Transgender Health

Syphilis. It is often called the “great imitator.” It is speculated that this infection led to King George III of England going mad and likely contributing to his death. In the modern era, the discovery of penicillin in 1928 was instrumental in treating this once-deadly infection. Over the ensuing decades, rates of syphilis continued to decline. However, according to the Centers for Disease Control and Prevention, from 2018-2022 reported cases of syphilis in the United States have increased by 79% and continue to increase each year. Men who have sex with men (MSM) accounted for 41.4% of infections nationwide during this time period. This extraordinary rise highlights the need for better screening in our patients.

I currently live and practice in Texas, so I will use it as a case example. In 2013, Texas reported 1,471 cases of primary or secondary syphilis. By 2022, this number had risen to 4,655, a 216% increase. CDC data shows that Texas cases among men increased from 1,917 in 2019 to 3,324 in 2022, with MSM accounting for 1,341 (40%) of those infections. Adolescents and young adults aged 15-24 accounted for the second-highest number of new infections. Interestingly, rates of syphilis in men began to rise in Texas starting in 2013, the first full year that Truvada (emtricitabine and tenofovir disoproxil fumarate) was available for HIV pre-exposure prophylaxis (PrEP). While no definitive study has proven that the availability of PrEP caused an increase in condomless sexual intercourse, the number of high school students in Texas who did not use a condom at their last intercourse increased from 47.1% in 2013 to 50% in 2021.

UT Southwestern Medical Center

The data above highlights the need to increase screening, especially in primary care and emergency room settings. According to the 2021 Youth Risk Behavior Survey, 94.8% of high school students surveyed that they were not tested for STIs in the 12 months prior to the survey. This compares with 91.4% in the 2019 survey. When STI testing is done, many adolescents often choose to forgo blood testing for HIV and syphilis and decide only to do urine NAATs testing for Neisseria gonorrhoeae and Chlamydia trachomatis. Therefore, those physicians and other healthcare providers who take care of adolescents and young adults must work to improve screening for ALL STIs. According to the American Academy of Pediatrics Bright Futures Periodicity Guidelines, pediatricians should screen for HIV in all patients at least once starting at age 15 and then thereafter based on risk assessment. Adding syphilis screening at the same time as the above HIV screening is an easy way to improve testing and treatment for this potentially deadly condition. If access to phlebotomy is not available, there are rapid HIV and syphilis tests that can be done in physicians’ offices. To perform these risk assessments, pediatricians must spend time alone with their adolescent and young patients at nearly every visit to discuss behaviors. Pediatricians should also be aware to consider syphilis on their differential for patients with unexplained rashes, sores in the mouth, or flu-like symptoms if that young person is sexually active.

Compounding the issue of increasing cases of syphilis is a national shortage of intramuscular penicillin G benzathine, the preferred treatment, which began in April 2023 only recently began to improve as of August 2024. Oral doxycycline can be used as a backup for some patients. Still, IM penicillin G is the only recommended treatment available for pregnant patients or those with advanced disease. The increasing number of cases, as well as the medication shortages, remind all of us that we must continue to aggressively screen patients for sexually transmitted infections in all patients who are at risk to get patients on treatment and reduce the risk of further transmission in the community.

Dr. M. Brett Cooper, is an assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

Syphilis. It is often called the “great imitator.” It is speculated that this infection led to King George III of England going mad and likely contributing to his death. In the modern era, the discovery of penicillin in 1928 was instrumental in treating this once-deadly infection. Over the ensuing decades, rates of syphilis continued to decline. However, according to the Centers for Disease Control and Prevention, from 2018-2022 reported cases of syphilis in the United States have increased by 79% and continue to increase each year. Men who have sex with men (MSM) accounted for 41.4% of infections nationwide during this time period. This extraordinary rise highlights the need for better screening in our patients.

I currently live and practice in Texas, so I will use it as a case example. In 2013, Texas reported 1,471 cases of primary or secondary syphilis. By 2022, this number had risen to 4,655, a 216% increase. CDC data shows that Texas cases among men increased from 1,917 in 2019 to 3,324 in 2022, with MSM accounting for 1,341 (40%) of those infections. Adolescents and young adults aged 15-24 accounted for the second-highest number of new infections. Interestingly, rates of syphilis in men began to rise in Texas starting in 2013, the first full year that Truvada (emtricitabine and tenofovir disoproxil fumarate) was available for HIV pre-exposure prophylaxis (PrEP). While no definitive study has proven that the availability of PrEP caused an increase in condomless sexual intercourse, the number of high school students in Texas who did not use a condom at their last intercourse increased from 47.1% in 2013 to 50% in 2021.

UT Southwestern Medical Center

The data above highlights the need to increase screening, especially in primary care and emergency room settings. According to the 2021 Youth Risk Behavior Survey, 94.8% of high school students surveyed that they were not tested for STIs in the 12 months prior to the survey. This compares with 91.4% in the 2019 survey. When STI testing is done, many adolescents often choose to forgo blood testing for HIV and syphilis and decide only to do urine NAATs testing for Neisseria gonorrhoeae and Chlamydia trachomatis. Therefore, those physicians and other healthcare providers who take care of adolescents and young adults must work to improve screening for ALL STIs. According to the American Academy of Pediatrics Bright Futures Periodicity Guidelines, pediatricians should screen for HIV in all patients at least once starting at age 15 and then thereafter based on risk assessment. Adding syphilis screening at the same time as the above HIV screening is an easy way to improve testing and treatment for this potentially deadly condition. If access to phlebotomy is not available, there are rapid HIV and syphilis tests that can be done in physicians’ offices. To perform these risk assessments, pediatricians must spend time alone with their adolescent and young patients at nearly every visit to discuss behaviors. Pediatricians should also be aware to consider syphilis on their differential for patients with unexplained rashes, sores in the mouth, or flu-like symptoms if that young person is sexually active.

Compounding the issue of increasing cases of syphilis is a national shortage of intramuscular penicillin G benzathine, the preferred treatment, which began in April 2023 only recently began to improve as of August 2024. Oral doxycycline can be used as a backup for some patients. Still, IM penicillin G is the only recommended treatment available for pregnant patients or those with advanced disease. The increasing number of cases, as well as the medication shortages, remind all of us that we must continue to aggressively screen patients for sexually transmitted infections in all patients who are at risk to get patients on treatment and reduce the risk of further transmission in the community.

Dr. M. Brett Cooper, is an assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

Syphilis. It is often called the “great imitator.” It is speculated that this infection led to King George III of England going mad and likely contributing to his death. In the modern era, the discovery of penicillin in 1928 was instrumental in treating this once-deadly infection. Over the ensuing decades, rates of syphilis continued to decline. However, according to the Centers for Disease Control and Prevention, from 2018-2022 reported cases of syphilis in the United States have increased by 79% and continue to increase each year. Men who have sex with men (MSM) accounted for 41.4% of infections nationwide during this time period. This extraordinary rise highlights the need for better screening in our patients.

I currently live and practice in Texas, so I will use it as a case example. In 2013, Texas reported 1,471 cases of primary or secondary syphilis. By 2022, this number had risen to 4,655, a 216% increase. CDC data shows that Texas cases among men increased from 1,917 in 2019 to 3,324 in 2022, with MSM accounting for 1,341 (40%) of those infections. Adolescents and young adults aged 15-24 accounted for the second-highest number of new infections. Interestingly, rates of syphilis in men began to rise in Texas starting in 2013, the first full year that Truvada (emtricitabine and tenofovir disoproxil fumarate) was available for HIV pre-exposure prophylaxis (PrEP). While no definitive study has proven that the availability of PrEP caused an increase in condomless sexual intercourse, the number of high school students in Texas who did not use a condom at their last intercourse increased from 47.1% in 2013 to 50% in 2021.

UT Southwestern Medical Center

The data above highlights the need to increase screening, especially in primary care and emergency room settings. According to the 2021 Youth Risk Behavior Survey, 94.8% of high school students surveyed that they were not tested for STIs in the 12 months prior to the survey. This compares with 91.4% in the 2019 survey. When STI testing is done, many adolescents often choose to forgo blood testing for HIV and syphilis and decide only to do urine NAATs testing for Neisseria gonorrhoeae and Chlamydia trachomatis. Therefore, those physicians and other healthcare providers who take care of adolescents and young adults must work to improve screening for ALL STIs. According to the American Academy of Pediatrics Bright Futures Periodicity Guidelines, pediatricians should screen for HIV in all patients at least once starting at age 15 and then thereafter based on risk assessment. Adding syphilis screening at the same time as the above HIV screening is an easy way to improve testing and treatment for this potentially deadly condition. If access to phlebotomy is not available, there are rapid HIV and syphilis tests that can be done in physicians’ offices. To perform these risk assessments, pediatricians must spend time alone with their adolescent and young patients at nearly every visit to discuss behaviors. Pediatricians should also be aware to consider syphilis on their differential for patients with unexplained rashes, sores in the mouth, or flu-like symptoms if that young person is sexually active.

Compounding the issue of increasing cases of syphilis is a national shortage of intramuscular penicillin G benzathine, the preferred treatment, which began in April 2023 only recently began to improve as of August 2024. Oral doxycycline can be used as a backup for some patients. Still, IM penicillin G is the only recommended treatment available for pregnant patients or those with advanced disease. The increasing number of cases, as well as the medication shortages, remind all of us that we must continue to aggressively screen patients for sexually transmitted infections in all patients who are at risk to get patients on treatment and reduce the risk of further transmission in the community.

Dr. M. Brett Cooper, is an assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

Primary care physicians frequently offer postexposure prophylaxis for various infections, including influenza, pertussis, tetanus, hepatitis, and Lyme disease, among others. However, the scope of postexposure prophylaxis in primary care is expanding, presenting an opportunity to further integrate it into patient care. As primary care providers, we have the unique advantage of being involved in both preventive care and immediate response, particularly in urgent care or triage scenarios. This dual role is crucial, as timely administration of postexposure prophylaxis can prevent infections from taking hold, especially following high-risk exposures.

Recently, the use of doxycycline as a form of postexposure prophylaxis for sexually transmitted infections (STIs) has gained attention. Traditionally, doxycycline has been used as preexposure or postexposure prophylaxis for conditions like malaria and Lyme disease but has not been widely employed for STI prevention until now. Doxycycline is a relatively common medication, generally safe with side effects that typically resolve upon discontinuation. Several open-label studies have shown that taking 200 mg of doxycycline within 72 hours of condomless sex significantly reduces the incidence of chlamydia, gonorrhea, and syphilis among gay, bisexual, and other men who have sex with men, as well as transgender women who have previously had a bacterial STI. However, these benefits have not been consistently observed among cisgender women and heterosexual men.

Given these findings, the Centers for Disease Control and Prevention now recommends that clinicians discuss the risks and benefits of doxycycline PEP (Doxy PEP) with gay, bisexual, and other men who have sex with men, as well as transgender women who have had a bacterial STI in the past 12 months. This discussion should be part of a shared decision-making process, advising the use of 200 mg of doxycycline within 72 hours of oral, vaginal, or anal sex, with the recommendation not to exceed 200 mg every 24 hours and to reassess the need for continued use every 3-6 months. Doxy PEP can be safely prescribed with preexposure prophylaxis for HIV (PrEP). Patients who receive PrEP may often be eligible for Doxy PEP, though the groups are not always the same.

The shared decision-making process is essential when considering Doxy PEP. While cost-effective and proven to reduce the risk of gonorrhea, chlamydia, and syphilis, its benefits vary among different populations. Moreover, some patients may experience side effects such as photosensitivity and gastrointestinal discomfort. Since the effectiveness of prophylaxis is closely tied to the timing of exposure and the patient’s current risk factors, it is important to regularly evaluate whether Doxy PEP remains beneficial. As there is not yet clear benefit to heterosexual men and cisgender women, opportunities still need to be explored for them.

Integrating Doxy PEP into a primary care practice can be done efficiently. A standing order protocol could be established for telehealth visits or nurse triage, allowing timely administration when patients report an exposure within 72 hours. It could also be incorporated into electronic medical records as part of a smart set for easy access to orders and as standard educational material in after-visit instructions. As this option is new, it is also important to discuss it with patients before they may need it so that they are aware should the need arise. While concerns about antibiotic resistance are valid, studies have not yet shown significant resistance issues related to Doxy PEP use, though ongoing monitoring is necessary.

