Saturday, January 19, 2019

Doctors should be knowledgeable about the criteria for gender-affirming treatment

The Endocrine Society has updated its guidelines for providing managing gender-dysphoric/ gender-incongruent persons, or simply transgender individuals published in the Journal of Clinical Endocrinology & Metabolism.

According to the guidelines, “Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender.” 

The guidelines also call on physicians managing such individuals to be “knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition”. Some key recommendations include:

·         Adolescents who meet diagnostic criteria for gender-dysphoria/gender incongruence, fulfil criteria for treatment, and are requesting treatment should initially undergo treatment to suppress pubertal development. Pubertal hormone suppression with GnRH analogs should begin after the adolescent first shows the physical changes of puberty.
·         Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons.
·         Transgender adults should be evaluated for medical conditions that can be exacerbated by hormone depletion and treatment with sex hormones of the affirmed gender before beginning treatment, which should be addressed.
·         Such individuals require a safe and effective hormone regimen that will suppress endogenous sex hormone secretion determined by the person’s genetic/gonadal sex and also maintain sex hormone levels within the normal range for the person’s affirmed gender.
·         Transgender persons should be clinically examined for physical changes and potential adverse changes due to sex steroid hormones. Sex steroid hormone levels should be measured every 3 months during the first year of hormone therapy and then once or twice yearly.
·         Cardiovascular risk factors, bone mineral density should be evaluated.
·         Transgender females with no known increased risk of breast cancer should follow breast-screening guidelines recommended for non-transgender females
·         Transgender females treated with estrogens are recommended to follow individualized screening according to personal risk for prostatic disease and prostate cancer.
·         Gender-affirming surgery should only be undertaken when both the mental health professional and the clinician responsible for endocrine transition therapy agree that surgery is medically necessary and would benefit the patient’s overall health and/or well-being.
·         Gender-affirming genital surgery involving gonadectomy and/or hysterectomy should be delayed until the patient is at least 18 years old or legal age of majority.
·         Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete.

(Source: J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869-3903)

Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

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