 12 months after initiating GAHT. Transgender women received estradiol plus cyproterone acetate, while transgender men received testosterone. Cystatin C-based eGFR was calculated using the full-age-spectrum equation.

RESULTS

In transgender women, cystatin C decreased by 0.069 mg/L (95% confidence interval [CI], 0.049 to 0.089), corresponding with a 7 ml/min per 1.73 m 2 increase in eGFR. In transgender men, cystatin C increased by 0.052 mg/L (95% CI, 0.031 to 0.072), corresponding with a 6 ml/min per 1.73 m 2 decrease in eGFR. Creatinine concentrations decreased (-0.065 mg/dl; 95% CI, -0.076 to -0.054) in transgender women and increased (+0.131 mg/dl; 95% CI, 0.119 to 0.142) in transgender men. Changes in creatinine-based eGFR varied substantially depending on the sex used in the equation.

CONCLUSIONS

In this cohort of transgender individuals, cystatin C-based eGFR increased with estradiol and antiandrogen therapy and decreased with testosterone therapy.

[Nutritional problems in cis and trans women]

Introduction

Women deserve special attention due to the different requirements they have in comparison with men. In the same way, transgender women need individualized attention. Transgender women are at greater risk of suffering heart attacks or ischemic accidents, among other diseases, and are also at greater risk of developing eating disorders, poorer weight control and poorer perception of their image. Hormone therapy for gender reaffirmation in trans women modifies their body composition, and may also increase the risk of suffering from some pathologies. The nutritional needs of cisgender women are different from those of men, and trans women also have special needs, which may depend on whether or not they follow hormone therapy. Dietary studies, although scarce, suggest that transgender women have poor dietary habits and lifestyle. It is necessary to deepen the study of the nutritional situation of the female group, considering its diversity, and to develop standards and references appropriate to each case that allow better attention to the needs of these groups.

LGBTQ-competent obesity prevention and management

ABSTRACT

Obesity is a complex and largely preventable disease that is an enormous burden to patient health and to the healthcare system. Lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients and their healthcare providers should be aware of their personal risks and causes of weight gain and obesity. Sensitive, comprehensive, and competent LGBTQ preventive care and treatment are needed to address the needs of this population, improve patient outcomes, and reduce healthcare inequalities. Research is needed to further evaluate the confluence of obesity and metabolic risk factors in LGBTQ patients, and to develop prevention and treatment strategies to reduce the risk for obesity-related comorbidities, chronic disease, and death.

Kidney transplantation for a transgender male

The proportion of transgender people has increased over time, but few cases of transgender people undergoing kidney transplantation have been described. A 41-year-old transgender man (female-to-male) had chronic kidney disease caused by IgA nephropathy. He had received testosterone therapy and sex reassignment surgeries (chest masculinization surgery, metoidioplasty, scrotoplasty, and hysterectomy-ovariectomy) since he was 19 years due to gender incongruence. He underwent a preemptive living-donor kidney transplantation from his wife. His skeletal muscle mass was closer to that of a female than that of a male and suggested that eGFR should be calculated with the equation based on the gender assigned at birth (female) rather than the gender identity (male). Moreover, the recovery of kidney function due to successful kidney transplantation decreased serum gonadotropin levels, but normalization of his sex hormone profile was not achieved. Further accumulation of experience with kidney transplantation for transgender people is needed.

Lipid profile and risk of cardiovascular disease in adult transgender men receiving cross-sex hormone therapy: a systematic review

CONTEXT

A recent US national survey of the health status of the male transgender population has raised awareness about the little-studied relationship between testosterone hormone therapy in transgender men and cardiovascular outcomes.

OBJECTIVE

The aim of this systematic review was to assess the relationship between cross-sex hormone therapy in transgender men and lipid profiles and cardiovascular risk.

DATA SOURCES

The PubMed, SciELO, SpringerLink, and EBSCOhost databases were searched up to March 2021 for studies assessing the association between cross-sex hormone therapy and the incidence of outcomes related to cardiovascular disease in transgender men over 18 years of age .

DATA EXTRACTION

Data extracted were sorted into clinical data (systolic, diastolic, and mean blood pressure), anthropometric data (body mass index, weight, waist circumference, fat mass, and lean mass), and biochemical data (triglycerides, total cholesterol, low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], very low-density lipoprotein cholesterol [VLDL-C], and the HDL-C to LDL-C ratio).

