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Contributors CONSULTINGEDITOR
ADRIANAG.IOACHIMESCU,MD,PhD,FACE
ProfessorofMedicine(Endocrinology)andNeurosurgery,EmoryUniversitySchoolof Medicine,Atlanta,Georgia,USA
EDITOR
VINTANGPRICHA,MD,PhD
Professor,DepartmentofMedicine,DivisionofEndocrinology,MetabolismandLipids, EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA;AtlantaVAMedicalCenter, Decatur,Georgia,USA
AUTHORS
JESSICAABRAMOWITZ,MD
AssistantProfessor,DivisionofEndocrinologyandMetabolism,DepartmentofMedicine, UniversityofTexasSouthwesternMedicalCenter,Dallas,Texas,USA
CASSIEG.ACKERLEY,MD
ClinicalFellow,DivisionofInfectiousDiseases,DepartmentofMedicine,EmoryUniversity SchoolofMedicine,Atlanta,Georgia,USA;TheHopeClinicoftheEmoryVaccineCenter, Decatur,Georgia,USA
NOAHADAMS,MSW
Consultant,Toronto,Canada
JENSU.BERLI,MD
AssistantProfessor,DepartmentofSurgery,DivisionofPlasticandReconstructive Surgery,OregonHealth&ScienceUniversity,Portland,Oregon,USA
ELICOLEMAN,PhD UniversityofMinnesota,Minneapolis,Minnesota,USA
TREVORCORNEIL,MD,MHSc
UniversityofBritishColumbia,SchoolofPopulationandPublicHealth,Vancouver, Canada
CAROLINEJ.DAVIDGE-PITTS,MB,BCh
AssistantProfessor,DivisionofEndocrinology,Diabetes,andNutrition,MayoClinic, Rochester,Minnesota,USA
CHRISTELJ.M.DEBLOK,MD
DepartmentofInternalMedicine,CenterofExpertiseonGenderDysphoria,Amsterdam UMC,VUUniversityMedicalCenter,Amsterdam,TheNetherlands
JUSTINEDEFREYNE,MD
PhDResearcher,DepartmentofEndocrinology,GhentUniversityHospital,Ghent, Belgium
MARTINDENHEIJER,MD,PhD
DepartmentofInternalMedicine,CenterofExpertiseonGenderDysphoria,Amsterdam UMC,VUUniversityMedicalCenter,Amsterdam,TheNetherlands
KOENM.A.DREIJERINK,MD,PhD
DepartmentofInternalMedicine,CenterofExpertiseonGenderDysphoria,Amsterdam UMC,VUUniversityMedicalCenter,Amsterdam,TheNetherlands
ELIZABETHS.DUDA,BA
EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA
DANIELD.DUGIIII,MD,FACS
AssociateProfessor,DepartmentofUrology,OregonHealth&ScienceUniversity, Portland,Oregon,USA
MOLLYJ.ELSON,BA
EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA
LINFRASER,EdD
PrivatePractice,SanFrancisco,California,USA
MICHAELGOODMAN,MD,MPH
DepartmentofEpidemiology,EmoryUniversityRollinsSchoolofPublicHealth,Atlanta, Georgia,USA
OKSANAHAMIDI,DO
AssistantProfessor,DivisionofEndocrinologyandMetabolism,UniversityofTexas SouthwesternMedicalCenter,Dallas,Texas,USA
HEATHERS.HIPP,MD
AssistantProfessor,DivisionofReproductiveEndocrinologyandInfertility,Departmentof GynecologyandObstetrics,EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA
BENJAMINKAHN,BA
DepartmentofDermatology,EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA
COLLEENF.KELLEY,MD,MPH
AssociateProfessor,DepartmentofMedicine,DivisionofInfectiousDiseases,Emory UniversitySchoolofMedicine,Atlanta,Georgia,USA;TheHopeClinicoftheEmory VaccineCenter,Decatur,Georgia,USA;DepartmentofEpidemiology,EmoryUniversity RollinsSchoolofPublicHealth,Atlanta,Georgia,USA
GAILKNUDSON,MD,MEd,FRCPC
ClinicalProfessor,FacultyofMedicine,UniversityofBritishColumbia,Vancouver, Canada
SIRAKORPAISARN,MD
SectionofEndocrinology,Diabetes,NutritionandWeightManagement,BostonMedical Center,BostonUniversitySchoolofMedicine,Boston,Massachusetts,USA
BAUDEWIJNTJEKREUKELS,PhD
DepartmentofMedicalPsychology,VUUniversityMedicalCenter,Amsterdam, TheNetherlands
BAOCHAULY,BS
DepartmentofDermatology,EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA
TESSALYNMORRISON,BA
Student,SchoolofMedicine,OregonHealth&ScienceUniversity,Portland,Oregon,USA
SCOTTMOSSER,MD,FACS
DirectoroftheGenderInstitute,SaintFrancisMemorialHospital,SanFrancisco, California,USA
JOZMOTMANS,PhD
GhentUniversityHospital,Ghent,Belgium
SASHAK.NARAYAN,BA
Student,SchoolofMedicine,OregonHealth&ScienceUniversity,Portland,Oregon,USA
MICHAELF.NEBLETTII,MD
ResidentPhysician,DepartmentofGynecologyandObstetrics,EmoryUniversity,Emory UniversitySchoolofMedicine,Atlanta,Georgia,USA
TONIAPOTEAT,PhD,MPH,PA-C
AssistantProfessorofSocialMedicine,CenterforHealthEquityResearch,Universityof NorthCarolinaSchoolofMedicine,ChapelHill,NorthCarolina,USA
JOSHUAD.SAFER,MD,FACP
CenterforTransgenderMedicineandSurgery,MountSinaiHealthSystem,IcahnSchool ofMedicineatMountSinai,NewYork,NewYork,USA
JASONS.SCHNEIDER,MD
AssociateProfessor,DivisionofGeneralMedicineandGeriatrics,Departmentof Medicine,EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA
PAULPARKERSCHWAB,BBA
EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA
MARYO.STEVENSON,MD
AssistantProfessor,DepartmentofMedicine,DivisionofEndocrinology,Metabolismand Lipids,EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA
GUYT’SJOEN,MD,PhD
Head,DepartmentofEndocrinology,CenterforSexologyandGender,GhentUniversity Hospital,Ghent,Belgium
VINTANGPRICHA,MD,PhD
