User:GJustVibin/Transgender health care

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Gender variance and medicine[edit]

Gender variance is defined in medical literature as "gender identity, expression, or behavior that falls outside of culturally defined norms associated with a specific gender".[1] For centuries, gender variance was seen by medicine as a pathology.[2][3] The World Health Organization identified gender dysphoria as a mental disorder in the International Classification of Diseases (ICD) until 2018.[4] Gender dysphoria was also listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association, where it was previously called "transsexualism" and "gender identity disorder".[5][6]

In 2018, the ICD-11 included the term "gender incongruence" as "marked and persistent incongruence between an individual's experienced gender and the assigned sex", where gender variant behaviour and preferences do not necessarily imply a medical diagnosis.[7] However, the difference between "gender dysphoria" and "gender incongruence" is not always clear in the medical literature.[8]

Some studies posit that treating gender variance as a medical condition has negative effects on the health of transgender people and claim that assumptions of coexisting psychiatric symptoms should be avoided.[2][9][10] Other studies argue that gender incongruence diagnosis may be important and even positive for transgender people at the individual and social level.[11]

As there are various ways of classifying or characterizing those who are either diagnosed or self-affirm as transgender individuals, the literature cannot clearly estimate how prevalent these experiences are within the total population. The results of a recent systematic review highlight the need to standardize the scope and methodology related to data collection of those presenting as transgender.[12]

Gender-affirming care[edit]

Various options are available for transgender people to pursue physical transition. There have been options for transitioning for transgender individuals since 1917.[13] Gender-affirming care helps people to change their physical appearance and/or sex characteristics to accord with their gender identity; it includes hormone replacement therapy and gender-affirming surgery. While many transgender people do elect to transition physically, every transgender person has different needs and, as such, there is no required transition plan.[14] Preventive health care is a crucial part of transitioning and a primary care physician is recommended for transgender people who are transitioning.[14]

Eligibility[edit]

In the International Classification of Diseases, the diagnosis is known as transsexualism.[15] The US Diagnostic and Statistical Manual of Mental Disorders (DSM) names it gender dysphoria (in version 5[16]). Some people who are validly diagnosed have no desire for all or some parts of sex reassignment therapy, particularly genital reassignment surgery, and/or are not appropriate candidates for such treatment.

The general standard for diagnosing, as well as treating, gender dysphoria is outlined in the WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. As of February 2014, the most recent version of the standards is Version 7.[17] According to the standards of care, "gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). Only some gender-nonconforming people experience gender dysphoria at some point in their lives". Gender nonconformity is not the same as gender dysphoria; nonconformity, according to the standards of care, is not a pathology and does not require medical treatment.

The informed consent model is an alternative to the standard WPATH approach which does not require a person seeking transition related medical treatment to undergo formal assessment of their mental health or gender dysphoria. Arguments in favor of this model describe required assessments as gatekeeping, dehumanizing, pathologizing, and reinforcing a reductive perception of transgender experiences.[18] Informed consent approaches include conversations between the medical provider and person seeking care on the details of risks and outcomes, current understandings of scientific research, and how the provider can best assist the person in making decisions.[19]

Local standards of care exist in many countries.

Eligibility for different stages of treatment[edit]

While a mental health assessment is required by the standards of care, psychotherapy is not an absolute requirement but is highly recommended.[17]

Hormone replacement therapy is to be initiated from a qualified health professional. The general requirements, according to the WPATH standards, include:

  1. Persistent, well-documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. Age of majority in a given country (however, the WPATH standards of care provide separate discussion of children and adolescents);
  4. If significant medical or mental health concerns are present, they must be reasonably well-controlled.

Often, at least a certain period of psychological counseling is required before initiating hormone replacement therapy, as is a period of living in the desired gender role, if possible, to ensure that they can psychologically function in that life-role. On the other hand, some clinics provide hormone therapy based on informed consent alone.[17]

Eligibility of minors[edit]

While the WPATH standards of care generally require the patient to have reached the age of majority, they include a separate section devoted to children and adolescents.[17]

Hormone replacement therapy[edit]

Main article: Transgender hormone therapy
A transgender woman before and after two years of hormone replacement therapy.

