What’s New in Transgender Medicine?

By Connell Knight, MD and Vin Tangpricha, MD, PhD
transgender imagery

Like all areas within the expansive realm of medical care, the field of transgender medicine is one that is continually evolving.

Transgender medicine refers to medical care for transgender individuals, those whose gender identity differs from the gender that was assigned to them at birth. Gender identity is a deeply held sense of one’s gender, and as the term suggests, it is integral to a person’s sense of self. Every human has a gender identity. Some transgender individuals don’t identify neither as male or female since their gender identity is not strictly male or female. These individuals are sometimes called “non-binary”. It is estimated that somewhere between one and two million people in the United States identify as transgender.

"Gender identity is a deeply held sense of one’s gender, and as the term suggests, it is integral to a person’s sense of self. Every human has a gender identity."

A significant part of transgender medicine focuses on a patient’s transition, which usually involves the use of medical and surgical therapies to allow an individual’s outward appearance and physiology to better match their gender identity. Such therapies are gender-affirming therapies, and they involve the use of hormones, hormone blockers, and surgical techniques. Transgender medicine, however, is not limited to the transition itself – like all people, transgender individuals can benefit from regular screening and health maintenance visits, mental health care, and appropriate specialty care.

Gender-affirming hormone therapy (GAHT) is usually the first step in a person’s medical transition. Transgender women, assigned male gender at birth, undergo GAHT to induce feminizing physical features and physiology. GAHT for transgender females usually consists of an anti-androgen, which decreases testosterone or blocks its masculinizing effects, and an estrogen, which induces feminization. For transgender men, assigned female at birth, GAHT is employed to induce masculinizing features. GAHT for transgender men consists of testosterone therapy alone.

Medical and surgical therapies for a transitioning patient are evolving continuously, with new interventions being utilized and studied. Current research in GAHT is focused on determining which formulations of hormonal and/or anti-androgen therapy offer patients stable, consistent, and effective feminization or masculinization, while minimizing adverse effects and remaining cost-effective.

In the past, transgender patients required evaluation by mental health professionals prior to initiating medical and hormonal GAHT. This practice is becoming less common since being transgender is not a mental health issue. More physicians are becoming proficient at identifying transgender individuals who would benefit from GAHT, and current standards of care are evolving to suggest that mental health evaluation may not be necessary in all cases.

Providers competent in GAHT are scarce, and those who provide surgical therapies are even fewer, which causes significant barriers to appropriate transgender care, often to the detriment of patients’ health. Fortunately, however, a number of professional medical societies are advocating for incorporating education on transgender medicine into medical training, and more and more primary care physicians, nurse practitioners, physicians’ assistants, and specialists outside of endocrinology are becoming proficient in gender-affirming care.

As with any emerging field in medicine, research in transgender medicine is limited. Much of the scientific literature used in developing best practice is either of low quality or extrapolated from research in cisgender patients (persons who identify with the gender assigned to them at birth) . The few high-quality studies usually have very few older patients, and more research is needed to address how to adjust practice for elderly transgender patients. A similar need exists for transgender children and adolescents in the process of forming their gender identity, and for whom emerging evidence suggests that early GAHT can be beneficial. Uncertainties exist in how to best conduct cancer screening for transgender patients, particularly in organ systems affected by GAHT. Further research in GAHT’s effects on fertility and strategies for preserving fertility is in critical need as well, particularly in young transgender populations.