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Hormone Concentrations in Transgender Women Who Self-Prescribe Gender Affirming Hormone Therapy: A Retrospective Study
Abstract
Background
Self-prescribed gender-affirming hormone therapy (GAHT) is common practice among transgender women, especially in resource-limited countries, yet the effectiveness of each GAHT regimen to achieve female range sex hormone concentrations is not known.
Aim
To describe the use and sex hormone concentrations of various GAHT regimens among transgender women who self prescribe in Thailand.
Methods
This was a retrospective study in a community-based setting. Five hundred and 27 records of transgender women taking GAHT who were receiving care at a community health center between January 1, 2018, and December 31, 2020 were included for the analysis.
Main Outcome Measures
Blood total testosterone and estradiol concentration after at least a 6-month period of GAHT.
Results
Multiple GAHT regimens were identified including oral estradiol valerate (EV), transdermal 17β-estradiol gel, injectable EV with hydroxyprogesterone caproate, injectable estradiol benzoate with progesterone, oral EV with cyproterone acetate (CPA), and oral contraceptive pills (OCPs). The most common GAHT regimen used by 49.1% of the participants was OCPs that contained 0.035 mg of ethinyl estradiol and 2 mg of CPA. Only 25.2% of this group had female range testosterone concentrations (<50 ng/dL). Oral EV and CPA were used by 23.1% of the participants. Most of them used 12.5 mg of CPA and 47.7% of this group had female range testosterone concentrations. There was no statistical significance between mean testosterone concentrations in CPA 12.5 and 25 mg groups, (P = .086).
Clinical Implications
The inadequate sex hormone levels found in these commonly self-prescribed GAHT regimens provide information regarding the efficacy and safety of GAHT regimens for health care providers working with transgender women in a community-based setting.
Strengths and Limitations
This study reflected a real-world situation and provided hormonal profiles among transgender women taking self-prescribed GAHT. However, issues in recall, medical literacy, and adherence to the medication may limit the results.
Conclusion
Combined hormonal contraceptive pill was a commonly used GAHT regimen in Thai transgender women who self prescribe GAHT. However, this regimen was not effective to decrease testosterone concentrations to the recommended range of less than 50 ng/dL. Overall, self-prescription of GAHT does not appear to be effective in reaching target sex hormone concentrations. Including health care providers in the prescription and monitoring of GAHT may be a more effective approach in the delivery of GAHT.
Salakphet T, Mattawanon N, Manojai N, et al. Hormone Concentrations in Transgender Women Who Self-Prescribe Gender Affirming Hormone Therapy: A Retrospective Study. J Sex Med 2021;XX:XXX–XXX.
... Sao praphet song are Thai transfeminine individuals assigned male at birth (AMAB) who are typically attracted to cisgender men (Winter 2006a(Winter , 2006bCoome et al. 2020) and are characterized as markedly feminine relative to gay cisgender men (Totman 2003;Coome et al. 2020). A large majority (i.e., 75%-90%) of sao praphet song use exogenous genderaffirming hormones (GAH), which may include estrogenic, progesteronic, and/or anti-androgenic doses (Guadamuz et al. 2011;Gooren et al. 2015;Humphries-Waa 2014;Salakphet et al. 2022;Skorska et al. 2023). GAH use onset typically occurs during adolescence and emerging adulthood for sao praphet song . ...
... Additionally, the measurement of GAH use may have posed some limitations to the study. Access to exogenous hormones in Thailand is not limited to those with a physician prescription or referral (Salakphet et al. 2022;Skorska et al. 2023), which may have contributed to the varied hormone use among participants. GAH is relatively accessible in Thailand in the form of hormonal contraception from pharmacies, and this likely contributes to there being little consistency in use patterns across individuals . ...
