Gender-affirming Care Research Articles

Health Care Utilization During the First 5½ Years of Authorized Service by Transgender U.S. Service Members (2016-2021).

Purpose: This study examined the utilization of gender-affirming health care by active-duty service members during the initial 5½ years that transgender and gender-diverse (TGD) individuals were authorized to serve in the U.S. military. The aim of this study was to inform policy discussions regarding inclusion of TGD individuals in the military. Methods: We conducted a retrospective cohort study using administrative health care data from the Military Data Repository (MDR). We assessed the association of demographic factors with the utilization of gender-affirming medical and surgical care. We calculated the incidence rate of initial TGD-related encounters and new prescriptions for gender-affirming hormones among Defense Department Service members between July 2016 and December 2021. Results: We identified 2481 service members with an initial health care encounter with an associated TGD-related diagnosis. More than half (53%) of these service members started gender-affirming hormones, and 14% underwent gender-affirming surgery. Mastectomies and hysterectomies accounted for more than 70% of surgeries. Service members made 3.22 initial encounters with a TGD-related diagnosis per 10,000 service members per year, with an overrepresentation of service members who were designated female in the MDR (8.62), junior enlisted (4.98), and young (4.64). Individuals designated female in the MRD comprised 17% of all service members but accounted for 46% of initial encounters, 51% of new prescriptions, and 73% of surgeries. Conclusion: The study revealed a higher-than-expected number of service members seeking gender-affirming care, particularly among service members designated female in the MDR. Military Health System clinicians provided most of this care, which may mitigate the cost of delivering this essential medical care.

The gender minority stress model and/or cisnormativity? The need for pluralistic theoretical perspectives in improving trans health and medicine

The minority stress model has become a well-used framework to explain and analyse health among LGBTQ people, and specifically among transgender and gender-diverse people (TGD), when it is sometimes called ‘the gender minority stress model’. Scholars have argued the need for critical discussions about some of the assumptions underlying the gender minority stress model and how it has been used and discussed. Drawing on a pluralistic understanding of theories and employing a Foucauldian understanding of critique, we discuss implicit assumptions and epistemological standpoints of the gender minority stress model and the connected limitations. We also ask what the concept of cisnormativity can give rise to in comparison with the minority stress framework. We make four arguments: 1) the calls for extensions to the model could be seen as a desire to understand and analyse TGD people's health from an all-encompassing perspective, resulting in theoretical vagueness and the silencing of excluded aspects; 2) in the gender minority stress literature, identity is largely taken for granted and there is no consideration of how power is constitutive for all subjects; 3) the model risks individualising the effects of social norms, and internalisation could be further theoretically developed in relation to the repression hypothesis; 4) in the translation process from LGB minorities to TGD, as well as in thinking about cisnormativity, the issue of gender-affirming care has largely been neglected. By initiating a critical discussion around these issues and illustrating how different theories and frameworks can illuminate different possibilities for thinking and knowing, we aim to open up new routes for thinking about TGD health and medicine.

Considerations in gender-affirming hormone therapy in transgender and gender diverse patients undergoing liver transplantation

Liver transplantation is lifesaving for patients with end-stage liver disease. Similar to the role of transplantation for patients with end-stage liver disease, gender-affirming hormone therapy (GAHT) can be lifesaving for transgender and gender diverse (TGGD) patients who experience gender dysphoria. However, management of such hormone therapy during the perioperative period is unknown and without clear guidelines. Profound strides can be made in improving care for TGGD patients through gender-affirming care and appropriate management of GAHT in liver transplantation. In this article, we call for the transplant community to acknowledge the integral role of GAHT in the care of TGGD liver transplant candidates and recipients. We review the current literature and describe how the transplant community is ethically obligated to address this health care gap. We suggest tangible steps that clinicians may take to improve health outcomes for this minoritized patient population.

Characteristics of a transgender and gender-diverse patient population in Utah: Use of electronic health records to advance clinical and health equity research.

