Gender-Affirming Care: Bridging the Gap

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As transgender medical care becomes unfairly politicized, presentations such as ENDO 2022’s Meet the Professor session “Beginner’s Guide to Gender-Affirming Hormone Therapy for Transgender and Gender Diverse Adults” are more essential than ever. Attendees will be shown a variety of best practices in providing affirming care to transgender and gender diverse adults.  

On the afternoon of Sunday, June 12, ENDO 2022 will feature a Meet the Professor session titled, “Beginner’s Guide to Gender-Affirming Hormone Therapy for Transgender and Gender Diverse Adults.” The fact that the title specifically references beginners is apt, since caring for transgender patients may still be something some endocrinologists have yet to experience, but if trends continue the way they are, they soon will.

A 2016 study by the Williams Institute at the UCLA School of Law found that 1.4 million adults identify as transgender. (The authors of that study noted that figure was nearly double the estimates from a decade earlier.) The 2015 U.S. Transgender Survey (USTS) had more than 27,000 respondents across the U.S., and the 2022 USTS is aiming for 40,000 respondents, and will almost certainly show that more than 1.4 million adults now identify as transgender.

As the population continues to grow, so too does the likelihood of endocrinologists taking them on as patients. Endocrinologists should of course be well versed in how to care for these patients and should especially be interested in providing these patients with safe and effective gender-affirming care. But studies continue to show that barriers to providing affirming care to transgender and gender diverse (TGD) patients include lack of knowledge and comfort among providers, making it difficult for these patients to find trained clinicians.

The 2015 USTS reported that 33% of respondents had been mistreated when seeking healthcare, whether it was being verbally harassed or simply denied care at all.

“Unfortunately, much of this is driven by insufficient education in medical schools and training programs, including endocrinology fellowships,” says Caroline Davidge-Pitts, MD, MBBCH, associate professor of Medicine and associate chair of the Division of Endocrinology, Diabetes, and Nutrition at Mayo Clinic Rochester. She is also medical director of the Transgender and Intersex Specialty Clinic, and one of the two presenters of this Meet the Professor session. “Our session, ‘A Beginner’s Guide to Gender-Affirming Hormone Therapy (GAHT) for TGD Adults,’ will be geared towards endocrinologists, and those interested in endocrinology who would like to become more active in providing GAHT for TGD people in their clinics.”

Indeed, study after study show that providing gender-affirming care, including GAHT when desired, improves health and well-being, even, and especially, mental health. A 2021 paper published in the Journal of the Endocrine Society by Baker et al reported: “Hormone therapy [in transgender patients] was associated with increased QOL, decreased depression, and decreased anxiety. Associations were similar across gender identity and age.” 

More Studies Needed

But there seems to be a sea change coming. Interest in providing safe and effective gender-affirming care – including GAHT – is growing among clinicians and researchers. “We are thrilled to see increasing funding opportunities for researchers interested in identifying, characterizing, and reducing health disparities among sexual and gender minorities,” says Sean J. Iwamoto, MD, assistant professor of Medicine at the University of Colorado School of Medicine and Rocky Mountain VA Medical Center and the other presenter of the session.

One of the learning objectives of this ENDO session is to show that GAHT can be provided to TGD patients in safe and effective ways, but the presenters are careful to point out that more studies are needed to get a better picture of how this care affects patients over the course of their lives. “While we have valuable data from large longitudinal cohorts in Europe that have significantly informed our clinical practice guidelines, more rigorous large studies with diversity among TGD patients and GAHT routes of administration are needed to better assess long-term health outcomes (especially cardiovascular disease and blood clots) and potential interventions to mitigate risk,” Iwamoto says. ““Research on GAHT effects on older TGD adults and long-term effects of puberty blockade on future adult health are also important topics to study that will complement existing data on the safety and efficacy of GAHT across much of the lifespan.”

“We want clinicians to take away that being involved in transgender health saves lives, and that with the right resources and knowledge, it is possible to be an affirming clinician, both in academics and private practice.” – Caroline Davidge-Pitts, MD, MBBCH, associate professor of Medicine; associate chair, Division of Endocrinology, Diabetes, and Nutrition; medical director, Transgender and Intersex Specialty Clinic, Mayo Clinic, Rochester, Minn.