White matter (WM) microstructure is differentiated in relation to sex/gender, psychosexuality, and, among transgender people, gender‐affirming hormone (GAH) use. Prior research focused on Western samples, which limits generalizability to other populations. Here, diffusion tensor imaging (DTI) was used to assess WM microstructure in a Thai sample (N = 128) of straight cisgender men, straight cisgender women, gay cisgender men, and sao praphet song (i.e., transfeminine individuals assigned male at birth and sexually attracted to cisgender men). Sao praphet song were further grouped by GAH use. Groups were compared on fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) using whole‐brain tract‐based spatial statistics (TBSS). FA, AD, and RD were further examined via multivariate analysis to assess covariance across WM microstructural indices and participant groups. A significant multivariate pattern differentiated the feminine‐ from masculine‐identifying groups irrespective of sex assigned at birth and suggested WM tissue organization was greater among the latter in the bilateral cingulum, anterior corona radiata, left corpus callosum, and right superior longitudinal fasciculus, forceps minor, and corticospinal tracts. TBSS analyses reinforced that WM differed by gender identity in various regions. Among sao praphet song, GAH use was associated with lower regional FA, suggesting less WM organization bilaterally in the corpus callosum, cingulum, and anterior corona radiata. The findings aligned with prior studies in Western samples, indicating cross‐population generalizability of WM microstructural differentiation in relation to sex/gender, psychosexuality, and GAH use.
... This included 7/22 in the estradiol-alone group and 5/37 in the estradiol plus progestin group who had undergone "sex reassignment surgery [sic]" (type not specified) and would thus be expected to have very low testosterone levels. Salakphet et al, 24 which relied on selfreported and often self-prescribed regimens, reported total testosterone levels in the cisgender male range in conjunction with very low estradiol levels, indicating inadequate GAHT treatment. ...
... 21 Similarly, in the Salakphet study with self-reported data and up to 28-day intervals between injections, it is difficult to assess how to interpret a level drawn on any given day. 24 Other papers were identified that did not fulfill the study inclusion criteria but support the above discussion. Pappas et al 27 looked at a combination of oral and injectable estradiol to understand what dose would achieve an estradiol level within guideline range. ...
... However, a possible lack of drug reimbursement data due to off-label use, not quantified in our study, could alter the quality of follow-up of this particular population. Indeed, this phenomenon has been observed in other countries [41][42][43]. ...
Purpose
To measure the impact of national regulatory actions implemented in France in August 2018 and June 2019 to reduce the risk of meningioma associated with the use of cyproterone acetate (CPA).
Methods
Using the French National Healthcare database, we calculated the monthly number of CPA users among cisgender women, men and transgender women in 2010–2021, the monthly proportion of users with cerebral imaging screening, and the annual rate of meningioma surgery associated with CPA use. CPA discontinuations and switches were analysed.
Results
Between 2018 and 2021, the number of individuals exposed to CPA fell by 85% (55 000 in August 2018 versus 7900 users of high‐dose CPA in December 2021), corresponding to two waves of decrease in both use and initiation. This drop was greater among cisgender women (88%) than men (69%) or transgender women (50%). Cerebral imaging screening increased from 11% in June 2018 to 70% in June 2021 for ciswomen (13%–51% for men, 9%–60% for transwomen). After CPA discontinuation, no massive shift to a single product was observed, but, instead, dispersion towards other hormonal therapies. The overall annual rate of meningioma surgery associated with CPA exposure spectacularly decreased between 2017 and 2021 (−93% for ciswomen and −86% for men).
Conclusion
In France, high‐dose CPA use sharply decreased after the implementation of national regulatory measures without a massive switch to other hormonal therapies. The increase in cerebral imaging screening did not result in an increase in meningioma surgery associated with CPA, but rather a massive drop of over 90%.
Objectives: We aimed to describe the gender-affirming hormonal therapy (GAHT) intake behaviour and regimen and the factors associated with the use of hormones inconsistent with reference GAHT regimen among transgender people in the Philippines.
Design: Cross-sectional study.
Setting: Transgender community clinic in Metro Manila, Philippines from March 2017 to December 2019.
Participants: Gender-affirming care-seeking individuals of at least 18 years old, who self-identified as transgender or non-binary, and who self-reported current or previous use of GAHT at baseline consult.
Primary outcome measures: Reported drugs and/or administration routes not congruent with the World Professional Association for Transgender Health Standard of Care eighth edition were classified as hormone use outside the reference regimen.