You might wonder why primary care should prioritize this intervention. As the first point of contact, primary care providers are well-positioned to identify the need for prophylaxis, particularly since its effectiveness diminishes over time. Furthermore, the established, trusting relationships that primary care physicians often have with their patients create a nonjudgmental environment that encourages disclosure of potential exposures. This trust, combined with easier access to care, can make a significant difference in the timely provision of postexposure prophylaxis. By offering comprehensive, holistic care, including prophylaxis, primary care physicians can prevent infections and address conditions before they lead to serious complications. Therefore, family medicine physicians should consider incorporating Doxy PEP into their practices as a standard of care.
 

Dr. Wheat is vice chair of Diversity, Equity, and Inclusion, Department of Family and Community Medicine, and associate professor, Family and Community Medicine, at Northwestern University’s Feinberg School of Medicine, Chicago. She has no relevant financial disclosures.

References

Bachmann LH et al. CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024. MMWR Recomm Rep 2024;73(No. RR-2):1-8.

Traeger MW et al. Potential Impact of Doxycycline Postexposure Prophylaxis Prescribing Strategies on Incidence of Bacterial Sexually Transmitted Infections. (Clin Infect Dis. 2023 Aug 18. doi: 10.1093/cid/ciad488).

Primary care physicians frequently offer postexposure prophylaxis for various infections, including influenza, pertussis, tetanus, hepatitis, and Lyme disease, among others. However, the scope of postexposure prophylaxis in primary care is expanding, presenting an opportunity to further integrate it into patient care. As primary care providers, we have the unique advantage of being involved in both preventive care and immediate response, particularly in urgent care or triage scenarios. This dual role is crucial, as timely administration of postexposure prophylaxis can prevent infections from taking hold, especially following high-risk exposures.

Recently, the use of doxycycline as a form of postexposure prophylaxis for sexually transmitted infections (STIs) has gained attention. Traditionally, doxycycline has been used as preexposure or postexposure prophylaxis for conditions like malaria and Lyme disease but has not been widely employed for STI prevention until now. Doxycycline is a relatively common medication, generally safe with side effects that typically resolve upon discontinuation. Several open-label studies have shown that taking 200 mg of doxycycline within 72 hours of condomless sex significantly reduces the incidence of chlamydia, gonorrhea, and syphilis among gay, bisexual, and other men who have sex with men, as well as transgender women who have previously had a bacterial STI. However, these benefits have not been consistently observed among cisgender women and heterosexual men.

Given these findings, the Centers for Disease Control and Prevention now recommends that clinicians discuss the risks and benefits of doxycycline PEP (Doxy PEP) with gay, bisexual, and other men who have sex with men, as well as transgender women who have had a bacterial STI in the past 12 months. This discussion should be part of a shared decision-making process, advising the use of 200 mg of doxycycline within 72 hours of oral, vaginal, or anal sex, with the recommendation not to exceed 200 mg every 24 hours and to reassess the need for continued use every 3-6 months. Doxy PEP can be safely prescribed with preexposure prophylaxis for HIV (PrEP). Patients who receive PrEP may often be eligible for Doxy PEP, though the groups are not always the same.

The shared decision-making process is essential when considering Doxy PEP. While cost-effective and proven to reduce the risk of gonorrhea, chlamydia, and syphilis, its benefits vary among different populations. Moreover, some patients may experience side effects such as photosensitivity and gastrointestinal discomfort. Since the effectiveness of prophylaxis is closely tied to the timing of exposure and the patient’s current risk factors, it is important to regularly evaluate whether Doxy PEP remains beneficial. As there is not yet clear benefit to heterosexual men and cisgender women, opportunities still need to be explored for them.

Integrating Doxy PEP into a primary care practice can be done efficiently. A standing order protocol could be established for telehealth visits or nurse triage, allowing timely administration when patients report an exposure within 72 hours. It could also be incorporated into electronic medical records as part of a smart set for easy access to orders and as standard educational material in after-visit instructions. As this option is new, it is also important to discuss it with patients before they may need it so that they are aware should the need arise. While concerns about antibiotic resistance are valid, studies have not yet shown significant resistance issues related to Doxy PEP use, though ongoing monitoring is necessary.

You might wonder why primary care should prioritize this intervention. As the first point of contact, primary care providers are well-positioned to identify the need for prophylaxis, particularly since its effectiveness diminishes over time. Furthermore, the established, trusting relationships that primary care physicians often have with their patients create a nonjudgmental environment that encourages disclosure of potential exposures. This trust, combined with easier access to care, can make a significant difference in the timely provision of postexposure prophylaxis. By offering comprehensive, holistic care, including prophylaxis, primary care physicians can prevent infections and address conditions before they lead to serious complications. Therefore, family medicine physicians should consider incorporating Doxy PEP into their practices as a standard of care.
 

Dr. Wheat is vice chair of Diversity, Equity, and Inclusion, Department of Family and Community Medicine, and associate professor, Family and Community Medicine, at Northwestern University’s Feinberg School of Medicine, Chicago. She has no relevant financial disclosures.

References

Bachmann LH et al. CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024. MMWR Recomm Rep 2024;73(No. RR-2):1-8.

Traeger MW et al. Potential Impact of Doxycycline Postexposure Prophylaxis Prescribing Strategies on Incidence of Bacterial Sexually Transmitted Infections. (Clin Infect Dis. 2023 Aug 18. doi: 10.1093/cid/ciad488).

Primary care physicians frequently offer postexposure prophylaxis for various infections, including influenza, pertussis, tetanus, hepatitis, and Lyme disease, among others. However, the scope of postexposure prophylaxis in primary care is expanding, presenting an opportunity to further integrate it into patient care. As primary care providers, we have the unique advantage of being involved in both preventive care and immediate response, particularly in urgent care or triage scenarios. This dual role is crucial, as timely administration of postexposure prophylaxis can prevent infections from taking hold, especially following high-risk exposures.

Recently, the use of doxycycline as a form of postexposure prophylaxis for sexually transmitted infections (STIs) has gained attention. Traditionally, doxycycline has been used as preexposure or postexposure prophylaxis for conditions like malaria and Lyme disease but has not been widely employed for STI prevention until now. Doxycycline is a relatively common medication, generally safe with side effects that typically resolve upon discontinuation. Several open-label studies have shown that taking 200 mg of doxycycline within 72 hours of condomless sex significantly reduces the incidence of chlamydia, gonorrhea, and syphilis among gay, bisexual, and other men who have sex with men, as well as transgender women who have previously had a bacterial STI. However, these benefits have not been consistently observed among cisgender women and heterosexual men.

Given these findings, the Centers for Disease Control and Prevention now recommends that clinicians discuss the risks and benefits of doxycycline PEP (Doxy PEP) with gay, bisexual, and other men who have sex with men, as well as transgender women who have had a bacterial STI in the past 12 months. This discussion should be part of a shared decision-making process, advising the use of 200 mg of doxycycline within 72 hours of oral, vaginal, or anal sex, with the recommendation not to exceed 200 mg every 24 hours and to reassess the need for continued use every 3-6 months. Doxy PEP can be safely prescribed with preexposure prophylaxis for HIV (PrEP). Patients who receive PrEP may often be eligible for Doxy PEP, though the groups are not always the same.

The shared decision-making process is essential when considering Doxy PEP. While cost-effective and proven to reduce the risk of gonorrhea, chlamydia, and syphilis, its benefits vary among different populations. Moreover, some patients may experience side effects such as photosensitivity and gastrointestinal discomfort. Since the effectiveness of prophylaxis is closely tied to the timing of exposure and the patient’s current risk factors, it is important to regularly evaluate whether Doxy PEP remains beneficial. As there is not yet clear benefit to heterosexual men and cisgender women, opportunities still need to be explored for them.

Integrating Doxy PEP into a primary care practice can be done efficiently. A standing order protocol could be established for telehealth visits or nurse triage, allowing timely administration when patients report an exposure within 72 hours. It could also be incorporated into electronic medical records as part of a smart set for easy access to orders and as standard educational material in after-visit instructions. As this option is new, it is also important to discuss it with patients before they may need it so that they are aware should the need arise. While concerns about antibiotic resistance are valid, studies have not yet shown significant resistance issues related to Doxy PEP use, though ongoing monitoring is necessary.

You might wonder why primary care should prioritize this intervention. As the first point of contact, primary care providers are well-positioned to identify the need for prophylaxis, particularly since its effectiveness diminishes over time. Furthermore, the established, trusting relationships that primary care physicians often have with their patients create a nonjudgmental environment that encourages disclosure of potential exposures. This trust, combined with easier access to care, can make a significant difference in the timely provision of postexposure prophylaxis. By offering comprehensive, holistic care, including prophylaxis, primary care physicians can prevent infections and address conditions before they lead to serious complications. Therefore, family medicine physicians should consider incorporating Doxy PEP into their practices as a standard of care.
 

Dr. Wheat is vice chair of Diversity, Equity, and Inclusion, Department of Family and Community Medicine, and associate professor, Family and Community Medicine, at Northwestern University’s Feinberg School of Medicine, Chicago. She has no relevant financial disclosures.

References

Bachmann LH et al. CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024. MMWR Recomm Rep 2024;73(No. RR-2):1-8.

Traeger MW et al. Potential Impact of Doxycycline Postexposure Prophylaxis Prescribing Strategies on Incidence of Bacterial Sexually Transmitted Infections. (Clin Infect Dis. 2023 Aug 18. doi: 10.1093/cid/ciad488).

The allegations against Algerian boxer Imane Khelif at the Paris Olympics raised the questions of intersexuality and its implications in competitive sports. This news organization has decided to delve into the topic to assist doctors who suspect a similar condition in their patients. No certain clinical data about Ms. Khelif have been made public, so this article does not concern the boxer but rather takes inspiration from the media controversy.

What Is Intersexuality?

Intersexuality encompasses a spectrum of variations in sexual development that lead to the simultaneous presence of typical male and female characteristics. As reiterated by the United Nations Office of the High Commissioner for Human Rights, the medical definition does not affect the patient’s self-identification of gender or sexual orientation.

“The percentage of people who fall within the intersexuality spectrum is less than 0.5 per thousand of the general population, but there are no precise statistics, given the difficulty of definition,” said Roberto Lala, MD, pediatric endocrinologist and president of the Federation of Rare Childhood Diseases.

Indeed, there is not only a strict definition of intersexuality that involves a significant presence of these mixed physical characteristics in a way that conditions the self-image of the subject but also a broad definition, said Dr. Lala. “For example, clitoral hypertrophy in a female otherwise conforming to the female gender, which does not raise doubts about identity,” he said.
 

Chromosomes, Genes, and Hormones

A patient’s sexual characteristics are determined by the complex interaction of chromosomal, genetic, and hormonal factors. “The human body is, so to speak, programmed to take on female appearances in development and shifts toward male ones only if exposed to testosterone and other factors. For this to happen, testosterone must be produced during embryonic development, and it must function properly,” said Paolo Moghetti, full professor of endocrinology at the University of Verona, Italy.

The protein encoded by SRY, which is located on the Y chromosome, determines the development of the testicles from undifferentiated tissue of the embryonic gonads. The testicles of the embryo then produce testosterone. The absence of the Y chromosome is a common characteristic of most female individuals. However, there are individuals with a female phenotype who have X and Y chromosomes but lack SRY or have a variant of it that is not entirely functional.

Numerous other chromosomal or genetic variations can lead to alterations in sexual differentiation. “In phenotypically male adult subjects (with a chromosomal makeup of 46XY) with complete androgen insensitivity (so-called Morris syndrome), testosterone levels in the blood are elevated, above normal even for a male, but the hormone is totally ineffective, and the phenotype is totally female at birth, with completely female development of secondary sexual characteristics at puberty,” said Dr. Moghetti.

This means that affected individuals have well-developed breasts and a complete lack or extremely reduced presence of hair, including underarm and pubic hair. Menstruation is also completely absent because there is no uterus, and there are testes, not visible because they are considered in the abdomen.

“There are syndromes that are currently considered congenital but not genetic, of which a genetic origin will probably be identified in the future,” said Dr. Lala.

Some variations in sexual development can be diagnosed prenatally, such as an alteration of the number of sex chromosomes or a discordance between the morphologic characteristics highlighted by ultrasound and the genotype detected by amniocentesis. Some variations are evident at birth because of atypical anatomical characteristics. Others are diagnosed during puberty or later in adulthood, in the presence of infertility. The Italian National Institute of Health details these variations on its website, describing the characteristics that determine diagnosis and treatment.
 

