Transgender Health

An Endocrine Society Position Statement

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INTRODUCTION

Over the last few decades, there has been a rapid expansion in the understanding of gender identity along with the implications for the care of transgender and gender incongruent individuals. In parallel with the greater societal awareness of transgender individuals, evidence-based and data-driven protocols have increased. While there continue to be gaps in knowledge about the optimal care for transgender individuals, the framework for providing care is increasingly well-established as is the recognition of needed policy changes.

BACKGROUND

The medical consensus in the late 20th century was that transgender and gender incongruent individuals suffered a mental health disorder termed “gender identity disorder.” Gender identity was considered malleable and subject to external influences. Today, however, this attitude is no longer considered valid. Considerable scientific evidence has emerged demonstrating a durable biological element underlying gender identity.1,2 Individuals may make choices due to other factors in their lives, but there do not seem to be external forces that genuinely cause individuals to change gender identity.

Although the specific mechanisms guiding the biological underpinnings of gender identity are not entirely understood, there is evolving consensus that being transgender is not a mental health disorder. Such evidence stems from scientific studies suggesting that: 1) attempts to change gender identity in intersex patients to match external genitalia or chromosomes are typically unsuccessful3,4; 2) identical twins (who share the exact same genetic background) are more likely to both experience transgender identity as compared to fraternal (non-identical) twins5; 3) among individuals with female chromosomes (XX), rates of male gender identity are higher for those exposed to higher levels of androgens in utero relative to those without such exposure, and male (XY)-chromosome individuals with complete androgen insensitivity syndrome typically have female gender identity6; and 4) there are associations of certain brain scan or staining patterns with gender identity rather than external genitalia or chromosomes7,8.

CONSIDERATIONS

Transgender individuals are often denied insurance coverage for appropriate medical and psychological treatment. Over the last decade, there has been considerable research on and development of evidence-based standards of care that have proven to be both safe and efficacious for the treatment of gender dysphoria/gender incongruence. There is also a growing understanding of the impact that increased access to such treatments can have on the mental health of these individuals.

The Endocrine Society’s Clinical Practice Guideline on gender dysphoria/gender incongruence9 provides the standard of care for treating transgender individuals. The guideline establishes a framework for the appropriate treatment of these individuals and standardizes terminology to be used by healthcare professionals. These recommendations include evidence that treatment of gender dysphoria/incongruence is medically necessary and should be covered by insurance.

Despite increased awareness, many barriers to improving the health and well-being of transgender patients remain. Oftentimes, treatment for gender dysphoria/gender incongruence is considered elective by insurance companies, which fail to provide coverage for physician-prescribed treatment. Access to appropriately trained healthcare professionals can also be challenging as there is a lack of formal education on gender dysphoria/gender incongruence among clinicians trained in the United States. A 2016 survey of endocrinologists, the physicians most likely to care for these patients, found that over 80% have never received training on care of transgender patients10. This can have an adverse impact on patient outcomes, particularly in rural and underserved areas. In fact, studies have indicated that 70% of transgender individuals have experienced maltreatment by medical providers, including harassment and violence.11 Transgender individuals who have been denied care show an increased likelihood of committing suicide and self-harm.12 It is critical that transgender individuals have access to the appropriate treatment and care to ensure their health and well-being.

FUTURE CONSIDERATIONS

While the data are strong for both a biological underpinning to gender identity and the relative safety of hormone treatment (when appropriately monitored medically), the gaps in knowledge to optimize care over a lifetime are profound. Comparative effectiveness research in hormone regimens is needed to determine: the best endocrine and surgical protocols, as it is not yet known if certain regimens are safer or more effective than others; the degree of improvement as a result of the intervention (e.g. decrease in mental health diagnoses); the need for training of health care providers and the most effective training methods; and whether there are cardiovascular, malignancy, or other long-term risks from hormone interventions, particularly as the transgender individual ages. Further, studies are needed to elucidate the biological processes underlying gender identity as well as to determine strategies for fertility preservation and for the optimal approaches to gender non-conforming children. To successfully establish and enact these protocols requires long-term, large-scale studies across countries that employ the same care protocols.

POSITIONS

  • There is a durable biological underpinning to gender identity that should be considered in policy determinations.
  • Medical intervention for transgender individuals (including both hormone therapy and medically indicated surgery) is effective, relatively safe (when appropriately monitored), and has been established as the standard of care.13 Federal and private insurers should cover such interventions as prescribed by a physician as well as the appropriate medical screenings that are recommended for all body tissues that a person may have.
  • Increased funding for national research programs is needed to close the gaps in knowledge regarding transgender medical care and should be made a priority.

September 2017


  1. Saraswat A, et al. Evidence Supporting the Biologic Nature of Gender Identity. Endocr Pract. 2015 Feb;21(2): 199-204.
  2. Rosenthal SM. Approach to the Patient: Transgender Youth: Endocrine Considerations. J Clin Endocrinol Metab. 2014 Dec;99(12):4379-89.
  3. Saraswat A, et al. Evidence Supporting the Biologic Nature of Gender Identity. Endocr Pract. 2015 Feb;21(2): 199-204.
  4. Rosenthal SM. Approach to the Patient: Transgender Youth: Endocrine Considerations. J Clin Endocrinol Metab. 2014 Dec;99(12):4379-89.
  5. Heylens G, et al. Gender Identity Disorder in Twins: A Review of the Case Report Literature. J Sex Med. 2012 Mar;9(3):751-7.
  6. Dessens AB, et al. Gender Dysphoria and Gender Change in Chromosomal Females with Congenital Adrenal Hyperplasia. Arch Sex Behav. 2005 Aug;34(4):389-97.
  7. Saraswat A, et al. Evidence Supporting the Biologic Nature of Gender Identity. Endocr Pract. 2015 Feb;21(2): 199-204.
  8. Rosenthal SM. Approach to the Patient: Transgender Youth: Endocrine Considerations. J Clin Endocrinol Metab. 2014 Dec;99(12):4379-89.
  9. Endocrine Society Draft Clinical Practice Guideline on Gender Dysphoria/ Gender Incongruence (publication expected September 13, 2017).
  10. Davidge-Pitts, C., et al. Transgender Health in Endocrinology: Current Status of Endocrinology Fellowship Program and Practicing Clinicians. J Clin Endocrinol Metab. (2017) 102(4):1286-1290.
  11. ibid.
  12. ibid.
  13. Endocrine Society Draft Clinical Practice Guideline on Gender Dysphoria/ Gender Incongruence (publication expected September 13, 2017).