Results: 253 transgender people reported current or previous intake of GAHT. Many trans women and transfeminine people (TWTFP; 58.9%, 86/146) reported using oral contraceptive pills (OCPs), whereas most trans men (TM; 73.8%, 79/107) reported injecting testosterone esters. Furthermore, 59.7% (151/253) used hormones outside the reference regimen, widely using OCP and anabolic steroids among TWTFP and TM, respectively. TWTFP (crude prevalence ratio, PR, 3.52; 95% CI 2.35 to 5.49) and those who take unprescribed GAHT (crude PR 2.37; 95% CI 1.08 to 6.68) were more likely to use hormones outside the reference regimen than TM and taking healthcare provider-prescribed GAHT, respectively. On adjusting for covariates, the prevalence of using hormones outside the reference regimen was approximately three times higher (adjusted PR 3.22; 95% CI 2.09 to 5.12) among TWTFP than TM.
Conclusion: Trans people act on their high unmet gender-affirming care needs by taking unprescribed GAHT, many outside the reference regimen. Structural changes in the health system are warranted, including strengthened community-based self-administration practices.
Objective:
Gender-affirming hormone therapy (GAHT) guidelines describe estradiol doses for intramuscular (IM), but not subcutaneous (SC) routes. Objective was to compare SC and IM estradiol doses and hormone concentrations in transgender and gender diverse (TGD) individuals.
Methods:
Retrospective cohort study at a single site tertiary care referral center. Patients were TGD individuals receiving injectable estradiol with at least 2 estradiol measurements. Main outcomes were median doses and achieved serum hormone concentrations between SC and IM routes.
Results:
There was no statistical difference in age, BMI or anti-androgen use between patients on SC estradiol (n = 74) vs IM estradiol (n = 56). Median weekly doses of SC estradiol, 3.75 mg [IQR 3-4 mg] were statistically significantly lower than IM estradiol, 4 mg [IQR 3-5.15 mg] (p = 0.005), but estradiol concentrations achieved by both groups were not significantly different, (p = 0.69) and median testosterone concentrations were in the cisgender female range and were not significantly different between routes (p = 0.92). Subgroup analysis demonstrated significantly higher doses in the IM group when estradiol > 100 pg/mL, testosterone < 50 ng/dL, with gonads present, or use of anti-androgens. Multiple Regression Analysis demonstrated that estradiol dose was significantly associated with estradiol concentrations after adjusting for injection route, BMI, anti-androgen use, and gonadectomy status.
Conclusions:
Both SC and IM estradiol GAHT achieve therapeutic estradiol concentrations without a meaningful difference in estradiol dose (3.75 vs 4 mg). SC use may require lower doses than IM to achieve therapeutic concentrations.
Context
Cyproterone acetate (CPA) is a competitive inhibitor of the androgen receptor and exerts negative hypothalamic feedback. It is often used in combination with estrogens in trans women to achieve feminization. However, CPA has been associated with side effects such as changes in liver enzyme concentrations and increases in prolactin concentrations. The question is whether testosterone lowering, as well as these side effects, are dose-dependent.
Objective
To assess the lowest effective dose of CPA in trans women to prevent side effects.
Design
This longitudinal study is part of the European Network for the Investigation of Gender Incongruence (ENIGI), a multicenter prospective cohort study.
Setting
Gender identity centers in Amsterdam, Ghent, and Florence
Participants
Trans women (n = 882) using estrogens only or in combination with 10mg, 25mg, 50mg, or 100mg CPA daily.
Intervention
Different doses of CPA.
Main Outcome measure
The concentration of testosterone at 3 and/or 12 months of hormone therapy.
Results
Using estrogens only (without CPA) led to testosterone concentrations of 5.5nmol/L (SEM 0.3). All doses of CPA resulted in testosterone concentrations below the pre-defined threshold of suppression of 2nmol/L (10mg: 0.9nmol/L, SEM 0.7; 25mg: 0.9nmol/L, SEM 0.1; 50mg: 1.1nmol/L, SEM 0.1; 100mg: 0.9nmol/L, SEM 0.7). Higher prolactin and lower high-density lipoprotein concentrations were observed with increasing doses of CPA. No differences in liver enzyme concentrations were found between the doses.
Conclusions
Compared to higher doses of CPA, a daily dose of 10mg is equally effective in lowering testosterone concentrations in trans women, while showing fewer side effects.