Pathologies or Variations?

Some anomalies in sexual development negatively affect the patient’s physical health. One example is congenital adrenal hyperplasia. “It results from an inherited defect of the adrenal glands, which reduces cortisol production while increasing testosterone production,” said Dr. Lala. “In addition to the appearance of male characteristics in females, in more severe forms, it carries the risk of collapse and shock and requires pharmacological treatment.” It is undoubtedly a pathology.

Other variations in sexual characteristics do not affect the patient’s physical health negatively. They may, however, have a psychologic effect, sometimes a significant one, because of the lack of social acceptance of a person who cannot be classified within the binary classification of sexes.

“Conditions in which mixed male and female aspects are clearly evident have been and are still pathologized by the family, the treating physician, and society,” said Dr. Lala. “In the late 1970s, when a child was born with intersexual anatomical characteristics, it was common practice to surgically intervene, making them female, because it was technically easier.”

Over the years, patients who, as they grew up, were dissatisfied with the solution adopted at birth began to make their voices heard, Dr. Lala added. Scientific societies and international organizations have spoken out against subjecting intersexual newborns to surgical interventions that are not medically necessary. “Nowadays, decisions are made on a case-by-case basis, taking into account the families’ wishes. Interventions are justified with medical reasons, which are often very nuanced,” Dr. Lala concluded.
 

Implications for Sports

Traditionally, athletes participating in competitions in certain sports have been divided into male and female categories to ensure a certain equity and uniformity in performance. Over the years, the emergence of new information about sexual development has made it necessary to update the criteria used in this division.

The main factor responsible for the performance diversity between males and females is the action of testosterone on the male and female organism. “Testosterone has important effects on muscle mass and enhances training results,” said Dr. Moghetti. “As a demonstration of this fact, before puberty, the best performances in athletics or swimming by males and females are similar, then males gain a significant advantage of around 10%-20%.”

A few years ago, the World Athletics Federation conducted widespread screening of athletes participating in its world championships. “It identified a small group of individuals with potentially abnormal testosterone levels for the female sex,” said Dr. Moghetti. “Some were found to be doping, others had genetic defects, and for some, an interpretation was not even possible.”

Some of the individuals had a male genotype but a defect in 5-alpha-reductase, an enzyme essential for the formation of male genitals and hair growth. An athlete with these characteristics, assigned female sex at birth, has a male level of testosterone that stimulates the accumulation of muscle mass, Dr. Moghetti explained. Therefore, the individual has a considerable advantage in performances influenced by this hormone.

“In the end, the Federation decided to set limits on the testosterone levels of athletes participating in certain types of races, especially those in middle distance, that appeared to be more sensitive to differences in hormone levels,” said Dr. Moghetti. “The limitation does not apply to athletes with Morris syndrome, ie, with a male genotype and complete resistance to testosterone, for whom the high level of this hormone does not provide any advantage.” Given the complexity of the problem, he hopes for a case-by-case policy that considers the needs of patients with genetic alterations and those of athletes who have to compete with them.
 

Not the First Time

A recent incident underscored the difficulty of regulating such complex issues. The World Athletics Federation excluded South African middle-distance runner Caster Semenya from competitions years ago because of excessively high testosterone levels.

“The Federation’s regulations recommend that athletes in these cases reduce hormone levels to values below the threshold of 5 nmol/L of blood for a period of at least 6 months before the race by using hormonal contraceptives. The use of such drugs does not pose a health risk, as they are substances normally taken by women for contraception purposes,” said Amelia Filippelli, a pharmacologist at the University of Salerno in Italy. The South African middle-distance runner refused the drug and appealed to the Court of Arbitration for Sport and later to the Swiss Federal Court. Both rejected her appeal. Finally, Ms. Semenya appealed to the European Court of Human Rights, which in 2023 recognized a violation of her rights but does not have the authority to order a change in the Federation’s regulations.

Beyond the ideologic positions of nonexperts, therefore, the issue is still the subject of debate in the scientific community, which is evaluating not only its medical aspects but also its ethical implications.
 

This story was translated from Univadis Italy, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

The allegations against Algerian boxer Imane Khelif at the Paris Olympics raised the questions of intersexuality and its implications in competitive sports. This news organization has decided to delve into the topic to assist doctors who suspect a similar condition in their patients. No certain clinical data about Ms. Khelif have been made public, so this article does not concern the boxer but rather takes inspiration from the media controversy.

What Is Intersexuality?

Intersexuality encompasses a spectrum of variations in sexual development that lead to the simultaneous presence of typical male and female characteristics. As reiterated by the United Nations Office of the High Commissioner for Human Rights, the medical definition does not affect the patient’s self-identification of gender or sexual orientation.

“The percentage of people who fall within the intersexuality spectrum is less than 0.5 per thousand of the general population, but there are no precise statistics, given the difficulty of definition,” said Roberto Lala, MD, pediatric endocrinologist and president of the Federation of Rare Childhood Diseases.

Indeed, there is not only a strict definition of intersexuality that involves a significant presence of these mixed physical characteristics in a way that conditions the self-image of the subject but also a broad definition, said Dr. Lala. “For example, clitoral hypertrophy in a female otherwise conforming to the female gender, which does not raise doubts about identity,” he said.
 

Chromosomes, Genes, and Hormones

A patient’s sexual characteristics are determined by the complex interaction of chromosomal, genetic, and hormonal factors. “The human body is, so to speak, programmed to take on female appearances in development and shifts toward male ones only if exposed to testosterone and other factors. For this to happen, testosterone must be produced during embryonic development, and it must function properly,” said Paolo Moghetti, full professor of endocrinology at the University of Verona, Italy.

The protein encoded by SRY, which is located on the Y chromosome, determines the development of the testicles from undifferentiated tissue of the embryonic gonads. The testicles of the embryo then produce testosterone. The absence of the Y chromosome is a common characteristic of most female individuals. However, there are individuals with a female phenotype who have X and Y chromosomes but lack SRY or have a variant of it that is not entirely functional.

Numerous other chromosomal or genetic variations can lead to alterations in sexual differentiation. “In phenotypically male adult subjects (with a chromosomal makeup of 46XY) with complete androgen insensitivity (so-called Morris syndrome), testosterone levels in the blood are elevated, above normal even for a male, but the hormone is totally ineffective, and the phenotype is totally female at birth, with completely female development of secondary sexual characteristics at puberty,” said Dr. Moghetti.

This means that affected individuals have well-developed breasts and a complete lack or extremely reduced presence of hair, including underarm and pubic hair. Menstruation is also completely absent because there is no uterus, and there are testes, not visible because they are considered in the abdomen.

“There are syndromes that are currently considered congenital but not genetic, of which a genetic origin will probably be identified in the future,” said Dr. Lala.

Some variations in sexual development can be diagnosed prenatally, such as an alteration of the number of sex chromosomes or a discordance between the morphologic characteristics highlighted by ultrasound and the genotype detected by amniocentesis. Some variations are evident at birth because of atypical anatomical characteristics. Others are diagnosed during puberty or later in adulthood, in the presence of infertility. The Italian National Institute of Health details these variations on its website, describing the characteristics that determine diagnosis and treatment.
 

Pathologies or Variations?

Some anomalies in sexual development negatively affect the patient’s physical health. One example is congenital adrenal hyperplasia. “It results from an inherited defect of the adrenal glands, which reduces cortisol production while increasing testosterone production,” said Dr. Lala. “In addition to the appearance of male characteristics in females, in more severe forms, it carries the risk of collapse and shock and requires pharmacological treatment.” It is undoubtedly a pathology.

Other variations in sexual characteristics do not affect the patient’s physical health negatively. They may, however, have a psychologic effect, sometimes a significant one, because of the lack of social acceptance of a person who cannot be classified within the binary classification of sexes.

“Conditions in which mixed male and female aspects are clearly evident have been and are still pathologized by the family, the treating physician, and society,” said Dr. Lala. “In the late 1970s, when a child was born with intersexual anatomical characteristics, it was common practice to surgically intervene, making them female, because it was technically easier.”

Over the years, patients who, as they grew up, were dissatisfied with the solution adopted at birth began to make their voices heard, Dr. Lala added. Scientific societies and international organizations have spoken out against subjecting intersexual newborns to surgical interventions that are not medically necessary. “Nowadays, decisions are made on a case-by-case basis, taking into account the families’ wishes. Interventions are justified with medical reasons, which are often very nuanced,” Dr. Lala concluded.
 

Implications for Sports

Traditionally, athletes participating in competitions in certain sports have been divided into male and female categories to ensure a certain equity and uniformity in performance. Over the years, the emergence of new information about sexual development has made it necessary to update the criteria used in this division.

The main factor responsible for the performance diversity between males and females is the action of testosterone on the male and female organism. “Testosterone has important effects on muscle mass and enhances training results,” said Dr. Moghetti. “As a demonstration of this fact, before puberty, the best performances in athletics or swimming by males and females are similar, then males gain a significant advantage of around 10%-20%.”

A few years ago, the World Athletics Federation conducted widespread screening of athletes participating in its world championships. “It identified a small group of individuals with potentially abnormal testosterone levels for the female sex,” said Dr. Moghetti. “Some were found to be doping, others had genetic defects, and for some, an interpretation was not even possible.”

Some of the individuals had a male genotype but a defect in 5-alpha-reductase, an enzyme essential for the formation of male genitals and hair growth. An athlete with these characteristics, assigned female sex at birth, has a male level of testosterone that stimulates the accumulation of muscle mass, Dr. Moghetti explained. Therefore, the individual has a considerable advantage in performances influenced by this hormone.

“In the end, the Federation decided to set limits on the testosterone levels of athletes participating in certain types of races, especially those in middle distance, that appeared to be more sensitive to differences in hormone levels,” said Dr. Moghetti. “The limitation does not apply to athletes with Morris syndrome, ie, with a male genotype and complete resistance to testosterone, for whom the high level of this hormone does not provide any advantage.” Given the complexity of the problem, he hopes for a case-by-case policy that considers the needs of patients with genetic alterations and those of athletes who have to compete with them.
 

Not the First Time

A recent incident underscored the difficulty of regulating such complex issues. The World Athletics Federation excluded South African middle-distance runner Caster Semenya from competitions years ago because of excessively high testosterone levels.

“The Federation’s regulations recommend that athletes in these cases reduce hormone levels to values below the threshold of 5 nmol/L of blood for a period of at least 6 months before the race by using hormonal contraceptives. The use of such drugs does not pose a health risk, as they are substances normally taken by women for contraception purposes,” said Amelia Filippelli, a pharmacologist at the University of Salerno in Italy. The South African middle-distance runner refused the drug and appealed to the Court of Arbitration for Sport and later to the Swiss Federal Court. Both rejected her appeal. Finally, Ms. Semenya appealed to the European Court of Human Rights, which in 2023 recognized a violation of her rights but does not have the authority to order a change in the Federation’s regulations.

Beyond the ideologic positions of nonexperts, therefore, the issue is still the subject of debate in the scientific community, which is evaluating not only its medical aspects but also its ethical implications.
 

This story was translated from Univadis Italy, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

The allegations against Algerian boxer Imane Khelif at the Paris Olympics raised the questions of intersexuality and its implications in competitive sports. This news organization has decided to delve into the topic to assist doctors who suspect a similar condition in their patients. No certain clinical data about Ms. Khelif have been made public, so this article does not concern the boxer but rather takes inspiration from the media controversy.

What Is Intersexuality?

Intersexuality encompasses a spectrum of variations in sexual development that lead to the simultaneous presence of typical male and female characteristics. As reiterated by the United Nations Office of the High Commissioner for Human Rights, the medical definition does not affect the patient’s self-identification of gender or sexual orientation.

“The percentage of people who fall within the intersexuality spectrum is less than 0.5 per thousand of the general population, but there are no precise statistics, given the difficulty of definition,” said Roberto Lala, MD, pediatric endocrinologist and president of the Federation of Rare Childhood Diseases.

Indeed, there is not only a strict definition of intersexuality that involves a significant presence of these mixed physical characteristics in a way that conditions the self-image of the subject but also a broad definition, said Dr. Lala. “For example, clitoral hypertrophy in a female otherwise conforming to the female gender, which does not raise doubts about identity,” he said.
 

