Transgender - Medical
Transgender is an umbrella term used to describe individuals whose gender identity differs from the sex assigned to them at birth. Gender identity refers to a person's deeply held sense of their own gender, whether it aligns with the sex assigned to them at birth (cisgender) or not (transgender). Transgender people may identify as male, female, non-binary (not exclusively male or female) gender non-conforming, or another gender identity that is not binary. transgender and/or gender expansive (TGE) is an umbrella term encompassing individuals and gender identities that may exist beyond the binary framework [eg, may include nonbinary, genderqueer, and agender individuals]).
Some individuals may pursue medical interventions, such as hormone therapy or gender-affirming surgeries, to align their physical appearance with their gender identity. However, it's important to note that not all transgender individuals undergo these procedures, as gender identity is a deeply personal and individual experience. Transgender individuals may insist on the use of their preferred name and pronouns to avoid misgendering.
Gender dysphoria (previously gender identity disorder), according to Diagnostic and Statistical Manual of Mental (DSM 5), are disorders defined as a "marked incongruence between their experienced or expressed gender and the one they were assigned at birth." According to a sexual health study published in 2017, there is a markedly high prevalence ranging from 0.5% to 1.3% for self-reported transgender identity in children, adolescents, and adults. It was traditionally a rare or uncommon diagnosis; however, the numbers have increased in the past few decades.
According to one national survey, 1.4 million individuals (0.6%) in the United States identified as transgender. It is also believed that these numbers are underrepresented due to social stigma. Also, a part of this population might not want to engage in studies; hence, the true prevalence remains higher than what is reported. Nevertheless, an increasing shift has been observed in this population seeking health care over the last decade.
A 2022 Pew Research Center survey found that 1.6% of US adults are transgender or nonbinary – that is, their gender differs from the sex they were assigned at birth. Adults under 30 are more likely than older adults to be trans or nonbinary. Some 5.1% of adults younger than 30 are trans or nonbinary, including 2.0% who are a trans man or trans woman and 3.0% who are nonbinary – that is, they are neither a man nor a woman or aren’t strictly one or the other. (Due to rounding, subtotals may not add up to the total.) This compares with 1.6% of 30- to 49-year-olds and 0.3% of those 50 and older who are trans or nonbinary.
According to a study conducted by Cedars Sinai in June 2020, approximately 78% of transgender males experienced gender dysphoria by the age of 7. The mean age to experience gender dysphoria was less in transgender males, which is about 6.2 years.
As recently as June 2021, 48% of Democrats said they knew a trans person, compared with 35% of Republicans – a gap of 13 percentage points. Today, 48% of Democrats and 42% of Republicans say this – a gap of just 6 points.
A survey of American Council of Academic Plastic Surgeons (ACAPS) members conducted for a Plastic and Reconstructive Surgery publication in August 2020 revealed that 32% of the transgender population underwent gender affirmation surgery (GAS). The US gender-affirming surgery market size was valued at USD 1.9 billion in 2021 and is expected to expand at a compound annual growth rate (CAGR) of 11.23% from 2022 to 2030. Gender-affirming surgery has become increasingly performed for this growing patient population. GAS has been shown to improve quality of life among TGNB patients experiencing gender dysphoria. Terminology such as “gender confirmation surgery” may be considered outdated and/or stigmatizing to some. As of 2022 at least 22 states and Washington DC had Medicaid programs coverage of gender affirming care, whilel 10 states explicitly denied such coverage,
Insurance providers such as Aetna and Unicare provide insurance for necessary surgical procedures, such as salpingo-oophorectomy, hysterectomy, orchiectomy, or ovariectomy. In the U.S., around 152,000 transgender individuals are enrolled in Medicaid and only 69,000 among them have access to gender-affirming care coverage under state law.
The widespread working assumption is that early treatment of kids with gender dysphoria can prevent more anguish later on. Treatment typically begins with puberty-blocking medication to temporarily pause sexual development. The idea is to give youngsters time to mature enough mentally and emotionally to make informed decisions about whether to pursue permanent treatment. Sex hormones — estrogen or testosterone — can produce permanent physical changes. So does transgender surgery, including breast removal or augmentation, which sometimes is offered during the mid-teen years but more typically not until age 18 or later. .
But some experts say children with the disorder often grow out of their gender-related anxiety. Some may be victims of confusion borne out of other reasons like depression and self-esteem issues. The patients are too young to entirely foresee the consequences of their decision, and doctors may not always provide sufficient warnings before the treatments start. .
When a female takes testosterone, the effects can be seen in a matter of months. Voices drop, beards sprout, body fat is redistributed. Sexual interest explodes, aggression increases, and mood can be unpredictable. Bicalutamide is a cancer drug used as as a puberty blocker and feminizing agent for boys. It is a medication used to treat metastatic prostate cancer, and one of its side effects is that it feminizes the bodies of males who take it, including the appearance of breasts. .
