transgenderChastity Bono was the only child of the famed entertainers Sonny and Cher, and born a daughter. After years of being labeled a lesbian in the media, Chastity came out as being a transgender man named Chaz in 1995, and represented one the first well publicized gender transitions in the media. In 2014 Lavern Cox, an openly transwoman actress, was on the cover of Time Magazine with the headline “The Transgender Tipping Point” which asserted that transgender acceptance represented the new social justice movement after gay marriage. In April 2015 Bruce Jenner, a male Olympian athlete, was interviewed on national television by Barbara Walters to 20 million viewers and pronounced himself a transgender woman. Weeks later Caitlyn Jenner broke the internet with her Vanity Fair cover shoot in full presentation as a woman posed in a corset.

What does transgender mean?

While transgender social issues have gained historic traction, awareness, and acceptance in recent decades, transgender people have always existed in society. The prevalence of transgendered people is unknown, largely because we don’t count them. The U.S. Census Bureau doesn’t ask who is transgender, nor does the Centers for Disease Control and Prevention. Some studies have suggested gender variant population prevalence to be roughly 0.3 percent, but this is likely an underestimate.

Transgender is a term for people who feel that they were born as the wrong sex. Transgender people might take medicines or have surgery to change their bodies so they can look and feel more like the opposite sex. Gender orientation and sexual orientation are different — transgender is not the same as homosexuality. Sexual orientation is who someone is attracted to, whereas gender orientation is the gender they identify as. Transgender people also differ from “transvestites” (also called “cross-dressers”), who sometimes dress like a member of the opposite sex but do not identify inherently as that gender. Every transgendered person’s story is unique, however, the most common symptom a transgendered person reports is feeling that they were born the wrong sex. Many transgender adults say they had these feelings as children, and have lifelong sought to find their “true gendered” selves.

What is transgender medicine and how to people qualify for treatment?

Transgender medicine is a specialized field of study where a healthcare provider has received training specifically in the area of providing medical and mental health services to support people who feel their gender varies from what they were born with.  The process of gender reassignment is a multidisciplinary area of healthcare. Talk therapy is often the first step in exploring gender identity concerns, with a therapist who is experienced in this area. Medical treatment includes hormone therapy to promote the desired gender, as well as medications that block hormones of the previous gender. Cosmetic procedures improve the appearance of the desired gender, and sex reassignment surgeries provide options to remove or create gender specific anatomy.

Standards of medical care for transgender health care were initially developed by an endocrinologist named Harry Benjamin who was introduced to transgender issues by Alfred Kinsey in San Francisco during the 1940s. He was one of the first physicians to specialize in providing medical care for transgendered people, and he created what is still known as the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People, which remains a publication of the World Professional Association for Transgender Health (WPATH) and has undergone numerous revisions in recent decades. This document outlines the evaluation guidelines for gender variant people, consequences of hormone and surgical interventions, and recommends criteria that must be met to begin medical therapies, which typically includes a letter of readiness from a mental health professional, as well as living as the desired gender for 6 months or longer before starting medical treatment for gender transition. The Endocrine Society published medical guidelines relatively comparable to Harry Benjamin’s standards in 2009, entitled Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline, which expands on details of diagnosis, evaluation of readiness, and evidence based medical therapies available for gender transition.

The WPATH guidelines were later contrasted by a different school of thought known as ICATH, which advocates for the idea that people of all gender presentations can access gender affirming healthcare through making informed decisions. Also, they should not be held to specific qualifying criteria to receive gender transition supporting medical interventions. ICATH promotes autonomy, the right to self-determination, and access to medical services without a requirement to go to therapy that pertains only to trans people, and asserts that a specific time required to live in public as a gender restricts timely acquisition of hormone or surgical therapies for some people.

The mental health impacts for a person who does not have support in exploring their gender identity can be crippling. Studies have found that for gender-nonconforming adults, 41 percent report attempting suicide, and the risk is highest for those who’ve experienced rejection, harassment, discrimination, or violence. For those 16 to 25 years old, the rate is 45 percent. For the homeless, the rate is 69 percent. And for those who’d sought help from a doctor and been turned away, 60 percent (3). These numbers don’t even include those who contemplate suicide or succeed. Providing resources for transgender health is clearly a necessary priority.