Professor,DepartmentofMedicine,DivisionofEndocrinology,MetabolismandLipids, EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA;AtlantaVAMedicalCenter, Decatur,Georgia,USA
OGULERSINUNER,BA
EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA
SHAWNWEN,MS
EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA
BRITTANYL.WHITLOCK,BS
EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA
HOWAYEUNG,MD
DepartmentofDermatology,EmoryUniversitySchoolofMedicine,Atlanta,Georgia,USA
Contents Foreword:TransgenderMedicinexiii
AdrianaG.Ioachimescu
Preface:TransgenderMedicine:BestPracticesandClinicalCarefortheFuturexv VinTangpricha
SizeandDistributionofTransgenderandGenderNonconformingPopulations: ANarrativeReview303
MichaelGoodman,NoahAdams,TrevorCorneil,BaudewijntjeKreukels, JozMotmans,andEliColeman
Accurateestimatesofthenumberandproportionoftransgenderand gendernonconformingpeopleinapopulationarenecessaryfordevelopingdata-basedpolicyandforplanningandfundingofhealthcaredeliveryandresearch.Thewiderangeofestimatesreportedintheliteratureis attributableprimarilytodifferencesindefinitions.Othersourcesofvariabilityincludediverseculturalandgeographicsettingsandimportant seculartrends.Thetransgenderandgendernonconformingpopulation isundergoingrapidchangesinsizeanddemographiccharacteristics. Moreaccurateandpreciseestimateswillbeavailablewhenpopulation censusescollectdataonsexassignedatbirthandgenderidentity.
EtiologyofGenderIdentity323 SiraKorpaisarnandJoshuaD.Safer
Thisarticlereviewsthecurrentliteraturecharacterizingpotentialfactors associatedwiththeetiologiesofgenderidentity.ThePubMeddatabase wassearchedforallliteraturethatassessedkeyelementsaffectingdevelopmentofgenderidentity.Currentmodelsattributegenderidentityetiology toendogenousbiologyalongwithprenatalandrogenexposure.However, nogeneticlociorspecificneuroanatomicregionshavebeenconsistently identifiedasthesingleexplanationfortransgenderidentity.Althoughenvironmentmayplayaroleingenderexpression,therearenodatatosuggest anexogenousexplanationforthedevelopmentofgenderidentity.
HormoneTherapyinChildrenandAdolescents331 JessicaAbramowitz
Forchildrenandadolescentswithgenderdysphoria,aninterdisciplinary careteamisessentialforproperdiagnosisandappropriatetreatment. Forchildrenwhopresentwithgenderdysphoria,oncepubertybegins, theycanbetreatedwithgonadotropin-releasinghormoneanalogsto stoppubertalprogression.Thisallowsforfurthergenderexploration,relief ofdysphoria,andbettercosmeticoutcomesbyavoidingthephysical changesassociatedwithpubertyofthegenderassignedatbirth.Afterpubertalsuppression,theindividualmayopttoproceedwithpubertyorstart treatmentwithgender-affirminghormones.
TransfeminineHormoneTherapy341 OksanaHamidiandCarolineJ.Davidge-Pitts
Transgenderwomenoftenseekhormonetherapytoattainfemininephysicalfeaturescongruentwiththeirgenderidentity.Theaimoffeminizing hormonetherapy(FHT)istoprovidesuppressionofendogenoustestosteroneandtomaintainestradiollevelswithinthenormalfemalerange. Overall,FHTissafeifprovidedundersupervisionofanexperiencedhealth careproviderandhasbeenshowntoimprovequalityoflife.Dataoncare oftransgenderwomenarescarceandhigh-qualityevidence-basedrecommendationsarelacking.ThisarticleaimstoreviewthepublishedliteratureonFHTandprovideguidancetoclinicianscaringfortransgender women.
TransmasculineHormoneTherapy357 JustineDefreyneandGuyT’Sjoen Prescribinggender-affirminghormonaltherapyintransgendermen(TM) notonlyinducesdesirablephysicaleffectsbutalsobenefitsmentalhealth. InTM,testosteronetherapyisaimedatachievingcisgendermaleserum testosteronetoinducevirilization.Testosteronetherapyissafeonthe shorttermandmiddletermifadequateendocrinologicalfollow-upisprovided.Transgendermedicineisnotastrongpartofthemedicalcurriculum,althoughalargenumberoftransgenderpersonswillsearchfor somekindofgender-affirmingcare.Becausehormonaltherapyhasbeneficialeffects,allendocrinologistsorhormone-prescribingphysicians shouldbeabletoprovidegender-affirminghormonalcare.
PrimaryCareinTransgenderPersons377 BrittanyL.Whitlock,ElizabethS.Duda,MollyJ.Elson,PaulParkerSchwab, OgulErsinUner,ShawnWen,andJasonS.Schneider
Thepreventivehealthcareneedsoftransgenderpersonsarenearlyidenticaltotherestofthepopulation.Specialconsiderationshouldbegiven, however,totheimpactofgender-affirminghormoneregimensandsurgicalcareonpreventivescreenings.Providersshouldintegrateamore comprehensiveviewofhealthwhencaringfortransgenderpersonsand addresstheimpactofsocialdeterminantsandotherbarrierstoaccessing affirming,inclusivehealthcare.Inindividualinteractions,providersmust considertheuniqueimpactthatagenderidentityandexpressiondifferent fromtheassignedgenderatbirthaffectspatient-providerinteractions, includingthehistory,physicalexamination,anddiagnostictesting.