In a review of 27 studies involving almost 8,000 teens and adults who had transgender surgeries, mostly in Europe, the U.S and Canada, 1% on average expressed regret. For some, regret was temporary, but a small number went on to have detransitioning or reversal surgeries, the 2021 review said. .
The origin of the word gender came from the Old French "gendre" (now termed "genre"), which meant "kind, sort, genus." Generally, children are assigned to their gender at birth based on their anatomy and chromosomes. For most children, this gender assignment corresponds to their gender identity, an innate sense of identifying oneself as male or female.
Some children might experience incongruity and grow into transgender adults. People who experience this turmoil cannot correlate to their gender expression when identifying themselves within the traditional, rigid societal binary male or female roles, which may cause cultural stigmatization. This can further result in relationship difficulties with family, peers, friends and lead to interpersonal conflicts, rejection from society, symptoms of depression and anxiety, substance use disorders, a negative sense of well-being and poor self-esteem, and an increased risk of self-harm and suicidality.
Children born with congenital adrenal hyperplasia or androgen insensitivity syndrome can present with ambiguous genitalia. Individuals born with congenital adrenal hyperplasia or androgen insensitivity syndrome are usually brought up and socialized as girls, even though they often cross-dress and have an innate sense of belonging to the opposite sex. These changes are more evident around and during puberty. This is one of the well-established biological links.
Associations have also been found with in-utero exposure to phthalates in plastics and polychlorinated biphenyls. They are known to disrupt the regular endocrinology of sex determination before birth. Phthalates can lead to an increase in total fetal testosterone levels, which in turn increases the risk of autism spectrum disorder as well as GD.
GD has been found to have a higher prevalence in people with psychiatric illnesses such as schizophrenia and autism spectrum disorder. The link seems to be neuroanatomical and needs more research. There was growing evidence that the autistic population has a higher risk of GD. However, certain studies seek to disprove this hypothesis.
There is also growing evidence that childhood abuse, neglect, maltreatment, and physical or sexual abuse may be associated with GD. Individuals reporting higher body dissatisfaction and GD have a worse prognosis in terms of mental health.
In the 1970s, it was postulated that the development of GD is entirely a learned environmental pathology, and the approach was aimed at adopting conversion and aversion behavior techniques to criticize feminine characteristics in young boys. It is now believed that gender is not dichotomously branched and is actually a spectrum of the “cis-gender” and “transgender” umbrella. Renowned psychoanalyst Sigmund Freud emphasized that gender dysphoria arises in children from oedipal triangle conflicts.
Patients with this condition can be provided with psychiatric support. Hormonal therapy and surgical therapy are also available depending on the individual case and patient needs. The World Professional Association for Transgender Health (WPATH) currently publishes the Standards of Care (SOC) to provide clinical guidelines for the health care of transsexual, transgender, and gender non-conforming persons in order to maximize the health and well-being of patients with gender dysphoria.
The surgeries are often referred to as "top surgery" and "bottom surgery." For MTF: breast augmentation is a common top surgery that trans-women desire. Also, gonadectomy, including penectomy and vaginoplasty, is desired to remove the primary source of testosterone from the body. Vaginal dilators are also routinely used to maintain anatomy if sexual intercourse is a goal. For FTM: Metoidioplasty, where the clitoris is released from the ligament it is attached to, and tissue is added to increase the length and the girth. Scrotoplasty (testicular implants) and phalloplasty (penile implant) are also methods; however, the expense involved is significant, and the expertise required for these surgeries is not very common.
Uterus transplantation provides a promising potential treatment for women with Uterine Factor Infertility (UFI) a previously irreversible form of female infertility that affects hundreds of thousands of reproductive-aged women in the U.S. A woman with UFI cannot carry a pregnancy. She is either born without a uterus, had her uterus removed, or has a nonfunctioning uterus. A uterus transplant has the potential to give women with UFI an opportunity to carry and deliver a child.
Many programs around the globe have focused on transplantation exclusively from living donors, and to date, there have been approximately 70 uterus transplants globally. However, Penn Medicine’s trial is one of few to explore donation from both living or deceased donors — an approach that has the potential to expand the pool of organs available for donation and allows investigators the opportunity to directly compare outcomes from the different types of donors.
Following the establishment of the International Society of Uterine Transplantation (ISUTx), and the formation of research teams globally, it is anticipated that UTx will make the transition from research to clinical care in the future. Following these developments, speculation has escalated regarding the possibility of performing UTx in male to female (M2F) transgender women, which would enable them to gestate and give birth to their own children. UK and EU legislation would make it legally impermissible to refuse to perform UTx in transgender women solely because of their gender identity.
Performing UTx in this population, however, raises a number of anatomical, physiological, fertility, and obstetric considerations. Following M2F transgender UTx, the presence of a skin or intestinal neovagina, in the context of immunosuppression, may increase susceptibility to recurrent neovaginal infections and create a hostile environment that may be incapable of sustaining pregnancy. As the requisite mode of delivery in women following UTx is caesarean section, owing to concerns regarding the mechanical strain of labour, this should also be the case in M2F transgender women.
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