The purpose of any standards of care or guideline is to provide gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, minimize side effects of medical interventions, promote psychological well-being, and ultimately personal self-fulfillment. Most physicians who specialize in transgender healthcare individually evaluate the readiness for medical or surgical therapies on a case per case basis, and make recommendations for therapy or outside evaluations with collaborating specialists such as urology, endocrinology, gynecology, psychology or psychiatry, as is warranted for the individual based on their presentation and health status.

Are medical therapies for gender transitioning safe?

Transgender medical therapy outcome studies have historically been far and few between, but in recent years we have begun to have more research data to help understand the short and long term effects of hormone and surgical outcomes for gender transition therapies. This research has been reassuring in finding serious harm from these treatments are rare. Male to female (MtF) therapies have different risk profiles than female to male (FtM), and co morbid conditions an individual may have before beginning gender transition therapies such as diabetes, obesity, heart, kidney, or liver disease, increases possible harm from gender altering treatments. The healthier a person is before and during gender therapy, the better high dose hormone and other medical treatments will be tolerated.

A recent study showed transgender young adults have hormone profiles expected for their born gender, meaning hormonal imbalances do not cause someone to be transgender (2). Some changes associated with initiating hormone therapy can be reversed if treatment is discontinued, however some changes are permanent. Secondary sex characteristics may take a two year period of time to fully develop after initiating cross sex hormone treatment. When an individual wishes to transition their gender, their focus is usually on the development of desired gender anatomy, however, I always remind them that medically, my job also includes taking care of the ‘previously-known-as’ anatomy of the original gender, such as prostate health despite gender transition to female, or uterine health for transmen.

In general, high dose estrogen therapy for MtF treatment has more long term health consequences noted in medical studies than high dose testosterone therapy for FtM;  mortality rates have been shown to be  increased in male-to-female, but not female-to male transgender individuals. This is primarily due to the fact that estrogen causes clots, both in biologically born women (bio or cisgendered women), but especially so in transwomen because a long duration of high dose estrogen therapy is necessary for gender transformation. One report demonstrated mortality rate to be 51 percent higher in the MtF population, mainly due to drug abuse, HIV, and suicide in addition to the increased risk of cardiovascular events associated with high dose estrogen (1).

The actual risk of coronary artery disease remains yet to be determined for people undergoing gender transition treatments, but it is known to be higher in MtF. In one study, the incidences of venous thromboembolic complications were 2 to 6 percent in transwomen receiving oral estrogen (4). Other studies have suggested the risk of clotting to be lower than this.

The risk of clotting with estrogen is dose dependent, and is higher in oral forms over transdermal creams applied to the skin. Comparatively high dose testosterone therapy for FtM treatment is associated with the development of polycythemia, an increase in hematocrit content of red blood cells, which can create increased blood viscosity and lead to clotting. Routine testing of hematocrit levels is therefore necessary with testosterone use.  It is considered prudent in both MtF and FtM persons to aggressively treat cardiovascular risks.

Prolactin is a hormone secreted from the pituitary gland, and should be periodically monitored in MtF, as high dose estrogen levels have been shown to increase prolactin levels over long durations of treatment, and case studies have revealed the development of benign tumors of the pituitary, called prolactinomas, in a few documented reports. In addition liver enzymes can sometimes become elevated in any high dose hormone therapy treatment.

Prostate cancer is rare among MtF but periodic assessment of PSA levels is advised per biological male guidelines, and digital rectal exams may infer screening benefit for prostatic disorders. Breast cancer is also very rare in MtF people, however documented cases exist and therefore routine mammography according to biological women guidelines is encouraged. Ovarian or uterine cancer occurrence is also unlikely in FtM, but should be taken into consideration if a FtM person retains their uterus and ovaries, as a handful of cases have been documented to occur with high dose testosterone therapy.

Hormone therapy dose adjustments as a transgender person ages may be considered prudent to reduce side effects of hormone therapy such as cancer and cardiovascular events, which are rare, but which inherently increase in all genders based on age alone and therefore a reduction of hormone doses with age, may reduce unwanted hormone consequences over time. However the hormone dose must remain adequate to maintain the sex characteristics of the desired sex, as well as maintain bone mineral density.