DATA ANALYSIS

Study quality was appraised independently by two reviewers using the Cochrane tools for assessment of methodological quality or risk of bias in nonrandomized studies, and the Newcastle-Ottawa Scale was applied. Of 735 studies identified, 11 were included in the review. Most studies reported no change in cholesterol or triglyceride levels after hormone treatment. A reduction in HDL-C levels was observed in 7 of 11 studies, although this alone cannot be considered a cardiovascular risk factor. Likewise, clinical and anthropometric findings showed no changes predictive of cardiovascular risk.

CONCLUSIONS

Although these findings suggest that hormone therapy may lead to a decrease in HDL-C levels and an increase in LDL-C levels, they are insufficient to establish a relationship with cardiovascular disease. Furthermore, no significant effects on metabolic and anthropometric values were found. Further studies with higher quality and longer follow-up periods are needed to establish cardiovascular risk.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD 42020212560.

Filling a gap in care: addressing obesity in transgender and gender diverse patients

Transgender and gender diverse (TGD) adults are more likely to have obesity compared to cisgender peers. Based on surveys, the TGD population experiences disparities in healthy lifestyle behaviors (e.g., physical activity, screen time) compared to reference groups. They also face significant socioeconomic and healthcare barriers to accessing affirming care and gender minority stress, potentially contributing to increased weight. Gender-affirming hormone therapy is associated with changes in body composition and increased weight, which may impact cardiometabolic risk trajectory. Obesity can also be a barrier to gender-affirming surgeries, and affirming weight management services tailored to TGD patients are an important gap in healthcare to address. This Perspective briefly reviews current literature on the unique barriers experienced by TGD people and their identified needs regarding weight management interventions. It also suggests areas for future research to best fill this gap in healthcare and research while supporting the provision of lifesaving gender-affirming care.

Registered Dietitian Nutritionists' Knowledge, Attitudes, and Beliefs Regarding Nutrition for the Transgender Population in Three New England States: A Cross-Sectional Study

This Study examined the knowledge, attitudes, and beliefs of Registered Dietitian Nutritionists (RDN's) practicing in Maine, New Hampshire, and Vermont, regarding the transgender population. 196 RDN's from the Commission of Dietetics Registration registry located in the tri-state area responded to an anonymous online survey. The survey used the Transgender Knowledge, Attitudes and Beliefs (T-KAB) Scale and nine true/false clinically-focused questions. Descriptive statistics and chi-square analysis were used to identify trends and associations in RDN's knowledge, attitudes, and beliefs regarding the transgender population. Political views (p < 0.0001), years practicing (p = 0.0454), and religious commitment (p = 0.0429) were negatively associated, and health disparities awareness (p < 0.0002) was positively associated, with total T-KAB Score. RDN's surveyed had positive attitudes and beliefs, but a low level of knowledge. Future research should focus on training and education of RDN's, and use of the T-KAB scale to evaluate pre/post-education modules regarding nutrition care for transgender patients.

Sports Medicine Considerations When Caring for the Transgender Athlete

Orthopaedic surgeons and other orthopaedic care providers have expressed a desire to care for transgender patients but have a self-perceived knowledge deficit. Transgender athletes experience many psychosocial barriers to sport that are useful for clinicians to understand. Medical and surgical gender-affirming care can impact musculoskeletal physiology and pathophysiology. Transgender women (TW) have demonstrated an increased risk of insufficiency fractures and thromboembolism in patients receiving exogenous estrogen therapy. The impact of gender-affirming care on sex-based differences in athletic injuries is less well studied.

Sex hormones, insomnia, and sleep quality: Subjective sleep in the first year of hormone use in transgender persons

STUDY OBJECTIVES

Transgender persons can use gender-affirming hormone therapy (GAHT) to align their physical appearance with their identified gender. Many transgender persons report poor sleep, but the effects of GAHT on sleep are unknown. This study examined the effects of a 12 months of GAHT use on self-reported sleep quality and insomnia severity.

