madman
Super Moderator
Summary
Background: No data are available at present on the prevalence of gender dysphoria (trans-identity) in Germany. On the basis of estimates from the Netherlands, it can be calculated that approximately 15 000 to 25 000 persons in Germany are affected. Persons suffering from gender dysphoria often experience significant distress and have a strong desire for gender reassignment treatment.
Method: This review is based on pertinent publications retrieved by a selective search in the PubMed database employing the searching terms “transsexualism,” “transgender,” “gender incongruence,” “gender identity disorder,” “gender-affirming hormone therapy,” and “gender dysphoria.”
Results: In view of its far-reaching consequences, some of which are irreversible, hormonal gender reassignment treatment should only be initiated after meticulous individual consideration, with the approval of the treating psychiatrist/psychotherapist, and after extensive information of the patient by an experienced endocrinologist. Before the treatment is begun, the patient must be extensively screened for risk factors. The contraindications include severe preexisting thromboembolic diseases (mainly if untreated), hormone-sensitive tumors, and uncontrolled pre-existing chronic diseases such as arterial hypertension and epilepsy. Finding an appropriate individual solution is the main objective even if contraindications are present. Male-to-female treatment is carried out with 17β-estradiol or 17β-estradiol valerate in combination with cyproterone acetate or spironolactone as an antiandrogen, female-to-male treatment with transdermal or intramuscular testosterone preparations. The treatment must be monitored permanently with clinical and laboratory follow-up as well as with gynecological and urological early-detection screening studies. Prospective studies and a meta-analysis (based on low-level evidence) have documented an improvement in the quality of life after gender reassignment treatment. Female-to-male gender-incongruent persons often have difficulty being accepted in a gynecological practice as a male patient.
Conclusion: Further prospective studies for the quantification of the risks and benefits of hormonal treatment would be desirable. Potential interactions of the hormone preparations with other medications must always be considered.
Gender dysphoria—or gender incongruence or transsexuality–is characterized by a mismatch between the biological sex and the inner sense of gender (gender identity). A transgender woman is a biologically male person with female gender identity; correspondingly, a transgender man is a biologically female person with a male gender identity. In the Netherlands, the prevalence of gender dysphoria is estimated to be 0.02–0.03% (1). For Germany, no estimates have yet been published. Based on the above figures, it can be assumed that approximately 15 000 to 25 000 people are affected. While earlier studies (1, e1, e2) reported a gender ratio of transgender women to transgender men of approximately 2: 1, more recent studies found increasingly similar proportions (e3) or even a reversal of this ratio (2).
With the onset of puberty, transgender persons typically experience significant psychological distress (gender dysphoria) and consequently seek gender-affirming—or gender reassignment—treatment (e4). With 9% to 11% and 1.5% to 2%, the rates of suicide attempts (3) and committed suicides (4), respectively, are increased among people with gender dysphoria compared to the general population. In 2010, a meta-analysis found a decrease in mental and physical complaints as well as an increase in quality of life after the start of gender-affirming hormone therapy (GAHT) (5), but the data quality of this study was limited. However, later prospective studies confirmed these findings (6, e5). The two-year follow-up after GAHT revealed the following differences compared to the pre-treatment status:
● A decrease in depressive symptoms (Beck Depression Inventory [BDI] II scores: transgender women −1.41, p<0.001; transgender men −1.31, p<0.001)
● Reduction in body uneasiness (Body Uneasiness Test [BUT] index: transgender women −0.24, p<0.001; transgender men −0.24, p = 0.001)
● Decrease in gender dysphoria (GIDYQ AA score: transgender women −0.06, p<0.001; transgender men −0.05, p = 0.001) (6).
For persons with gender dysphoria, treatment with cross-sex hormones deliver a sense of identity. However, since gender-affirming hormone therapy has a significant effect on a person’s hormonal balance, it is associated with a risk of adverse effects which is particularly high in the event of unsupervised treatment or overdosing.
Using treatment data from a large Dutch gender identity clinic collected in the period from 1980 to 2015, Wiepjes et al. demonstrated a 20-fold increase in newly started GAHT (1). Similarly, many treatment providers in Germany have observed an increase in the number of affected persons in recent years (personal communication from colleagues of other institutes). Factors potentially contributing to this trend include growing societal acceptance and a significant increase in public attention and media coverage (e6–e10). Nevertheless, in Germany, too, those affected do frequently not receive optimal care (7, 8, e4, e11).