Hormone replacement therapy (HRT) is primarily concerned with alleviating gender dysphoria in transgender people.[14] Trans women are usually treated with estrogen and complementary anti-androgenic therapy. This therapy induces breast formation, reduces male hair pattern growth, and changes fat distribution, also leading to a decreased testicular size and erectile function.[20] Trans men are normally treated with exogenous testosterone, which is expected to cease menses, to increase facial and body hair, to cause changes in skin and in fat distribution, and to increase muscle mass and libido.[20] After at least three months, other effects are expected, such as the deepening of the voice and changes in sexual organs (such as atrophy of vaginal tissues, and increased clitoral size).[20] Regular monitoring by an endocrinologist is a strong recommendation to ensure the safety of individuals as they transition.[21]

Access to hormone replacement therapy has been shown to improve quality of life for people in the female-to-male community when compared to female-to-male people who do not have access to hormone replacement therapy.[22] Despite the improvement in quality of life, there are still dangers with hormone replacement therapy, in particular with self-medication. An examination of the use of self-medication found that people who self-medicated were more likely to experience adverse health effects from preexisting conditions such as high blood pressure as well as slower development of desired secondary sex characteristics.[23]

Hormone therapy for transgender individuals has been shown in medical literature to be safe, when supervised by a qualified medical professional.[24]

Transgender people seeking surgery may be informed they will need to take hormones for the rest of their life if they want to maintain the feminizing effects of oestrogen or the masculinizing effects of testosterone. Their dose of hormones will usually be reduced, but it should still be enough to produce the effects that they need and to keep them well, and to protect them against osteoporosis (thinning of the bones) as they get older. If they are still on hormone blockers, they will stop taking them altogether.[25]

Monitoring of risk factors associated with hormone replacement therapy, such as prolactin levels in transgender women and polycythemia levels in transgender men, are crucial for the preventive health care of transgender people taking these treatments.[14]

Reproductive Healthcare

Main article: Transgender pregnancy

There is a common misconception that starting hormone replacement therapy automatically leads to infertility. While it may impact the ability to be fertile, it does not mean it leads to a hundred percent infertility rate.[26] There’s been cases of transgender men experiencing pregnancy and abortion.[27] It’s important to keep people informed on their fertility options as trans men and doctors can be under the opinion that testosterone is a form of contraception itself.

For trans women, it’s possible for them to undergo cryopreservation before starting hormone replacement therapy. As evidence has shown that trans women tend to have lower motile sperm compared to their Cisgender counterparts[28], fertility preservation can be important for individuals anticipating having biological children in the future. While it’s important to consider fertility preservation before starting HRT, it is possible in some cases to regain fertility after halting HRT for a period of time.[29]

There’s also an importance to educate transgender youth on their fertility preservation options as few adolescents end up doing so.[30]

Gender-affirming surgery[edit]

Main article: gender-affirming surgery

The goal of gender-affirming surgery is to align the secondary sexual characteristics of transgender people with their gender identity. As hormone replacement therapy, gender-affirming surgery is also employed as a response to diagnosis gender dysphoria[14][31]

The World Professional Association for Transgender Health (WPATH) Standards of Care recommend additional requirements for gender-affirming surgery when compared to hormone replacement therapy. Whereas hormone replacement therapy can be obtained through something as simple as an informed consent form, gender-affirming surgery can require a supporting letter from a licensed therapist (two letters for genital surgery such as vaginoplasty or phalloplasty), hormonal treatment, and (for genital surgery) completion of a 12-month period in which the person lives full-time as their gender. WPATH standards, while commonly used in gender clinics, are non-binding; many trans patients undergoing surgery do not meet all of the eligibility criteria.

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References[edit]

