Paradigm Shift Occurring in Transgender Care

Veronica Hackethal, MD

December 21, 2015

NEW YORK — A paradigm shift is occurring in the care of transgender individuals in the United States, with the mainstream medical community embracing transgender medicine when previously access to care for this community had been heavily limited due to physician discomfort, says one expert.

This shift hinges on evidence going back at least 20 years and pointing to the biological underpinnings of gender identity, said Joshua Safer, MD, director of endocrinology education at Boston University School of Medicine, Massachusetts, speaking here at the recent Endocrine Society Hormones & Health Science Writers Conference.

"Gender identity, broadly speaking, is a durable biological phenomenon that even from birth we cannot change," Dr Safer asserted.

So, if gender is a biological phenomenon, treating transgenderism medically rather than as a psychological issue represents the "best treatment option" and is "fabulously successful," he says.

"Compelling Biological Evidence" for Gender Identity

The "most compelling" biological evidence, Dr Safer explained, comes from past attempts on the part of the medical community to manipulate gender identity.

For example, a study at Johns Hopkins University looked at 16 XY children born with ambiguous genitalia who underwent surgery to create female genitalia and who were raised as girls (with the exception of two individuals whose parents raised them as boys). When these children reached junior high school age, eight of them felt like boys, and the two raised as boys identified with being male, despite having female genitalia (N Engl J Med. 2004;350:333-341).

Other evidence comes from studies dating back to the 1990s in which researchers attempted to locate brain structures that correlate with gender identity.

One classic study, Dr Safer pointed out, suggested that an area of the brain called the bed nucleus of stria terminalis may correspond to gender identity. Slices of this area of the brain, originally thought by researchers to be involved in homosexuality, stained to match gender identity: the area was smaller in women and male-to-female transwomen, compared with straight men (Nature. 1995;378: 68-70).

"The bottom line is, if you survey transgender individuals who have changed their appearance so that when they walk down Fifth Avenue they get treated like they feel inside, they're very, very appreciative," Dr Safer explained.

"The numbers who regret having made these interventions is tiny, less than for most of our medical interventions."

And research backs this up, he noted. According to a Dutch study of 1285 individuals who changed their genders hormonally and/or surgically, 99% were satisfied with their decision (Arch Sex Behav. 1996;25:589-600).

Guidelines on Transgender Care, Treatment Recommendations

Going back to 2009, the US Endocrine Society recognized this issue with formal guidelines on transgender care. Currently, it has drawn up a task force, of which Dr Safer is a member, to revise these guidelines for the medical care of transgender patients.

Treatment follows three basic steps. First, puberty is postponed through a gonadotropin-releasing hormone (GnRH) analogue, the effects of which are reversible. GnRH analogues delay the development of permanent secondary sexual characteristics until a child is secure in his or her gender identity and is ready to start hormone therapy.

This is done because hormonal therapy can cause potentially irreversible changes. Patients transitioning from female to male receive testosterone, while male-to-female individuals receive androgen blockers and estrogen.

"We recognize that some young children who present as transgender are not so as adults, and so we don't want to do permanent things to these kids," Dr Safer explained.

The final step includes surgery as desired. For female-to-male individuals, that includes mastectomy and creation of a male chest. In male-to-female transitions, surgery includes orchiectomy, breast augmentation as desired, and facial feminization.

Phalloplasty (creation of a penis) or vaginoplasty (removal of the penis and creation of a vagina) happens last.

And while insurance coverage has long stood in the way of these procedures, these barriers are also beginning to fall, according to Dr Safer.

In June 2014, Massachusetts made it illegal to deny medically necessary gender transition care, requiring private insurers to cover these treatments.

And in March 2015, New York State required Medicaid to cover hormone therapy and gender reassignment surgery.

Transgender Individuals Require Lifelong Care

After surgery, patients require lifelong hormone therapy for bone health, which is dependent on sex steroids. Transgender women will continue to need estrogen, and transgender men will need natural levels of testosterone.

Little data exist on the long-term risks involved, which is an "active topic" of research, according to Dr Safer.

Risks include thrombosis with estrogen and a possible slight increased risk for cardiovascular disease with testosterone.

In addition, testosterone may have unknown effects on tumor formation.

For example, a recent study that looked at 3240 women over the course of 13 years found that women with high levels of testosterone at midlife were 1.33 times more likely to develop uterine fibroids, compared with women with low levels of testosterone, as reported by Medscape Medical News.

All things considered, though, hormone therapy in humans is "pretty safe," Dr Safer said.

"We worry about clot risk with estrogen. It's catastrophic, and we want to avoid it, but it really isn't a common event," he revealed.

"Possible heart disease with testosterone is still only a small degree [of risk], and if it's otherwise an appropriate intervention, it's not keeping me awake at night."

Europe Also Bringing Transgender Medicine Into Mainstream

Meanwhile across the Atlantic, Europe is also starting to bring transgender medicine into the mainstream, although progress is slower in some countries.

Describing the situation in Spain, Carlos Gonzalez Navajas, MD, a child and adolescent psychiatrist and unit coordinator at Clinica la Luz in Madrid, said Spanish transgender individuals have long experienced problems with access to care. These barriers are just beginning to fall, especially in more liberal areas like Extremadura, Andalucia, and Catalonia.

"The most important trend in the past few years has been the depathologization of transgenderism," he explained.

In the past year, Clinica la Luz began collaborating with different transgender organizations in Madrid to make the first step in the evaluation of transgender youth so that they can gain access to GnRH analogues, he said.

"These kids come to the psychiatrist not because they have a pathology, but because they need to have a report saying they don't have a problem. Apart from that, they should go to an endocrinologist," he stressed.

"We want to depathologize transgenderism. We want it to be taken out of the Diagnostic and Statistical Manual of Mental Disorders [DSM]."

The latest DSM — number 5 — labels someone who identifies with a different gender from the one they had at birth as having gender dysphoria. DSM-5 states that diagnostic terms may improve access to care, while acknowledging their potential to create stigma.

In Spain, a psychological evaluation is required in order for children to receive GnRH analogues.

Spanish families have been fighting for and, in some areas, gaining wider access to these drugs, in order to avoid the psychological trauma that often accompanies puberty in transgender youth, Dr Gonzalez Navajas explained.

Recently, Madrid elected a more progressive government that passed a new law protocolizing transgender treatment and making it less contingent on physician opinion. More progressive parties are also proposing a global transgender law.

So, even though the science and medicine are there, access to transgender treatment basically hinges on legal and social issues.

"The problem is the moral approach of the doctors [and]…religion. It's transgender acceptance at this moment in society," Dr Gonzalez Navajas concluded.

The Endocrine Society Hormones & Health Science Writers Conference was sponsored by Janssen Pharmaceuticals.


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