FertilityConsiderationsinTransgenderPersons391 MichaelF.NeblettIIandHeatherS.Hipp
Hormonaltherapyandgender-affirmingsurgeriesintransgenderpeople haveknowndeleteriousimpactsonfuturefertilityusingone’sowngametes.Thisreviewfocusesonfertilitypreservation,includingtheeffectsof medicalhormonetreatmentonfertility,availableandexperimentaloptions offertilitypreservationintransgenderadults,includingspermcryopreservationfortranswomenandoocytecryopreservationfortransmen,andoptionsforprepubertaltransgenderadolescents,includingtesticularand
ovariantissuecryopreservation.Transgenderpatientscontinuetoface barriersandreceiveinfrequentcounselingregardingfertilitypreservation. Physiciansshouldideallycounselanddiscussfertilitypreservationoptions beforetransgenderpatientsundergohormonetherapyofgenderaffirmationsurgery.
GenderConfirmationSurgeryfortheEndocrinologist403 SashaK.Narayan,TessalynMorrison,DanielD.DugiIII,ScottMosser,and JensU.Berli
Endocrinologistsareatthefrontlineforprovidinggender-affirmingcarefor transgenderpatientsbymanaginghormoneregimentsbeforeandaftersurgery.Thisarticleprovidestheendocrinologistwithanoverviewofthesurgicaloptionsfortransgenderandnonbinarypatientsconsideringgender confirmationsurgery,includingfeminizingandmasculinizingfacial,chest, andgenitalreconstruction.Discussionsoftheimpactofhormonesonsurgery,andviceversa,aswellasinformationonsurgicaldecisionmakingare providedtohelpinformpatienteducationviatheendocrinologist.
OsteoporosisandBoneHealthinTransgenderPersons421 MaryO.StevensonandVinTangpricha
Thisreviewsummarizescurrentstudies,systematicreviews,andclinical practiceguidelinesregardingthescreening,diagnosis,andtreatmentof osteoporosisintransgenderpersons.Gender-affirminghormonetherapy hasbeenshowntomaintainorpromoteacquisitionofbonedensityas measuredbydual-energyx-rayabsorptiometry.Nodifferencesinfracture rateshavebeenseenintranswomenormeninshort,prospectivetrials.Trans childrenandadolescentsongonadotropin-releasinghormonemaybeatrisk fordecreasingbonedensitywhilenotonsexsteroidhormonereplacement. Screeningforosteoporosisshouldbebasedonclinicalfactors.Treatmentfor osteoporosisfollowsthesameguidelinesascisgenderpopulations.
DermatologicConditionsinTransgenderPopulations429
HowaYeung,BenjaminKahn,BaoChauLy,andVinTangpricha
Transgenderpersonsreceivinggender-affirminghormonetherapyandproceduresmayfacespecificskinconditions.Skindiseasesintransgender patientsoftenareunderdiagnosedandunderrecognizeddespitetheir importantimpactonqualityoflifeandmentalhealth.Thisarticlediscusses pathophysiology,diagnosis,andtreatmentofcommonskindiseasesinthe transgenderpopulations.Fortransmasculinepatients,conditionsinclude acnevulgarisandmalepatternhairloss.Fortransfemininepatients,conditionsincludehirsutism,pseudofolliculitisbarbae,andmelasma.Postproceduralkeloidsandothercutaneouscomplicationsarediscussed.Unique aspectsofskinhealthintransgenderpersonsshouldbeconsideredin thecontextofmultidisciplinarygender-affirmingcare.
CancerRiskinTransgenderPeople441
ChristelJ.M.deBlok,KoenM.A.Dreijerink,andMartindenHeijer
Gender-affirminghormonaltreatment(HT)intransgenderpeopleis consideredsafeingeneral,butthequestionregarding(long-term)risk
onsexhormone-relatedcancerremains.Becausetheriskoncertaintypes ofcancerdiffersbetweenmenandwomen,andsomeofthesedifferences areattributedtoexposuretosexhormones,thecancerriskmaybealtered intransgenderpeoplereceivingHT.Althoughreliableepidemiologicdata aresparse,theavailabledatawillbediscussedinthisarticle.Furthermore, recommendationsforcancerscreeningandpreventionwillbediscussed aswellaswhethertowithdrawHTattimeofacancerdiagnosis.
HumanImmunodeficiencyVirusinTransgenderPersons453 CassieG.Ackerley,ToniaPoteat,andColleenF.Kelley
Worldwide,transgenderpopulationsaredisproportionatelyaffectedby humanimmunodeficiencyvirus(HIV).Pervasivestigmaanddiscrimination impactsocialandeconomicdeterminantsofhealth,whichperpetuateHIV disparitiesamongtransgenderindividuals.ThisarticlereviewstheprevalenceofHIVinfectionamongtransgenderpopulationsandpresentspsychosocial,behavioral,andindividuallevelfactorsthatcontributetoHIV acquisition.Theauthorsprovidepracticalrecommendationsregardinga patient-centeredapproachtoHIV/sexuallytransmittedinfectionrisk assessment.Theroleofpreexposureprophylaxisutilizationinpreventing thetransmissionofHIVisdiscussedaswellasthecurrentdataonHIV treatmentoutcomesfortransgenderpeoplelivingwithHIV.
EducationNeedsofProvidersofTransgenderPopulation465 LinFraserandGailKnudson
Thefieldoftranshealthisfastgrowing,interdisciplinary,andglobal.The educationneedsofprovidersarealsogrowingtokeepapaceofthisexpandingdiscipline.Scanteducationontranshealthisavailableinundergraduateandresidentcurricula,orcontinuingmedicaleducation.In additiontotheWorldProfessionalAssociationforTransgenderHealth’s (WPATH)StandardsofCare(SOC),TransgenderHealthGuidelines recentlypublishedbytheEndocrineSociety,WPATHhasdevelopedfoundationalandadvancededucationalprogrammingintheareasofendocrinologyandotherspecialtieswithininterdisciplinarycare.Thisarticle describesthehistoryoftransgenderhealthcareprofessionaleducation andoutlinesthecompetenciesrelatedtothisarea.