Transgender and gender-diverse (TGD) people, individuals whose gender identity differs from their sex assigned at birth, face unique challenges in accessing gender-affirming care and often experience disparities in a variety of health outcomes. Clinical research on TGD health is limited by a lack of standardization on how to best identify these individuals. The objective of this retrospective cohort analysis was to accurately identify and describe TGD adults and their use of gender-affirming care from 2003-2023 in a healthcare system in Utah, United States. International Classification of Disease (ICD)-9 and 10 codes and surgical procedure codes, along with sexual orientation and gender identity data were used to develop a dataset of 4,587 TGD adults. During this time frame, 2,985 adults received gender-affirming hormone therapy (GAHT) and/or gender-affirming surgery (GAS) within one healthcare system. There was no significant difference in race or ethnicity between TGD adults who received GAHT and/or GAS compared to TGD adults who did not receive such care. TGD adults who received GAHT and/or GAS were more likely to have commercial insurance coverage, and adults from rural communities were underrepresented. Patients seeking estradiol-based GAHT tended to be older than those seeking testosterone-based GAHT. The first GAS occurred in 2013, and uptake of GAS have doubled since 2018. This study provides a methodology to identify and examine TGD patients in other health systems and offers insights into emerging trends and access to gender-affirming care.

Treatment trajectories of gender incongruent Austrian youth seeking gender-affirming hormone therapy.

The aim of this study was to describe the treatment trajectories of Austrian children and adolescents with gender incongruence seeking gender-affirming medical care. Patients who presented with gender incongruence at the pediatric outpatient clinic for differences in sex development at a large university hospital in Austria from January 2008 to December 2022 were included in a retrospective chart review, and analyzed regarding referral numbers, patient characteristics, treatment trajectories, fertility preservation, and legal gender marker changes. Of 310 eligible patients, 230 (74.2%) were assigned female at birth (AFAB), and 80 (25.8%) were assigned male at birth (AMAB). The number of referrals increased steeply from 2008 to 2018, whereafter it stabilized at around 50 per year. At the time of initial presentation, the median age of patients was 15.6 years (IQR 14.3-16.8). AMAB individuals tended to be younger (median 14.9 years, IQR 13.9-16.8) than AFAB individuals (median 15.8 years, IQR 14.4-16.8; p= 0.012). 207 (66,8%) completed the assessment process and were eligible for gender affirming medical treatment (GAMT). Of those, 89% (186/207) commenced gender affirming hormone therapy in the pediatric outpatient clinic (79/186 received GnRHa monotherapy, 91/186 GnRHa and sex steroids, and 16/186 sex steroid monotherapy). Of the 54 AMAB individuals receiving GAMT, 6 (11.1%) completed fertility preservation prior to therapy initiation. Only 1/132 AFAB adolescents receiving GAMT completed fertility preservation. Chest masculinization surgery was performed in 22 cases (16.7%), and breast augmentation in two cases (3.7%) between the ages of 16 and 18. Changes in legal gender marker were common, with 205 individuals (66.1%) having changed their legal gender marker. This is the first time that treatment trajectories, fertility preservation rates, and changes of legal gender marker have been described in Austrian adolescents with gender incongruence seeking GAMT. The majority received GAMT and changed their legal gender marker, while gender affirming surgery rates were low, and utilization of fertility preservation treatment options was rare.

Intimate life-making and infrastructures of trans masculine desire

ABSTRACT This article proposes a theory of ‘trans infrastructuralism’. Through narrative and phenomenological description, trans infrastructures illuminate the enabling conditions for emergent, material, and intersubjective forms of trans masculine desire. We argue that the reproduction of intimate affects remains paradoxically obscured by the physical presence of public infrastructure. This is paradoxical because being intimate or maintaining intimate queer loving located an interstitial relation that contradicted the intended uses of public works. The odd intensities that emerge in the trans ordinary can therefore range from techno-social objects that comprise trans people who seek gender-affirming medical care to the important spatial relations that serve to propel new socialities. Many readers may find the insights gleaned from such scholarly writing about trans infrastructuralism. We do not depart dramatically from what construes public works as socially meaningful signs in ordinary life.

Troubling Trends in Health Misinformation Related to Gender-Affirming Care.

Amidst the misinformation climate about trans people and their health care that dominates policy and social discourse, autonomy-based rationales for gender-affirming care for trans and nonbinary youth are being called into question. In this commentary, which responds to "What Is the Aim of Pediatric 'Gender-Affirming' Care?," by Moti Gorin, we contextualize the virulent ideas circulating in misinformation campaigns that have become weaponized for unprecedented legal interference into standard health care. We conclude that the current legal justifications for upending gender-affirming care gloss over how this health care field meets conventional evidentiary standards and aligns protocols with most other fields of medicine. Refusal to offer gender-affirming care is more harmful than centralizing trans and nonbinary people's health autonomy.

