Endocrine Treatment in Transgender Individuals: Guidelines in Brief

A synopsis of the new Endocrine Society guidelines for endocrine treatment of people with gender incongruence or gender dysphoria has been published in JAMA.¹ These guidelines provide an update to previously released 2009 guidelines.

Approximately 1 million people — or 0.4% of the US population — are transgender.² Lifetime suicide attempt rates among this population are 40%.³ Research has shown that gender-affirming medical or surgical care can reduce gender dysphoria-associated psychological morbidity and that following medical interventions, transgender adolescents report feeling “well-adjusted and satisfied, with well-being scores that surpassed their peers.”^1,4,5

An Endocrine Society task force provided 28 recommendations focused on social transition and use of gonadotropin-releasing hormone (GnRH) agonists for prepubertal and pubertal children, gender-affirming hormone therapy for both pediatric and adult patients, surgery, and both primary care and preventive health.

For each of the major recommendations, the Endocrine Society task force rated the strength of each recommendation, as well as the strength of the evidence on which the recommendation is based.

Below is a summary of the major recommendations.

1. Clinicians should confirm a diagnosis of either gender dysphoria or gender incongruence prior to initiating gender-affirming hormone therapy (strong recommendation; moderate evidence).

2. Medical conditions that may be exacerbated by both hormone depletion and sex hormone treatment should be addressed before treatment is begun (strong recommendation; moderate evidence).

3. Patients should receive counseling about options for fertility before puberty-suppression and hormone therapy is initiated (strong recommendation; moderate evidence).

4. When indicated, adolescents should be offered GnRH agonists to suppress pubertal hormones (strong recommendations; low evidence).

5. Adolescents may begin hormone therapy following confirmation of persistent gender dysphoria or gender incongruence and the mental capacity to give informed consent by a multidisciplinary team of medical and mental health professionals (strong recommendation; low evidence).

6. Hormone-treated transgender individuals should be referred for genital surgery when the following conditions are met: the individual has satisfactorily changed the social role; the individual is satisfied with the effects of hormone therapy; and the individual desires definitive surgical changes. Both the clinician in charge of endocrine transition therapy and the mental health professional should agree that surgery is both medically necessary and would benefit the patient’s overall health and well-being (strong recommendation; very low evidence).

References

1. Radix A, Davis AM. Endocrine treatment of gender-dysphoric/gender-incongruent persons [published online September 13, 2017]. JAMA. doi:10.1001/jama.2017.13540
2. Meerwijk EL, Sevelius JM. Transgender population size in the United States: a meta-regression of population-based probability samples. Am J Public Health. 2017;107(2):216.
3. Perez-Brumer A, Day JK, Russell ST, Hatzenbuehler ML. Prevalence and correlates of suicidal ideation among transgender youth in California: findings from a representative, population-based sample of high school students. J Am Acad Child Adolesc Psychiatry. 2017;56(9):739-746.
4. White Hughto JM, Reisner SL. A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgend Health. 2016;1(1):21-31.
5. de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med. 2011;8(8):2276-2283.