ENDOCRINOLOGYAND METABOLISMCLINICSOF NORTHAMERICA FORTHCOMINGISSUES
September2019
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MarkE.Molitch, Editor
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EndocrineHypertension
AmirHekmatHamrahian, Editor
March2020
TechnologyinDiabetes
GraziaAleppo, Editor
RECENTISSUES March2019
ThyroidCancer
MichaelMingzhaoXing, Editor
December2018
Hypoparathyroidis
MichaelA.Levine, Editor
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AshleyGrossman, Editor
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Foreword TransgenderMedicine AdrianaG.Ioachimescu,MD,PhD,FACE ConsultingEditor
The“TransgenderMedicine”issueofthe EndocrinologyandMetabolismClinicsof NorthAmerica isacollectionofreviewarticlesthatexploreseveralimportantfacets ofthistopic.TheguesteditorisDrVinTangpricha,MD,PhD,ProfessorofMedicine atEmoryUniversityinAtlanta,Georgia,USA.DrTangprichaisanexpertinthefield andoneoftheauthorsoftheEndocrineSocietyclinicalpracticeguidelinesregarding endocrinetreatmentofgender-dysphoricandgender-incongruentpersonsfrom 2017.
Wededicatedthecurrentissuetotransgendermedicinebecauseofthesignificant increaseinknowledgeinthisfieldinthepast10years.Educationofmedicalprofessionalsplaysanimportantroleinimprovinghealthoutcomesoftransgenderorgender nonconformingidentitypatients.Endocrinologistsareattheforefrontofmedicalcare deliveryforthispopulationthatposesuniquehealthconcerns.Inthe“Transgender Medicine”issue,epidemiologyandbiologyoftransgenderorgendernonconforming identityarethoroughlyexplored.Currentprotocolsoftransfeminineandtransmasculinehormonetherapyarepresentedaswellasinformationregardinggender-affirming surgeries.Severalarticlesfocusonbonehealth,fertility,mentalhealth,cancerrisks, anddermatologicconditionsastheyspecificallyapplytothispopulation.Fromprimary carephysicianstoendocrinologists,fromsurgeonstomentalhealthspecialists,and fromtraineestoresearchers,thisissuecontainsessentialinformationonthetopicof transgendermedicine.
Ihopeyouwillfindthisissueofthe EndocrinologyandMetabolismClinicsofNorth America interestingandhelpfulinyourpractice.IthankDrTangprichaforguest-editing
EndocrinolMetabClinNAm48(2019)xiii–xiv https://doi.org/10.1016/j.ecl.2019.03.002
endo.theclinics.com 0889-8529/19/ª 2019PublishedbyElsevierInc.
thisimportantissueandtheauthorsfortheirexcellentcontributions.Inaddition,I wouldliketoacknowledgetheElseviereditorialstafffortheirsupport.
AdrianaG.Ioachimescu,MD,PhD,FACE EmoryUniversitySchoolofMedicine 1365BCliftonRoad
E-mailaddress: aioachi@emory.edu
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Preface TransgenderMedicine:Best PracticesandClinicalCareforthe Future VinTangpricha,MD,PhD Editor
Therehasbeengrowinginterestinthefieldoftransgendermedicineoverthepast15 years.PubMedkeywordtextsearchesfor“transgender”ortheantiquatedterm“transsexual”yieldedlessthan50entriespriorto2004.However,since2005,therehasbeen asteadyincreaseinpublications,whichreachedover1000publicationsperyearin 2018.Thisgrowthandinterestinthefieldhavebeenlargelyduetoincreasedawarenessofthemedicalneedsoftransgenderandgendernonconforming(TGGNC)people notonlybythelaypublicbutalsobythemedicalcommunity.Twoimportantguidelines coveringvariousaspectsofthemedicalandmentalhealthneedsofTGGNCpeopleby theEndocrineSocietyandtheWorldProfessionalAssociationofTransgenderHealth (WPATH),publishedin2009and2012(revisedagainin2017),respectively,havestimulatedmuchoftherecentinterestinthisfield.1–3
Whilethereremainmanyunansweredquestions,weknowthatTGGNCpeople representamuchlargernumberofthepopulationthanpreviouslybelieved.Inthis issue,Goodmanandcolleaguesreviewtheavailableevidenceandconcludethatup to2.7%ofthepopulationhaveagenderidentitythatistransgenderorgendernonconforming(pleaseseeMichaelGoodmanandcolleagues’article,“SizeandDistribution ofTransgenderandGenderNonconformingPopulations:ANarrativeReview,”inthis issue).Whilethefactorsthatleadtoformationofagenderidentityisnotknown,transgenderidentityisnotadiseasebutratheranormalvariationofhumanbiologybased onavarietyofbiologicfactors,asreviewedinSiraKorpaisarnandJoshuaD.Safer’s article,“EtiologyofGenderIdentity”,inthisissue.TGGNCpeoplehaveincreasedrates ofmentalhealthconcerns,suchasdepression,andincreasedratesofsuicide,whichis likelyduetomistreatmentbysociety.4 Gender-affirmingtherapieswithhormonesand/ orsurgeryappeartoimprovequalityoflifeofTGGNCpeople.4
EndocrinolMetabClinNAm48(2019)xv–xvii https://doi.org/10.1016/j.ecl.2019.03.001
endo.theclinics.com 0889-8529/19/ª 2019PublishedbyElsevierInc.