Practical guide to implementing patient-reported outcome measures in gender-affirming care: evaluating acceptability, appropriateness and feasibility

ObjectiveAssess acceptability, appropriateness and feasibility of the Practical Guide to Implementing patient-reported outcome measures (PROMs) in Gender-Affirming Care (PG-PROM-GAC) from a sample of patients and healthcare professionals.DesignCross-sectional study conducted August–October...

Values and Evidence in Gender-Affirming Care.

This commentary responds to the article "What Is the Aim of Pediatric 'Gender-Affirming' Care?," by Moti Gorin, in the same issue of the journal. Gender-affirming care is often treated as exceptional and subject to heightened scrutiny. This exceptionalization results in its being held to stricter evidentiary standards than other forms of medical interventions are. But values and value judgments are inextricable from the practice of evidence-based medicine. For gender-affirming care, values shape what counts as "strong" evidence, whether the legitimacy of transgender identity is assumed versus treated as something to be investigated, how to characterize the testimonial accounts of trans and gender-nonconforming patients, and more. We argue that these kinds of questions are part of the practice of medicine, not exceptional to transgender people and gender-affirming care. However, litigation of evidence for gender-affirming care in state and national policy underscores the moral urgency of thinking carefully about what values ought to guide evidence.

Minors Lack the Autonomy to Consent to Gender-Affirming Care: Best Interests Must Be Primary.

What ethically justifies the provision of invasive and irreversible treatments to minors? In this commentary, I examine this question in response to Moti Gorin's article "What Is the Aim of Pediatric 'Gender-Affirming' Care?," which critiques autonomy-based arguments for justification of gender-affirming care in minors. Minors generally lack sufficient autonomy to make significant medical decisions or major life decisions. For this reason, parents are generally their decision-makers, working with medical professionals to choose treatments that serve the best interests of the minor. Medical care in minors is justified by beneficence, not autonomy, and this should be no different for gender-affirming care. This severely undermines autonomy-based arguments for provision of gender-affirming care to minors. Given the lack of conclusive evidence for benefit, the nature of the treatment, and the fact that gender dysphoria in minors resolves spontaneously in most cases, there is presently insufficient justification for provision of such care to minors.

Removing Barriers and Honoring Autonomy: Rethinking Mental Health Professional Assessments in Adolescent Gender-Affirming Medical Care.

Adolescents seeking gender-affirming medical care (GAMC) face numerous barriers that may delay or inhibit their access to these services. Such obstacles include mental health professional (MHP) assessment requirements prior to initiating GAMC. MHP letters ultimately carry little benefit for patients. Their formulaic nature discourages nuance, reduces likelihood of capturing gender embodiment goals (beyond a narrow definition of gender dysphoria), and may cause clinicians to overlook presenting mental health concerns. MHP assessment requirements also reinforce the conception of gender dysphoria as a mental health disorder. Moreover, studies have not shown that requiring MHP assessment letters effectively reduces regret among patients. Fortunately, primary clinicians who provide GAMC are most often capable of assessing patients without additional input from an MHP. In this article, we provide an ethical framework for clinicians that prioritizes patient autonomy through an informed assent approach. We discuss Appelbaum's criteria and its application, and contexts in which MHP consultation is appropriate. We also address common questions about informed assent among clinicians, patients, and families. Finally, we advocate for bolstering multidisciplinary support teams involved in GAMC to facilitate the informed assent process. This approach upholds patient autonomy, expands access to GAMC, and utilizes the mental health workforce more effectively.

Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for Gender Affirmation [ID 2683658

INTRODUCTION: The process of transitioning from female to male in transgender persons usually includes medical treatment as well as surgical interventions, including removal of the uterus and ovaries. Nulliparity and prolonged exposure of the vaginal mucosa to testosterone, which are common among transgender men, may present challenges to perform a vaginal hysterectomy with salpingo-oophorectomy. The aim of this study is to describe outcomes of vaginal-assisted natural orifice transluminal endoscopic surgery (vNOTES) approach to perform hysterectomy among transgender men as part of their gender-affirming care. METHODS: This is a case series observational study conducted at single tertiary medical center including all patients undergoing hysterectomy with bilateral salpingo-oophorectomy by vNOTES approach for gender-affirming care between February 2022 and April 2023. Primary outcome was defined as compound complication rate including intraoperative and postoperative. Patients' demographic and clinical charectaristics were collected from the electronic medical files. Pain at postoperative follow-up was evaluated using visual analog scores, which ranges from 0 (no pain) to 10 (worst pain possible). RESULTS: The study population included eight transgender men, all of whom were nulliparous and had undergone testosterone treatment for more than a year. Median age at surgery was 24 years and median body mass index was 30 kg/m2. Mean operative time of the surgery was 111 minutes (range: 91–143 minutes) and none required converting from vNOTES to an alternative approach. No extensive bleeding or organ damage was reported. For one patient, there was one small vaginal laceration requiring suture. All but one patient was discharged the same day. The patient requiring next-day discharge was complicated by postoperative urinary retention. On postoperative follow-up, median pain score was 3 (range: 1–5). CONCLUSION: Outcomes from this case series suggest that a vNOTES approach to hysterectomy among transgender men can be performed without surgical complications and with low self-reported pain.

