Transgender Medicine Research Articles

IMPLANTING PLASTICITY INTO SEX AND TRANS/GENDER

This essay argues that the reigning medical and scientific understanding of the endocrine system, which insists on its fundamental biological plasticity, was historically constructed through a dual child–animal metaphor. The work accomplished by such organic metaphors, as Donna Haraway terms them, returns us to the endocrine laboratories and clinics in which they were built in Europe and the United States in the first half of the twentieth century. The child and animal metaphors implanted the concept of plasticity into the human body to the effect of bringing sexed and gendered life under the jurisdiction of science and medicine, where it could not only be normalized in a sense long appreciated by transgender studies but also cultivated towards the ostensible “improvement” and “perfection” of the human. This is also, then, a history of the eugenic heritage of modern endocrinology, which has been largely ignored in recent discussions of plasticity and the body’s materiality. To interrogate the role of foundational organic metaphors in endocrinology is to open up plasticity not only to its historical context but also to radical contestation, making the contemporary assumptions of transgender medicine untimely, particularly the medicalization of the transgender child.

Gender identity and the management of the transgender patient: a guide for non-specialists.

In this review, we introduce the topic of transgender medicine, aimed at the non-specialist clinician working in the UK. Appropriate terminology is provided alongside practical advice on how to appropriately care for transgender people. We offer a brief theoretical discussion on transgenderism and consider how it relates to broader understandings of both gender and disease. In respect to epidemiology, while it is difficult to assess the exact size of the transgender population in the UK, population surveys suggest a prevalence of between 0.2 and 0.6% in adults, with rates of referrals to gender identity clinics in the UK increasing yearly. We outline the legal framework that protects the rights of transgender people, showing that is not legal for physicians to deny transgender people access to services based on their personal beliefs. Being transgender is often, although not always, associated with gender dysphoria, a potentially disabling condition in which the discordance between a person's natal sex (that assigned to them at birth) and gender identity results in distress, with high associated rates of self-harm, suicidality and functional impairment. We show that gender reassignment can be a safe and effective treatment for gender dysphoria with counselling, exogenous hormones and surgery being the mainstay of treatment. The role of the general practitioner in the management of transgender patients is discussed and we consider whether hormone therapy should be initiated in primary care in the absence of specialist advice, as is suggested by recent General Medical Council guidance.

(Re)making sex: A praxiography of the gender clinic

This article traces the multiple enactments of sex in clinical practices of transgender medicine to argue against the presumed singularity of ‘transexuality’. Using autoethnography to analyse my own experience as a trans patient, I describe my clinical encounters with doctors, psychiatrists and surgeons in order to theorise sex as multiple. Following recent developments in science and technology studies (STS) that advance the work of Judith Butler on sex as performatively reproduced, I use a praxiographic approach to argue that treatment practices produce particular iterations of what sex (and transexuality) ‘is’ and how these processes limit and foreclose other trans possibilities. I consider the ethical, political and material-discursive implications of treatment practices and offer a series of reflections about the effects and effectiveness of current clinical practices and the possibilities for intervening in such processes in order that, following Annemarie Mol, we might (re)make sex (and transexuality) differently.

Transgender Medicine Curriculum: Integration Into an Organ System-Based Preclinical Program.

There is a recognized and articulated need for health professionals to understand the definitions, health disparities, and medical management of transgender patients. This recognition comes organically from students requesting more information, and top-down from governing bodies such as the AAMC or the Liaison Committee on Medical Education. Surveys of North American medical schools indicate that training in transgender medicine (specifically, the process of transition) is infrequent and inadequate. One problem underlying this trend may be the lack of resources to help conceptualize and roll out a transgender medicine curriculum. Here, we report the integration of training in transgender medicine into the organ system-based course Endocrine-Reproduction. This transgender curriculum includes coverage of basic science, clinical management, ethics, and clinical skills. The curriculum leverages an already existing, health care disparity-focused curriculum but adds (1) a didactic component for dissemination and discussion of basic science principles applied to transgender patients and (2) a mock initial encounter between a physician and patient with gender dysphoria. Following the first-time implementation of the transgender curriculum, students were surveyed, with a large majority reporting feeling more prepared to care for transgender patients. We conclude that including a multidisciplinary transgender medicine curriculum in medical school advances the goal of creating safe, effective physicians by providing fundamental knowledge about an underserved population of patients, as well as exampled application of that knowledge.