Therearemanypublishedhormoneregimensthatcanbeusedinchildrenandadults, asreviewedinthisissue(pleaseseeJessicaAbramowitz’sarticle,“HormoneTherapyin ChildrenandAdolescents,”OksanaHamidiandCarolineJ.Davidge-Pitts’saricle, “TransfeminineHormoneTherapy,”andJustineDefreyneandGuyT’Sjoen’sarticle, “TransmasculineHormoneTherapy,”inthisissue).Furthermore,thereareseveralprotocolswrittenonthedeliveryofprimarycareofTGGNCpeopleaspresentedinthe articlebyBrittanyL.Whitlockandcolleagues’article,“PrimaryCareinTransgender Persons,”inthisissue.However,manyTGGNCpeoplestilllackaccesstohealth careproviderswhoareadequatelytrainedtoprovideculturallycompetentcare(please seeLinFraserandGailKnudson’sarticle,“EducationNeedsofProvidersof TransgenderPopulation,”inthisissue).Educationprogramslikethecomprehensive trainingcourseofferedbyWPATH,asanexample,attempttoaddresstheeducation gapamonghealthcareproviders.OtherspecialneedsoftheTGGNCpopulation includeskinconditions,fertilityissues,bonehealth,cancer,andHIVrisk(pleasesee MichaelF.NeblettIIandHeatherS.Hipp’sarticle,“FertilityConsiderationsin TransgenderPersons,”MaryO.StevensonandVinTangpricha’sarticle, “OsteoporosisandBoneHealthinTransgenderPersons,”HowaYeungandcolleagues’article,“DermatologicConditionsinTransgenderPopulations,”andChristel J.M.deBlokandcolleagues’sarticle,“CancerRiskinTransgenderPeople,”inthis issue).Finally,thereisaneedformoresurgeonstobetrainedinthedeliveryof gender-affirmingsurgeries(pleaseseeSashaK.Narayanandcolleagues’article, “GenderConfirmationSurgeryfortheEndocrinologist,”inthisissue).
TGGNCpeopleareindividualswhohaveuniquehealthcareconcernsthatcanbe addressedfollowingestablishedmedicalguidelines.Increasedtraining,understanding,andacceptanceofthispopulationwillgraduallyimprovehealthoutcomesof thispopulation.Moreresearchisneededinthisfieldtooptimizecurrenthormonal andsurgicalregimens,improvementalhealthconditionsandqualityoflife,and improvelong-termhealthoutcomesforTGGNCpeople.However,fornow,physicians andhealthprovidersmustusethebestclinicalpracticeguidelinesavailableandprovidecarethatisunderstandingandaffirmingwhencaringforTGGNCpeople.
VinTangpricha,MD,PhD DivisionofEndocrinology,MetabolismandLipids DepartmentofMedicine EmoryUniversitySchoolofMedicine 101WoodruffCircleNortheast WRMB1301 Atlanta,GA30322,USA
AtlantaVAMedicalCenter 1670ClairmontRoadNortheast Decatur,GA30300,USA
E-mailaddress: vin.tangpricha@emory.edu
REFERENCES 1. ColemanE,BocktingW,BotzerM,etal.Standardsofcareforthehealthoftranssexual,transgender,andgender-nonconformingpeople,version7.IntJTransgend2012;13(4):165–232
2. HembreeWC,Cohen-KettenisP,Delemarre-vandeWaalHA,etal,EndocrineSociety.Endocrinetreatmentoftranssexualpersons:anEndocrineSocietyclinical practiceguideline.JClinEndocrinolMetab2009;94(9):3132–54
3. HembreeWC,Cohen-KettenisPT,GoorenL,etal.Endocrinetreatmentofgenderdysphoric/gender-incongruentpersons:anEndocrineSocietyclinicalpractice guideline.JClinEndocrinolMetab2017;102(11):3869–903
4. NobiliA,GlazebrookC,ArcelusJ.Qualityoflifeoftreatment-seekingtransgender adults:asystematicreviewandmeta-analysis.RevEndocrMetabDisord2018; 19(3):199–220
SizeandDistributionof TransgenderandGender NonconformingPopulations ANarrativeReview MichaelGoodman, MD,MPHa,*,NoahAdams, MSWb, TrevorCorneil, MD,MHScc,BaudewijntjeKreukels, PhDd, JozMotmans, PhDe,EliColeman, PhDf
KEYWORDS
KEYPOINTS
Accurateestimatesofthenumberandtheproportionoftransgenderandgendernonconforming(TGNC)peopleinapopulationarenecessaryfordevelopingdata-basedpolicy andforplanningandfundingofhealthcaredeliveryandresearch.
Theliteratureaddressingthistopicspansfivedecadesandpresentsdatafrom17 countries.
Onbalance,thedataindicatethatpeoplewhoself-identifyasTGNCrepresentasizable proportionofthegeneralpopulationwithrealisticestimatesrangingfrom0.1%to2%,dependingontheinclusioncriteriaandgeographiclocation.
Clinic-basedstudiesseemtocaptureonlyasmallsubsetoftheTGNCpopulation. TemporaltrendsshowthatTGNCpopulationisundergoingrapidchangesintermsofits sizeandintermsofitsdemographiccharacteristics.
INTRODUCTION Accurateestimatesofthenumberandtheproportionoftransgenderandgender nonconforming(TGNC)peopleinapopulationarenecessaryfordevelopingdatabasedrecommendationsandforplanningandfundingofhealthcaredeliveryand
Theauthorshavenothingtodisclose.
a DepartmentofEpidemiology,EmoryUniversityRollinsSchoolofPublicHealth,1518Clifton Road,Northeast,CNR3021,Atlanta,GA30322,USA; b Consultant,Toronto,Canada; c UniversityofBritishColumbia,SchoolofPopulationandPublicHealth,2206EastMall, Vancouver,BCV6T1Z3,Canada; d DepartmentofMedicalPsychology,VUUniversityMedical Center,MF-H243,VanderBoechorststraat7,1007MBAmsterdam,Netherlands; e GhentUniversityHospital,Blandijnberg2,9000Ghent,Belgium; f UniversityofMinnesota,180West BankOfficeBuilding,1300SSecondStreet,Minneapolis,MN55454,USA *Correspondingauthor.
E-mailaddress: mgoodm2@emory.edu
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research.1 Inaddition,accurateestimatesoftheTGNCpopulationsizeallowdevelopingsocialpolicythatprotectsagainststigmaanddiscrimination,informeffective transgenderhealthcareprograms,andeducateinsurancecompaniesonhowto providecoverageforsuchcare.2
In2012,theStandardsofCarefortheHealthofTranssexual,Transgender,and GenderNonconformingPeopleidentifiedonlyasmallnumberofarticlesattempting toestimatethesizeoftheTGNCpopulation,andcharacterizedthestate-of-thescienceasata“startingpoint”requiringfurthersystematicstudy.3 Inrecentyears, severalreviewssoughttosynthesizetheavailableinformationregardingthis issue 4–6;however,therapidlyexpandingliteraturewarrantsreevaluationofall availabledata.