Chromosomes, Genes, and Hormones

A patient’s sexual characteristics are determined by the complex interaction of chromosomal, genetic, and hormonal factors. “The human body is, so to speak, programmed to take on female appearances in development and shifts toward male ones only if exposed to testosterone and other factors. For this to happen, testosterone must be produced during embryonic development, and it must function properly,” said Paolo Moghetti, full professor of endocrinology at the University of Verona, Italy.

The protein encoded by SRY, which is located on the Y chromosome, determines the development of the testicles from undifferentiated tissue of the embryonic gonads. The testicles of the embryo then produce testosterone. The absence of the Y chromosome is a common characteristic of most female individuals. However, there are individuals with a female phenotype who have X and Y chromosomes but lack SRY or have a variant of it that is not entirely functional.

Numerous other chromosomal or genetic variations can lead to alterations in sexual differentiation. “In phenotypically male adult subjects (with a chromosomal makeup of 46XY) with complete androgen insensitivity (so-called Morris syndrome), testosterone levels in the blood are elevated, above normal even for a male, but the hormone is totally ineffective, and the phenotype is totally female at birth, with completely female development of secondary sexual characteristics at puberty,” said Dr. Moghetti.

This means that affected individuals have well-developed breasts and a complete lack or extremely reduced presence of hair, including underarm and pubic hair. Menstruation is also completely absent because there is no uterus, and there are testes, not visible because they are considered in the abdomen.

“There are syndromes that are currently considered congenital but not genetic, of which a genetic origin will probably be identified in the future,” said Dr. Lala.

Some variations in sexual development can be diagnosed prenatally, such as an alteration of the number of sex chromosomes or a discordance between the morphologic characteristics highlighted by ultrasound and the genotype detected by amniocentesis. Some variations are evident at birth because of atypical anatomical characteristics. Others are diagnosed during puberty or later in adulthood, in the presence of infertility. The Italian National Institute of Health details these variations on its website, describing the characteristics that determine diagnosis and treatment.
 

Pathologies or Variations?

Some anomalies in sexual development negatively affect the patient’s physical health. One example is congenital adrenal hyperplasia. “It results from an inherited defect of the adrenal glands, which reduces cortisol production while increasing testosterone production,” said Dr. Lala. “In addition to the appearance of male characteristics in females, in more severe forms, it carries the risk of collapse and shock and requires pharmacological treatment.” It is undoubtedly a pathology.

Other variations in sexual characteristics do not affect the patient’s physical health negatively. They may, however, have a psychologic effect, sometimes a significant one, because of the lack of social acceptance of a person who cannot be classified within the binary classification of sexes.

“Conditions in which mixed male and female aspects are clearly evident have been and are still pathologized by the family, the treating physician, and society,” said Dr. Lala. “In the late 1970s, when a child was born with intersexual anatomical characteristics, it was common practice to surgically intervene, making them female, because it was technically easier.”

Over the years, patients who, as they grew up, were dissatisfied with the solution adopted at birth began to make their voices heard, Dr. Lala added. Scientific societies and international organizations have spoken out against subjecting intersexual newborns to surgical interventions that are not medically necessary. “Nowadays, decisions are made on a case-by-case basis, taking into account the families’ wishes. Interventions are justified with medical reasons, which are often very nuanced,” Dr. Lala concluded.
 

Implications for Sports

Traditionally, athletes participating in competitions in certain sports have been divided into male and female categories to ensure a certain equity and uniformity in performance. Over the years, the emergence of new information about sexual development has made it necessary to update the criteria used in this division.

The main factor responsible for the performance diversity between males and females is the action of testosterone on the male and female organism. “Testosterone has important effects on muscle mass and enhances training results,” said Dr. Moghetti. “As a demonstration of this fact, before puberty, the best performances in athletics or swimming by males and females are similar, then males gain a significant advantage of around 10%-20%.”

A few years ago, the World Athletics Federation conducted widespread screening of athletes participating in its world championships. “It identified a small group of individuals with potentially abnormal testosterone levels for the female sex,” said Dr. Moghetti. “Some were found to be doping, others had genetic defects, and for some, an interpretation was not even possible.”

Some of the individuals had a male genotype but a defect in 5-alpha-reductase, an enzyme essential for the formation of male genitals and hair growth. An athlete with these characteristics, assigned female sex at birth, has a male level of testosterone that stimulates the accumulation of muscle mass, Dr. Moghetti explained. Therefore, the individual has a considerable advantage in performances influenced by this hormone.

“In the end, the Federation decided to set limits on the testosterone levels of athletes participating in certain types of races, especially those in middle distance, that appeared to be more sensitive to differences in hormone levels,” said Dr. Moghetti. “The limitation does not apply to athletes with Morris syndrome, ie, with a male genotype and complete resistance to testosterone, for whom the high level of this hormone does not provide any advantage.” Given the complexity of the problem, he hopes for a case-by-case policy that considers the needs of patients with genetic alterations and those of athletes who have to compete with them.
 

Not the First Time

A recent incident underscored the difficulty of regulating such complex issues. The World Athletics Federation excluded South African middle-distance runner Caster Semenya from competitions years ago because of excessively high testosterone levels.

“The Federation’s regulations recommend that athletes in these cases reduce hormone levels to values below the threshold of 5 nmol/L of blood for a period of at least 6 months before the race by using hormonal contraceptives. The use of such drugs does not pose a health risk, as they are substances normally taken by women for contraception purposes,” said Amelia Filippelli, a pharmacologist at the University of Salerno in Italy. The South African middle-distance runner refused the drug and appealed to the Court of Arbitration for Sport and later to the Swiss Federal Court. Both rejected her appeal. Finally, Ms. Semenya appealed to the European Court of Human Rights, which in 2023 recognized a violation of her rights but does not have the authority to order a change in the Federation’s regulations.

Beyond the ideologic positions of nonexperts, therefore, the issue is still the subject of debate in the scientific community, which is evaluating not only its medical aspects but also its ethical implications.
 

This story was translated from Univadis Italy, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

TOPLINE:

Long-term gender-affirming hormone treatment with testosterone increases the risk for metabolic syndromes in transmasculine individuals, whereas transfeminine individuals receiving estradiol have a lower risk.

METHODOLOGY:

• Many transgender individuals receive exogenous sex hormone therapy to reduce gender dysphoria and improve quality of life. These treatments, however, may influence the development of metabolic syndrome.
• This retrospective, longitudinal cohort study investigated the association between gender-affirming hormone treatment and metabolic syndrome scores in transfeminine and transmasculine individuals compared with cisgender men and women not receiving the treatment.
• Overall, 645 transgender participants (mean age at index date, 41.3 years; 494 transfeminine and 151 transmasculine) were matched with 645 cisgender participants (280 women and 365 men) from the Veterans Health Administration.
• Metabolic syndrome scores were calculated based on blood pressure; body mass index (BMI); and levels of high-density lipoprotein (HDL) cholesterol, triglycerides, and blood glucose.
• Changes in metabolic syndrome scores before and after hormonal transition were compared among transgender and cisgender individuals for the corresponding dates.

TAKEAWAY:

• After hormonal transition, all measured metabolic syndrome components significantly worsened in the transmasculine group (P < .05 for all).
• In contrast, the systolic blood pressure and triglyceride levels decreased, HDL cholesterol levels increased, and BMI showed no significant change in the transfeminine group after hormonal transition.
• The increase in metabolic syndrome scores after vs before the date of hormonal transition was the highest for transmasculine individuals (298.0%; P < .001), followed by cisgender women (108.3%; P < .001), cisgender men (49.3%; P = .02), and transfeminine individuals (3.0%; P = .77).

IN PRACTICE:

“This is relevant for the management of metabolic syndrome risk factors in cisgender and transgender individuals and to potentially predict the risk of atherosclerotic cardiovascular disease, type 2 diabetes, systolic hypertension, insulin resistance, and nonalcoholic fatty liver disease,” the authors wrote.

SOURCE:

Leila Hashemi, MD, MS, of the Department of General Internal Medicine, David Geffen School of Medicine, University of California, Los Angeles, led this study, which was published online in JAMA Network Open.

LIMITATIONS:

Causal inferences could not be drawn because of the study’s observational nature. The transmasculine and cisgender female groups were limited in size, and military veterans have special circumstances not representative of the general population. Minority stress among the transgender veterans was also not considered, which may have affected the health and well-being outcomes.

DISCLOSURES:

This study was supported by the National Institutes of Health and Office of Research on Women’s Health grants. One author received grants from the National Institutes of Health.

A version of this article first appeared on Medscape.com.

TOPLINE:

Long-term gender-affirming hormone treatment with testosterone increases the risk for metabolic syndromes in transmasculine individuals, whereas transfeminine individuals receiving estradiol have a lower risk.

METHODOLOGY:

• Many transgender individuals receive exogenous sex hormone therapy to reduce gender dysphoria and improve quality of life. These treatments, however, may influence the development of metabolic syndrome.
• This retrospective, longitudinal cohort study investigated the association between gender-affirming hormone treatment and metabolic syndrome scores in transfeminine and transmasculine individuals compared with cisgender men and women not receiving the treatment.
• Overall, 645 transgender participants (mean age at index date, 41.3 years; 494 transfeminine and 151 transmasculine) were matched with 645 cisgender participants (280 women and 365 men) from the Veterans Health Administration.
• Metabolic syndrome scores were calculated based on blood pressure; body mass index (BMI); and levels of high-density lipoprotein (HDL) cholesterol, triglycerides, and blood glucose.
• Changes in metabolic syndrome scores before and after hormonal transition were compared among transgender and cisgender individuals for the corresponding dates.

TAKEAWAY:

• After hormonal transition, all measured metabolic syndrome components significantly worsened in the transmasculine group (P < .05 for all).
• In contrast, the systolic blood pressure and triglyceride levels decreased, HDL cholesterol levels increased, and BMI showed no significant change in the transfeminine group after hormonal transition.
• The increase in metabolic syndrome scores after vs before the date of hormonal transition was the highest for transmasculine individuals (298.0%; P < .001), followed by cisgender women (108.3%; P < .001), cisgender men (49.3%; P = .02), and transfeminine individuals (3.0%; P = .77).

IN PRACTICE:

“This is relevant for the management of metabolic syndrome risk factors in cisgender and transgender individuals and to potentially predict the risk of atherosclerotic cardiovascular disease, type 2 diabetes, systolic hypertension, insulin resistance, and nonalcoholic fatty liver disease,” the authors wrote.

SOURCE:

Leila Hashemi, MD, MS, of the Department of General Internal Medicine, David Geffen School of Medicine, University of California, Los Angeles, led this study, which was published online in JAMA Network Open.

LIMITATIONS:

Causal inferences could not be drawn because of the study’s observational nature. The transmasculine and cisgender female groups were limited in size, and military veterans have special circumstances not representative of the general population. Minority stress among the transgender veterans was also not considered, which may have affected the health and well-being outcomes.

DISCLOSURES:

This study was supported by the National Institutes of Health and Office of Research on Women’s Health grants. One author received grants from the National Institutes of Health.

A version of this article first appeared on Medscape.com.

TOPLINE:

Long-term gender-affirming hormone treatment with testosterone increases the risk for metabolic syndromes in transmasculine individuals, whereas transfeminine individuals receiving estradiol have a lower risk.

METHODOLOGY:

• Many transgender individuals receive exogenous sex hormone therapy to reduce gender dysphoria and improve quality of life. These treatments, however, may influence the development of metabolic syndrome.
• This retrospective, longitudinal cohort study investigated the association between gender-affirming hormone treatment and metabolic syndrome scores in transfeminine and transmasculine individuals compared with cisgender men and women not receiving the treatment.
• Overall, 645 transgender participants (mean age at index date, 41.3 years; 494 transfeminine and 151 transmasculine) were matched with 645 cisgender participants (280 women and 365 men) from the Veterans Health Administration.
• Metabolic syndrome scores were calculated based on blood pressure; body mass index (BMI); and levels of high-density lipoprotein (HDL) cholesterol, triglycerides, and blood glucose.
• Changes in metabolic syndrome scores before and after hormonal transition were compared among transgender and cisgender individuals for the corresponding dates.