Transgender Surgical Options

Multiple surgical and cosmetic options exist to improve the appearance of the desired gender. “Top” surgery is a common option, and includes both FtM people who remove breast tissue in efforts to create a flat masculine chest, as well as MtF who receive breast implants.  “Bottom” surgery refers to sex reassignment surgery of the genitals, and is the final step for some transgendered individuals to live successfully in their preferred gender role. Surgical techniques have improved markedly during the past 10 years, and aesthetic outcome alongside preservation of neurological sensation is now the standard. The satisfaction rate with surgical reassignment of sex has been shown to be very high (5). Some health insurance has begun to pay for transgender therapies, but more often, these treatments are an out of pocket expense and therefore can be cost-prohibitive to obtain for many.

However, whether or not to pursue surgery is a very personal and individualized decision. One can live in their authentic gender expression regardless of surgical or even hormonal intervention if that is one’s personal preference. Transgender healthcare ultimately is about empowering and supporting a person’s whole being, which encompasses identity, social and relationship health, as well as medical attention to both gender transition related issues but also general vital health.

For people who choose medical interventions for gender transition as part of their gender journey, studies to date have surmised that overall gender reassignment treatments are safe, effective, and result in significant improvements in quality of life and psychosocial outcomes including improved mood, sexual function, relationship quality, and overall life satisfaction(5).

The Big Picture

Caitlyn Jenner received the Arthur Ashe Courage Award in one of her first public appearances as a transgender woman in July 2015. During her emotional speech she stated “So for the people out there wondering what this is all about, whether it’s about courage or controversy or publicity, well, I’ll tell you what it’s all about,” Jenner said. “It’s about what happens from here. It’s not just about one person. It’s about thousands of people. It’s not just about me, it’s about all of us accepting one another. We’re all different. That’s not a bad thing, it’s a good thing.” She petitioned her worldwide audience to “accept people for who they are.”

While transgender medicine is a complicated, multidisciplinary area of healthcare that requires thoughtful insight into medical diagnosis criteria and treatment readiness guidelines, as well as skilled application of numerous gender transition treatments, ultimately it is a field of healthcare designed to support gender variant people in becoming who they really are.

SUMMARY AND RECOMMENDATIONS

  • Transgender or gender variant is a condition in which a person identifies as the opposite gender from which they were born. It is associated with an often lifelong urge to be that gender hormonally, anatomically, and psychosocially.
  • There are numerous international organizations involved with the creation of numerous Standards of Care for the diagnosis and treatment of transgender people, which have similarities and some differences in their recommendations.
  • Before initiating hormonal or surgical treatment that will change a person’s sex, a clinician will counsel the patient about risks and benefits of the hormonal or surgical therapy, as well as realistic expectations about outcomes, and individually assess readiness and potential complications for gender transition.
  • Gender transition therapies have risks, which are different depending on MtF or FtM treatment, and depend on the health status of the individual, but overall have been found in medical studies to be reassuringly safe and serious adverse consequences of gender treatments are rare.

 References

  1. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. AU Asscheman H, Giltay EJ, Megens JA, de Ronde WP, van Trotsenburg MA, Gooren LJ SO Eur J Endocrinol. 2011;164(4):635.
  2. Hormone levels of transgender youth consistent with assigned sex. Olson J, et al. J Adolesc Health. 2015.
  3. Transgender? Or TrueGender? Transgender people don’t choose gender identity any more than the rest of us do. Post published by Deborah L. Davis Ph.D. on Jul 21, 2015 in Laugh, Cry, Live
  4. Venous thrombo-embolism as a complication of cross-sex hormone treatment of male-to-female transsexual subjects: a review. AU Asscheman H, T’Sjoen G, Lemaire A, Mas M, Meriggiola MC, Mueller A, Kuhn A, Dhejne C, Morel-Journel N, Gooren LJ SO Andrologia. 2014;46(7):791.
  5. Endocrine Treatment of Transsexual Persons:An Endocrine Society Clinical Practice Guideline.  Wylie C. Hembree, Peggy Cohen-Kettenis, Henriette A. Delemarre-van de Waal,Louis J. Gooren, Walter J. Meyer, III, Norman P. Spack, Vin Tangpricha, and Victor M. Montori