InreviewingepidemiologicconsiderationsrelatedthesizeofTGNCpopulationitis besttoavoidtheterms“incidence”and“prevalence”becausethesetermscanleadto inappropriate“pathologizing”ofTGNCpeople.7,8 Moreover,theterm“incidence”may notbeapplicableinthissituationbecauseitassumesthatTGNCstatushasaneasily identifiabletimeofonset,aprerequisiteforcalculatingincidenceestimates.9 Forallof thesereasonsweusetheterms“number”and“proportion,”whichmoreprecisely signifytheabsoluteandtherelativesizeoftheTGNCpopulation,respectively.
Atotalof43publicationsestimatingthenumberandtheproportionofTGNCpeople areavailabletodate(Fig.1).Ofthose22studieswereconductedinEurope,12were basedintheUnitedStates,twowerefromJapan,twofromTaiwan,andtwofrom NewZealand.Iran,Australia,andSingaporeeachcontributedasinglestudy.The yearsofpublicationrangedfrom1968to2018.
Themainfindingsfromtheavailablestudiesaresummarizednext.Wediscussthe evidenceaccordingtothedefinitionofTGNC,whichisdividedintofourmaincategories.Thefirstcategoryincludesindividualswhoreceivedorrequestedsurgicalor hormonalgender-affirmationtherapy.ThesecondcategoryislimitedtoTGNCpeople whoreceivedtransgender-relateddiagnoses,suchas“transsexualism,”“gender dysphoria,”or“genderidentitydisorder.”Thethirdcategorydefinesthepopulation ofinterestbasedonself-reportedTGNCstatus.Thefourthcategoryisbasedonlegal oradministrativenameorgenderchanges.Thereportedrangesforeachcategoryare
Fig.1. Geographicdistributionof41studiesestimatingthenumberandpopulationproportionofTGNCindividuals(circle correspondstothenumberofstudiesfromeachcountry).
evaluatedoverallandseparatelyforpersonsassignedmaleandfemaleatbirth(AMAB andAFAB,respectively).
InadditiontosummarizingreportedrangesofTGNCnumbersandproportions,we alsodiscussadditionalepidemiologicconsiderationsthatmaycontributetobetterunderstandingofthecharacteristicsanddistributionofthispopulation.Additionalconsiderationsincludeaneedtodistinguishbetweenstudiesthatwereconductedina clinicalsettingfromthosethatwerepopulation-based,importantdifferencesin geographicdistributions,andnotabletimetrends.
PROPORTIONSOFINDIVIDUALSRECEIVINGORREFERREDFORGENDERAFFIRMATIONTHERAPY Ninestudiesfocusedonindividualswhoreceivedorrequestedgender-affirmingtreatment(Table1).Ofthose,sevenpublicationshaveestimatedtheproportionsofTGNC peoplebyconsideringonlythosewhoreceivedorwerereferredforgender-affirming surgery.10–16 Thenumeratorsformostoftheseestimateswerebasedonclinicalcase seriesorsurveysofpractitionersprovidingtransgendercare,whereasthedenominatorsweretypicallyapproximatedfromdemographicdataforaparticulargeographic areaofinterest.TheestimatedproportionsofTGNCingeneralpopulationinthiscategoryofstudiesrangedbetween1and35per100,000individuals.Notethatthese rangescoveraperiodofnearly50years,andcomefromstudiesconductedinavarietyofsettingsandbasedondataofvariablequalityandcompleteness.
Thecorrespondingdatapertainingtotheproportionofindividualswhoreceived hormonetherapyarelimitedtotwostudiesconductedintheNetherlands.In1976, theFreeAmsterdamUniversityclinicestablishedagenderteam.Basedondata collectedthrough1986,atotalof538individualsbeganhormonetherapyatthatfacility.17 Ofthose,399wereAMABand139AFAB.UsingtheDutchBureauofStatistics datafordenominatorestimates,theproportionofTGNCintheDutchpopulationwas calculatedas5.6per100,000forAMABand1.9per100,000forAFAB.Inasubsequentstudybasedatthesameclinic,theanalysiswasextendedthroughtheend of1990.18 Bythattime,theclinicwasprovidinghormonetherapyto713transgender patientsolderthanage15years,507AMABand206AFAB.Thetotalpopulationofthe Netherlandsin1990wasusedtodetermineprevalenceestimatesof8.4/100,000 AMABand3.3/100,000AFAB.
PROPORTIONSOFINDIVIDUALSWHOMETTHECRITERIAFORTRANSGENDERAND GENDERNONCONFORMING–RELATEDDIAGNOSES
Ofthe18publicationslistedin Table2,13studiescalculatedtheproportionsofTGNC peopleusingdiagnosticcodesfor“transsexualism,”“genderdysphoria,”or“gender identitydisorder”.19–31 Methodologically,moststudiesthatreliedonTGNCdiagnoses aresimilartothosethatdefinedTGNCashavingreceivedgender-affirmingtherapy. Mostusedgeneraldemographicinformationtodefinethedenominatorandrelied onclinicalcaseseriesorsurveyofpractitionerstodeterminethesizeoftheTGNC population.ThereportedproportionsofindividualswithTGNC-specificdiagnoses acrosspopulationsinthesestudiesrangedfrom0.7to28per100,000.ThecorrespondingestimatesforAMABandAFABindividualsrangedfrom0.7to36andfrom 0.7to19,respectively.