Background:
Lesbian, gay, bisexual, transgender and questioning (LGBTQ) individuals experience higher rates of health disparities. These disparities may be driven, in part, by biases of medical providers encountered in health care settings. Little is known about how medical, nursing, or dental students are trained to identify and reduce the effects of their own biases toward LGBTQ individuals. Therefore, a systematic review was conducted to determine the effectiveness of programs to reduce health care student or provider bias towards these LGBTQ patients.
Methods:
The authors performed searches of online databases (MEDLINE/PubMed, PsycINFO, Web of Science, Scopus, Ingenta, Science Direct, and Google Scholar) for original articles, published in English, between March 2005 and February 2017, describing intervention studies focused on reducing health care student or provider bias towards LGBTQ individuals. Data extracted included sample characteristics (i.e., medical, nursing, or dental students or providers), study design (i.e., pre-post intervention tests, qualitative), program format, program target (i.e., knowledge, comfort level, attitudes, implicit bias), and relevant outcomes. Study quality was assessed using a five-point scale.
Results:
The search identified 639 abstracts addressing bias among medical, nursing, and dental students or providers; from these abstracts, 60 articles were identified as medical education programs to reduce bias; of these articles, 13 described programs to reduce bias towards LGBTQ patients. Bias-focused educational interventions were effective at increasing knowledge of LGBTQ health care issues. Experiential learning interventions were effective at increasing comfort levels working with LGBTQ patients. Intergroup contact was effective at promoting more tolerant attitudes toward LGBTQ patients. Despite promising support for bias education in increasing knowledge and comfort levels among medical, nursing, and dental students or providers towards LGBTQ persons, this systematic review did not identify any interventions that assessed changes in implicit bias among students or providers.
Conclusions:
Strategies for assessing and mitigating implicit bias towards LGBTQ patients are discussed and recommendations for medical, nursing, and dental school curricula are presented.
Objective
To update the “Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline,” published by the Endocrine Society in 2009.
Participants
The participants include an Endocrine Society–appointed task force of nine experts, a methodologist, and a medical writer.
Evidence
This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.
Consensus Process
Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines.
Conclusion
Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person’s genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person’s affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments—appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)—should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.
The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.
Adverse effects of long-term cross-sex hormone administration to transsexuals are not well documented. We assessed mortality rates in transsexual subjects receiving long-term cross-sex hormones.
A cohort study with a median follow-up of 18.5 years at a university gender clinic. Methods Mortality data and the standardized mortality rate were compared with the general population in 966 male-to-female (MtF) and 365 female-to-male (FtM) transsexuals, who started cross-sex hormones before July 1, 1997. Follow-up was at least 1 year. MtF transsexuals received treatment with different high-dose estrogen regimens and cyproterone acetate 100 mg/day. FtM transsexuals received parenteral/oral testosterone esters or testosterone gel. After surgical sex reassignment, hormonal treatment was continued with lower doses.
In the MtF group, total mortality was 51% higher than in the general population, mainly from increased mortality rates due to suicide, acquired immunodeficiency syndrome, cardiovascular disease, drug abuse, and unknown cause. No increase was observed in total cancer mortality, but lung and hematological cancer mortality rates were elevated. Current, but not past ethinyl estradiol use was associated with an independent threefold increased risk of cardiovascular death. In FtM transsexuals, total mortality and cause-specific mortality were not significantly different from those of the general population.
The increased mortality in hormone-treated MtF transsexuals was mainly due to non-hormone-related causes, but ethinyl estradiol may increase the risk of cardiovascular death. In the FtM transsexuals, use of testosterone in doses used for hypogonadal men seemed safe.
The incidence of venous thrombosis associated with estrogen treatment in male-to-female (M→F) transsexuals is considerably higher with administration of oral ethinyl estradiol (EE) than with transdermal (td) 17-β-estradiol (E2).
To find an explanation for the different thrombotic risks of oral EE and td E2 use, we compared the effects of treatment of M→F transsexuals with cyproterone acetate (CPA) only, and with CPA in combination with td E2, oral EE, or oral E2 on a number of hemostatic variables [activated protein C (APC) resistance and plasma levels of protein S, protein C, and prothombin], all of which are documented risk factors for venous thrombosis. APC resistance was determined by quantification of the effect of APC on the amount of thrombin generated during tissue factor-initiated coagulation; plasma levels of total and free protein S were determined by standard ELISA; and levels of prothrombin and protein C were determined with functional assays after complete activation of the zymogens with specific snake venom proteases.
