T R A N S GENDER HEALTH P O S ITIO N S TATE M E N T

INTRODUCTION levels of androgens in utero relative to those without such

Over the last few decades, there has been a rapid exposure, and male (XY)-chromosome individuals with
expansion in the understanding of gender identity along complete androgen insensitivity syndrome typically have
with the implications for the care of transgender and gender female gender identity4; and 4) there are associations of
diverse individuals. In parallel with the greater societal certain brain scan or staining patterns with gender identity
awareness of transgender individuals, evidence-based rather than external genitalia or chromosomes.1,2
practices in caring for pediatric and adult transgender
patients have been developed in response to scientific CONSIDERATIONS
research. While there continue to be gaps in knowledge Transgender individuals are often denied insurance coverage
about the optimal care for transgender individuals, the for appropriate medical and psychological treatment. Those
framework for providing care is increasingly well-established gender diverse youth who have barriers to accessing
as is the recognition of needed policy changes. adequate healthcare have poorer overall physical and
mental health compared to their cisgender peers.5 Over
BACKGROUND the last decade, there has been considerable research on
The medical consensus in the late 20th century was and development of evidence-based standards of care
that transgender and gender incongruent individuals that have proven to be both safe and efficacious for the
suffered a mental health disorder termed “gender identity treatment of gender dysphoria/gender incongruence in youth
disorder.” Gender identity was considered malleable and adults. There is also a growing understanding of the
and subject to external influences. Today, however, this positive impact that increased access to such treatments
attitude is no longer considered valid. Considerable can have on the mental health of these individuals.
scientific evidence has emerged demonstrating a
durable biological element underlying gender identity.1,2 The Endocrine Society’s Clinical Practice Guideline on gender
Individuals may make choices due to other factors in their dysphoria/gender incongruence6 provides the standard of
lives, but there do not seem to be external forces that care for supporting transgender individuals. The guideline
genuinely cause individuals to change gender identity. establishes a methodical, conservative framework for gender-
affirming care, including pubertal suppression, hormones
Although the specific mechanisms guiding the biological and surgery and standardizes terminology to be used by
underpinnings of gender identity are not entirely understood, healthcare professionals. These recommendations include
there is evolving consensus that being transgender is not a evidence that treatment of gender dysphoria/incongruence
mental health disorder. Such evidence stems from scientific is medically necessary and should be covered by insurance.
studies suggesting that: 1) attempts to change gender
identity in intersex patients to match external genitalia or Despite increased awareness, many barriers to improving
chromosomes are typically unsuccessful1,2; 2) identical the health and well-being of transgender youth and adults
twins (who share the exact same genetic background) remain. Oftentimes, medical treatment for gender dysphoria/
are more likely to both experience transgender identity gender incongruence is considered elective by insurance
as compared to fraternal (non-identical) twins3; 3) among companies, which fail to provide coverage for physician-
individuals with female chromosomes (XX), rates of male prescribed treatment. Access to appropriately trained
gender identity are higher for those exposed to higher healthcare professionals can also be challenging as there