  1. ^ Simons, Lisa K.; Leibowitz, Scott F.; Hidalgo, Marco A. (2014-06-01). "Understanding Gender Variance in Children and Adolescents". Pediatric Annals. 43 (6): e126–e131. doi:10.3928/00904481-20140522-07. ISSN 0090-4481. PMID 24972420.
  2. ^ a b Byne, William; Karasic, Dan H.; Coleman, Eli; Eyler, A. Evan; Kidd, Jeremy D.; Meyer-Bahlburg, Heino F.L.; Pleak, Richard R.; Pula, Jack (May 2018). "Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists". Transgender Health. 3 (1): 57–A3. doi:10.1089/trgh.2017.0053. ISSN 2380-193X. PMC 5944396. PMID 29756044.
  3. ^ von Krafft-Ebing, Richard (1894). Psychopathia Sexualis. ISBN 9782357792173.
  4. ^ Reed, Geoffrey M.; Drescher, Jack; Krueger, Richard B.; Atalla, Elham; Cochran, Susan D.; First, Michael B.; Cohen-Kettenis, Peggy T.; Arango-de Montis, Iván; Parish, Sharon J. (October 2016). "Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations". World Psychiatry. 15 (3): 205–221. doi:10.1002/wps.20354. PMC 5032510. PMID 27717275.
  5. ^ Reed, Geoffrey M.; Drescher, Jack; Krueger, Richard B.; Atalla, Elham; Cochran, Susan D.; First, Michael B.; Cohen-Kettenis, Peggy T.; Arango-de Montis, Iván; Parish, Sharon J. (October 2016). "Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations". World Psychiatry. 15 (3): 205–221. doi:10.1002/wps.20354. PMC 5032510. PMID 27717275.
  6. ^ Cohen-Kettenis, Peggy T.; Pfäfflin, Friedemann (2009-10-17). "The DSM Diagnostic Criteria for Gender Identity Disorder in Adolescents and Adults". Archives of Sexual Behavior. 39 (2): 499–513. doi:10.1007/s10508-009-9562-y. hdl:1871/34512. ISSN 0004-0002. PMID 19838784. S2CID 16336939.
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  9. ^ Castro-Peraza, Maria Elisa; García-Acosta, Jesús Manuel; Delgado, Naira; Perdomo-Hernández, Ana María; Sosa-Alvarez, Maria Inmaculada; Llabrés-Solé, Rosa; Lorenzo-Rocha, Nieves Doria (2019-03-18). "Gender Identity: The Human Right of Depathologization". International Journal of Environmental Research and Public Health. 16 (6): 978. doi:10.3390/ijerph16060978. ISSN 1660-4601. PMC 6466167. PMID 30889934.
  10. ^ Latham, J.R. (2017). "Making and Treating Trans Problems The Ontological Politics of Clinical Practices". Studies in Gender and Sexuality. 18 (1): 40–61. doi:10.1080/15240657.2016.1238682. S2CID 152123850.
  11. ^ Vargas-Huicochea, Ingrid; Robles, Rebeca; Real, Tania; Fresán, Ana; Cruz-Islas, Jeremy; Vega-Ramírez, Hamid; Medina-Mora, María Elena (November 2018). "A Qualitative Study of the Acceptability of the Proposed ICD-11 Gender Incongruence of Childhood Diagnosis Among Transgender Adults Who Were Labeled Due to Their Gender Identity Since Childhood". Archives of Sexual Behavior. 47 (8): 2363–2374. doi:10.1007/s10508-018-1241-4. ISSN 0004-0002. PMID 29971651. S2CID 49681691.
  12. ^ Collin, Lindsay; Reisner, Sari L.; Tangpricha, Vin; Goodman, Michael (2016). "Prevalence of Transgender Depends on the "Case" Definition: A Systematic Review". The Journal of Sexual Medicine. 13 (4): 613–626. doi:10.1016/j.jsxm.2016.02.001. PMC 4823815. PMID 27045261.
  13. ^ Gorton N, Grubb HM (2014). General, Sexual, and Reproductive health. In L. Erickson-Schroth. Trans Bodies, Trans Selves: A Resource for the transgender community (pp. 215-240). New York: Oxford University Press.
  14. ^ a b c d e Coleman, E.; Bockting, W.; Botzer, M.; Cohen-Kettenis, P.; DeCuypere, G.; Feldman, J.; Fraser, L.; Green, J.; Knudson, G. (2012-08-01). "Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7". International Journal of Transgenderism. 13 (4): 165–232. doi:10.1080/15532739.2011.700873. ISSN 1553-2739. S2CID 39664779.
  15. ^ F64.0"Excerpt from ICD 10".
  16. ^ "DSM-5". www.psychiatry.org.
  17. ^ a b c d "Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7" (PDF). Archived from the original (PDF) on 2016-01-06.