CPA-only, td-E2+CPA, or oral-E2+CPA treatment produced rather small effects on hemostatic variables, whereas oral EE treatment resulted in a large increase in APC resistance from 1.2 ± 0.8 to 4.1 ± 1 (P < 0.001), a moderate increase in plasma protein C (9%; P = 0.012), and a large decrease in both total and free plasma protein S (30%; P < 0.005). The large differential effect of oral EE and oral E2 indicates that the prothrombotic effect of EE is due to its molecular structure rather than to a first-pass liver effect (which they share). Moreover, these differences may explain why M→F transsexuals treated with oral EE are exposed to a higher thrombotic risk than transsexuals treated with td E2. Testosterone administration to female-to-male transsexuals had an antithrombotic effect.
Background
Spironolactone and cyproterone acetate are commonly used in feminizing hormone therapy to achieve the goal of female range testosterone level; however, the data on the efficacy comparing between these two anti-androgens are scarce.
Aim
To compare the anti-androgenic effects between spironolactone and cyproterone acetate as the component of feminizing hormone therapy among transgender women population.
Methods
The study was single-blinded randomized controlled trial involved 52 transgender women from two transgender health clinics. Each participant received oral estradiol valerate 4 mg/day combined with anti-androgen, spironolactone 100 mg/day or cyproterone acetate 25 mg/day, depending on which group they were randomized to. Clinical and biochemical variables were obtained at baseline and at 12 weeks of feminizing hormone therapy.
Main Outcome Measures
The change of testosterone level from baseline. Other changes including free testosterone, estradiol, prolactin and lipid profile after the therapy.
Results
After a 12 weeks of feminizing hormone therapy, the change of testosterone level in the cyproterone acetate group [558.0 ng/dL (IQR 352.0 to 783.3)] was significantly higher than the spironolactone group [226.2 ng/dL (IQR,-4.3 to 480.1)](p value <0.001). Testosterone and calculated free testosterone in the cyproterone acetate group were significantly lower than the spironolactone group. Consequently, a proportion of the participants who achieved the female range testosterone (<50 ng/dL) was significantly higher in cyproterone acetate group (90%) compared to the spironolactone group (19%). Serious adverse effects observed in cyproterone acetate users were drug-induced liver injury and asymptomatic hyperprolactinemia.
Clinical Implications
The data on the differences between the two anti-androgen could be benefit for the transgender health-care providers in medication selection and adverse-effects counseling.
Strengths & Limitations
The study design was randomized controlled trial and controlled the estrogen component by prescribed the same type and dose for each participant. However, the study was suffered from the confound feminizing effects from previous hormone therapy and the high drop-out rate.
Conclusion
For feminizing hormone therapy, cyproterone acetate had a higher testosterone suppression efficacy than spironolactone.
Burinkul S, Panyakhamlerd K, Suwan A, et al. Anti-Andorgenic Effects Comparison Between Cyproterone Acetate and Spironolactone in Transgender Women: A Randomized Controlled Trial. J Sex Med 2021;18:1299–1307.
Objective: To explore the desires and barriers to fertility preservation among transgender women and gender diverse people assigned male at birth in Thailand.
Material and methods: This study is a cross-sectional study in clinic-based setting. The data was obtained from a questionnaire. Three hundred and three participants visiting the Gender Care Clinic at Chiang Mai University Hospital and Mplus clinics between April 2019 and December 2019 were included. Of these, 199 were transgender women and 104 were gender diverse people assigned male at birth.
Results: The overall parental desire was 30.4% which was similar across the 2 groups (p = 0.897). A genetically related child was preferred in 40.9% of transgender women and 50.5% of gender diverse group (p = 0.115). Factors impacting a parental desire were a good relationship with family (OR 2.905, 95%CI 1.315–6.420, p = 0.008), being in a stable relationship (OR 4.183, 95%CI 1.738–10.069, p < 0.001) and belief in a positive attitude of society toward LGBTQ parenting (OR 2.572, 95%CI 1.207–5.479, p = 0.014). Access to fertility preservation services was low. The majority of transgender women (75.3%) and gender diverse people (95.2%) never received a consultation regarding fertility. The utilization rate of fertility treatments was 5.3% in our study.