Davidge-Pitts and Iwamoto tell Endocrine News that study recruitment may be a significant obstacle for TGD-related research, so it will be vital to involve TGD voices and experience in the study design. “This could include the principal investigator, study team members, families, clinicians, and other community stakeholders,” Iwamoto says.

Adjusting Reference Ranges

Another learning objective for “Beginner’s Guide to Gender-Affirming Hormone Therapy for Transgender and Gender Diverse Adults” is understanding laboratory test interpretation in people taking GAHT. “GAHT is associated with change in laboratory measures, such as hematocrit and creatinine. For example, we know that testosterone is a driver of erythrocytosis – so testosterone therapy will cause a higher hematocrit and estradiol therapy (which lowers testosterone) will cause a decrease in hematocrit,” Davidge-Pitts says. “Similarly, we find changes in creatinine with hormone therapy.”

Davidge-Pitts goes on to say: “When interpreting laboratory tests in TGD individuals, it is important to know what reference range the lab is using. Incorrect alerts to a result might occur, for example, if someone on estradiol therapy is flagged as anemic if the male reference range is used while on estradiol therapy.”

Politicizing the Process

Davidge-Pitts and Iwamoto are co-chairs of the Endocrine Society’s Transgender Research and Medicine Special Interest Group leadership team. In 2020, they co-authored a paper in The Journal of Clinical Endocrinology & Metabolism (JCEM) titled, “Proper Care of Transgender and Gender Diverse Persons in the Setting of Proposed Discrimination: A Policy Perspective.” The authors of the paper conclude that while they remain concerned about the ongoing attempted politicization of gender-affirming care for TGD patients, they write that the Endocrine Society and the Pediatric Endocrine Society remain dedicated to providing necessary gender-affirming medical care to TGD individuals, to advocating for increased funding for research to close the gaps in knowledge regarding the medical care of TGD individuals, and to sharing important knowledge learned to inform policy. “We remain steadfast in our belief that patient health management decisions should be evidence-based and doctor-patient determined, and health policy should be based in science with healthcare experts at the table as contributors,” they write.

“While we have valuable data from large longitudinal cohorts in Europe that have significantly informed our clinical practice guidelines, more rigorous large studies with diversity among TGD patients and GAHT routes of administration are needed to better assess long-term health outcomes (especially cardiovascular disease and blood clots) and potential interventions to mitigate risk.”- Sean J. Iwamoto, MD, assistant professor of Medicine, University of Colorado School of Medicine, Rocky Mountain VA Medical Center, Aurora, Colo.

The presenters acknowledge that controversies continue to swirl around this area, no matter how unfounded, but Iwamoto points any interested readers or attendees to the JCEM Policy Perspective. Davidge-Pitts says that their presentation is specific to adult care, and there is a lot to cover in a short time. “We therefore plan to center our conversations around providing affirming care to TGD adults and how we can support clinicians wanting to grow their practice in this area,” she says.

Providing a Bridge

Endocrinologists play a vital role in transgender healthcare, no matter their sub-specialty. Davidge-Pitts says this area of endocrinology will continue to be incorporated into training programs, and she’s excited to know that our future endocrinologists will have more knowledge in this area. “However, there is a large group of clinicians who will not have had any training, and may want to be more affirming, but find the process overwhelming,” she says.

“We hope to provide a bridge for this group of clinicians, expanding their knowledge base, increasing their comfort, and helping them identify resources to find additional gender-affirming management considerations,” Iwamoto says.

The first rule of medicine is Do No Harm, and it’s becoming more and more clear that health disparities are harming these patients. “We want clinicians to take away that being involved in transgender health saves lives,” Davidge-Pitts says, “and that with the right resources and knowledge, it is possible to be an affirming clinician, both in academics and private practice.”

Bagley is the senior editor of Endocrine News. In the April issue, he wrote about the possibility of how stem cell technology could potentially lead to a cure for diabetes.

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