May 18, 2022
4 min read
May 18, 2022
4 min read
For its 20th year in print, Endocrine Today is taking a look back at changes in endocrine gender care.
Reporting on the topic in Endocrine Today was sparse until 2009, when the Endocrine Society released the first consensus guidelines for treatment of “transsexuals.” Those practice recommendations focused on transgender as a mental health condition.
“The endocrinologist’s role is to confirm the diagnostic criteria that the mental health professional used to make the recommendation of sex reassignment and then collaborate with making the recommendation for surgical sex reassignment,” according to the reporter for Endocrine Today in July of that year.
In 2017, the Endocrine Society, together with the American Association of Clinical Endocrinology, revised the guidelines to focus less on mental health in cases of “gender incongruence” and advised that mental health screening was preferred, but not required, before prescribing hormone therapy.
Reporting in Endocrine Today expanded to cover studies about effects of gender-affirming HT, issues surrounding fertility preservation, insurance coverage and, more recently, political threats to gender care.
Healio | Endocrine Today spoke with two experts involved in shifting the understanding of gender over the past 2 decades.
Joshua D. Safer, MD, FACP, FACE, is an Endocrine Today Editorial Board Member, who is executive director of the Center for Transgender Medicine and Surgery at Mount Sinai Health System and professor of medicine at the Icahn School of Medicine at Mount Sinai.
Vin Tangpricha, MD, PhD, is professor of medicine in the division of endocrinology, metabolism and lipids at Emory University School of Medicine.
Endocrine Today: How has our conception of gender changed over the past 2 decades or so?
Tangpricha: Over the past 20 years, we have a better understanding that everyone has a gender identity and that some people have a gender identity that is not binary, that is not male or female. Furthermore, having a transgender or gender nonbinary identity is part of the normal spectrum of human gender identities.
Joshua D. Safer
Safer: A major change relating to our care for transgender and gender diverse people is our growing recognition that there must be a biological component underlying gender identity. Thus, there are people for whom gender identity may be coded differently than other elements of their biology. Further, there is greater recognition of how personal decisions are regarding what to do about being transgender. Gender-affirming treatment that might have been more protocol driven in the past, is now more customized — allowing for essentially the entire range of hormone profiles that would otherwise be considered healthy and for multiple choices regarding gender-affirming surgical options.
Endocrine Today: Has our language around gender changed to keep up with our changing conception?
Tangpricha: The language has been more inclusive of different gender identities. In the past, “transsexual” was a term used to describe people who had the gender identity that was the binary opposite of their sex assigned at birth, and that term had a negative connotation. Terms like “transgender” or “gender diverse” are more inclusive terms for people who don’t have a gender identity that is binary. Also, words like “gender affirming” to describe medical treatments indicate that we are not changing someone’s internal identity, but rather affirming their internal gender identity.
Safer: Our language has shifted to be more respectful of transgender people as simply being transgender. We use words like “transgender” as adjectives. We recognize that people have had their gender identity all along with the only change being their awareness and their choices for interventions. And we have stopped using terms like “gender nonconforming,” which suggest that someone ought to conform.
While it seemed that language was changing quickly, our framing has begun to plateau. For example, there may be many pronouns theoretically possible, but most people have settled into using he, she or they. The adjectives to describe people with gender identity not aligned with the rest of their biology seem to be stabilizing as well. The overwhelming majority of patients use one or more of the following five adjectives: trans, transgender, transsexual, gender nonbinary and genderqueer, with the latter two emphasizing someone who feels more on the gender identity spectrum rather than at a more masculine or more feminine pole. What once seemed like it might become quite complex, has become relatively straightforward.
Endocrine Today: How have guidelines to gender care changed over the past 20 years?
Safer: If being transgender is simply a biological phenomenon and most people can articulate gender identity at least as adults, then mental health providers can shift to helping people with the stresses involved in the situation rather than in screening people to confirm gender identity.
Tangpricha: We are seeing that gender-affirming hormone therapy is safer than previously thought. Thus, more recent guidelines are removing some of the requirements for testing; for example, liver function testing and prolactin levels. More studies are coming out regarding the need to follow electrolytes, such as potassium.
Endocrine Today: Are physicians better educated around gender today?
Tangpricha: Training programs are now including transgender medicine as part of their curriculum, and there is increased demand for education on how to provide care for transgender and gender diverse patients.
Safer: Only 2 decades ago there was no physician education regarding being transgender. Now, it is standard to be taught cultural sensitivity. Also, there is a growing capacity to teach gender-affirming medical and surgical interventions at the logical points in medical training.
Endocrine Today: What other important changes have there been in gender care in the past 20 years?
Tangpricha: There has been recognition by many professional societies that transgender people have important health care needs that are different from other underserved communities. This has resulted in increased educational programming, medical resources and advocacy for this vulnerable population. There are more research studies published today compared to over 20 years ago. However, more research funding is sorely needed to determine optimal medical and surgical therapies in this population.
Joshua D. Safer, MD, FACP, FACE, can be reached at [email protected]; Twitter: @JoshuaSafer.
Vin Tangpricha, MD, PhD, can be reached at [email protected]; Twitter: @vtangpricha.