METHODS

A sample of 262 transgender men (assigned female at birth, started masculinizing hormone use) and 183 transgender women (assigned male at birth, started feminizing hormone use), completed self-report questionnaires on insomnia (range 0-28), sleep quality (range 0-21) and sleep onset latency, total sleep time and sleep efficiency before start of GAHT and after 3, 6, 9, and 12 months of GAHT.

RESULTS

Reported sleep quality showed no clinically significant changes after GAHT. Insomnia showed significant but small decreases after 3 and 9 months of GAHT in trans men (-1.11; 95%CI: -1.82; -0.40 and -0.97; 95%CI: -1.81; -0.13, respectively) but no changes in trans women. In trans men, reported sleep efficiency decreased by 2.8% (95%CI: -5.5%; -0.2%) after 12 months of GAHT. In trans women, reported sleep onset latency decreased by 9 min (95%CI: -15; -3) after 12 months of GAHT.

CONCLUSIONS

These findings show that 12 months of GAHT use did not result in clinically significant changes in insomnia or sleep quality. Reported sleep onset latency and reported sleep efficiency showed small to modest changes after 12 months of GAHT. Further studies should focus on underlying mechanisms by which GAHT could affect sleep quality.

Meeting the Body Mass Index Requirement for Gender-affirming Surgery Using Antiobesity Medication

One-fourth of transgender and gender diverse (TGD) patients presenting for initial gender-affirming surgery (GAS) consult is denied surgery due to obesity. Many surgery centers enforce body mass index (BMI) requirements for GAS because of concerns about perioperative risks, cosmetic outcomes, and reoperation. TGD people experience gender minority stress and disparities in lifestyle factors that likely contribute to excess weight gain. Gender-affirming hormone therapy has also been associated with increased body weight. Effective and affirming weight management interventions for TGD patients with overweight and obesity are currently lacking. We report the case of a 40-year-old transgender woman with a BMI of 39.6 kg/m2 who presented for weight loss to qualify for gender-affirming bilateral breast augmentation, requiring BMI <35 kg/m2. In addition to lifestyle modification counseling, she was started on semaglutide with monthly dose escalation, leading to 13.9% weight loss with a BMI of 34.1 kg/m2 within 3 months. This case highlights the need for access to affirming weight management services for TGD patients pursuing GAS and the role of antiobesity medications in reaching presurgical BMI targets. Further studies should evaluate the needs of TGD patients in weight loss interventions and the effects of weight loss and antiobesity medications on gender-affirming hormone therapy.

Gender-Affirming Hormone Therapy: Physical and Sociopsychological Effects, Impact and Satisfaction

Background Gender dysphoria treatment includes gender-affirming hormone therapy (GAHT). Studies are still lacking on how to characterize its effects and impact on transgender people's lives more effectively. Aim To study the physical and psychological effects of GAHT on transgender individuals, assess its impact on their lives, and rate their overall satisfaction. Methods Participants (n = 114; ages 18-62 years; median age 24.0 (21.0 - 33.0) years) included transgender adults residing in Portugal who were undergoing or had undergone hormonal therapy for at least one uninterrupted year. Participants completed an original questionnaire. For most items, an ordinal Likert-style scale ranging from 0 (worst result) to 6 (best result) was used. Descriptive statistics and non-parametric tests, including Pearson's chi-squared test, Wilcoxon signed-rank test, and Mann-Whitney U test were used to analyze categorical and continuous variables, with a significance level set at 0.05. Outcomes The outcomes included desired physical changes rating (perception and satisfaction with changes); side effects of GAHT; the sociopsychological impact of GAHT (on self-esteem, body image, psychological wellbeing, social and family relations); overall satisfaction (with treatment results and medical follow-up). Results The changes classified as the most perceptible in those undergoing masculinizing treatment (Group M) were amenorrhea (6 (5.0-6.0) points) and clitoris enlargement (6 (5.0-6.0) points). These were also the ones rated as the most satisfactory (6 (6.0-6.0) points for amenorrhea and 6 (4.0-6.0) points for clitoris enlargement). On those undergoing feminizing therapy (Group F), the alteration voted as the most perceptible was sperm production decrease (6 (2.0-6.0) points), and the ones classified as the most satisfactory were sperm production decrease (6 (4.0-6.0) points) and spontaneous erections decrease (6 (5.0-6.0) points). Side effects were reported by 89.7% of Group M (mood swings were the most common) and 96.3% of Group F (decreased libido was the most frequent). The sociopsychological impact of hormonal treatment was significantly positive in all analyzed variables (p<0.001). Overall satisfaction with treatment results and medical follow-up were rated with 5 points and 4.5 points, respectively. Clinical implications This study provides clinicians with more evidence that GAHT may improve the physical, psychological and social health of transgender people seeking medical transition. Strengths and limitations The strengths of the current study include a high participant count relative to the target population, the acquisition of data on previously unexplored variables, and the significance of being one of the few investigations of its kind conducted in Portugal. However, the study has limitations, including differences in participant characteristics, a small sample size for some variables, potential bias due to the retrospective nature of the study, individualized treatment regimens, and the inclusion of participants from different countries, which limit the generalization of the results. Conclusions This study provides further evidence that GAHT is effective, and that its physical effects are satisfactory while resulting in mostly non-severe nor life-threatening side effects. GAHT is an important therapy in gender dysphoria and has consistent results in improving numerous sociopsychological variables.