Thrombotic issues in transgender medicine: A review.

Clinicians, including hematologists, are more frequently encountering transgender individuals in practice; however, most lack training on the management and complications of transgender medicine. Hormonal therapy forms the backbone of medical interventions for patients undergoing gender transition. While supplementing an individual's intrinsic sex hormone is associated with a variety of hematologic complications including increased rates of venous thrombosis, cardiovascular events, erthyrocytosis, and malignancy, the risks of supplementing with opposing sex hormones are not well understood. Data on the hematologic complications of these therapies are accumulating but remain limited, and clinicians have little experience with their management. This review highlights the current interventions available in transgender medicine and related potential hematologic complications, and it suggests simple, evidence-based management going forward. Am. J. Hematol. 92:204-208, 2017. © 2016 Wiley Periodicals, Inc.

Outcome and Impact Evaluation of a Transgender Health Course for Health Profession Students

Being transgender is associated with numerous health disparities, and transgender individuals face mistreatment and discrimination in healthcare settings. At the same time, healthcare professionals report inadequate preparation to care for transgender people, and patients often have to teach their own medical providers about transgender care. Our study aimed to evaluate the impact of an elective course for health profession students in transgender health that was implemented to address these gaps in provider knowledge. Students participated in a 10-session, lunch-hour elective course during the spring of 2015. To evaluate impact, course participants completed pre-, immediately post-, and 3-month postcourse questionnaires, including a previously validated nine-item transphobia scale, to determine the course's effect on knowledge, attitudes, and beliefs about transgender health. Forty-six students completed the pre- and immediately postelective questionnaire (74% response rate). Compared with pre-elective surveys, immediately postelective scores demonstrated increased knowledge in most domains and reduced transphobia. Specific knowledge domains with improvements included terminology, best practices for collecting gender identity, awareness of the DSM-V gender dysphoria diagnosis, medications used for gender affirmation, and relevant federal policies. A previously validated transphobia scale was found to have good reliability in the current sample. This elective course led to positive short-term changes in measures of multiple knowledge domains and reduced measures of transphobia among health profession students. Further study is needed to assess the long-term impact. Our methods and findings, including the demonstration of reliability of a previously validated nine-item transphobia scale, serve as formative data for the future development of theory-based transgender medicine curricula and measures.

Drug Therapy for Gender Transitions and Health Screenings in Transgender Older Adults.

Transgender medicine is a relatively new field in health care, with only a small amount of evidence-based literature available for reference. This is especially true for the older adult population, for whom most information must be extrapolated from younger adults. Be it a newly transitioned older adult or a transgendered individual who has been undergoing hormonal therapy for many years, it is important that healthcare professionals be aware of the significant effects that transgender pharmacotherapy can have on older adults. Healthcare providers must also recommend appropriate preventative screenings to transgendered persons.

Transgender Medicine in the Path to Progress and Human Rights

Transgender Medicine in the Path to Progress and Human Rights

What's in a Guideline? Developing Collaborative and Sound Research Designs that Substantiate Best Practice Recommendations for Transgender Health Care.

Transgender medicine presents a particular challenge for the development of evidence-based guidelines, due to limitations in the available body of evidence as well as the exclusion of gender identity data from most public health surveillance activities. The guidelines that have been published are often based on expert opinion, small studies, and data gathered outside the US. The existence of guidelines, however, helps legitimate the need for gender-affirming medical and surgical interventions. Research conducted on transgender populations should be grounded in gender-affirming methodologies and focus on key areas such as health outcomes after gender-affirming interventions.