TAKEAWAY:

• After hormonal transition, all measured metabolic syndrome components significantly worsened in the transmasculine group (P < .05 for all).
• In contrast, the systolic blood pressure and triglyceride levels decreased, HDL cholesterol levels increased, and BMI showed no significant change in the transfeminine group after hormonal transition.
• The increase in metabolic syndrome scores after vs before the date of hormonal transition was the highest for transmasculine individuals (298.0%; P < .001), followed by cisgender women (108.3%; P < .001), cisgender men (49.3%; P = .02), and transfeminine individuals (3.0%; P = .77).

IN PRACTICE:

“This is relevant for the management of metabolic syndrome risk factors in cisgender and transgender individuals and to potentially predict the risk of atherosclerotic cardiovascular disease, type 2 diabetes, systolic hypertension, insulin resistance, and nonalcoholic fatty liver disease,” the authors wrote.

SOURCE:

Leila Hashemi, MD, MS, of the Department of General Internal Medicine, David Geffen School of Medicine, University of California, Los Angeles, led this study, which was published online in JAMA Network Open.

LIMITATIONS:

Causal inferences could not be drawn because of the study’s observational nature. The transmasculine and cisgender female groups were limited in size, and military veterans have special circumstances not representative of the general population. Minority stress among the transgender veterans was also not considered, which may have affected the health and well-being outcomes.

DISCLOSURES:

This study was supported by the National Institutes of Health and Office of Research on Women’s Health grants. One author received grants from the National Institutes of Health.

A version of this article first appeared on Medscape.com.

As Pride Month drew to a close, the Supreme Court made a shocking announcement. For the first time in the history of the court, it is willing to hear a legal challenge regarding gender-affirming care for minors. The justices will review whether a 2023 Tennessee law, SB1, which bans hormone therapy, puberty blockers, and surgery for transgender minors, is unconstitutional. This is the first time the Supreme Court will directly weigh in on gender-affirming care.

There are few topics as politically and medically divisive as gender-affirming care for minors. When the World Professional Association for Transgender Health (WPATH) released its updated Standards of Care, SOC8, one of the noticeable changes to the document was its approach to caring for transgender children and adolescents.

Dr. Brandt

Before I highlight these recommendations and the ensuing controversy, it is imperative to establish proper terminology. Unfortunately, medical and legal terms often differ. Both activists and opponents use these terms interchangeably, which makes discourse about an already emotionally charged topic extremely difficult. From a legal perspective, the terms “minor” and “child” often refer to individuals under the age of majority. In the United States, the age of majority is 18. However, the term child also has a well-established medical definition. A child is an individual between the stages of infancy and puberty. Adolescence is a transitional period marked by the onset of puberty until adulthood (typically the age of majority). As medical providers, understanding these definitions is essential to identifying misinformation pertaining to this type of healthcare.

For the purposes of this article, I will be adhering to the medical terminology. Now, I want to be very clear. WPATH does not endorse surgical procedures on children. Furthermore, surgeons are not performing gender-affirming surgeries on children. On adolescents, rarely. But children, never.

According to the updated SOC8, the only acceptable gender-affirming intervention for children is psychosocial support.¹ This does not include puberty blockers, hormones, or surgery, but rather allowing a child to explore their gender identity by experimenting with different clothing, toys, hairstyles, and even an alternative name that aligns more closely with their gender identity.¹

It is only after children reach adolescence that medical, and in rare cases, surgical interventions, can be considered. Puberty blockers are appropriate for patients who have started puberty and experience gender dysphoria. These medications are reversible, and their purpose is to temporarily pause puberty to allow the adolescent to further explore their gender identity.

The most significant side effect of puberty blockers is decreased bone density.¹ As a result, providers typically do not prescribe these medications for more than 2-3 years. After discontinuation of the medication, bone density returns to baseline.¹ If the adolescent’s gender identity is marked and sustained over time, hormone therapy, such as testosterone or estrogen is then considered. Unlike puberty blockers, these medications can have permanent side effects. Testosterone use can lead to irreversible hair growth, alopecia, clitoromegaly, and voice deepening, while estrogen can cause permanent breast growth and halt sperm production.¹ Future fertility and these side effects are discussed with the patient in detail prior to the initiation of these medications.

Contrary to the current political narrative, gender-affirming care for children and adolescents is not taken lightly. These individuals often receive years of multidisciplinary assessments, with a focus on gender identity development, social development and support, and diagnostic assessment of possible co-occurring mental health or developmental concerns and capacity for decision making.¹ The clinical visits also occur with parental support and consent.

WPATH SOC8 also delineates the provider qualifications for health care professionals assessing these patients. Providers must be licensed by their statutory bodies and hold a postgraduate degree by a nationally accredited statutory institution; receive theoretical and evidence-based training and develop expertise in child, adolescent, and family mental health across the developmental spectrum; receive training and have expertise in gender identity development and gender diversity in children and adolescence; have the ability to assess capacity to assent/consent; receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations; and to continue engaging in professional development in all areas relevant to gender-diverse children, adolescents, and families.¹

The most controversial aspect of gender-affirming care for children and adolescents relates to surgical treatment. While the rates of gender-affirming surgeries have increased for this age group over the years, the overall rate of gender-affirming surgery for adolescents is markedly lower compared with other adolescents seeking cosmetic surgeries and compared with transgender adults undergoing gender-affirming surgery.

In a cohort study conducted between 2016 to 2020, 48,019 patients were identified who had undergone gender-affirming surgery.² Only 3678 or 7.7% of patients were aged between 12 and 18, with the most common procedure being chest/breast surgery.² So, under about 1000 cases per year were gender-affirming surgeries on patients under 18.

During 2020 alone, the number of cisgender adolescents between the ages of 13 and 19 who underwent breast augmentation and breast reduction was 3233 and 4666, respectively.³ The outrage about gender-affirming surgeries on transgender youth, yet the silence on cosmetic procedures in this same age group, speaks volumes.

All surgeries on adolescents should be taken seriously and with caution, regardless of gender identity. However, current legislation disproportionately targets only transgender youth. For whatever reason, surgeries on transgender individuals are labeled as “body mutilation,” whereas surgeries on cisgender youth are not even discussed. Such inflammatory rhetoric and complete lack of empathy impedes the common goal of all parties: what is in the best interest of the minor? Unfortunately, in a few short months, the answer to this question will be determined by a group of nine justices who have no experience in medicine or transgender health care, instead of by medical experts and the parents who care for these individuals.
 

Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pennsylvania. She has no conflicts of interest.
 

References

1. Coleman E et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgender Health. 2022;23(sup):S1-S259.

2. Wright JD et al. National estimates of gender affirming surgery in the US. JAMA Netw Open. 2023 Aug 1;6(8):e2330348.

3. American Society of Plastic Surgeons. Plastic Surgery Statistics Report. ASPS National Clearinghouse of Plastic Surgery Procedural Statistics. 2020.

As Pride Month drew to a close, the Supreme Court made a shocking announcement. For the first time in the history of the court, it is willing to hear a legal challenge regarding gender-affirming care for minors. The justices will review whether a 2023 Tennessee law, SB1, which bans hormone therapy, puberty blockers, and surgery for transgender minors, is unconstitutional. This is the first time the Supreme Court will directly weigh in on gender-affirming care.

There are few topics as politically and medically divisive as gender-affirming care for minors. When the World Professional Association for Transgender Health (WPATH) released its updated Standards of Care, SOC8, one of the noticeable changes to the document was its approach to caring for transgender children and adolescents.

Dr. Brandt

Before I highlight these recommendations and the ensuing controversy, it is imperative to establish proper terminology. Unfortunately, medical and legal terms often differ. Both activists and opponents use these terms interchangeably, which makes discourse about an already emotionally charged topic extremely difficult. From a legal perspective, the terms “minor” and “child” often refer to individuals under the age of majority. In the United States, the age of majority is 18. However, the term child also has a well-established medical definition. A child is an individual between the stages of infancy and puberty. Adolescence is a transitional period marked by the onset of puberty until adulthood (typically the age of majority). As medical providers, understanding these definitions is essential to identifying misinformation pertaining to this type of healthcare.

For the purposes of this article, I will be adhering to the medical terminology. Now, I want to be very clear. WPATH does not endorse surgical procedures on children. Furthermore, surgeons are not performing gender-affirming surgeries on children. On adolescents, rarely. But children, never.

According to the updated SOC8, the only acceptable gender-affirming intervention for children is psychosocial support.¹ This does not include puberty blockers, hormones, or surgery, but rather allowing a child to explore their gender identity by experimenting with different clothing, toys, hairstyles, and even an alternative name that aligns more closely with their gender identity.¹

It is only after children reach adolescence that medical, and in rare cases, surgical interventions, can be considered. Puberty blockers are appropriate for patients who have started puberty and experience gender dysphoria. These medications are reversible, and their purpose is to temporarily pause puberty to allow the adolescent to further explore their gender identity.

The most significant side effect of puberty blockers is decreased bone density.¹ As a result, providers typically do not prescribe these medications for more than 2-3 years. After discontinuation of the medication, bone density returns to baseline.¹ If the adolescent’s gender identity is marked and sustained over time, hormone therapy, such as testosterone or estrogen is then considered. Unlike puberty blockers, these medications can have permanent side effects. Testosterone use can lead to irreversible hair growth, alopecia, clitoromegaly, and voice deepening, while estrogen can cause permanent breast growth and halt sperm production.¹ Future fertility and these side effects are discussed with the patient in detail prior to the initiation of these medications.

Contrary to the current political narrative, gender-affirming care for children and adolescents is not taken lightly. These individuals often receive years of multidisciplinary assessments, with a focus on gender identity development, social development and support, and diagnostic assessment of possible co-occurring mental health or developmental concerns and capacity for decision making.¹ The clinical visits also occur with parental support and consent.

WPATH SOC8 also delineates the provider qualifications for health care professionals assessing these patients. Providers must be licensed by their statutory bodies and hold a postgraduate degree by a nationally accredited statutory institution; receive theoretical and evidence-based training and develop expertise in child, adolescent, and family mental health across the developmental spectrum; receive training and have expertise in gender identity development and gender diversity in children and adolescence; have the ability to assess capacity to assent/consent; receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations; and to continue engaging in professional development in all areas relevant to gender-diverse children, adolescents, and families.¹

The most controversial aspect of gender-affirming care for children and adolescents relates to surgical treatment. While the rates of gender-affirming surgeries have increased for this age group over the years, the overall rate of gender-affirming surgery for adolescents is markedly lower compared with other adolescents seeking cosmetic surgeries and compared with transgender adults undergoing gender-affirming surgery.

In a cohort study conducted between 2016 to 2020, 48,019 patients were identified who had undergone gender-affirming surgery.² Only 3678 or 7.7% of patients were aged between 12 and 18, with the most common procedure being chest/breast surgery.² So, under about 1000 cases per year were gender-affirming surgeries on patients under 18.

During 2020 alone, the number of cisgender adolescents between the ages of 13 and 19 who underwent breast augmentation and breast reduction was 3233 and 4666, respectively.³ The outrage about gender-affirming surgeries on transgender youth, yet the silence on cosmetic procedures in this same age group, speaks volumes.

All surgeries on adolescents should be taken seriously and with caution, regardless of gender identity. However, current legislation disproportionately targets only transgender youth. For whatever reason, surgeries on transgender individuals are labeled as “body mutilation,” whereas surgeries on cisgender youth are not even discussed. Such inflammatory rhetoric and complete lack of empathy impedes the common goal of all parties: what is in the best interest of the minor? Unfortunately, in a few short months, the answer to this question will be determined by a group of nine justices who have no experience in medicine or transgender health care, instead of by medical experts and the parents who care for these individuals.
 

Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pennsylvania. She has no conflicts of interest.
 

References

1. Coleman E et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgender Health. 2022;23(sup):S1-S259.

2. Wright JD et al. National estimates of gender affirming surgery in the US. JAMA Netw Open. 2023 Aug 1;6(8):e2330348.

3. American Society of Plastic Surgeons. Plastic Surgery Statistics Report. ASPS National Clearinghouse of Plastic Surgery Procedural Statistics. 2020.

As Pride Month drew to a close, the Supreme Court made a shocking announcement. For the first time in the history of the court, it is willing to hear a legal challenge regarding gender-affirming care for minors. The justices will review whether a 2023 Tennessee law, SB1, which bans hormone therapy, puberty blockers, and surgery for transgender minors, is unconstitutional. This is the first time the Supreme Court will directly weigh in on gender-affirming care.