Conclusion: Transgender women and gender diverse people assigned male at birth have parental desires for a genetically related child. However, access to reproductive information, consultation and services were very limited. Social support along with competent health services might increase access to reproductive services in transgender and gender diverse populations.
Objective: To examine the association of various gender affirmation hormone therapy (GAHT) regimens with blood hormone concentrations in transgender individuals.
Methods: This retrospective study included transgender persons receiving GAHT between January 2000 and September 2018. Data on patient demographics, laboratory values, and hormone dose and frequency were collected. Non-parametric tests and linear regression analyses were used to identify factors associated with serum hormone concentrations.
Results: Overall 196 subjects (134 trans women, 62 trans men) with a total of 941 clinical visits were included into this study. Trans men receiving transdermal testosterone had a significantly lower median value of total serum testosterone when compared to those who were receiving injectable preparations (326.0 vs. 524.5 ng/dL respectively, p=0.018). Serum total estradiol concentrations of trans women was higher in those receiving intramuscular estrogen compared to those receiving oral and transdermal estrogen (366.0 vs. 102.0 vs. 70.8 pg/mL respectively, p<0.001). A dose dependent response in hormone levels was observed for oral estradiol (p<0.001) and injectable testosterone (p=0.018), but not for intramuscular estradiol and not for transdermal formulations. Older age and history of gonadectomy in both trans men and women were associated with significantly higher concentrations of serum gender-affirmed hormone.
Conclusion: In trans men, all routes and formulations of testosterone appear to be equally effective in achieving concentrations in the male range. Intramuscular injections of estradiol resulted in the highest serum concentrations of estradiol whereas transdermal estradiol resulted in the lowest concentration. Dose was directly related to hormone levels for oral estradiol and injectable testosterone.
Abbreviations: TGGNB = Transgender and gender non-binary; GAHT = gender affirming hormone therapy, SD = standard deviation, BMI = body mass index, IQR = interquartile range, VTE = venous thromboembolism, HDL = high-density lipoprotein, TG = triglycerides, LDL = low-density lipoprotein, SHBG = sex hormone binding globulin.
Background
Gender-affirming hormone therapy and surgery are important medically necessary approaches to transgender care. However, few related data exist in China.
Aim
To understand the desire and access of transgender cares in the Chinese transgender men and women population.
Methods
A cross-sectional self-selecting survey targeting the Chinese transgender population was conducted in 2017 using a snowball sampling method. Participants completed an online questionnaire anonymously. Gender identity was verified by specifically designed questions. Data analysis of this study was performed in 2019.
Outcomes
The main outcome was the status of receiving transgender medical care, including the desire vs actual state of receiving gender-affirming hormone treatment and gender-affirmation surgery, methods of accessing hormonal therapy and surgery, and risky behaviors associated with obtaining treatments.
Results
Of the total 2060 valid questionnaires, there were 1,304 transgender individuals (626 transgender men and 678 transgender women), with a median age of 22 (interquartile range, 19–26) years. Among them, 1,036 (79.4%) expressed desires for hormonal therapy, but of 1,036, 741 (71.5%) considered it difficult to obtain medications from doctors. Of 1,036 individuals, 275 (26.5%) and 172 (16.6%) had thoughts or behaviors of self-injury, respectively, when lacking access to hormone therapy. Of 1,036 individuals, 602 (58.1%) had used hormones. Of those 602 hormone users, 407 (67.6%) had ever obtained medications from informal drug dealers, and 372 (61.8%) of them did not perform regular monitoring. 868 of 1,303 (66.6%) participants had received or wanted to undergo gender-affirming surgeries, but 710 of 868 (81.8%) considered the surgery resources not adequate or very scarce.
Clinical Implications
The transgender medical resources in China are scarce, and many transgender individuals have engaged in high-risk activities to access care.
Strengths & Limitations
This is the first study to focus on the current status of gender-affirming hormone therapy and surgery in the Chinese transgender population, providing valuable and real-world data for understanding the need for transgender health care in China. But, the online questionnaire could not provide the prevalence and other epidemiologic information about transgender individuals in China, and the survey did not address specific medication regimens, dosages, sex hormone levels, and specific hormone therapy–related or surgery-related adverse events.
