Joshua D. Safer
The Endocrine Society released a new clinical practice guideline this week outlining recommended care for transgender individuals, along with a position statement calling on federal and private insurers to cover such interventions as prescribed by a physician.
The guideline, published online in the Journal of Clinical Endocrinology & Metabolism, makes several new recommendations not advocated in past guidelines, including a suggestion that clinicians begin hormone suppression for transgender adolescents who meet diagnostic criteria for gender dysphoria once they exhibit the first physical changes of puberty. The guideline does not recommend gender-affirming hormone treatment for pre-pubertal children.
“The earlier guidelines focused on legal definitions for decision making, therefore suggesting beginning interventions at age 16 years and older,” Joshua D. Safer, MD, endocrinologist and medical director of the Center for Transgender Surgery and Medicine at Boston Medical Center, told Endocrine Today. “The revised guideline is much more biologically oriented, using when an adolescent actually begins puberty as a reference for when interventions might take place. It makes more sense to start to think about biology.”
For children and adolescents who know that they are transgender, Safer said, avoiding the “wrong” puberty can be helpful on several fronts.
Puberty suppression “avoids the development of tissue that they may not want, and, in the current circumstances, what they might be addressing with surgery later in life,” Safer said. “If we can avoid that [development] in the first place, then we’re saving surgeries, which is a good thing.”
Wylie C. Hembree
Gender dysphoria may occur during childhood, but it persists beyond the onset of puberty only in approximately 25% of individuals, said Wylie C. Hembree, MD, a retired professor of medicine with the College of Physicians and Surgeons at Columbia University and the chair of the Endocrine Society’s Transgender Task Force. For this group, the guideline recommends the suppression of physical endocrine changes until treatment with sex hormones that reflect the desired gender of the adolescent, Hembree said.
“Despite persistence of gender dysphoria into adolescence, adulthood or even old age, there are some who seek medical care later for changes in their sex steroids, physical characteristics and life style,” Hembree told Endocrine Today. “Although the principles of treatment are similar, the strategies and monitoring for older persons may be more complex and may have higher risks.”
When treating adolescents, the guidelines also recommends that individuals seeking gender-affirming therapies receive counseling on options for fertility preservation prior to initiating puberty suppression; adults should receive similar counseling prior to any treatment with hormone therapy.
“The biggest cost to transgender therapy is risk to fertility,” Safer said. “If we look downstream, what is it that transgender people who go through the regimen might have sacrificed for those medical interventions?”
Safer said conversations with older transgender patients have helped to inform the guidelines regarding fertility preservation.
“We see it on the other side,” Safer said. “People who transition later, and have had a harder time with it, who have had kids along the way before they transitioned, will sometimes reflect that the one silver lining to their late transition is that they have these children.”
When high doses of sex steroids are required to suppress the body’s secretion of hormones, the guidelines noted that removal of the gonads may be considered. Additionally, clinicians should monitor levels of prolactin, metabolic disorders and bone loss, as well as cancer risks, in transgender men and women who have not undergone surgical treatment.
‘Intervention should be covered’
In a separate position statement, the Endocrine Society is calling for both federal and private insurers to cover medical interventions for transgender care, along with any appropriate medical screenings, adding that such interventions are “effective, relatively safe and established as the standard of care.”
“The Endocrine Society is interested in having this conversation be a conversation on its scientific merits, as opposed to a political conversation, where arguments are made that are not necessarily relevant scientifically,” Safer said. “The [statement] is intended to make this less political. People have gender identity and sexual anatomy that is incongruent. That is a biological phenomenon that we see in humans. That is not the debate. We do see that, and that is a medical concern.”
Additionally, Safer said, there is harm stemming from gender incongruence.
“We in the medical community want to intervene and do the right thing for these people, just like we do with any other medical or biological condition,” Safer said. “Of course, medical intervention for transgender individuals should be covered. We in the community will debate which regimens make the most sense, and that debate is open and blunt — but that’s where the conversation lies now. The huge change is simply that recognition.”
The position statement also calls for increased funding for national research programs to “close the gaps in knowledge” regarding transgender medical care, adding such programs should be made a priority. – by Regina Schaffer
For more information:
, MD, can be reached at email@example.com.
Joshua D. Safer, MD, can be reached at the BMC Center for Transgender Medicine and Surgery, 1 Boston Medical Center Place Boston, MA 02118; email: firstname.lastname@example.org.
: Hembree and Safer report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.