Endocrine Society Updates Guidelines on Transgender Medical Care

Veronica Hackethal, MD

September 25, 2017

The Endocrine Society has updated its guidelines for providing gender-affirming treatment to transgender individuals, published online in the Journal of Clinical Endocrinology & Metabolism.

At the same time, the society issued a position statement calling for policy makers to consider the biological underpinning of gender identity. This asks US federal and private insurers to cover physician-prescribed medical interventions for transgender individuals and highlights the need for increased funding and prioritization of research on transgender medical care.

The latest guidelines represent an update to 2009 Endocrine Society recommendations for managing transgender individuals.

In particular, they provide detailed advice on the appropriate age for teens to start treatment. They also emphasize standard fertility preservation counseling for all individuals deciding about puberty suppression or hormone therapy.

"Diagnosing clinicians, mental-health providers for adolescents, and mental-health professionals for adults should all be knowledgeable about the diagnostic criteria for gender-affirming treatment, have sufficient training and experience in assessing related mental-health conditions, and be willing to participate in the ongoing care throughout the endocrine transition," Wylie Hembree, MD, of the College of Physicians and Surgeons at Columbia University and chair of the guidelines task force, said in a press release.

The new guideline is cosponsored by the American Association of Clinical Endocrinologists, American Society of Andrology, European Society for Paediatric Endocrinology, European Society of Endocrinology, Pediatric Endocrine Society, and the World Professional Association for Transgender Health.
 

Individuals Can Decide About Gender by Age 16

To update the guidelines, a group of experts examined all the available published evidence. They provide an overview of the recent, rapid expansion of research supporting the biological determinants of gender identity development. They also provide standardized terminology for use by healthcare providers.

The guidelines focus on gender-affirming hormone therapy, which can reduce the suffering experienced by gender-dysphoric/gender-incongruent individuals whose physical characteristics do not match their assigned birth sex.

Hormone therapy suppresses the body's sex hormones, which cause many of the physical changes seen at puberty. Treatment should be safe and effective, and sex hormone levels should be kept within the normal range for gender affirmation, say the guidelines. 

Because gender-affirming therapy is partially irreversible, it should be provided only after confirming the persistence of gender dysphoria/gender incongruence in individuals with sufficient mental capacity to give informed consent.

Most people can do that by age 16, write the authors, while recognizing that some individuals may have compelling reasons to start therapy before age 16. However, minimal published evidence exists regarding treatment before ages 13.5 to 14 years. Gender-affirming surgery and removal of gonads or the uterus should not be performed before age 18 or the legal age of majority in the individual's country.

The authors also stress the importance of a multidisciplinary team composed of appropriately trained diagnosing clinicians, endocrinologists, mental-health providers, and other professionals who can provide appropriate services for gender-dysphoric/gender-incongruent individuals. Clinicians should have expertise in providing transgender-specific care.

Recommendations cover the evaluation of youth and adults, treatment of adolescents, hormonal therapy for transgender adults, prevention of adverse outcomes, long-term care, and surgery for sex reassignment and gender confirmation.

Key recommendations include:

  • Hormone therapy is not advised for prepubertal individuals with gender dysphoria or gender incongruence.

  • Clinicians should inform and counsel all individuals seeking gender-affirming medical treatment about the options for fertility preservation before starting puberty suppression in adolescents and before starting hormonal therapy in both adolescents and adults.

  • In adolescents who meet diagnostic and treatment criteria, pubertal hormone suppression using GnRH analogues should start after girls and boys first exhibit the physical changes of puberty.

  • In adults, clinicians should evaluate and address medical conditions that can be exacerbated by hormone depletion and treatment before starting hormone therapy.

  • Surgical removal of gonads may be considered when high doses of sex steroids are needed to suppress the body's own secretion of sex steroids and/or in advanced age.

  • All individuals receiving hormone therapy should have regular monitoring for prolactin; bone loss; cardiovascular, lipid, and metabolic disorders; and cancer screening.

The guidelines also include detailed protocols for the induction of puberty and hormone regimens in transgender persons, as well as information on timing to onset of physical changes after starting hormone therapy, treatment monitoring, and medical risks and adverse effects of therapy, as well as criteria for gender-affirming surgery.

Dr Hembree reports no relevant financial relationships. Disclosures for the coauthors are listed in the paper.

J Clin Endocrinol Metab. Published online September 13, 2017. Abstract

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