A relatively new field, transgender medicine will be featured in the ENDO 2021 session, “Transgender Care: A Comprehensive Assessment for a Multi-Faceted Condition,” a live, 90-minute program taking place Sunday, March 21, 2021, at 12:15 p.m. Program co-chair, Stephen M. Rosenthal, MD, and Sabine Hannema, MD, PhD, talk to Endocrine News about what attendees can expect from the three varied programs that will each have moderated Q&A sessions with world-renowned experts.
On Sunday, March 21, ENDO 2021 will feature a session titled “Transgender Care: A Comprehensive Assessment for a Multi-Faceted Condition.” As the name suggests, this session will review the care of transgender persons, from pediatric to adult care, and even as they transition from youth to adult care – patients who need specialized, targeted care, from hormonal management to psychosocial assessment.
The session comes at an exciting but challenging time for transgender patients. While there has been some promising research on the mental health side and the beneficial physiologic outcomes of the current models of care (a paper recently published in Journal of the Endocrine Society by Baker et. al., found that hormone therapy is associated with increased quality of life, decreased depression, and decreased anxiety), some barriers to care on the political and legislative fronts – not to mention the already numerous barriers to care transgender patients face day to day.
The United Kingdom’s High Court on December 1, 2020, decided that minors under age 16 likely could not give informed consent for pubertal suppression. And while the High Court has granted permission or a coalition of LGBTQ+, youth, reproductive health, and medical organizations — including the Endocrine Society — to intervene in an appeal of its decision, similar legislation is pending in various U.S. states. These measures would restrict gender-affirming care for gender diverse individuals under 18 and would criminalize providers following practice guidelines.
After transgender and gender diverse minors start puberty, prescribing hormones to suppress puberty is the recommended strategy if it is desired by the patient and if diagnostic and treatment criteria are met. This treatment, which is completely reversible, gives adolescents more time to explore their options.
“This is going to be an exciting talk,” says Stephen M. Rosenthal, MD, a pediatric endocrinologist, medical director of the Child and Adolescent Gender Center at the University of California San Francisco, and co-chair of this ENDO 2021 session. “There’s going to be an opportunity to not just listen, but directly ask questions to the presenters.”
A Rapidly Growing Field
This is a relatively new and small field, but it’s progressing growing rapidly. The chance of an endocrinologist caring for a transgender patient rises every day. “More and more people are presenting to pediatric endocrinologists and adult endocrinologists for services related to gender care,” Rosenthal says. “It’s really important to be current on the latest research and the latest research and outcomes.”
Rosenthal says that in the past two years, there has been a tremendous amount of high-quality research outcomes studies. However, what’s needed now are long-term follow-up studies. “Just by definition, it’s going to be a while before we have those,” he says.
Mental Health Impacts
For now, Rosenthal invites ENDO 2021 attendees to listen to the expert speakers, pioneers in the field of transgender medicine. “The panel that has been put together by the Annual Meeting Steering Committee is absolutely superb,” Rosenthal says. “All three of them are internationally recognized experts in transgender care.”
“The mental health provider that has performed the diagnostic evaluation of the adolescent, and therefore knows about their specific situation and their development, assesses the ability of the adolescent to provide informed consent, together with the multidisciplinary team. We feel that this is more appropriate than involving a court to perform such an assessment.” — Sabine E. Hannema, MD, PhD, Amsterdam University Medical Centers, Amsterdam, Netherlands
Sabine E. Hannema, MD, PhD, Amsterdam University Medical Centers in Amsterdam, Netherlands, will speak to the hormonal management in adolescents, as well as counseling prior to treatment and fertility preservation. “In my talk I will discuss the endocrine treatment recommended for transgender adolescents by current guidelines, i.e. puberty suppression and gender affirming hormone treatment (testosterone for transboys and estradiol for transgirls),” she says. “I will review the aims of the treatment and show data on the outcome, including effects on psychological functioning. In addition, the safety of treatment will be considered, taking into account effects on bone mineral density and cardiovascular risk factors.”
For transgender adolescent patients, developing secondary sex characteristics can be very stressful, which can have a very real and very damaging impact on psychosocial functioning and school performance, which can then lead to depression and anxiety. “Puberty blockers are used to stop further pubertal development, alleviate the distress, and improve well-being,” Hannema says. “While puberty is suppressed, the adolescent has time to carefully consider if they wish to pursue further treatment such as gender affirming hormone treatment. “
And while the UK and the US mull legislation that could harm transgender patients seeking care, in the Netherlands, where Hannema practices, puberty blockers are available without legal restraints, so transgender patients are able to get optimal care through a multidisciplinary team – through which the adolescents and their providers are able to make the best decisions for the health of the patient. “The mental health provider that has performed the diagnostic evaluation of the adolescent, and therefore knows about their specific situation and their development, assesses the ability of the adolescent to provide informed consent, together with the multidisciplinary team,” Hannema says. “We feel that this is more appropriate than involving a court to perform such an assessment.”
Hannema tells Endocrine News that even though puberty blockers are reversible, if adolescents subsequently start gender affirming hormones and choose to undergo a gonadectomy, that will leave them infertile, so her talk will also highlight the importance of fertility preservation as well as some of the challenges that unfortunately await these patients. “Many adolescents are interested in becoming a parent and they may wish to pursue fertility preservation prior to the start of treatment, although several studies have shown that there are many barriers that adolescents face,” she says.
Recent data have shown that current care models do have a positive impact on mental health in transgender adolescents, so most professional societies endorse the treatment recommended in current guidelines, but according to Hannema, these recommendations are based on low-level evidence and there are still many questions to be answered. “Some people argue that the positive outcomes reported by several studies do not weigh up against possible risks,” she says. “I will show the data that are available on the efficacy and safety of the treatment so that people can draw their own conclusions.”
“More and more people are presenting to pediatric endocrinologists and adult endocrinologists for services related to gender care. It’s really important to be current on the latest research and the latest research and outcomes.” – Stephen M. Rosenthal, MD, medical director, Child and Adolescent Gender Center at the University of California San Francisco, San Francisco, Calif.
And as the number of transgender patients seeking endocrine care grows, that means that not only will endocrinologists find themselves treating more transgender patients, transgender patients will see more physicians in different specialties for their care. “I hope that after attending the session, people will feel that they have a good overview of the treatment options, the benefits and potential risks, and are aware of issues that deserve special attention when counseling adolescents and their families, and during follow-up,” Hannema says.
— Bagley is the senior editor of Endocrine News. In the February issue, he wrote the cover story on how endocrine nurses have become more essential than ever during the COVID-19 pandemic.