madman
Super Moderator
Abstract
In line with increasing numbers of transgender (trans) and gender non-binary people requesting hormone treatment, the body of available research is expanding. More clinical research groups are presenting data, and the number of participants in these studies is rising. Many previous review papers have focused on all available data, as these were scarce, but a more recent literature review is timely. Hormonal regimens have changed over time, and older data may be less relevant for today’s practice.
In recent literature, we have found that even though mental health problems are more prevalent in trans people compared to cisgender (cis) people, fewer psychological difficulties occur, and life satisfaction increases with gender-affirming hormone treatment (GAHT) for those who feel this is a necessity. With GAHT, body composition and contours change towards the affirmed sex. Studies in bone health are reassuring, but special attention is needed for adolescent and adult trans women, aiming at an adequate dosage of hormonal supplementation and stimulating therapy compliance. Existing epidemiological data suggest that the use of (certain) estrogens in transgender women induces an increased risk of myocardial infarction and stroke, the reason that lifestyle management can be an integral part of trans health care. The observed cancer risk in trans people does not exceed the known cancer-risk differences between men and women.
Now it is time to integrate the most reassuring data, to leave the overly cautious approach behind, to not copy the same research questions repeatedly, and to focus on longer follow-up data with larger cohorts.
Introduction
As early as 1923, Hirschfeld described the term “transsexual” to describe people who want to live a life according to their experienced gender, instead of their assigned gender (1). The 20th century marked the social awakening for men and women who knew that they were—as at the time often described—“trapped in the wrong body” (2). Gender incongruence is a newer term to describe the incongruence between a person’s gender identity (GI) and the assigned gender at birth (3,4). GI reflects a complex interplay of biological, psychological, environmental, and cultural factors. Individuals with gender incongruence are a heterogeneous group and have been described throughout past decades with various terminologies such as transsexuals, genderqueer, gender variant, gender incongruent, transgender (trans) individuals, or people with gender identity disorder or gender dysphoria. Gender dysphoria refers to profound distress or discomfort caused by the discrepancy between a person’s assigned sex at birth and gender identity (5). Not every transgender person suffers from gender dysphoria, and the need for psychological counseling and medical intervention may vary (5). For some, a social change can be sufficient. Many others will access transgender health care services, if available, to receive counseling and gender-affirming treatment. This can include hormone treatment and/or gender-affirming surgery.
Population-based estimates of gender incongruence range from 0,5% to 1,3% for birth-assigned male persons and from 0,4% to 1,2% for birth-assigned female persons (6)(7). The true prevalence is probably underestimated in this research due to the attached stigma. Luckily, over the past decades and at least in some regions, social acceptance has improved and has permitted individuals to explore their GI more freely. The number of trans people seeking gender-affirming care has increased in many specialized centers, and also other health care services are seeing a higher number of trans people (7,8). Still, sometimes there are many barriers to access to gender-affirming care or health care in general (9). Ideally, hormone treatment is started under the supervision of endocrinologists or other hormone-prescribing specialists (10). GAHT has been shown to be safe and effective in trans people in a growing body of short- and middle-term follow-up studies (11,12,21,13–20). Many previous review papers have included data from all available literature, with hormone treatments that are no longer in use, or advised against and therefore not-so-relevant anymore. The focus of this paper is to give an update on recent data available from larger cohorts, when available.
Gender-affirming hormone treatment
1. Mental Health and Body Image
2. Body Composition and Contours
3. Bone Health
4. Cardiovascular and thromboembolic safety
5. Cancer risk
Limitations
For this review we relied on published data from a limited group of clinical research teams that are active in this field. Per definition, this is biased literature, with participants having access to well-organized research centers. In the papers, feminizing and masculinizing treatments are described, assuming participants are trans men or trans women. Categorization of gender identity can only rely on self-identification, and we assume some of the people categorized as trans are in fact non-binary individuals seeking GAHT. Also, many variations in GAHT exist, making generalization difficult.
Conclusions
The body of available data on GAHT in trans people is steadily increasing, and short-to-midterm outcomes are quite reassuring in relation to effectiveness and safety. Integration of these findings in clinical care is timely. Still, there are many trans people who are confronted with mental health difficulties, and appropriate counseling should be easily available. Therefore, lowering barriers to health care that are still present is very meaningful.