Conclusion
Significant improvement in access to gender-affirming medical and surgery care is needed in China.
Liu Y, Xin Y, Qi J, et al. The Desire and Status of Gender-Affirming Hormone Therapy and Surgery in Transgender Men and Women in China: A National Population Study. J Sex Med 2020;XX:XXX–XXX.
This review summarizes current studies, systematic reviews, and clinical practice guidelines regarding the screening, diagnosis, and treatment of osteoporosis in transgender persons. Gender-affirming hormone therapy has been shown to maintain or promote acquisition of bone density as measured by dual-energy x-ray absorptiometry. No differences in fracture rates have been seen in trans women or men in short, prospective trials. Trans children and adolescents on gonadotropin-releasing hormone may be at risk for decreasing bone density while not on sex steroid hormone replacement. Screening for osteoporosis should be based on clinical factors. Treatment for osteoporosis follows the same guidelines as cisgender populations.
Approximately 0.6% of the U.S. population identifies as transgender. Depending on patient preference, treatment may involve hormone therapy (testosterone in transgender men, estrogens and androgen-lowering agents in transgender women), surgery customized to patient goals, and fertility preservation.
The indications for initial and follow-up bone mineral density (BMD) in transgender and gender nonconforming (TGNC) individuals are poorly defined, and the choice of which gender database to use to calculate Z-scores is unclear. Herein, the findings of the Task Force are presented after a detailed review of the literature. As long as a TGNC individual is on standard gender-affirming hormone treatment, BMD should remain stable to increasing, so there is no indication to monitor for bone loss or osteoporosis strictly on the basis of TGNC status. TGNC individuals who experience substantial periods of hypogonadism (>1 yr) might experience bone loss or failure of bone accrual during that time, and should be considered for baseline measurement of BMD. To the extent that this hypogonadism continues over time, follow-up measurements can be appropriate. TGNC individuals who have adequate levels of endogenous or exogenous sex steroids can, of course, suffer from other illnesses that can cause osteoporosis and bone loss, such as hyperparathyroidism and steroid use; they should have measurement of BMD as would be done in the cisgender population. There are no data that TGNC individuals have a fracture risk different from that of cisgender individuals, nor any data to suggest that BMD predicts their fracture risk less well than in the cisgender population. The Z-score in transgender individuals should be calculated using the reference data (mean and standard deviation) of the gender conforming with the individual's gender identity. In gender nonconforming individuals, the reference data for the sex recorded at birth should be used. If the referring provider or the individual requests, a set of "male" and "female" Z-scores can be provided, calculating the Z-score against male and female reference data, respectively.
Background:
Gender-affirming hormonal therapy consists of testosterone in transgender men and estrogens and antiandrogens in transgender women. Research has concluded that gender-affirming therapy generally leads to high satisfaction rates, increased quality of life, and higher psychological well-being. However, given the higher incidence of cardiometabolic morbidity and mortality in cisgender men compared with cisgender women, concerns about the cardiometabolic risk of androgen therapy have been raised.
Content:
A literature research was conducted on PubMed, Embase, and Scopus, searching for relevant articles on the effects of gender-affirming hormone therapy on cardiometabolic risk and thrombosis. After screening 734 abstracts, 77 full text articles were retained, of which 11 were review articles.
Summary:
Studies describing a higher risk for cardiometabolic and thromboembolic morbidity and/or mortality in transgender women (but not transgender men) mainly covered data on transgender women using the now obsolete ethinyl estradiol and, therefore, are no longer valid. Currently, most of the available literature on transgender people adhering to standard treatment regimens consists of retrospective cohort studies of insufficient follow-up duration. When assessing markers of cardiometabolic disease, the available literature is inconclusive, which may be ascribed to relatively short follow-up duration and small sample size. The importance of ongoing large-scale prospective studies/registries and of optimal management of conventional risk factors cannot be overemphasized.
Objective: The recommended dose of cyproterone acetate (CPA), an anti-androgen that is commonly used in the hormonal treatment of transgender women, is 50–100 mg daily. Our objective was to determine whether CPA at 25 mg daily would suppress total testosterone as effectively as 50 mg daily in transgender women.