Clinical Concerns on Sex Steroids Variability in Cisgender and Transgender Women Athletes

In the female athletic community, there are several endogenous and exogenous variables that influence the status of the hypothalamus-pituitary-ovarian axis and serum sex steroid hormones concentrations (e. g., 17β-estradiol, progesterone, androgens) and their effects. Moreover, female athletes with different sex chromosome abnormalities exist (e. g., 46XX, 46XY, and mosaicism). Due to the high variability of sex steroid hormones serum concentrations and responsiveness, female athletes may have different intra- and inter-individual biological and functional characteristics, health conditions, and sports-related health risks that can influence sports performance and eligibility. Consequently, biological, functional, and/or sex steroid differences may exist in the same and in between 46XX female athletes (e. g., ovarian rhythms, treated or untreated hypogonadism and hyperandrogenism), between 46XX and 46XY female athletes (e. g., treated or untreated hyperandrogenism/disorders of sexual differentiation), and between transgender women and eugonadal cisgender athletes. From a healthcare perspective, dedicated physicians need awareness, knowledge, and an understanding of sex steroid hormones' variability and related health concerns in female athletes to support physiologically healthy, safe, fair, and inclusive sports participation. In this narrative overview, we focus on the main clinical relationships between hypothalamus-pituitary-ovarian axis function, endogenous sex steroids and health status, health risks, and sports performance in the heterogeneous female athletic community.

Techniques and Applications of Lower Extremity Feminization and Masculinization

Background

Significant differences exist between feminine and masculine lower extremities, and this region contributes to gender dysphoria in transgender and nonbinary individuals.

Methods

A systematic review was conducted for primary literature on lower extremity (LE) gender affirmation techniques as well as anthropometric differences between male and female lower extremities, which could guide surgical planning. Multiple databases were searched for articles before June 2, 2021 using Medical Subject Headings. Data on techniques, outcomes, complications, and anthropometrics were collected.

Results

A total of 852 unique articles were identified: 17 met criteria for male and female anthropometrics and 1 met criteria for LE surgical techniques potentially applicable to gender affirmation. None met criteria for LE gender affirmation techniques specifically. Therefore, this review was expanded to discuss surgical techniques for the LE, targeting masculine and feminine anthropometric ideals. LE masculinization can target feminine qualities, such as mid-lateral gluteal fullness and excess subcutaneous fat in the thigh and hips. Feminization can target masculine qualities like a low waist-to-hip ratio, mid-lateral gluteal concavity, calf hypertrophy, and body hair. Cultural differences and patient body habitus, which influence what is considered "ideal" for both sexes, should be discussed. Applicable techniques include hormone therapy, lipo-contouring, fat grafting, implant placement, and botulinum toxin injection, among others.

Conclusions

Due to lack of existing outcomes-based literature, gender affirmation of the lower extremities will rely on application of an array of existing plastic surgery techniques. However, quality outcomes data for these procedures is required to determine best practices.