In line with increasing numbers of transgender (trans) and gender non-binary people requesting hormone treatment, the body of available research is expanding. More clinical research groups are presenting data, and the number of participants in these studies is rising. Many previous review papers have focused on all available data, as these were scarce, but a more recent literature review is timely. Hormonal regimens have changed over time, and older data may be less relevant for today’s practice.
In recent literature, we have found that even though mental health problems are more prevalent in trans people compared to cisgender (cis) people, fewer psychological difficulties occur, and life satisfaction increases with gender-affirming hormone treatment (GAHT) for those who feel this is a necessity. With GAHT, body composition and contours change towards the affirmed sex. Studies in bone health are reassuring, but special attention is needed for adolescent and adult trans women, aiming at an adequate dosage of hormonal supplementation and stimulating therapy compliance. Existing epidemiological data suggest that the use of (certain) estrogens in transgender women induces an increased risk of myocardial infarction and stroke, the reason that lifestyle management can be an integral part of trans health care. The observed cancer risk in trans people does not exceed the known cancer-risk differences between men and women.
Now it is time to integrate the most reassuring data, to leave the overly cautious approach behind, to not copy the same research questions repeatedly, and to focus on longer follow-up data with larger cohorts.
Introduction
As early as 1923, Hirschfeld described the term “transsexual” to describe people who want to live a life according to their experienced gender, instead of their assigned gender (1). The 20th century marked the social awakening for men and women who knew that they were—as at the time often described—“trapped in the wrong body” (2). Gender incongruence is a newer term to describe the incongruence between a person’s gender identity (GI) and the assigned gender at birth (3,4). GI reflects a complex interplay of biological, psychological, environmental, and cultural factors. Individuals with gender incongruence are a heterogeneous group and have been described throughout past decades with various terminologies such as transsexuals, genderqueer, gender variant, gender incongruent, transgender (trans) individuals, or people with gender identity disorder or gender dysphoria. Gender dysphoria refers to profound distress or discomfort caused by the discrepancy between a person’s assigned sex at birth and gender identity (5). Not every transgender person suffers from gender dysphoria, and the need for psychological counseling and medical intervention may vary (5). For some, a social change can be sufficient. Many others will access transgender health care services, if available, to receive counseling and gender-affirming treatment. This can include hormone treatment and/or gender-affirming surgery.
Population-based estimates of gender incongruence range from 0,5% to 1,3% for birth-assigned male persons and from 0,4% to 1,2% for birth-assigned female persons (6)(7). The true prevalence is probably underestimated in this research due to the attached stigma. Luckily, over the past decades and at least in some regions, social acceptance has improved and has permitted individuals to explore their GI more freely. The number of trans people seeking gender-affirming care has increased in many specialized centers, and also other health care services are seeing a higher number of trans people (7,8). Still, sometimes there are many barriers to access to gender-affirming care or health care in general (9). Ideally, hormone treatment is started under the supervision of endocrinologists or other hormone-prescribing specialists (10). GAHT has been shown to be safe and effective in trans people in a growing body of short- and middle-term follow-up studies (11,12,21,13–20). Many previous review papers have included data from all available literature, with hormone treatments that are no longer in use, or advised against and therefore not-so-relevant anymore. The focus of this paper is to give an update on recent data available from larger cohorts, when available.
Gender-affirming hormone treatment
1. Mental Health and Body Image
2. Body Composition and Contours
3. Bone Health
4. Cardiovascular and thromboembolic safety
5. Cancer risk
Limitations
For this review we relied on published data from a limited group of clinical research teams that are active in this field. Per definition, this is biased literature, with participants having access to well-organized research centers. In the papers, feminizing and masculinizing treatments are described, assuming participants are trans men or trans women. Categorization of gender identity can only rely on self-identification, and we assume some of the people categorized as trans are in fact non-binary individuals seeking GAHT. Also, many variations in GAHT exist, making generalization difficult.
Conclusions
The body of available data on GAHT in trans people is steadily increasing, and short-to-midterm outcomes are quite reassuring in relation to effectiveness and safety. Integration of these findings in clinical care is timely. Still, there are many trans people who are confronted with mental health difficulties, and appropriate counseling should be easily available. Therefore, lowering barriers to health care that are still present is very meaningful.
