BUMC Transgender Medicine Research Group

Transgender individuals have unique healthcare needs, particularly those who elect to receive hormone therapy and/or gender confirmation surgery. However to-date, very little research has been conducted on important health topics for transgender individuals that genuinely addresses their healthcare concerns and outcomes.

Joshua D. Safer, M.D., FACP, is engaged in clinical research to address this critical lack of knowledge on medical topics regarding transgender-identified individuals.

Our research emphasis is on improving the current medical knowledge on health topics that specifically impact the transgender community, with the goal of continually improving the health and outcomes of transgender individuals who receive medical care. Our BUMC Transgender Research Group affirms the right of all individuals to be able to discuss their health concerns with practitioners who are knowledgeable and respectful towards a patient’s unique, identity-specific needs.

Current Guidelines for the Hormone Treatment of Transgender Individuals

Joshua D. Safer, MD

Gender identity refers to an individual’s self-perceived gender.  This may be different than the sexual anatomy, the chromosomal sex, the gender role, or the sex recorded at birth (which usually simply reflects external genitalia at the time).

Opposite to the dogma of many years, gender identity appears a durable biological phenomenon. While individuals may make choices related to other inputs in their lives, there do not seem to be external manipulations that truly cause individuals to change gender identity.

Diagnosis

Diagnosis of transgender identity is straightforward among adults. Most individuals who recognize that there is a choice will be able to determine a gender identity without much doubt.  Whether a given individual with a transgender identity wants to address the incongruence is a very personal decision relating to many other factors in life.

In order to avoid a rare instance of a psychiatric condition confounding the situation to such a degree that gender identity is not clear, a mental health provider is included on the treatment team to confirm the absence of a confounder and to assist with transition related stress which can be significant.

Because some children who present as transgender will not be so as adults, early medical treatment carries significant risk. The issue is problematic because individuals who wish to avail themselves of transgender treatment will find it easier at a younger age; prior to the need to reverse opposite sex characteristics developed in puberty.  A paradigm to address the tension is to use GnRH analogs which delay puberty in a reversible fashion until a longer term plan is in place.  GnRH analogs would be started at the first visible signs of puberty or approximately Tanner 2.

Note that pre-pubertal children do not require any medical intervention. Because of the biological nature of gender identity, there does not seem to be any reason for parents to fear allowing pre-pubertal children to explore and even to live as transgender.  The parents can be reassured that non-transgender children will not be convinced to be transgender any more than transgender children can be convinced to not be transgender.

Therefore, the most successful medical treatment for patients who seek it is to change external appearance to match gender identity.

Medical Treatment

Hormone treatment of transgender individuals is straightforward – following conventional hormone paradigms with the anticipated concerns and effects that are seen when using the same hormones for other purposes.

Typically, female to male hormone treatment consists of testosterone to bring the serum testosterone from the female range to the male range. The doses required are similar to those used for treatment of hypogonadal males in general.

100 mg IM or SQ testosterone (enanthate or cypionate) q week; gel is fine; patches are OK if tolerated (they often itch).

Typically, male to female hormone treatment consists of an anti-androgen to lower testosterone levels (if testes are present) and estrogen supplementation.

The anti-androgen of choice in the United States is spironolactone because of its long-term safety profile arising from its 50-year history as a potassium sparing diuretic to treat hypertension. Higher doses are used than are required for blood pressure control.  Anticipate using up to 200 mg/day (in divided doses if needed for the patient to tolerate).

Multiple estrogen options exist. The 2 most popular are Premarin (conjugated estrogens originally obtained from horse urine) and estradiol (a pure laboratory produced product).  The former is available virtually anywhere.  The latter is cheapest.  Anticipate doses double to quadruple those for post-menopause for true replacement of a larger woman (i.e. 2 mg instead of 0.625 mg).  The doses sometimes need to be higher yet for individuals with testes present (4 mg/day or more) in order to achieve female level testosterone levels.

Endpoints

The endpoints for female to male treatment:

  • Absence of menses
  • Increased facial hair
  • Increased acne

The endpoints for male to female treatment:

  • Absence of erections/ejaculations
  • Loss of facial hair
  • Reversal of baldness
  • Breast development

Concerns

Female to male (trans-masculine treatment)

  • The biggest concerns for testosterone therapy are an increase in hematocrit (with an increased thrombosis risk?) and a decrease in HDL cholesterol (with an increased CAD risk?). Patients may also be advised to be aware of more aggressive behavior.
  • Androgen therapy is also associated with increased sleep apnea.
  • Usual monitoring includes serum testosterone (to determine success of therapy), hematocrit and lipid profile.
  • Malignancy screening must include all body parts present regardless of whether or not they are associated with one sex or another (e.g. don’t forget Pap smears and mammograms if required for transgender men with cervixes and breasts respectively).

Male to female (trans-feminine treatment)

  • Anti-androgen therapy of any sort (note that transgender Rx, like oral birth control [for birth control, acne, or hirsutism] may result in decreased libido).
  • Usual monitoring includes serum testosterone (to determine success of therapy), estrogen level (estradiol), prolactin, potassium, and triglycerides (lipid profile).
  • Malignancy screening must include all body parts (including remaining prostates and newly developing breasts for transgender women)

Pitfalls

Special concerns unique to transgender treatment include making sure that diagnosis is not confounded by a rare psychiatric disorder that might confuse the issue (e.g. the desire to wear clothing of the opposite sex, or well-masked delusional thinking/psychosis).

As well, the contradictory agendas regarding treatment of children must be appreciated (some children identifying as transgender will prove not later; however, there is benefit in the degree to which sexual characteristics of puberty can be avoided – avoiding the necessity to reverse them later).

 

Click below for more information on current published BUMC-connected research in the below topics:

– Clinical transgender health care

– Evidence of biological nature of gender identity

– Improving medical education for medical trainees

– Research gaps for transgender health care

 

Additionally, our work includes the development of a Transgender Health Registry at BMC.  All transgender-identified individuals who have had hormone therapy or other transgender health care management at Boston Medical Center (BMC) who give consent to participate will have their name, date of birth, and medical record number recorded in a registry. By compiling a list of those treated here at BMC, researchers (approved by the Institutional Review Board) will be able to access more complete data when studying the long term effects of hormonal treatment and/or other aspects of care.  It is our hope that by establishing the first BMC registry of Transgender Health, we will be able to better serve individuals who identify as transgender within our community both now and in the future.