Medical considerations in the care of transgender and gender diverse patients with eating disorders

Transgender and gender diverse (TGD) individuals are at increased risk for the development of eating disorders, but very little has been published with regards to the unique aspects of their medical care in eating disorder treatment. Providing gender affirming care is a critical component of culturally competent eating disorder treatment. This includes knowledge of gender affirming medical and surgical interventions and how such interventions may be impacted by eating disordered behaviors, as well as the role of such interventions in eating disorder treatment and recovery. TGD individuals face barriers to care, and one of these can be provider knowledge. By better understanding these needs, clinicians can actively reduce barriers and ensure TGD individuals are provided with appropriate care. This review synthesizes the available literature regarding the medical care of TGD patients and those of patients with eating disorders and highlights areas for further research.

Cardiopulmonary capacity and muscle strength in transgender women on long-term gender-affirming hormone therapy: a cross-sectional study

OBJECTIVE

For transgender women (TW) on oestrogen therapy, the effects of prior exposure to testosterone during puberty on their performance, mainly cardiopulmonary capacity (CPC), while exerting physical effort are unknown. Our objective was to evaluate CPC and muscle strength in TW undergoing long-term gender-affirming hormone therapy.

METHODS

A cross-sectional study was carried out with 15 TW (34.2±5.2 years old), 13 cisgender men (CM) and 14 cisgender women (CW). The TW received hormone therapy for 14.4±3.5 years. Bioimpedance, the hand grip test and cardiopulmonary exercise testing on a treadmill with an incremental effort were performed.

RESULTS

The mean VO2peak (L/min) was 2606±416.9 in TW, 2167±408.8 in CW and 3358±436.3 in CM (TW vs CW, p<0.05; TW vs CM, p<0.0001; CW vs CM, p<0.0001). The O2 pulse in TW was between that in CW and CM (TW vs CW, p<0.05, TW vs CM, p<0.0001). There was a high correlation between VO2peak and fat-free mass/height² among TW (r=0.7388; p<0.01), which was not observed in the other groups. The mean strength (kg) was 35.3±5.4 in TW, 29.7±3.6 in CW and 48.4±6.7 in CM (TW vs CW, p<0.05; TW vs CM, p<0.0001).

CONCLUSION

CPC in non-athlete TW showed an intermediate pattern between that in CW and CM. The mean strength and VO2 peak in non-athlete TW while performing physical exertion were higher than those in non-athlete CW and lower than those in CM.

Effects of gender-affirming hormone therapy on cardiovascular risk factors focusing on glucose metabolism in an Austrian transgender cohort

Objective

We aimed to investigate the effect of gender-affirming hormone therapy (GAHT) on cardiovascular disease risk factors focusing on glucose tolerance.

Patients and Methods

This primarily translational study enrolled 16 transgender persons assigned female at birth (AFAB), 22 assigned male at birth (AMAB), and 33 age- and BMI-matched cisgender controls at the Medical University of Vienna from 2013 to 2020. A 3-Tesla MRI scan to measure intramyocardial, pancreatic, hepatic fat content and subcutaneous-to-visceral adipose tissue ratio (SAT/VAT-ratio), an oral glucose tolerance test (oGTT), bloodwork including brain natriuretic peptide (pro-BNP), sex hormones and two glucose-metabolism related biomarkers (adiponectin, betatrophin) were performed.

Results

Estrogen intake was associated with higher fasting insulin (p = 0.034) and Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) (p = 0.037), however, lower HbA1c levels (p = 0.031) in AMAB than cisgender males. Adiponectin (p = 0.001) and betatrophin (p = 0.034) levels were higher in AMAB than cisgender males, but similar to cisgender females. Compared to cisgender females, AFAB displayed no differences in glucose metabolism or SAT/VAT-ratio. AFAB had lower pro-BNP levels (p = 0.014), higher liver enzymes (AST: p = 0.011; ALT: p = 0.012) and lower HDL levels (p = 0.017) than cisgender females, but comparable levels to cisgender males. AMAB showed an increased heart rate (p < 0.001) and pro-BNP (p = 0.002) levels, but a more favorable SAT/VAT-ratio (p = 0.013) and lower creatine kinase (CK) (p = 0.001) than cisgender males. There were no relevant differences in organ fat content between transgender persons and their respective cisgender controls.

Conclusion

In AMAB, most investigated parameters adapted to levels seen in cisgender females except for parameters related to fasted insulin resistance. AMAB should be monitored with respect to the development of insulin resistance.

Multicenter Analysis of Cardiometabolic-related Diagnoses in Transgender and Gender-Diverse Youth: A PEDSnet Study

CONTEXT

Studies on cardiometabolic health in transgender and gender-diverse youth (TGDY) are limited to small cohorts.