Uncertain Expertise and the Limitations of Clinical Guidelines in Transgender Healthcare

To alleviate uncertainty in the specialized field of transgender medicine, mental and physical healthcare providers have introduced the rhetoric of evidence-based medicine (EBM) in clinical guidelines to help inform medical decision making. However there are no diagnostic tests to assess the effectiveness of transgender medical interventions and no scientific evidence to support the guidelines. Using in-depth interviews with a purposive sample of 23 healthcare providers, I found that providers invoked two strategies for negotiating the guidelines. Some used the rhetoric of EBM and closely followed clinical guidelines to contain uncertainty. Others flexibly interpreted the guidelines to embrace uncertainty. These findings raise questions about the effectiveness of EBM and guidelines in medical decision making. While trans medicine involves an identity and not a biomedical illness, providers use the same strategies to respond to uncertainty as they may in other medical arenas.

Evidence-Based Curricular Content Improves Student Knowledge and Changes Attitudes towards Transgender Medicine

Previous studies have demonstrated that the addition of transgender medicine content to a medical school curriculum increased students' comfort and willingness to treat transgender patients. We aimed to demonstrate that (1) evidence-based curricular content would improve knowledge of and change attitudes towards transgender medicine, and (2) students would consider cross-sex hormone therapy a legitimate treatment option for transgender patients. Curricular content with a focus on the biologic evidence for the durability of gender identity was added to the first-year medical program at Boston University School of Medicine. Immediately before and after exposure to the content, students were presented with an assessment of their knowledge of the etiology of gender identity. Immediately following exposure to the content, a significant number of students changed their answer regarding the etiology of gender identity so that the number of correct responses increased from 63% (n = 56) to 93% (n = 121) (P<.001). For transgender treatment, the number of correct responses increased from 20% (n = 56) before exposure to the content to 50% (n = 121) following exposure (P<.001). The addition of transgender medicine content to a medical school curriculum with a focus on the biologic evidence for a durable gender identity is an effective means of educating students about the etiology of gender identity and the appropriateness of cross-sex hormone therapy as a treatment for transgender patients.

A Perspective on the Evolving Landscape in Male Reproductive Medicine.

Men's health and aging are emerging as important areas of research opportunity because of advances in reproductive biology and the recognition of men's health as a unique and important aspect of public health. A perspective of the evolving landscape in male reproductive medicine. Remarkable discoveries in reproductive biology have greatly advanced the treatment of erectile dysfunction, androgen deficiency, infertility, hormone sensitive cancers, and prostate diseases. Although the off-label use of testosterone in middle-aged and older men has grown, the management of androgen deficiency syndromes remains suboptimal. There is a pressing need for wider adoption of accurate testosterone assays and harmonized reference ranges and large randomized trials of testosterone's efficacy and cardiovascular and prostate safety. The transformation in idealized body image towards greater muscularity has contributed to increasing prevalence of body image disorders and the use of muscle building drugs in men. Therapeutic options for fertility regulation in men remain limited, the pathophysiologic basis of infertility in a vast majority of infertile men remains unknown, and assisted reproductive technologies remain inaccessible to many infertile men. Much of the dogma on testosterone's binding to its binding proteins remains inaccurate, and the role of free and albumin-bound testosterone poorly understood. The reproductive health of cancer survivors and the availability of wider contraceptive choices for men are other areas of unmet need. Suboptimal care of transgender persons has framed transgender medicine as an important healthcare disparities issue. Transformative changes in societal attitudes towards men's sexual health, body image, and gender identity, and in the economics of reproductive healthcare services, offer extraordinary opportunities for translational science that is patient focused, mechanism based, and integrated with healthcare.

Gaps in Transgender Medicine Content Identified Among Canadian Medical School Curricula.