Methods: We conducted a retrospective cohort analysis of transgender women attending an endocrinology clinic between April 1, 2009, and June 30, 2015. We used a generalized linear mixed model to compare total testosterone between patients on CPA 25 mg versus CPA 50 mg or higher. In a subgroup of patients for which the CPA dose was decreased from 50 mg to 25 mg, we compared total testosterone levels before and after the decrease.
Results: We divided the sixty-eight patients included in the study into 4 groups: group 1, CPA 25 mg (N =31); group 2, CPA 50 mg or higher (N = 19); group 3, CPA dose lowered from 50 mg to 25 mg (N = 15); group 4, CPA dose increased from 25 mg to 50 mg (N = 3). The mean total testosterone on treatment was 0.9 nmol/L (95% CI 0.7 to 1.1) in group 1 and 1.2 nmol/L (95% CI 0.9–1.5) in group 2 and were not significantly different (p = 0.087). In group 3, there was no significant difference between total testosterone levels before and after decreasing the dose of CPA from 50 mg to 25 mg, p = 0.86. Group 4 was excluded from analysis.
Conclusions: We found that 25 mg of CPA daily was effective at suppressing testosterone levels to within normal female range when used in combination with recommended estrogen therapy in transgender women. Clinicians should consider using a lower dose of CPA in order to minimize potential adverse effects.
Transgender women experience lifelong gender dysphoria due to a gender assignment at birth that is incongruent with their gender identity. They often seek hormone therapy, with or without surgery, to improve their gender dysphoria and to better align their physical and psychological features with a more feminine gender role. Some of the desired physical changes from oestrogen and anti-androgen therapy include decreased body and facial hair, decreased muscle mass, breast growth, and redistribution of fat. Overall the risks of treatment are low, but include thromboembolism, the risk of which depends on the dose and route of oestrogen administration. Other associated conditions commonly seen in transgender women include increased risks of depression and osteoporosis. The risk of hormone-sensitive cancer seems to be low in transgender women, with no increased risk of breast cancer compared with women and no increase in prostate cancer when compared with men. The evidence base for the care of transgender women is limited by the paucity of high-quality research, and long-term longitudinal studies are needed to inform future guidelines.
There exists limited understanding of cross-sex hormone use and mental well-being among transgender women and, particularly, among transgender men. Moreover, most studies of transgender people have taken place in the Global North and often in the context of HIV. This exploratory study compared 60 transgender men (toms) with 60 transgender women (kathoeys) regarding their use of cross-sex hormones, mental well-being and acceptance by their family. Participants also completed a dispositional optimism scale (the Life Orientation Test Revised), the Social Functioning Questionnaire and the Short Form Health Survey 36 assessing their profile of functional health and mental well-being. Cross-sex hormones were used by 35% of toms and 73% of kathoeys and were largely unsupervised by health-related personnel. There were no differences in functional health and mental well-being among toms and kathoeys. However, toms currently using cross-sex hormones scored on average poorer on bodily pain and mental health, compared to non-users. Furthermore, compared to non-users, cross-sex hormone users were about eight times and five times more likely to be associated with poor parental acceptance among toms and kathoeys, respectively. This study was the first to compare cross-sex hormone use, functional health and mental well-being among transgender women and transgender men in Southeast Asia.
While Male-to-female transgender persons (TG) are believed to often engage in sex work and have high HIV infection risk, little is known about demographics, surgical and hormone use history, risk behaviors and HIV prevalence. Between March and October 2005, 474 TG from Bangkok, Chiangmai, and Phuket were surveyed using venue-day-time sampling. Of 474 participants, overall HIV prevalence was 13.5%. Most participants had completed at least secondary or vocational education (79.2%), gender self-identified as female (89.0%), had received money, gifts or valuables for sex (60.8%), and reported hormone use (88.6%). Surgical history was taken from 325 participants. Of these, 68.6% reported some form of surgery and 11.1% had undergone penile-vaginal reconstructive surgery. In multivariate analysis, being recruited from a park/street; older age, anal sex role identification as "versatile" and anal sex debut before age 13 were independently associated with HIV prevalence. The development, implementation and evaluation of culturally appropriate sexual health interventions for Thai TG is urgently needed.