Thenumeratorsintheclinic-orphysicianinterview-basedstudiesaremostlikely underestimatesbecausetheyprimarilycapturesubjectswhoreceivecareatspecializedfacilities.Twostudies(oneinTaiwanandoneinIceland)addressedthislimitation byusingdiagnosticinterviewsofthegeneralpopulationcohorts.32,33 Bothstudies
Table1
Numberandpopulationproportionofindividualswhoreceivedorrequestedtoreceivesurgicalorhormonalgender-affirmationtherapy
SourceandSizeof Denominator
Numerator
713507206CenterofStatistics: 6,019,546males and6,252,566 females
Sourceof Numerator
Location; TimePeriod Case Definition
Reference
FreeUniversityof Amsterdam (AZVU)clinic records
Bakkeretal, 18 1993 Netherlands, 1976–1990 Receipt ofHT
Caldarera& Pfa ¨ fflin, 10 2011 Italy, 1992–2008 GAS receipt Surgicalclinics549424125NationalInstitute ofStatistics2009: total59,619,290 (28,949,747males and30,669,543 females)
412292120January2003 population: 3,758,969males and4,048,095 females 7.73.02.43:1
Questionnaires sentto“gender teams”and plasticsurgeons
DeCuypere etal, 11 2007 Belgium, 1985–2003 GAS receipt
767(681)478(429)289(252)December2010 population: 3,704,685malesand 3,791,791females 10.2(9.1)12.9(11.6)7.5(6.6)1.7:1
NationalBoardof Healthand Welfare Statistics
Dhejneetal, 15 2014 Sweden, 1960–2010 Request (receipt) ofGAS
1980:0.5 1983:1.0 1986:1.9 3:1
1980:2.2 1983:3.8 1986:5.6
538399159Dutchcensusdata: 7,125,000males and8,368,421 females a
FreeUniversityof Amsterdam (AZVU)clinic records
Eklundetal, 17 1988 Netherlands, 1976–1986 Receipt ofHT
3303Spanishpopulation 15–64yearsold, 33,030,000 a 10.01.9:1
Questionnaires senttogender identityunits
Estevade Antonio etal, 16 2012 Spain, 1999–2011 Request forGAS
2000500200,000totalUS populationused forbothAMAB andAFAB calculations 1.00.254:1
Pauly, 14 1968UnitedStates, datesnot specified Request forGAS Author’s communication withspecialized centers
Tsoi, 12 1988Singapore, until1986 Request forGAS Documented diagnosisof transsexualism aspartofpre- GCSevaluation 458343115PopulationJune 1986:979,300 malesand 954,900females
Vujovicetal, 13 2009 Serbia, 1987–2006 Receipt ofGAS Informedwritten consentto undergo treatment 14771767,500,000(World Bankdata)
Abbreviations: GAS,gender-affirmingsurgery;HT,hormonetherapy. a Denominatorcalculatedfromthenumeratorandthereportedproportion.
Table2
Proportion(per100,000)Ratio
Numerator
Numberandpopulationproportionofindividualswhoreceivedatransgender-specificdiagnosis
SourceandSizeof Denominator
Sourceof Numerator
ReferenceLocation;TimePeriodCaseDefinition
TehranPsychiatric Institute 281138143CenterofStatisticsof
Iran,population aged15–44: 39,526,948
Hokkaidoresidents: 5,500,000 3.978.21:2
SapporoMedical University Hospital 342104238NativeJapanese
Iran,2002–2009GIDdiagnosis
DSM-IV-TR
Ahmadzad-Asl, etal, 24 2010
22.131.212.92.2:1
1171803368Officialpopulationin theautonomous regionofMadrid >15yearoldin 2015:5,310,409 (2,516,147males and2,794,262 females)
Patientsreferredto theGIUatthe Hospital Universitario RamonyCajal (Madrid)
GIDdiagnosisICD-10 andDSM-IV
Hokkaido,Japan, December2003– January2010
Babaetal, 23 2011
ICD-10and/orgender identitydisorder basedonthe DSM-IV-TR
AutonomousRegion ofMadrid(Spain), 2007–2015
Becerra- ´Ferna ndez etal, 29 2017
2002:12.5 2011:22.9
TotalVHApatients: 4,544,353(2002), 5,795,165(2011)
243148RegionalPopulation: 2,359,223malesand 2,276,923females a 10.36.51.64:1
Catalonia: 2.1 Barcelona: 2.5 2.6:1
Catalonia: 4.8 Barcelona: 5.5
Catalonia: 48 Barcelona: 45 Catalonia: 2,376,538males 2,308,611females Barcelona: 1,996,708males 1,776,269females
Catalonia: 113 Barcelona: 100
2002:569 2011:1329
ConfirmedGID diagnosisinVHA, FY2000–2011
GIDdiagnosisICD-9 codes302.85(GID) or302.6(GIDNOS)
VAsystem,United States,2002–2011
Blosnich etal, 34 2013
populationJune30, 1970:3,498,700 (1,652,000males 1,846,700females) 1.92.90.93.25:1
664917Manchester
GIDdiagnosisRegionalgender identitydisorder unit
Andalucı ´ a,Spain, 1999–2004
Estevaetal, 20 2006
Psychiatricand Psychology Instituteatthe Barcelona Hospital,1996– 2004
ICD-10F64.0 (transsexualism)
Catalonia,Spain, 1996–2004
´Go mezGil etal, 21 2006
GIDRoyalInfirmary
Manchesteratthe University Departmentof Psychiatry
EnglandandWales, 1958–1968
Hoenig& Kenna, 19 1974
Taipei:1:2
Taipei:80
Smalltowns: 420 Ruralvillages: 70
Taipei:40 Small towns:0 Rural villages:0
Taipei:60 Small towns: 200 Rural villages: 30
Taipei:5000 Smalltowns:3000 Ruralvillages;3000
Taipei:3 Small towns:6 Rural villages:3
Multistagerandom samplingmethod
Taiwan,1982–1986DiagnosticInterview Survey
Hwuetal, 32 1989
2182011censusreports: total3,205,882 a
Ireland,2005–2014GID,DSM-IV/VGDclinicreferrals 2005–2014
Judgeetal, 25 2014
2006:1.7:1 2014:1.7:1
2567VHAenrollees: 7,809,269
ConfirmedGID diagnosisVHA,FY 2006–2013
Kauthetal, 35 2014 VAsystem,US, 2006–2013 GIDdiagnosisICD-9 codes302.85, 302.6,302.5
O’Gorman, 31 1982 NorthernIreland, datesnotspecified GIDClinicbased,>14y28217NorthernIreland population: 1,500,000