Purpose: The transgender community is a diverse group that requires unique consideration in the healthcare setting. However, several studies have suggested that their needs are not currently being met by our medical system. Although the reason for this discrepancy is likely multifactorial, inadequate training of healthcare professionals to manage this population has been cited as a contributing factor.Methods: To evaluate the role that Canadian medical schools play in addressing these proposed deficits, program administrators were invited to provide curricular information detailing their delivery of transgender health, and medical students were surveyed to assess the impact of current curricula on their knowledge, attitudes, and experiences with regard to transgender health.Results: Six of fourteen schools provided curricular information about their instruction in transgender health and wide variation was found; 255/1152 University of British Columbia (UBC) students and 155/2358 students from eight other Canadian medical schools responded to the survey. Greater than 95% of responders agreed that transgender issues are important and should be addressed by physicians. However, fewer than 10% of students felt that they were sufficiently knowledgeable to do so. At UBC, there was no significant improvement in the self-reported knowledge levels after receiving the transgender-related curricula, and only 24% of students felt the topic was proficiently taught.Conclusion: This study showed that the majority of students who responded do not feel comfortable addressing the needs of transgender individuals in a healthcare setting and suggests that a reevaluation of related curricula may be warranted.

Gender-affirming Surgeries in the Era of Insurance Coverage: Developing a Framework for Psychosocial Support and Care Navigation in the Perioperative Period.

Transgender people have a gender identity different from their birth-assigned sex. Transgender people may seek gender-affirming surgeries to align their body with their identified gender. With increasing visibility of transgender identities, and recognition of the importance of gender-affirming care, has come a policy shift toward mandated coverage or provision of blanket exclusions of these procedures by insurance companies and Medicaid. The World Professional Association for Transgender Health provides guidance to mental health professionals evaluating patients for gender-affirming surgeries, including making a diagnosis and assessing for capacity to consent. However the expansion of covered gender-affirming surgeries to safety-net populations has highlighted the need for an expanded presurgical process which includes a psychosocial assessment and care navigation. The proposed framework expands the preoperative assessment to include these components, and can be used to guide both health systems and insurance providers in the development of transgender medicine programs.

A Simple Intervention Raised Resident-Physician Willingness to Assist Transgender Patients Seeking Hormone Therapy

Lack of physician knowledge about transgender medicine is a barrier to care. An intervention with medical students changed attitudes about providing transgender medical care, but it is unknown whether at the level of postgraduate education an intervention could have a similar effect. We conducted such an intervention with resident-physicians. An intervention on transgender medicine covering the durability of gender identity and hormonal treatment regimens was added to the curriculum for residents. An anonymous survey assessed the residents' knowledge and willingness to assist with hormonal therapy before and after the lecture. The percent of residents who agreed that they felt sufficiently knowledgeable to assist with hormonal therapy for a female-to-male patient increased significantly, from 5% before to 76% following the lecture (χ(2), 24.7; degrees of freedom, 1; P<.001). The percent of residents who reported that they felt sufficiently knowledgeable to assist with hormonal therapy for a male-to-female patient increased significantly, from 5% before to 71% following the lecture (χ(2), 24.0; degrees of freedom, 1; P<.001). The intervention increased resident knowledge about hormonal therapy for hypogonadal men (χ(2), 11.4; degrees of freedom, 1; P<.001) and women (χ(2), 9.4; degrees of freedom, 1; P = .002). The intervention made more residents agree that gender identity has a biologic basis that remains constant (P<.001) and that hormonal and surgical therapies should be offered (P = .047). The lecture significantly increased residents' knowledge and willingness to assist with hormonal therapy for transgender patients.

"Living in a Shell of Something I'm Not": Transsexuality, Medical Ethics, and the Judeo-Christian Culture.

A surgeon participating in a 2008 congress on the topic of trans-identified people posed the question of whether doctors would have to defend themselves when "judgment day" comes for having employed surgical means to turn men into women or vice versa? What might be viewed as a certain level of (medical) irrationality surrounding transgender life, coupled with widely documented cases of violence directed at these groups may well partly be attributable to the deeply internalized doctrine of creation in Judeo-Christian culture. Objections, however, to the use of transgender medicine "in the name of normalization" cannot relate to the biblical tradition, for there is no normative concept of gender and no text whose scope is to articulate theory of gender. In the vast expanse and freedom of the Judeo-Christian creator there is space for diversity, variations, and, above all, for the development of individual freedom.