OBJECTIVE

This work aimed to determine the odds of cardiometabolic-related diagnoses in TGDY compared to matched controls in a cross-sectional analysis, using a large, multisite database (PEDSnet).

METHODS

Electronic health record data (2009-2019) were used to determine odds of cardiometabolic-related outcomes based on diagnosis, anthropometric, and laboratory data using logistic regression among TGDY youth vs controls. The association of gender-affirming hormone therapy (GAHT) with these outcomes was examined separately among TGDY. TGDY (n = 4172) were extracted from 6 PEDSnet sites and propensity-score matched on 8 variables to controls (n = 16 648). Main outcomes measures included odds of having cardiometabolic-related diagnoses among TGDY compared to matched controls, and among TGDY prescribed GAHT compared to those not prescribed GAHT.

RESULTS

In adjusted analyses, TGDY had higher odds of overweight/obesity (1.2; 95% CI, 1.1-1.3) than controls. TGDY with a testosterone prescription alone or in combination with a gonadotropin-releasing hormone agonist (GnRHa) had higher odds of dyslipidemia (1.7; 95% CI, 1.3-2.3 and 3.7; 95% CI, 2.1-6.7, respectively) and liver dysfunction (1.5; 95% CI, 1.1-1.9 and 2.5; 95% CI, 1.4-4.3) than TGDY not prescribed GAHT. TGDY with a testosterone prescription alone had higher odds of overweight/obesity (1.8; 95% CI, 1.5-2.1) and hypertension (1.6 95% CI, 1.2-2.2) than those not prescribed testosterone. Estradiol and GnRHa alone were not associated with greater odds of cardiometabolic-related diagnoses.

CONCLUSION

TGDY have increased odds of overweight/obesity compared to matched controls. Screening and tailored weight management, sensitive to the needs of TGDY, are needed.

The Effect of Gender-Affirming Hormone Therapy on Measures of Kidney Function: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Gender-affirming hormone therapy modifies body composition and lean muscle mass in transgender persons. We sought to characterize the change in serum creatinine, other kidney function biomarkers, and GFR in transgender persons initiating masculinizing and feminizing gender-affirming hormone therapy.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We searched PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov from inception to September 16, 2020 for randomized controlled trials, observational studies, and case series that evaluated the change in serum creatinine, other kidney function biomarkers, and GFR before and after the initiation of gender-affirming hormone therapy in adult transgender persons. Two reviewers independently screened and abstracted data, and disagreements were resolved by a third reviewer. A random effects meta-analysis was performed to determine the change in outcomes over follow-up of 3, 6, and 12 months.

RESULTS

Of the 4758 eligible studies, 26 met the inclusion criteria, including nine studies that recruited 488 transgender men and 593 women in which data were meta-analyzed. There was heterogeneity in study design, populations, gender-affirming hormone therapy routes, and dosing. At 12 months after initiating gender-affirming hormone therapy, serum creatinine increased by 0.15 mg/dl (95% confidence interval, 0.00 to 0.29) in 370 transgender men and decreased by -0.05 mg/dl (95% confidence interval, -0.16 to 0.05) in 361 transgender women. No study reported the effect of gender-affirming hormone therapy on albuminuria, proteinuria, cystatin C, or measured GFR.

CONCLUSIONS

Gender-affirming hormone therapy increases serum creatinine in transgender men and does not affect serum creatinine in transgender women. The effect on gender-affirming hormone therapy on other kidney function biomarkers and measured GFR is unknown.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Change in Kidney Function Biomarkers in Transgender Persons on Gender Affirmation Hormone Therapy-A Systematic Review and Meta-Analysis, CRD42020214248.

