Treating transgenderism ..............

I would have preferred a different title from the Observer but for what it is worth

Dr Derrick Aarons

WITH increased evidence over the past 20 years pointing to the biological underpinnings of gender identity, a paradigm shift is occurring in the health care offered to transgender individuals in some countries.

In some settings, transgender medicine is a fully fledged subspecialty, and treats transgenderism as a medical and biological issue, rather than as a psychological matter.

At a recent Endocrine Society Hormones & Health: Science Writers Conference at the Boston University School of Medicine in Massachusetts, USA, the director of endocrinology education reported that gender identity is a durable biological phenomenon that, even from birth, we cannot change. In that setting, the best treatment option involved treating transgenderism medically, and this was reportedly very successful.

BIOLOGICAL EVIDENCE FOR GENDER IDENTITY

In the past, numerous attempts were made by the medical community to manipulate gender identity to align with the sex organs that were perceived at birth. For example, a research study conducted at Johns Hopkins University in the USA and published in the

New England Journal of Medicine, examined 16 children born with ‘XY’ chromosomes but with ambiguous genitalia (uncertainty in appearance, whether male or female) who underwent surgery to create female genitalia. They were all subsequently raised as girls, with the exception of two individuals whose parents raised them as boys.

When these children reached the age of puberty (around age 10-11 years), eight of them felt like boys despite being raised as girls, and the two that were raised as boys identified with being male, despite them all having female genitalia.

Other biological evidence comes from research studies dating back to the 1990s in which researchers attempted to locate brain structures that correlate with gender identity. In one classic study, published in the journal

Nature, an area of the brain (the bed nucleus of stria terminalis) was thought to correspond to gender identity, and to be involved in homosexuality. At autopsy, however, slices of this area of the brain were stained to match gender identity, and revealed instead that the area was actually smaller in women and in male-to-female transgender women, compared to that in heterosexual men.

Further, in contrast to those so reared during early childhood, a Dutch study published in the journal

Archives of Sexual Behaviour revealed that of 1,285 individuals who voluntarily changed their genders hormonally and/or surgically to match their own perceived gender identity, 99 per cent of them were satisfied with their decision.

GUIDELINES FOR CARE

Consequently, in 2009, the US Endocrine Society recognised the issue and published formal guidelines on the medical care of transgender patients. The specific treatment follows three basic steps. First, the onset of puberty is postponed by using a gonadotropin-releasing hormone analogue (a chemical which acts like the hormone), the effects of which are reversible. These analogues delay the development of the permanent, secondary sexual characteristics until a child is secure in his or her gender identity and is ready to start hormone therapy.

This approach is necessary as hormonal therapy can cause potentially irreversible changes. Patients transitioning from female to male will receive testosterone, while male-to-female individuals will receive androgen (male hormone) blockers and be given oestrogen hormone.

The specialists recognise that some young children who present as transgender may not be so as adults, and as a consequence, these professionals would not want to effect permanent changes at that first stage of puberty.

The final step may include surgery, if so desired. For female-to-male individuals, mastectomy (surgical removal of the breasts) is done to create a ‘male’ chest. In male-to-female transitions, surgery includes removal of the testicles, breast augmentation if desired, and feminisation of the face. The creation of a penis (phalloplasty) or removal of the penis and the creation of a vagina (vaginoplasty) will occur last.

LIFELONG CARE

After surgery, patients will require lifelong hormonal therapy for the health of their bones, as the latter is normally dependent on the sex steroids. Transgender women will continue to need oestrogen, and transgender men will need natural levels of testosterone.

However, we know that long-term use of steroids may carry risks, which could include blood clot (thrombosis) with the use of oestrogen, and a possible slightly increased risk for cardiovascular disease with the use of testosterone. Testosterone may also have unknown effects on tumour formation.

An example of this research was reported in the Medscape Medical News, where 3,240 women were examined over a course of 13 years, with the finding that women with high levels of testosterone at midlife were 1.33 times more likely to develop uterine fibroids, compared with women with low levels of testosterone. However, despite such occurrences, when all considerations are made, hormone therapy in humans is considered relatively safe even with the concern regarding the risk of clotting with oestrogen use. The occurrence of the latter is very uncommon.

The way forward

Evidence-based research has been greatly beneficial, but in some societies access to transgender treatment still hinges on legal and social issues, and around moral issues and religious beliefs. All these issues notwithstanding, this matter should go deeper to that of our common humanity and one’s basic right to self-expression, self-actualisation and self-fulfilment.

Derrick Aarons MD, PhD is a consultant bioethicist/family physician, a specialist in ethical issues in medicine, the life sciences and research, and is the ethicist at the Caribbean Public Health Agency – CARPHA. (The views expressed here are not written on behalf of CARPHA)