Transgender and Gender-Nonconforming Patients' Obstetrics and Gynecology Care

INTRODUCTION: The transgender and gender-nonconforming community long has been marginalized in society. As transgender individuals become more visible, obstetrician–gynecologists should direct educational initiatives to enhancing clinical templates that ensure inclusive, competent, and sensitive health services for this population, incorporating partner, culture, and community implications. Gender-unbiased health services are necessary to eliminate real and perceived barriers to care. METHODS: A review of literature on transgender medicine on PubMed over the past 5 years was conducted. RESULTS: There is scant research on transgender patients in obstetric and gynecologic health care settings, especially outside of hormonal and surgical transition. There are few studies on barriers to quality transgender health care, fewer quantitative studies on transgender patients' experiences in health care settings, and still fewer studies dealing with cultural and interpersonal practices that can help improve experiences for the patient and health care team. One non–peer-reviewed survey reports that 24% of transgender respondents were denied equal treatment in doctor's offices or hospitals, 19% were refused treatment owing to their gender identity, 28% were verbally harassed and 2% physically attacked in a medical setting, and 28% postponed or avoided necessary medical care owing to discrimination. A “gender-equal” gynecologic template of care will be presented. CONCLUSION/IMPLICATIONS: More quantitative and qualitative studies should be performed assessing the needs of the transgender and gender-nonconforming community in obstetric and gynecologic practice. Existing statistics indicate that unacceptable bias and discrimination are occurring, making transgender patients less likely to seek care. Care templates on gender-equal patient encounters should be implemented to better address global and specific health needs in this population in a nonbiased manner.

The aging population: Imperative to uncouple sex and gender to establish “gender equal” health care

AimThe transgender community has long been marginalized in society. As the world's population ages, gender-unbiased health services for this growing population, with age-related chronic illnesses, will be essential. To optimally eliminate hurdles that trans individuals often confront when requesting services, it appears judicious to eliminate the strict and antiquated definition of what constitutes “normal” female and “normal” male. MethodsA review of literature on transgender medicine on PubMed over the last five years was conducted. ResultsExisting statistics indicate that unacceptable bias and discrimination are occurring, making trans patients less likely to seek care. There are emerging initiatives that address the transgender and gender non-conforming population. Ongoing needs include defining what constitutes “gender equal,” understanding the continuum of gender identity, and establishing and implementing guidelines for gender equal counseling and care. ConclusionsWith the routine practice of defining sex at birth and equating sex with gender in the health care setting, the transgender patient encounters multiple barriers to accessing and acquiring health care services. These strict gender labels appear to preclude the institution of gender equal care. Care templates on gender equal patient encounters should be implemented to better address transgender health needs in a non-biased manner.

Transgender medicine—long-term outcomes from 'the Dutch model'

Medical intervention for transgender adolescents is a controversial issue but a recently published article describing long-term psychological outcomes using ‘the Dutch model’ of care should help to silence critics and reassure the growing number of clinicians treating this patient population.

Treating a Transgender Patient: Overview of the Guidelines

Transgenderism and gender dysphoria are becoming more prevalent diagnoses and the patient population is increasing. Primary care practitioners, endocrinologists, and mental health professionals are all part of the medical care team that treats these patients, but family and internal medicine physicians continue to deliver the care in the long term. Transgender medicine is not a strong part of the medical curriculum, and recent studies have shown there is anxiety in new physicians in taking care of these patients. There are many aspects to transgender care that involve different specialities, including, but not limited to, mental health, primary care, endocrinology, surgery, and obstetrics and gynecology. This article gives an overview of the current guidelines for standards of care of transgender patients as delineated by the World Professional Association for Transgender Health and the Endocrine Society.