  18. ^ Ashley, Florence (2019-07-01). "Gatekeeping hormone replacement therapy for transgender patients is dehumanising". Journal of Medical Ethics. 45 (7): 480–482. doi:10.1136/medethics-2018-105293. ISSN 0306-6800. PMID 30988174.
  19. ^ Lambert, Cei; Hopwood, Ruben; Cavanaugh, Timothy (2016-11-01). "Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients". AMA Journal of Ethics. 18 (11): 1147–1155. doi:10.1001/journalofethics.2016.18.11.sect1-1611. ISSN 2376-6980. PMID 27883307.
  20. ^ a b c Unger, Cécile A. (December 2016). "Hormone therapy for transgender patients". Translational Andrology and Urology. 5 (6): 877–884. doi:10.21037/tau.2016.09.04. PMC 5182227. PMID 28078219.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  21. ^ Moore, Eva; Wisniewski, Amy; Dobs, Adrian (2003-08-01). "Endocrine Treatment of Transsexual People: A Review of Treatment Regimens, Outcomes, and Adverse Effects". The Journal of Clinical Endocrinology & Metabolism. 88 (8): 3467–3473. doi:10.1210/jc.2002-021967. ISSN 0021-972X. PMID 12915619.
  22. ^ Newfield, Emily; Hart, Stacey; Dibble, Suzanne; Kohler, Lori (2006-06-07). "Female-to-male transgender quality of life". Quality of Life Research. 15 (9): 1447–1457. CiteSeerX 10.1.1.468.9106. doi:10.1007/s11136-006-0002-3. ISSN 0962-9343. PMID 16758113. S2CID 12727036.
  23. ^ Israel, Gianna (2001). Transgender Care: Recommended Guidelines, Practical Information, and Personal Accounts. Temple University Press. ISBN 978-1-56639-852-7.
  24. ^ Weinand, Jamie D.; Safer, Joshua D. (Feb 2015). "Hormone therapy in transgender adults is safe with provider supervision; A review of hormone therapy sequelae for transgender individuals". Journal of Clinical & Translational Endocrinology. 2 (2): 55–60. doi:10.1016/j.jcte.2015.02.003. PMC 5226129. PMID 28090436.
  25. ^ "A guide to hormone therapy for trans people" (PDF). August 2014. p. 10. Retrieved March 2, 2021.
  26. ^ Moravek, Molly B. (2019-06). "Fertility preservation options for transgender and gender-nonconforming individuals". Current Opinion in Obstetrics & Gynecology. 31 (3): 170–176. doi:10.1097/GCO.0000000000000537. ISSN 1473-656X. PMID 30870185. {{cite journal}}: Check date values in: |date= (help)
  27. ^ Light, Alexis; Wang, Lin-Fan; Zeymo, Alexander; Gomez-Lobo, Veronica (2018-10-01). "Family planning and contraception use in transgender men". Contraception. 98 (4): 266–269. doi:10.1016/j.contraception.2018.06.006. ISSN 0010-7824.
  28. ^ Marsh, Courtney; McCracken, Megan; Gray, Meredith; Nangia, Ajay; Gay, Judy; Roby, Katherine F. (2019-08-01). "Low total motile sperm in transgender women seeking hormone therapy". Journal of Assisted Reproduction and Genetics. 36 (8): 1639–1648. doi:10.1007/s10815-019-01504-y. ISSN 1573-7330. PMC 6708020. PMID 31250175.{{cite journal}}: CS1 maint: PMC format (link)
  29. ^ Barnard, Emily P.; Dhar, Cherie Priya; Rothenberg, Stephanie S.; Menke, Marie N.; Witchel, Selma F.; Montano, Gerald T.; Orwig, Kyle E.; Valli-Pulaski, Hanna (2019-09). "Fertility Preservation Outcomes in Adolescent and Young Adult Feminizing Transgender Patients". Pediatrics. 144 (3): e20183943. doi:10.1542/peds.2018-3943. ISSN 1098-4275. PMID 31383814. {{cite journal}}: Check date values in: |date= (help)
  30. ^ Nahata, Leena; Tishelman, Amy C.; Caltabellotta, Nicole M.; Quinn, Gwendolyn P. (2017-07). "Low Fertility Preservation Utilization Among Transgender Youth". The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine. 61 (1): 40–44. doi:10.1016/j.jadohealth.2016.12.012. ISSN 1879-1972. PMID 28161526. {{cite journal}}: Check date values in: |date= (help)
  31. ^ Choices, NHS. "Gender dysphoria – NHS Choices". www.nhs.uk. Retrieved 9 December 2016.
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