579349230Inhabitantsof WesternJapan, estimatedat 40,000,000
Okabeetal, 22 2008 Japan,April 1997–October2005 GID,DSM-IVGIDClinic-Okayama University Hospital
GA:3.5
Allmembersenrolled inagivenyear 2006
SoCal:5.5 NoCal:17 2014 GA:38 SoCal:44 NoCal:75
24320934Australia’spopulation onJune31,1978: 10,616,188 a 2.44.20.76.1:1
100
1862persons representinghalfof the1931birth cohortinIceland (441males,421 females)
Electronicmedical recordsatKaiser Permanentesites inGeorgia, NoCal,andSoCal
Transgender-specific diagnosesand free-textkeywords
Quinnetal, 36 2017 KaiserPermanente, UnitedStates, 2006–2014
Australia,1976–1978TranssexualQuestionnairesto registered psychiatrists
Rossetal, 27 1981
( continuedonnextpage
Diagnosticinterview schedule
Iceland,1931–1986“Transsexual” diagnosis
Stefansson etal, 33 1991
(continued )
ReferenceLocation;TimePeriodCaseDefinition
Wa ˚ linder,26 1968 Sweden,asof1965GIDSurveyof psychiatrists 110Notstated,estimate: 6,272,886a 1.92.71.02.5:1
Wiepjes etal,30 2018 Amsterdam, 1972–2015 ICD-9andICD-10 codes Medicalfilesofall peoplewho attendedthe genderidentity clinic 679344322361Totalpopulationof peopleatleast 16yearsoldinthe Netherlandsin 2015:13,870,426 27.736.419.31.9:1
Wilson etal,28 1999 Scotland,1998GDQuestionnairesto generalmedical practices 27321855Registeredpatients >15yofage: 3,336,261 (1,622,090males 1,714,171females) 8.213.43.24:1
Abbreviations: DSM,diagnosticandstatisticalmanualofmentaldisorders;GD,genderdysphoria;GID,genderidentitydisorder;ICD,internationalclassificationofdiseases;NoCal,NorthernCalifornia;SoCal, SouthernCalifornia;VHA,veteranshealthadministration. a Denominatorcalculatedfromthenumeratorandthereportedproportion.
administeredsite-specificversionsoftheDiagnosticInterviewSchedulebytheUS NationalInstituteofMentalHealth.Althoughthesestudieswereconductedseveral decadesagoandmaynolongerbeapplicable,bothreportedproportions(range, 30–100per100,000)thatexceededthoseobtainedfromclinicsorfromsurveysof healthcareproviders.Note,however,thattheestimatesinbothstudieswerestatisticallyimprecisebecausetheywerebasedonsmallsamplesizesandidentifiedfew TGNCpeople.
SeveralstudiesestimatedproportionsofTGNCpeopleamongindividualsenrolled inhealthcaresystems.Blosnichandcolleagues34 usedVeteransHealthAdministrationelectronicmedicalrecordsfrom2000through2011.Thenumeratorforthestudy includedindividualsthathadreceivedanInternationalClassificationofDiseases-9th editiondiagnosticcodeofeither302.85(genderidentitydisorder)or302.6(gender identitydisordernototherwisespecified).UsingtheVeteransHealthAdministration dataandelectronicrecorddatabasetodefinethedenominator,theauthorsreported prevalenceestimatesfordifferentyearsstartingin2002.The2002estimatewas12.5 per100,000andtheproportionreportedin2011was22.9per100,000.Inamore recentsimilarlydesignedVA-basedstudythenumeratorwasexpandedtoinclude InternationalClassificationofDiseases-9theditioncode302.5(transsexualism).The proportionofTGNCveteransin2013was32.9per100,000.35
Anotherhealthsystems–basedstudyevaluatedelectronicmedicalrecordsdataat KaiserPermanentesitesinGeorgia,NorthernCalifornia,andSouthernCalifornia.36 Thenumeratorwasascertainedusingstep-wisemethodology,whichinvolved computerizedsearchesofdiagnosticcodessupplementedbyareviewoffreetext toidentifyTGNCindividuals.TheproportionsofTGNCKaiserPermanenteenrollees increasedovertimeateachofthethreeparticipatingsites.In2006,theestimates per100,000enrolleeswere3.5,5.5,and17inGeorgia,SouthernCalifornia,and NorthernCalifornia,respectively;however,by2014,thecorrespondingestimates increasedto38,44,and75.
PROPORTIONSOFADULTSWITHSELF-REPORTEDTRANSGENDERANDGENDER NONCONFORMINGIDENTITY Ninestudieslistedin Table3 usedsurvey-baseddatatoestimatetheproportionof adults(personsolderthanage18years)whoself-identifiedasTGNC.37–45 Theuse ofself-reportgreatlyincreasedthelikelihoodthatanindividualwouldmeetthecriteria forinclusioninthenumerator.Theresultingproportionswerealsoordersofmagnitude higherandthuscouldbeexpressedaspercentages.
IntheUnitedStates,severalstudiestookadvantageoftheBehavioralRiskFactor SurveillanceStudy(BRFSS),anannualtelephonesurveyconductedinall50states andUSterritories.37–40 OneoftheearliestBRFSS-basedstudiesanalyzeddata collectedbetween2007and2009intheStateofMassachusetts.37 Thesurveywas administeredto28,662adults,andcontainedthefollowingmodule:“Somepeople describethemselvesastransgenderwhentheyexperienceadifferentgenderidentity fromtheirsexatbirth.Forexample,apersonbornintoamalebody,butwhofeelsfemaleorlivesasawoman.Doyouconsideryourselftobetransgender?”Atotalof131 participantsresponded“yes”tothatquestion,correspondingtoaproportionof0.5%.
In2014,thesameBRFSSquestionwasadoptedby19statesandtheterritoryof Guam.Acrossallparticipatingsites,TGNCindividualsmadeup0.53%.38 AnadditionalanalysisofthesamedataestimatedtheproportionofTGNCpopulationfor theentireUSbyextrapolatingdatafromthe20participatingsites.39 ThemissinginformationforstatesandterritoriesthatdidnotinquireaboutTGNCstatuswasimputed