The aim of this article is to provide up-to-date insights into and recommendations for gender-affirming hormone therapy (GAHT) as well as information about special aspects that should be taken into account by general practitioners and specialists involved in the care of transgender persons.
Overall, the evidence from studies on the effects and risks of GAHT—which also forms the basis of the guidelines of the Endocrine Society which were initially created under the US and European co-authorship in 2009 and then updated in 2017 (9)—is weak. Most studies are retrospective data analyses, frequently based on comparatively few cases. Prospective studies are scarce. There are no randomized controlled trials and, ultimately, it is difficult to imagine that studies designed will ever be conducted, not least for ethical reasons. A German or European guideline on GAHT has not yet been created.
*Requirements
*Medical diagnostic work-up prior to treatment initiation
*Male-to-female gender dysphoria
-Treatment recommendations
-Course and limitations of treatment
-Adverse reactions and risks
-Fertility
*Female-to-male gender dysphoria
-Treatment recommendations
-Course and limitations of treatment
-Adverse reactions and risks
-Contraception/fertility
*Follow-up examinations
*Gynecological and urological care
-Male-to-female gender dysphoria
-Female-to-male gender dysphoria
*Treatment of pre-existing chronic conditions and intercurrent diseases
Key messages
● Since gender-affirming hormone therapy (GAHT) quickly leads to significant and partly irreversible changes, it is crucial to ensure that the treatment is clearly indicated.
● Prior to initiation of GAHT, risk factors (especially substance abuse, overweight, age, personal or family history positive for thrombophilia or hormone-sensitive cancer) and pre-existing chronic conditions (e.g. arterial hypertension, diabetes, dyslipidemia, chronic hepatitis B and C, HIV) should be identified and adequately treated.
● As recommended in the available guidelines, 17ß-estradiol (valerate) in combination with an anti-androgen is used for feminizing therapy. The use of Ethinyl estradiol is obsolete due to the significantly worse side effect profile. For virilizing GAHT, transdermal or intramuscular testosterone preparations are used.
● After the initiation of therapy, clinical and laboratory checks should be performed at regular intervals.
● For persons with gender dysphoria, access to regular gynecological/urological care has to be ensured—even after their legal sex status has changed.
Background: No data are available at present on the prevalence of gender dysphoria (trans-identity) in Germany. On the basis of estimates from the Netherlands, it can be calculated that approximately 15 000 to 25 000 persons in Germany are affected. Persons suffering from gender dysphoria often experience significant distress and have a strong desire for gender reassignment treatment.
Method: This review is based on pertinent publications retrieved by a selective search in the PubMed database employing the searching terms “transsexualism,” “transgender,” “gender incongruence,” “gender identity disorder,” “gender-affirming hormone therapy,” and “gender dysphoria.”
Results: In view of its far-reaching consequences, some of which are irreversible, hormonal gender reassignment treatment should only be initiated after meticulous individual consideration, with the approval of the treating psychiatrist/psychotherapist, and after extensive information of the patient by an experienced endocrinologist. Before the treatment is begun, the patient must be extensively screened for risk factors. The contraindications include severe preexisting thromboembolic diseases (mainly if untreated), hormone-sensitive tumors, and uncontrolled pre-existing chronic diseases such as arterial hypertension and epilepsy. Finding an appropriate individual solution is the main objective even if contraindications are present. Male-to-female treatment is carried out with 17β-estradiol or 17β-estradiol valerate in combination with cyproterone acetate or spironolactone as an antiandrogen, female-to-male treatment with transdermal or intramuscular testosterone preparations. The treatment must be monitored permanently with clinical and laboratory follow-up as well as with gynecological and urological early-detection screening studies. Prospective studies and a meta-analysis (based on low-level evidence) have documented an improvement in the quality of life after gender reassignment treatment. Female-to-male gender-incongruent persons often have difficulty being accepted in a gynecological practice as a male patient.
Conclusion: Further prospective studies for the quantification of the risks and benefits of hormonal treatment would be desirable. Potential interactions of the hormone preparations with other medications must always be considered.
Gender dysphoria—or gender incongruence or transsexuality–is characterized by a mismatch between the biological sex and the inner sense of gender (gender identity). A transgender woman is a biologically male person with female gender identity; correspondingly, a transgender man is a biologically female person with a male gender identity. In the Netherlands, the prevalence of gender dysphoria is estimated to be 0.02–0.03% (1). For Germany, no estimates have yet been published. Based on the above figures, it can be assumed that approximately 15 000 to 25 000 people are affected. While earlier studies (1, e1, e2) reported a gender ratio of transgender women to transgender men of approximately 2: 1, more recent studies found increasingly similar proportions (e3) or even a reversal of this ratio (2).