Forensic alcohol calculations in transgender individuals undergoing gender-affirming hormonal treatment

There are an increasing number of individuals undergoing gender-affirming hormonal treatment (GAHT) to treat gender dysphoria. Current forensic alcohol calculations require knowledge of the sex of the individual, but this may disadvantage trans people as research has demonstrated that there are physiological changes in individuals who are undergoing GAHT. Using previously published studies on total body water (TBW) in cis individuals, and the known changes in lean body mass and hematocrit in trans individuals, it is possible to estimate TBW in trans individuals and compare them to those cis equation estimations. When using these revised rubrics, we determined that for trans women the use of the cis male anthropometric TBW equation only gives a small underestimation of TBW (0.9%) compared to the underestimation of TBW using the cis female TBW equation (-17.7%). For trans men, the use of the cis female TBW equation gives the largest disadvantage, underestimating TBW by -10.8% compared to the cis male TBW equation, that overestimates TBW by 6.6%. For this reason, we recommend that if the sex at birth of an individual is not known or disclosed, any forensic alcohol calculations in a forensic alcohol reports are made assuming that the gender declared by the individual is their sex at birth. Further research to develop validated anthropometric TBW equations are urgently needed as to not disadvantage trans people when forensic alcohol calculations are carried out.

Weight Status, Medication Use, and Recreational Activities of Treatment-Naïve Transgender Youth

Background: Studies of transgender/gender diverse (TGD) youth indicate a high prevalence of overweight/obesity and concern for unhealthy weight management behavior. This study describes the association of weight status with medication use and recreational activities among treatment-naïve, pediatric TGD patients. Methods: This study is a chart review of 277 patients [aged 9-18 years, 79.1% female sex assigned at birth (SAB), and 86.3% white] seen at a medical center from 2017 to 2020. BMI was calculated by age and SAB using CDC growth charts. BMI percentile (BMI%) and BMI z-score (BMIz) were used to define weight status. Results: By BMI% category, 3.6% patients were in the underweight range (BMI <5%); 50.5% had BMI >85%; and 30.3% had BMI >95%. Overweight and obesity rates were higher than national norms (χ2 = 15.152, p < 0.01). Female SAB participants had higher BMIz values than male SAB participants. Youth who reported watching/listening to media (t = 3.50, p < 0.01) and parent-reported creative arts involvement (t = 1.97, p = 0.05) were associated with higher BMIz values. Conversely, spending time with friends and family was associated with a lower BMIz. Over half of the patients were prescribed medications, and those patients taking medications had higher BMIz values than those not taking medications (t = -1.96, p < 0.05). Female SAB, involvement in sedentary recreational activities, and taking medications to treat gastrointestinal conditions were associated with elevated BMIz. Conclusions: Overweight/obesity is a common problem among TGD youth. TGD youth should be considered a high-risk group and targeted in obesity prevention and treatment efforts. Interventions to decrease sedentary activities and improve connections with friends and family are promising strategies to address overweight and obesity among TGD youth.

Reference intervals for biochemical analytes in transgender individuals on hormone therapy

BACKGROUND

Hormone therapy in transgender individuals may impact processes that lead to changes in biochemical analytes, and therefore reference intervals. Currently, few reference interval studies are available for the transgender population. We determined biochemical reference intervals for transgender individuals receiving hormone therapy.

METHODS

Our retrospective, laboratory-based, observational study included healthy transgender males (N = 24) and transgender females (N = 84) on hormone therapy. Various biochemical reference intervals were established for each cohort and compared to their cisgender counterparts.

RESULTS

We detected significant differences in reference intervals for sodium, 139-142 mmol/L vs. 136-145 mmol/L when comparing transgender males (TM) with cisgender males (CM). The following significant changes in upper reference limits (URL) for TM versus CM were detected, ALP (URL: 96 U/L vs. 128 U/L), GGT (URL: 27 U/L vs. 67 U/L) and testosterone (URL: 46.7 nmol/L vs. 29.0 nmol/L), respectively. Moreover, when comparing transgender female (TF) to cisgender female (CF), significant differences in creatinine (URL: 117 μmol/L vs. 90 μmol/L), albumin (lower reference limit: 41 g/L, vs. 35 g/L), AST (URL: 50 U/L vs. 35 U/L), ALP (URL: 118 U/L vs. 98 U/L) and oestradiol (URL: 934 pmol/L vs. 213 pmol/L) were noted, respectively. Significantly higher LDL-C was observed for TM on hormone treatment, compared to baseline (2.9 mmol/L vs. 2.2 mmol/L, p <0.01).

CONCLUSIONS

Biochemical results for TM and TF receiving hormone therapy can be evaluated against our transgender-specific reference intervals for some analytes, while others can be compared to their identified gender reference intervals.