1
Saraswat A, Weinand JD, Safer JD. Evidence supporting the biologic nature of gender 4
Dessens AB, Slijper FM, Drop SL. Gender dysphoria and gender change in
identity. Endocr Pract. Feb 2015;21(2):199-204. doi:10.4158/ep14351.ra chromosomal females with congenital adrenal hyperplasia. Arch Sex Behav.
2
Rosenthal SM. Approach to the patient: transgender youth: endocrine considerations. J Aug 2005;34(4):389-97. doi:10.1007/s10508-005-4338-5
Clin Endocrinol Metab. Dec 2014;99(12):4379-89. doi:10.1210/jc.2014-1919 5
Rider GN, McMorris BJ, Gower AL, Coleman E, Eisenberg ME. Health and Care
3
Heylens G, De Cuypere G, Zucker KJ, et al. Gender identity disorder in twins: a review of the case Utilization of Transgender and Gender Nonconforming Youth: A Population-Based
report literature. J Sex Med. Mar 2012;9(3):751-7. doi:10.1111/j.1743-6109.2011.02567.x Study. Pediatrics. 2018;141(3):e20171683. doi:10.1542/peds.2017-1683
6
Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/
Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin
Endocrinol Metab. Nov 1 2017;102(11):3869-3903. doi:10.1210/jc.2017-01658
is a lack of formal education on gender dysphoria/gender in hormone regimens is needed to determine: the best
incongruence among clinicians trained in the United States. endocrine and surgical protocols13, as it is not yet known if
A 2016 survey of endocrinologists, the physicians most certain regimens are safer or more effective than others; the
likely to care for these patients, found that over 80% have degree of improvement as a result of the intervention (e.g.
never received training on care of transgender patients.7 decrease in mental health diagnoses); the need for training
of health care providers and the most effective training
This can have an adverse impact on patient outcomes, methods; and to build the body of evidence pertaining to
particularly in rural and underserved areas. In fact, studies cardiovascular, malignancy, or other long-term risks from
have indicated that 70% of transgender individuals have hormone interventions, particularly as the transgender
experienced maltreatment by medical providers, including individual ages. Additional studies are needed to elucidate the
harassment and violence.7 Many transgender individuals biological processes underlying gender identity; such studies
have been subjected to conversion therapy, or efforts may lead to destigmatization and may also decrease health
to change a transgender person’s gender identity using disparities for gender minorities. In addition, further studies
psychological interventions; this is known to be associated are needed to determine strategies for fertility preservation
with adverse mental health outcomes, including suicidality, and to investigate long-term outcomes of early medical
and is banned in 20 states and the District of Columbia.8 intervention, including pubertal suppression, gender-affirming
hormones and gender-affirming surgeries for transgender/
Transgender individuals who have been denied care show gender incongruent youth. To successfully establish and
an increased likelihood of dying by suicide and engaging enact these protocols requires long-term, large-scale studies
in self-harm.7 Transgender/gender incongruent youth who across countries that employ similar care protocols.
had access to pubertal suppression, a treatment which is
fully reversible and prevents development of secondary sex POSITIONS
characteristics not in alignment with their gender identity, • There is a durable biological underpinning
have lower lifetime odds of suicidal ideation compared to gender identity that should be
to those youth who desired pubertal suppression but considered in policy determinations.
did not have access to such treatment.9 Youth who are
able to access gender-affirming care, including pubertal • Medical intervention for transgender youth and adults
suppression, hormones and surgery based on conservative (including puberty suppression, hormone therapy
medical guidelines and consultation from medical and and medically indicated surgery) is effective, relatively
mental health experts, experience significantly improved safe (when appropriately monitored), and has been
mental health outcomes over time, similar to their cis- established as the standard of care.6 Federal and
gender peers.10-12 Pre-pubertal youth who are supported private insurers should cover such interventions as
and affirmed in their social transitions long before medical prescribed by a physician as well as the appropriate
interventions are indicated, experience no elevation in medical screenings that are recommended for
depression compared to their cis-gender peers.12 It is critical all body tissues that a person may have.
that transgender individuals have access to the appropriate
treatment and care to ensure their health and well-being. • Increased funding for national pediatric and adult
transgender health research programs is needed to
FUTURE CONSIDERATIONS close the gaps in knowledge regarding transgender
While the data are strong for both a biological underpinning medical care and should be made a priority.
to gender identity and the relative safety of hormone
treatment (when appropriately monitored medically), there
are gaps in knowledge that are necessary to address in
order to optimize care. Comparative effectiveness research

7
Davidge-Pitts C, Nippoldt TB, Danoff A, Radziejewski L, Natt N. Transgender Health in 11
Kuper LE, Stewart S, Preston S, Lau M, Lopez X. Body Dissatisfaction and Mental Health Outcomes of
Endocrinology: Current Status of Endocrinology Fellowship Programs and Practicing Clinicians. Youth on Gender-Affirming Hormone Therapy. Pediatrics. Apr 2020;145(4)doi:10.1542/peds.2019-3006
J Clin Endocrinol Metab. Apr 1 2017;102(4):1286-1290. doi:10.1210/jc.2016-3007 12
Achille C, Taggart T, Eaton NR, et al. Longitudinal impact of gender-affirming endocrine
8
Turban JL, Beckwith N, Reisner SL, Keuroghlian AS. Association Between Recalled Exposure to Gender intervention on the mental health and well-being of transgender youths: preliminary
Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender results. Int J Pediatr Endocrinol. 2020;2020:8. doi:10.1186/s13633-020-00078-2
Adults. JAMA Psychiatry. Sep 11 2019;77(1):1-9. doi:10.1001/jamapsychiatry.2019.2285 13
Safer JD, Tangpricha V. Care of the Transgender Patient. Ann Intern Med.
9
Turban JL, King D, Carswell JM, Keuroghlian AS. Pubertal Suppression for Transgender Youth Jul 2 2019;171(1):Itc1-itc16. doi:10.7326/aitc201907020
and Risk of Suicidal Ideation. Pediatrics. Feb 2020;145(2)doi:10.1542/peds.2019-1725
10
de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT.
Young adult psychological outcome after puberty suppression and gender reassignment.
Pediatrics. Oct 2014;134(4):696-704. doi:10.1542/peds.2013-2958

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