With the onset of puberty, transgender persons typically experience significant psychological distress (gender dysphoria) and consequently seek gender-affirming—or gender reassignment—treatment (e4). With 9% to 11% and 1.5% to 2%, the rates of suicide attempts (3) and committed suicides (4), respectively, are increased among people with gender dysphoria compared to the general population. In 2010, a meta-analysis found a decrease in mental and physical complaints as well as an increase in quality of life after the start of gender-affirming hormone therapy (GAHT) (5), but the data quality of this study was limited. However, later prospective studies confirmed these findings (6, e5). The two-year follow-up after GAHT revealed the following differences compared to the pre-treatment status:
● A decrease in depressive symptoms (Beck Depression Inventory [BDI] II scores: transgender women −1.41, p<0.001; transgender men −1.31, p<0.001)
● Reduction in body uneasiness (Body Uneasiness Test [BUT] index: transgender women −0.24, p<0.001; transgender men −0.24, p = 0.001)
● Decrease in gender dysphoria (GIDYQ AA score: transgender women −0.06, p<0.001; transgender men −0.05, p = 0.001) (6).
For persons with gender dysphoria, treatment with cross-sex hormones deliver a sense of identity. However, since gender-affirming hormone therapy has a significant effect on a person’s hormonal balance, it is associated with a risk of adverse effects which is particularly high in the event of unsupervised treatment or overdosing.
Using treatment data from a large Dutch gender identity clinic collected in the period from 1980 to 2015, Wiepjes et al. demonstrated a 20-fold increase in newly started GAHT (1). Similarly, many treatment providers in Germany have observed an increase in the number of affected persons in recent years (personal communication from colleagues of other institutes). Factors potentially contributing to this trend include growing societal acceptance and a significant increase in public attention and media coverage (e6–e10). Nevertheless, in Germany, too, those affected do frequently not receive optimal care (7, 8, e4, e11).
The aim of this article is to provide up-to-date insights into and recommendations for gender-affirming hormone therapy (GAHT) as well as information about special aspects that should be taken into account by general practitioners and specialists involved in the care of transgender persons.
Overall, the evidence from studies on the effects and risks of GAHT—which also forms the basis of the guidelines of the Endocrine Society which were initially created under the US and European co-authorship in 2009 and then updated in 2017 (9)—is weak. Most studies are retrospective data analyses, frequently based on comparatively few cases. Prospective studies are scarce. There are no randomized controlled trials and, ultimately, it is difficult to imagine that studies designed will ever be conducted, not least for ethical reasons. A German or European guideline on GAHT has not yet been created.
*Requirements
*Medical diagnostic work-up prior to treatment initiation
*Male-to-female gender dysphoria
-Treatment recommendations
-Course and limitations of treatment
-Adverse reactions and risks
-Fertility
*Female-to-male gender dysphoria
-Treatment recommendations
-Course and limitations of treatment
-Adverse reactions and risks
-Contraception/fertility
*Follow-up examinations
*Gynecological and urological care
-Male-to-female gender dysphoria
-Female-to-male gender dysphoria
*Treatment of pre-existing chronic conditions and intercurrent diseases
Key messages
● Since gender-affirming hormone therapy (GAHT) quickly leads to significant and partly irreversible changes, it is crucial to ensure that the treatment is clearly indicated.
● Prior to initiation of GAHT, risk factors (especially substance abuse, overweight, age, personal or family history positive for thrombophilia or hormone-sensitive cancer) and pre-existing chronic conditions (e.g. arterial hypertension, diabetes, dyslipidemia, chronic hepatitis B and C, HIV) should be identified and adequately treated.
● As recommended in the available guidelines, 17ß-estradiol (valerate) in combination with an anti-androgen is used for feminizing therapy. The use of Ethinyl estradiol is obsolete due to the significantly worse side effect profile. For virilizing GAHT, transdermal or intramuscular testosterone preparations are used.
● After the initiation of therapy, clinical and laboratory checks should be performed at regular intervals.
● For persons with gender dysphoria, access to regular gynecological/urological care has to be ensured—even after their legal sex status has changed.