What Is the Aim of PEDIATRIC "Gender-Affirming" Care?

The original "Dutch Protocol"-the treatment model comprised of puberty blockers, cross-sex hormones, and surgery-was intended to improve the mental and physical health of pediatric patients experiencing distress over their sexed bodies. Consequently, both researchers and clinicians have couched eligibility for treatment and measures of treatment efficacy in terms of the interventions' effects on outcomes such as gender dysphoria, depression, anxiety, and suicide. However, recent systematic reviews have concluded that the scientific evidence supporting these interventions is uncertain, leading to significant international differences in what treatments are offered to youth. Against this backdrop, a different argumentative approach has emerged in support of gender-affirming care. This approach appeals not to reductions in patient morbidity or mortality but to patient autonomy, where medical intervention is pursued as a means to the satisfaction of a patient's "embodiment goals." In this article, I raise objections to autonomy-based justifications for pediatric gender-affirming care, concluding that these arguments misunderstand the place of autonomy in clinical decision-making and, consequently, put patients at risk of medical harm.

Gender-Affirming Hysterectomies: Analysis of Temporal Trends and Characteristics Pre- and Post-Expansion of Health Care Coverage at a Large Integrated California Health Care System [ID 2683540

INTRODUCTION: Despite expansion of gender-affirming health care coverage in 2013, few studies have investigated temporal trends in gender-affirming surgeries (GAS) including hysterectomies. Our study aims to investigate the temporal trends of hysterectomies for transgender men and gender-diverse persons (TGD) compared to cisgender women between 2010–2012 and 2013–2019, and annually from 2010 to 2019. METHODS: We conducted an observational retrospective cohort study on TGD and cisgendered patients, aged 18 and older, within Kaiser Permanente Northern California (KPNC) between 2010 and 2019. Data on demographics, surgical characteristics, concurrent procedures, and postoperative complications were extracted from electronic medical records. Bivariate comparisons were performed using chi-squared analysis for categorical variables and t-tests for continuous variables. RESULTS: This study included 41,341 hysterectomies performed within KPNC between 2010 and 2019. Among all hysterectomies, 461 (1.1%) were for TGD. TGD who underwent hysterectomies were more likely to be younger, White, and nulliparous compared to their cisgender counterparts (P<.05). The incidence of hysterectomies remained similar in cisgender women—from 3,750 (99.7%) in 2010 to 4,361 (98.4%) in 2019. For TGD, the incidence of hysterectomies increased gradually—from 10 (0.3%) in 2010 to 70 (1.6%) in 2019, with the largest increase occurring from 40 (1.0%) hysterectomies in 2014 to 62 (1.5%) in 2015. After expansion of GAS coverage, hysterectomy rates increased eightfold from 55 (0.5%) in 2010–2012 to 406 (1.4%) in 2013–2019. CONCLUSION: Gender-affirming hysterectomies have increased substantially because of changes in GAS policies. Future data will evaluate trends of ovarian conservation during concurrent GAS hysterectomy.

Transgender Transitioning and Responsiveness to Policy: Evidence from the Netherlands

This study examines a 2014 policy change in the Netherlands that simplified the process to legally transition gender. Administrative data for 2006-2022 indicate that there was a 725 percent increase in transitions after the policy change, suggesting that legal gender transitions are elastic to costs and barriers. The policy change was followed by a ten-year reduction in the average age at transition and a reduction in the use of gender-affirming care in the three years prior to transitioning. This research sheds light on how policy changes can influence decisions related to gender transitioning and the use of gender-affirming care.