There are few topics as politically and medically divisive as gender-affirming care for minors. When the World Professional Association for Transgender Health (WPATH) released its updated Standards of Care, SOC8, one of the noticeable changes to the document was its approach to caring for transgender children and adolescents.

Dr. Brandt

Before I highlight these recommendations and the ensuing controversy, it is imperative to establish proper terminology. Unfortunately, medical and legal terms often differ. Both activists and opponents use these terms interchangeably, which makes discourse about an already emotionally charged topic extremely difficult. From a legal perspective, the terms “minor” and “child” often refer to individuals under the age of majority. In the United States, the age of majority is 18. However, the term child also has a well-established medical definition. A child is an individual between the stages of infancy and puberty. Adolescence is a transitional period marked by the onset of puberty until adulthood (typically the age of majority). As medical providers, understanding these definitions is essential to identifying misinformation pertaining to this type of healthcare.

For the purposes of this article, I will be adhering to the medical terminology. Now, I want to be very clear. WPATH does not endorse surgical procedures on children. Furthermore, surgeons are not performing gender-affirming surgeries on children. On adolescents, rarely. But children, never.

According to the updated SOC8, the only acceptable gender-affirming intervention for children is psychosocial support.¹ This does not include puberty blockers, hormones, or surgery, but rather allowing a child to explore their gender identity by experimenting with different clothing, toys, hairstyles, and even an alternative name that aligns more closely with their gender identity.¹

It is only after children reach adolescence that medical, and in rare cases, surgical interventions, can be considered. Puberty blockers are appropriate for patients who have started puberty and experience gender dysphoria. These medications are reversible, and their purpose is to temporarily pause puberty to allow the adolescent to further explore their gender identity.

The most significant side effect of puberty blockers is decreased bone density.¹ As a result, providers typically do not prescribe these medications for more than 2-3 years. After discontinuation of the medication, bone density returns to baseline.¹ If the adolescent’s gender identity is marked and sustained over time, hormone therapy, such as testosterone or estrogen is then considered. Unlike puberty blockers, these medications can have permanent side effects. Testosterone use can lead to irreversible hair growth, alopecia, clitoromegaly, and voice deepening, while estrogen can cause permanent breast growth and halt sperm production.¹ Future fertility and these side effects are discussed with the patient in detail prior to the initiation of these medications.

Contrary to the current political narrative, gender-affirming care for children and adolescents is not taken lightly. These individuals often receive years of multidisciplinary assessments, with a focus on gender identity development, social development and support, and diagnostic assessment of possible co-occurring mental health or developmental concerns and capacity for decision making.¹ The clinical visits also occur with parental support and consent.

WPATH SOC8 also delineates the provider qualifications for health care professionals assessing these patients. Providers must be licensed by their statutory bodies and hold a postgraduate degree by a nationally accredited statutory institution; receive theoretical and evidence-based training and develop expertise in child, adolescent, and family mental health across the developmental spectrum; receive training and have expertise in gender identity development and gender diversity in children and adolescence; have the ability to assess capacity to assent/consent; receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations; and to continue engaging in professional development in all areas relevant to gender-diverse children, adolescents, and families.¹

The most controversial aspect of gender-affirming care for children and adolescents relates to surgical treatment. While the rates of gender-affirming surgeries have increased for this age group over the years, the overall rate of gender-affirming surgery for adolescents is markedly lower compared with other adolescents seeking cosmetic surgeries and compared with transgender adults undergoing gender-affirming surgery.

In a cohort study conducted between 2016 to 2020, 48,019 patients were identified who had undergone gender-affirming surgery.² Only 3678 or 7.7% of patients were aged between 12 and 18, with the most common procedure being chest/breast surgery.² So, under about 1000 cases per year were gender-affirming surgeries on patients under 18.

During 2020 alone, the number of cisgender adolescents between the ages of 13 and 19 who underwent breast augmentation and breast reduction was 3233 and 4666, respectively.³ The outrage about gender-affirming surgeries on transgender youth, yet the silence on cosmetic procedures in this same age group, speaks volumes.

All surgeries on adolescents should be taken seriously and with caution, regardless of gender identity. However, current legislation disproportionately targets only transgender youth. For whatever reason, surgeries on transgender individuals are labeled as “body mutilation,” whereas surgeries on cisgender youth are not even discussed. Such inflammatory rhetoric and complete lack of empathy impedes the common goal of all parties: what is in the best interest of the minor? Unfortunately, in a few short months, the answer to this question will be determined by a group of nine justices who have no experience in medicine or transgender health care, instead of by medical experts and the parents who care for these individuals.
 

Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pennsylvania. She has no conflicts of interest.
 

References

1. Coleman E et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgender Health. 2022;23(sup):S1-S259.

2. Wright JD et al. National estimates of gender affirming surgery in the US. JAMA Netw Open. 2023 Aug 1;6(8):e2330348.

3. American Society of Plastic Surgeons. Plastic Surgery Statistics Report. ASPS National Clearinghouse of Plastic Surgery Procedural Statistics. 2020.

TOPLINE:

Isotretinoin was effective in treating acne in individuals undergoing masculinizing gender-affirming hormone therapy in a case series, but more information is needed on dosing and barriers to treatment.

METHODOLOGY:

• Acne can be a side effect of masculinizing hormone therapy for transmasculine individuals. While isotretinoin is an effective treatment option for acne, its effectiveness and safety in transgender and gender-diverse individuals are not well understood.
• This retrospective case series included 55 patients (mean age, 25.4 years) undergoing masculinizing hormone therapy at four medical centers, who were prescribed isotretinoin for acne associated with treatment.
• Isotretinoin treatment was started a median of 22.1 months after hormone therapy was initiated and continued for a median of 6 months with a median cumulative dose of 132.7 mg/kg.
• Researchers assessed acne improvement, clearance, recurrence, adverse effects, and reasons for treatment discontinuation.

TAKEAWAY:

• Overall, 48 patients (87.3%) experienced improvement, and 26 (47.3%) achieved clearance during treatment. A higher proportion of patients experienced improvement (97% vs 72.7%) and achieved clearance (63.6% vs 22.7%) with cumulative doses of ≥ 120 mg/kg than those who received cumulative doses < 120 mg/kg.
• The risk for recurrence was 20% (in four patients) among 20 patients who achieved clearance and had any subsequent health care encounters, with a mean follow-up time of 734.3 days.
• Common adverse effects included dryness (80%), joint pain (14.5%), and headaches (10.9%). Other adverse effects included nose bleeds (9.1%) and depression (5.5%).
• Of the 22 patients with a cumulative dose < 120 mg/kg, 14 (63.6%) were lost to follow-up; among those not lost to follow-up, 2 patients discontinued treatment because of transfer of care, 1 because of adverse effects, and 1 because of gender-affirming surgery, with concerns about wound healing.

IN PRACTICE:

“Although isotretinoin appears to be an effective treatment option for acne among individuals undergoing masculinizing hormone therapy, further efforts are needed to understand optimal dosing and treatment barriers to improve outcomes in transgender and gender-diverse individuals receiving testosterone,” the authors concluded.

SOURCE:

The study, led by James Choe, BS, Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, was published online in JAMA Dermatology.

LIMITATIONS:

The study population was limited to four centers, and variability in clinician- and patient-reported acne outcomes and missing information could affect the reliability of data. Because of the small sample size, the association of masculinizing hormone therapy regimens with outcomes could not be evaluated.

DISCLOSURES:

One author is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Three authors reported receiving grants or personal fees from various sources. The other authors declared no conflicts of interest.

A version of this article first appeared on Medscape.com.

TOPLINE:

Isotretinoin was effective in treating acne in individuals undergoing masculinizing gender-affirming hormone therapy in a case series, but more information is needed on dosing and barriers to treatment.

METHODOLOGY:

• Acne can be a side effect of masculinizing hormone therapy for transmasculine individuals. While isotretinoin is an effective treatment option for acne, its effectiveness and safety in transgender and gender-diverse individuals are not well understood.
• This retrospective case series included 55 patients (mean age, 25.4 years) undergoing masculinizing hormone therapy at four medical centers, who were prescribed isotretinoin for acne associated with treatment.
• Isotretinoin treatment was started a median of 22.1 months after hormone therapy was initiated and continued for a median of 6 months with a median cumulative dose of 132.7 mg/kg.
• Researchers assessed acne improvement, clearance, recurrence, adverse effects, and reasons for treatment discontinuation.

TAKEAWAY:

• Overall, 48 patients (87.3%) experienced improvement, and 26 (47.3%) achieved clearance during treatment. A higher proportion of patients experienced improvement (97% vs 72.7%) and achieved clearance (63.6% vs 22.7%) with cumulative doses of ≥ 120 mg/kg than those who received cumulative doses < 120 mg/kg.
• The risk for recurrence was 20% (in four patients) among 20 patients who achieved clearance and had any subsequent health care encounters, with a mean follow-up time of 734.3 days.
• Common adverse effects included dryness (80%), joint pain (14.5%), and headaches (10.9%). Other adverse effects included nose bleeds (9.1%) and depression (5.5%).
• Of the 22 patients with a cumulative dose < 120 mg/kg, 14 (63.6%) were lost to follow-up; among those not lost to follow-up, 2 patients discontinued treatment because of transfer of care, 1 because of adverse effects, and 1 because of gender-affirming surgery, with concerns about wound healing.

IN PRACTICE:

“Although isotretinoin appears to be an effective treatment option for acne among individuals undergoing masculinizing hormone therapy, further efforts are needed to understand optimal dosing and treatment barriers to improve outcomes in transgender and gender-diverse individuals receiving testosterone,” the authors concluded.

SOURCE:

The study, led by James Choe, BS, Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, was published online in JAMA Dermatology.

LIMITATIONS:

The study population was limited to four centers, and variability in clinician- and patient-reported acne outcomes and missing information could affect the reliability of data. Because of the small sample size, the association of masculinizing hormone therapy regimens with outcomes could not be evaluated.

DISCLOSURES:

One author is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Three authors reported receiving grants or personal fees from various sources. The other authors declared no conflicts of interest.

A version of this article first appeared on Medscape.com.

TOPLINE:

Isotretinoin was effective in treating acne in individuals undergoing masculinizing gender-affirming hormone therapy in a case series, but more information is needed on dosing and barriers to treatment.

METHODOLOGY:

• Acne can be a side effect of masculinizing hormone therapy for transmasculine individuals. While isotretinoin is an effective treatment option for acne, its effectiveness and safety in transgender and gender-diverse individuals are not well understood.
• This retrospective case series included 55 patients (mean age, 25.4 years) undergoing masculinizing hormone therapy at four medical centers, who were prescribed isotretinoin for acne associated with treatment.
• Isotretinoin treatment was started a median of 22.1 months after hormone therapy was initiated and continued for a median of 6 months with a median cumulative dose of 132.7 mg/kg.
• Researchers assessed acne improvement, clearance, recurrence, adverse effects, and reasons for treatment discontinuation.

TAKEAWAY:

• Overall, 48 patients (87.3%) experienced improvement, and 26 (47.3%) achieved clearance during treatment. A higher proportion of patients experienced improvement (97% vs 72.7%) and achieved clearance (63.6% vs 22.7%) with cumulative doses of ≥ 120 mg/kg than those who received cumulative doses < 120 mg/kg.
• The risk for recurrence was 20% (in four patients) among 20 patients who achieved clearance and had any subsequent health care encounters, with a mean follow-up time of 734.3 days.
• Common adverse effects included dryness (80%), joint pain (14.5%), and headaches (10.9%). Other adverse effects included nose bleeds (9.1%) and depression (5.5%).
• Of the 22 patients with a cumulative dose < 120 mg/kg, 14 (63.6%) were lost to follow-up; among those not lost to follow-up, 2 patients discontinued treatment because of transfer of care, 1 because of adverse effects, and 1 because of gender-affirming surgery, with concerns about wound healing.

IN PRACTICE:

“Although isotretinoin appears to be an effective treatment option for acne among individuals undergoing masculinizing hormone therapy, further efforts are needed to understand optimal dosing and treatment barriers to improve outcomes in transgender and gender-diverse individuals receiving testosterone,” the authors concluded.

SOURCE:

The study, led by James Choe, BS, Department of Dermatology, Brigham and Women’s Hospital, Harvard Medical School, Boston, was published online in JAMA Dermatology.

LIMITATIONS:

The study population was limited to four centers, and variability in clinician- and patient-reported acne outcomes and missing information could affect the reliability of data. Because of the small sample size, the association of masculinizing hormone therapy regimens with outcomes could not be evaluated.

DISCLOSURES:

One author is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Three authors reported receiving grants or personal fees from various sources. The other authors declared no conflicts of interest.

A version of this article first appeared on Medscape.com.

TORONTO — In the course of a well visit, the way in which clinicians elicit an adolescent’s sexual orientation and gender identity (SOGI) matters, and there are different preferences for those with a gender identity different from their birth assignment or non-heterosexuals relative to those in neither of these categories.

In a study that surveyed more than 60,000 adolescents, one of the messages was that there is a “balancing act” that involves affirming the child’s self-identity while recognizing the substantial vulnerability at this step in development, reported Scott Jelinek, MD, a third-year pediatrics resident in the Children’s Hospital of Philadelphia, University of Pennsylvania.

Based on his work, there are two aims.

“The first is to determine the comfort level of the adolescent in discussing sensitive health information,” said Dr. Jelinek, referring to the discussion of SOGI irrespective of how the adolescent responds. “To understand this is crucial because this first encounter with healthcare can be formative.”

Yet, for those who identify as lesbian, gay, bisexual, transsexual, queer, or with another sexual or gender orientation (LBGTQ+), the encounter can be more delicate, according to Dr. Jelinek. One reason is that there is greater uncertainty about acceptance of these identities from peers, parents, and others, Dr. Jelinek said.

This was reinforced by results of a cross-sectional study of 62,695 adolescents in 31 pediatric clinics in the Philadelphia area. Of these, 10,381 (16.6%) identified as LGBTQ+. The adolescents aged in range from 13 to 21 years with a mean age of 15.3.

These data were presented at the Pediatric Academic Societies annual meeting. Dr. Jelinek received this year’s Society of Pediatric Research Richard D. Rowe Award for clinical research by a fellow.
 

Revealing Sensitive Information

With the intention of comparing responses from LBGTQ+ youth to those of cisgender heterosexuals, the first of two primary questions elicited information about comfort level discussing SOGI in the presence of parents or caregivers during a primary care visit. The second asked for a preference regarding electronic or oral capture of the information. “Almost half [49.4%] of the LGBTQ+ adolescents expressed discomfort discussing this information with the caregiver present,” reported Dr. Jelinek. This proportion, which was close to double the 25.5% rate among the cisgender heterosexual respondents, reached significance (P < .01). After adjustment for covariates, there was a 60% greater odds ratio (OR) among LBGTQ+ adolescents for expressing reluctance to share this information in front of a caregiver (adjusted odds ratio [aOR] 0.37; 95% CI: 0.35-0.39).

The greater preference among LBGTQ+ adolescents for electronic capture of SOGI-relevant information also reached statistical significance. Even though the proportional difference was modest (74.2% vs 72.7%; P < .01), it corresponded to about a 10% greater preference for electronic data collection after adjustment (aOR 1.08; 95% CI: 1.03-1.14), Dr. Jelinek reported.

These results were generally consistent across clinics, which were located in urban, suburban, and rural areas. Responses among Black adolescents, which represented 29.7% of the study population, were similar to those provided by White adolescents, which represented 46.1%, and Hispanics, which represented about 10% of the sample.

The results are not entirely surprising in the context of the potential for LBGTQ+ stigma, but Dr. Jelinek emphasized the need for being aware that this discussion is delicate and might have ramifications after the visit for children trying to accept and affirm their self-identification.

“Let us remember that the healthcare system has the potential to be a powerful ally in the lives of LBGTQ+ youth and to meet their unique needs,” he said.

The interaction is also delicate because parents might not yet be aware of their child’s sexual orientation. Indeed, Dr. Jelinek said that completion of the Attitudes Toward Homosexuality Questionnaire (AHQ) might be the first time that these individuals have revealed this aspect of their identity to anyone.

For confirming a non-heterosexual orientation, “pediatricians are on the front line and often the first point of contact for adolescents seeking health support and affirmation,” he said.

For this reason, it is also essential to maintain confidentiality to the degree that the patient specifies. Dr. Jelinek recognizes tension when balancing visibility and affirmation against the need for privacy, but he said both are important. Even if pediatricians should provide a positive experience for adolescents revealing their sexual orientation, there might be personal, family, and social adjustments to navigate over time.

As a result, Dr. Jelinek warned that there are issues for protecting information that an adolescent is not ready to reveal.

In this regard. “there is an urgent need for innovative solutions to balance visibility with privacy in primary care,” he said, reporting that electronic medical records (EMR) do not necessarily guarantee confidentiality, particularly from family members.

When adolescents arrive at the office to complete an AHQ, front desk staff at Dr. Jelinek’s center are instructed to hand the tablet to the child, not the caregiver. However, he recognizes that this does not prevent the caregiver from reviewing the answers or in some cases taking the tablet to complete the answers.

“If I enter the exam room and see the tablet in a parent’s lap, I am going to want to have a conversation with the patient to verify the answers,” he said.
 

Protecting Patients

The data from this study provoke important questions about how to achieve the goals that Dr. Jelinek described, according to Ashley M. Lekach, MSN, RN, a family nurse practitioner working in pediatric endocrinology at NewYork-Presbyterian’s Methodist Hospital in Brooklyn, New York. Ms. Lekach was not involved with the study.

“My concern is that once we are given this sensitive information, how do we make sure we are going to protect the patient from unwanted disclosure?” Ms. Lekach said. She agreed that there is a risk that EMRs can be accessed by individuals to which the patient would not want SOGI information revealed.

“It is a vote of confidence for the patient to reveal this information to me, and it is clearly our job to make sure the patient feels safe,” she said.

She also expressed concern that adolescents who reveal this information might need resources to cope with issues raised by non-heterosexual identification. She agreed that discussing sexual orientation and gender identity in the clinical setting is often a major step for adolescents, particularly young adolescents, but she believes follow-up and next steps are in the interest of the patient.

Although the need for affirmation and confidentiality are not new ideas, Ms. Lekach said that the talk provided some useful context for thinking about these issues.

Dr. Jelinek and Ms. Lekach report no potential conflicts of interest.

TORONTO — In the course of a well visit, the way in which clinicians elicit an adolescent’s sexual orientation and gender identity (SOGI) matters, and there are different preferences for those with a gender identity different from their birth assignment or non-heterosexuals relative to those in neither of these categories.

In a study that surveyed more than 60,000 adolescents, one of the messages was that there is a “balancing act” that involves affirming the child’s self-identity while recognizing the substantial vulnerability at this step in development, reported Scott Jelinek, MD, a third-year pediatrics resident in the Children’s Hospital of Philadelphia, University of Pennsylvania.

Based on his work, there are two aims.

“The first is to determine the comfort level of the adolescent in discussing sensitive health information,” said Dr. Jelinek, referring to the discussion of SOGI irrespective of how the adolescent responds. “To understand this is crucial because this first encounter with healthcare can be formative.”

Yet, for those who identify as lesbian, gay, bisexual, transsexual, queer, or with another sexual or gender orientation (LBGTQ+), the encounter can be more delicate, according to Dr. Jelinek. One reason is that there is greater uncertainty about acceptance of these identities from peers, parents, and others, Dr. Jelinek said.

This was reinforced by results of a cross-sectional study of 62,695 adolescents in 31 pediatric clinics in the Philadelphia area. Of these, 10,381 (16.6%) identified as LGBTQ+. The adolescents aged in range from 13 to 21 years with a mean age of 15.3.

These data were presented at the Pediatric Academic Societies annual meeting. Dr. Jelinek received this year’s Society of Pediatric Research Richard D. Rowe Award for clinical research by a fellow.
 

Revealing Sensitive Information

With the intention of comparing responses from LBGTQ+ youth to those of cisgender heterosexuals, the first of two primary questions elicited information about comfort level discussing SOGI in the presence of parents or caregivers during a primary care visit. The second asked for a preference regarding electronic or oral capture of the information. “Almost half [49.4%] of the LGBTQ+ adolescents expressed discomfort discussing this information with the caregiver present,” reported Dr. Jelinek. This proportion, which was close to double the 25.5% rate among the cisgender heterosexual respondents, reached significance (P < .01). After adjustment for covariates, there was a 60% greater odds ratio (OR) among LBGTQ+ adolescents for expressing reluctance to share this information in front of a caregiver (adjusted odds ratio [aOR] 0.37; 95% CI: 0.35-0.39).

The greater preference among LBGTQ+ adolescents for electronic capture of SOGI-relevant information also reached statistical significance. Even though the proportional difference was modest (74.2% vs 72.7%; P < .01), it corresponded to about a 10% greater preference for electronic data collection after adjustment (aOR 1.08; 95% CI: 1.03-1.14), Dr. Jelinek reported.

These results were generally consistent across clinics, which were located in urban, suburban, and rural areas. Responses among Black adolescents, which represented 29.7% of the study population, were similar to those provided by White adolescents, which represented 46.1%, and Hispanics, which represented about 10% of the sample.

The results are not entirely surprising in the context of the potential for LBGTQ+ stigma, but Dr. Jelinek emphasized the need for being aware that this discussion is delicate and might have ramifications after the visit for children trying to accept and affirm their self-identification.

“Let us remember that the healthcare system has the potential to be a powerful ally in the lives of LBGTQ+ youth and to meet their unique needs,” he said.

The interaction is also delicate because parents might not yet be aware of their child’s sexual orientation. Indeed, Dr. Jelinek said that completion of the Attitudes Toward Homosexuality Questionnaire (AHQ) might be the first time that these individuals have revealed this aspect of their identity to anyone.

For confirming a non-heterosexual orientation, “pediatricians are on the front line and often the first point of contact for adolescents seeking health support and affirmation,” he said.

For this reason, it is also essential to maintain confidentiality to the degree that the patient specifies. Dr. Jelinek recognizes tension when balancing visibility and affirmation against the need for privacy, but he said both are important. Even if pediatricians should provide a positive experience for adolescents revealing their sexual orientation, there might be personal, family, and social adjustments to navigate over time.

As a result, Dr. Jelinek warned that there are issues for protecting information that an adolescent is not ready to reveal.

In this regard. “there is an urgent need for innovative solutions to balance visibility with privacy in primary care,” he said, reporting that electronic medical records (EMR) do not necessarily guarantee confidentiality, particularly from family members.

When adolescents arrive at the office to complete an AHQ, front desk staff at Dr. Jelinek’s center are instructed to hand the tablet to the child, not the caregiver. However, he recognizes that this does not prevent the caregiver from reviewing the answers or in some cases taking the tablet to complete the answers.

“If I enter the exam room and see the tablet in a parent’s lap, I am going to want to have a conversation with the patient to verify the answers,” he said.
 

Protecting Patients

The data from this study provoke important questions about how to achieve the goals that Dr. Jelinek described, according to Ashley M. Lekach, MSN, RN, a family nurse practitioner working in pediatric endocrinology at NewYork-Presbyterian’s Methodist Hospital in Brooklyn, New York. Ms. Lekach was not involved with the study.

“My concern is that once we are given this sensitive information, how do we make sure we are going to protect the patient from unwanted disclosure?” Ms. Lekach said. She agreed that there is a risk that EMRs can be accessed by individuals to which the patient would not want SOGI information revealed.

“It is a vote of confidence for the patient to reveal this information to me, and it is clearly our job to make sure the patient feels safe,” she said.

She also expressed concern that adolescents who reveal this information might need resources to cope with issues raised by non-heterosexual identification. She agreed that discussing sexual orientation and gender identity in the clinical setting is often a major step for adolescents, particularly young adolescents, but she believes follow-up and next steps are in the interest of the patient.

Although the need for affirmation and confidentiality are not new ideas, Ms. Lekach said that the talk provided some useful context for thinking about these issues.

Dr. Jelinek and Ms. Lekach report no potential conflicts of interest.

TORONTO — In the course of a well visit, the way in which clinicians elicit an adolescent’s sexual orientation and gender identity (SOGI) matters, and there are different preferences for those with a gender identity different from their birth assignment or non-heterosexuals relative to those in neither of these categories.

In a study that surveyed more than 60,000 adolescents, one of the messages was that there is a “balancing act” that involves affirming the child’s self-identity while recognizing the substantial vulnerability at this step in development, reported Scott Jelinek, MD, a third-year pediatrics resident in the Children’s Hospital of Philadelphia, University of Pennsylvania.