A Qualitative Study of Transgender and Nonbinary Perspectives Regarding the Desired Properties of a Peer Support Intervention for the Initiation of Gender-Affirming Hormone Therapy [ID 2683451

INTRODUCTION: Transgender and nonbinary (TNB) people experience significant mental health disparities and challenges accessing gender-affirming care. Peer support interventions have been shown to improve mental health in other populations and contexts but have not been uniquely tailored to the initiation of gender-affirming hormones. This study aims to identify the desired properties of a peer support intervention for TNB people initiating gender-affirming hormones. METHODS: We conducted semistructured interviews with TNB adults who had initiated or attempted to initiate gender-affirming hormones (IRB: HUM00203630: approved/exempt; gender-affirmation: off-label). Participants were selected by snowball and purposive sampling methods. Interview questions focused on the participants' experiences with peer support and their vision for ideal peer support while initiating hormones. Interviews were transcribed and analyzed using reflective thematic analysis with inductive and deductive coding. A TNB community advisory board collaborated in the study design and interviews were conducted by TNB research team members. RESULTS: The ages of the participants ranged from 20 to 52 years (mean=32); 8/18 identified as men or trans men; 4/18 identified as nonbinary; 3/18 identified as women or trans women; 3/18 identified as genderqueer or genderfluid; 10/18 identified as a person of color. Themes include the importance of 1) trans community knowledge in guiding hormone therapy decisions, 2) having support structures attend to intersectional identities, and 3) recognizing barriers to peer engagement, including anxieties about fitting in and internalized transphobia. CONCLUSION: Centering TNB voices is essential in designing a peer support intervention for hormone initiation. Our participants offered nuanced approaches for how to share information about hormones, attend to intersectional identities, and navigate barriers to peer engagement.

Breaking Binaries: The Critical Need for Feminist Bioethics in Pediatric Gender-Affirming Care.

This commentary responds to Moti Gorin's article "What Is the Aim of Pediatric 'Gender-Affirming' Care?" We argue that Gorin's case against pediatric gender-affirming care rests upon numerous false conceptual binaries: female/male, public/private, objective/subjective, and medically necessary/elective. Drawing on feminist bioethics, we show how such dichotomous thinking is both inaccurate and marginalizing of gender minorities.

Providing Gender-Affirming Care for a Veteran with a New Spinal Cord Injury

Providing Gender-Affirming Care for a Veteran with a New Spinal Cord Injury

Rapidly expanding gender-affirming care based on consensus instead of evidence justifies rigorous governance and transparency.

Public services offering gender-affirming care to minors have rapidly expanded across Australia. Despite limited evidence of safety and efficacy, no public information about these services is routinely available. Data from freedom of information requests sent to Australian public gender services for minors is summarised. Gender service numbers increased rapidly in Queensland (2017:190 - 2022:922) and in Victoria (2019:472 - 2023:1290). Limited transparency prevented strong confidence in the number of patients receiving hormone therapy. Staff FTE employed by gender services jumped after 2020 in NSW (to 16.7 across two sites in 2023), Queensland (to 11.4 in 2023), Victoria (to 9.4 in 2022), and WA (to 10.2 in 2023). Despite low confidence in their safety and efficacy, the number of patients seen by public gender services has expanded rapidly since 2018. Limited transparency makes it difficult to judge the number of patients seen, treatments provided, and outcomes achieved. Safe, effective care of this vulnerable group requires clear treatment goals, and annual reporting.

Beyond the Rainbow: Advancing 2S/LGBTQ+ Health Equity at a Time of Political Volatility.

Two-Spirit, lesbian, gay, bisexual, transgender, queer and other sexual and gender minority (2S/LGBTQ+) populations continue to experience profound health disparities. In this article, we prioritize five issues in 2S/LGBTQ+ health equity and discuss policy interventions to address disparities in each area: (1) poverty in 2S/LGBTQ+ communities; (2) Two-Spirit mental health; (3) health equity issues in migrant and racialized LGBTQ+ populations; (4) challenges in implementing bans on conversion therapy; and (5) the evolving context of gender-affirming care. Multi-level policy interventions, including those in healthcare-adjacent contexts such as housing and immigration, will be critical to address the structural undercurrents driving health inequities for 2S/LGBTQ+ populations. Recognizing growing complexity and political volatility in the lives of 2S/LGBTQ+ people across Canada, we challenge healthcare policy actors to recognize the breadth of structural barriers to 2S/LGBTQ+ health equity issues and act with urgency in this area.