Based on his work, there are two aims.

“The first is to determine the comfort level of the adolescent in discussing sensitive health information,” said Dr. Jelinek, referring to the discussion of SOGI irrespective of how the adolescent responds. “To understand this is crucial because this first encounter with healthcare can be formative.”

Yet, for those who identify as lesbian, gay, bisexual, transsexual, queer, or with another sexual or gender orientation (LBGTQ+), the encounter can be more delicate, according to Dr. Jelinek. One reason is that there is greater uncertainty about acceptance of these identities from peers, parents, and others, Dr. Jelinek said.

This was reinforced by results of a cross-sectional study of 62,695 adolescents in 31 pediatric clinics in the Philadelphia area. Of these, 10,381 (16.6%) identified as LGBTQ+. The adolescents aged in range from 13 to 21 years with a mean age of 15.3.

These data were presented at the Pediatric Academic Societies annual meeting. Dr. Jelinek received this year’s Society of Pediatric Research Richard D. Rowe Award for clinical research by a fellow.
 

Revealing Sensitive Information

With the intention of comparing responses from LBGTQ+ youth to those of cisgender heterosexuals, the first of two primary questions elicited information about comfort level discussing SOGI in the presence of parents or caregivers during a primary care visit. The second asked for a preference regarding electronic or oral capture of the information. “Almost half [49.4%] of the LGBTQ+ adolescents expressed discomfort discussing this information with the caregiver present,” reported Dr. Jelinek. This proportion, which was close to double the 25.5% rate among the cisgender heterosexual respondents, reached significance (P < .01). After adjustment for covariates, there was a 60% greater odds ratio (OR) among LBGTQ+ adolescents for expressing reluctance to share this information in front of a caregiver (adjusted odds ratio [aOR] 0.37; 95% CI: 0.35-0.39).

The greater preference among LBGTQ+ adolescents for electronic capture of SOGI-relevant information also reached statistical significance. Even though the proportional difference was modest (74.2% vs 72.7%; P < .01), it corresponded to about a 10% greater preference for electronic data collection after adjustment (aOR 1.08; 95% CI: 1.03-1.14), Dr. Jelinek reported.

These results were generally consistent across clinics, which were located in urban, suburban, and rural areas. Responses among Black adolescents, which represented 29.7% of the study population, were similar to those provided by White adolescents, which represented 46.1%, and Hispanics, which represented about 10% of the sample.

The results are not entirely surprising in the context of the potential for LBGTQ+ stigma, but Dr. Jelinek emphasized the need for being aware that this discussion is delicate and might have ramifications after the visit for children trying to accept and affirm their self-identification.

“Let us remember that the healthcare system has the potential to be a powerful ally in the lives of LBGTQ+ youth and to meet their unique needs,” he said.

The interaction is also delicate because parents might not yet be aware of their child’s sexual orientation. Indeed, Dr. Jelinek said that completion of the Attitudes Toward Homosexuality Questionnaire (AHQ) might be the first time that these individuals have revealed this aspect of their identity to anyone.

For confirming a non-heterosexual orientation, “pediatricians are on the front line and often the first point of contact for adolescents seeking health support and affirmation,” he said.

For this reason, it is also essential to maintain confidentiality to the degree that the patient specifies. Dr. Jelinek recognizes tension when balancing visibility and affirmation against the need for privacy, but he said both are important. Even if pediatricians should provide a positive experience for adolescents revealing their sexual orientation, there might be personal, family, and social adjustments to navigate over time.

As a result, Dr. Jelinek warned that there are issues for protecting information that an adolescent is not ready to reveal.

In this regard. “there is an urgent need for innovative solutions to balance visibility with privacy in primary care,” he said, reporting that electronic medical records (EMR) do not necessarily guarantee confidentiality, particularly from family members.

When adolescents arrive at the office to complete an AHQ, front desk staff at Dr. Jelinek’s center are instructed to hand the tablet to the child, not the caregiver. However, he recognizes that this does not prevent the caregiver from reviewing the answers or in some cases taking the tablet to complete the answers.

“If I enter the exam room and see the tablet in a parent’s lap, I am going to want to have a conversation with the patient to verify the answers,” he said.
 

Protecting Patients

The data from this study provoke important questions about how to achieve the goals that Dr. Jelinek described, according to Ashley M. Lekach, MSN, RN, a family nurse practitioner working in pediatric endocrinology at NewYork-Presbyterian’s Methodist Hospital in Brooklyn, New York. Ms. Lekach was not involved with the study.

“My concern is that once we are given this sensitive information, how do we make sure we are going to protect the patient from unwanted disclosure?” Ms. Lekach said. She agreed that there is a risk that EMRs can be accessed by individuals to which the patient would not want SOGI information revealed.

“It is a vote of confidence for the patient to reveal this information to me, and it is clearly our job to make sure the patient feels safe,” she said.

She also expressed concern that adolescents who reveal this information might need resources to cope with issues raised by non-heterosexual identification. She agreed that discussing sexual orientation and gender identity in the clinical setting is often a major step for adolescents, particularly young adolescents, but she believes follow-up and next steps are in the interest of the patient.

Although the need for affirmation and confidentiality are not new ideas, Ms. Lekach said that the talk provided some useful context for thinking about these issues.

Dr. Jelinek and Ms. Lekach report no potential conflicts of interest.

Recent newspaper headlines have focused almost exclusively on gender-affirming medical interventions for transgender youth (eg, puberty blockers and gender-affirming hormones like estrogen and testosterone). It is true that these are important treatments that are consistently tied to improvements in mental health. However, an additional powerful predictor of good mental health outcomes for transgender youth is parental support and acceptance.

It is essential that clinicians consider this when creating treatment plans for transgender youth. While transgender young people are struggling with gender dysphoria, their parents are often struggling as well. Sadly, they are often afraid to share their own struggles, despite working through these being essential for their children’s thriving and well-being. I have a few key tips for combating this issue. My upcoming book Free to Be: Understanding Kids & Gender Identity provides much more context for parents and providers, but I will highlight a few big takeaways here.

Stanford Lucille Packard Children&#039;s Hospital.

Give Parents Their Own Space

Many parents have never encountered a transgender person in their life and have a lot of questions. At times, they may be “thinking out loud” and say things in passing that aren’t their final thoughts or opinions on a matter. This can, unfortunately, be damaging to their children. I often speak with adult transgender people whose parents said something they no longer believe (eg, “being trans is just a mental illness – you need therapy to fix it”), but these comments stick in the person’s mind and drive shame and self-esteem challenges later in life, sometimes for decades. Parents need to have a safe space, with a trained professional with expertise in gender, to work through their concerns and questions away from their children, so that when they talk to their kids about gender, they are presenting their fully formed thoughts.

Validate Parents’ Difficult Experiences

As pediatric providers, we are often focused on the difficult experiences of our transgender pediatric patients. However, their parents tend to be struggling as well, and that struggling predicts adverse mental health outcomes for their children.

The most common reaction a parent has upon learning their child is transgender is fear. It’s important to validate this fear (and other feelings that come out), so that parents know they can share with you what’s really going on in their minds.

There are some common themes we see for parents. Some are big fears: fear that their child will be victimized or fear that their child will later regret taking gender-affirming hormones and blame the parents for giving permission to take them. Parents often say they had a gendered vision for what their child’s future would be like, and their child coming out as transgender changes that (it can be helpful to gently remind parents that children almost never grow up exactly how we predict).

Some themes are more mundane but nonetheless distressing for parents, such as not wanting to throw away meaningful souvenirs from past vacations that have their child’s birth name on them. Clinicians can and should validate these thoughts and feelings, while also providing additional context and education. I often recommend the book Found in Transition by Pariah Hassouri, a pediatrician who goes through many of these common struggles after her daughter comes out as transgender.

 

Take a Three-Stage Approach When Adolescents Are Considering Gender-Affirming Medical Interventions

We recently outlined our process for conducting a biopsychosocial assessment for adolescents considering pubertal suppression for adolescent gender dysphoria in The Journal of the American Academy of Child & Adolescent Psychiatry, for those who want more detail on how to conduct these assessments. On the theme of supporting parents, I would highlight the value of taking a three-stage approach. In the first stage, a clinician meets with an adolescent alone to collect their gender history and discuss important considerations regarding the medical intervention. In stage two, the same information about the medical intervention is shared with parents, along with a summary of what the adolescent shared with the clinician (with the adolescent’s consent, of course). Often there will be some areas of disconnect. We make a list of these areas of disconnect that are addressed in stage three, in which the full family is brought together to get everyone on the same page and understanding each other’s perspectives.

Common disconnects include gender dysphoria seeming to “come out of nowhere” from the parents’ perspective, necessitating the young person to recount an early life experience in which they were harassed for expressing gender nonconformity, leading them to act stereotypically in line with their sex assigned at birth for years to avoid being “outed” and harassed more. Conversations around fertility preservation can be particularly complex. Young people and their parents also sometimes have different conceptualizations of gender identity and require a shared framework for talking about gender identity (which I offer in my forthcoming book). This list of family therapy topics can be diverse and highly dependent on the family. An additional resource for this phase of the family therapy is The Family Acceptance Project, which has created culturally tailored materials to help parents understand their sexual and gender minority children.

In summary, fostering healthy family functioning is essential for the care of transgender and gender diverse youth, and parents require support in addition to their children needing support. I encourage all gender providers to incorporate the vital element of family therapy into their practice.

 

Dr. Turban is director of the Gender Psychiatry Program at the University of California, San Francisco, where he is an assistant professor of child & adolescent psychiatry and affiliate faculty at the Philip R. Lee Institute for Health Policy Studies. He is on X @jack_turban.

Recent newspaper headlines have focused almost exclusively on gender-affirming medical interventions for transgender youth (eg, puberty blockers and gender-affirming hormones like estrogen and testosterone). It is true that these are important treatments that are consistently tied to improvements in mental health. However, an additional powerful predictor of good mental health outcomes for transgender youth is parental support and acceptance.

It is essential that clinicians consider this when creating treatment plans for transgender youth. While transgender young people are struggling with gender dysphoria, their parents are often struggling as well. Sadly, they are often afraid to share their own struggles, despite working through these being essential for their children’s thriving and well-being. I have a few key tips for combating this issue. My upcoming book Free to Be: Understanding Kids & Gender Identity provides much more context for parents and providers, but I will highlight a few big takeaways here.

Stanford Lucille Packard Children&#039;s Hospital.

Give Parents Their Own Space

Many parents have never encountered a transgender person in their life and have a lot of questions. At times, they may be “thinking out loud” and say things in passing that aren’t their final thoughts or opinions on a matter. This can, unfortunately, be damaging to their children. I often speak with adult transgender people whose parents said something they no longer believe (eg, “being trans is just a mental illness – you need therapy to fix it”), but these comments stick in the person’s mind and drive shame and self-esteem challenges later in life, sometimes for decades. Parents need to have a safe space, with a trained professional with expertise in gender, to work through their concerns and questions away from their children, so that when they talk to their kids about gender, they are presenting their fully formed thoughts.

Validate Parents’ Difficult Experiences

As pediatric providers, we are often focused on the difficult experiences of our transgender pediatric patients. However, their parents tend to be struggling as well, and that struggling predicts adverse mental health outcomes for their children.

The most common reaction a parent has upon learning their child is transgender is fear. It’s important to validate this fear (and other feelings that come out), so that parents know they can share with you what’s really going on in their minds.

There are some common themes we see for parents. Some are big fears: fear that their child will be victimized or fear that their child will later regret taking gender-affirming hormones and blame the parents for giving permission to take them. Parents often say they had a gendered vision for what their child’s future would be like, and their child coming out as transgender changes that (it can be helpful to gently remind parents that children almost never grow up exactly how we predict).

Some themes are more mundane but nonetheless distressing for parents, such as not wanting to throw away meaningful souvenirs from past vacations that have their child’s birth name on them. Clinicians can and should validate these thoughts and feelings, while also providing additional context and education. I often recommend the book Found in Transition by Pariah Hassouri, a pediatrician who goes through many of these common struggles after her daughter comes out as transgender.

 

Take a Three-Stage Approach When Adolescents Are Considering Gender-Affirming Medical Interventions

We recently outlined our process for conducting a biopsychosocial assessment for adolescents considering pubertal suppression for adolescent gender dysphoria in The Journal of the American Academy of Child & Adolescent Psychiatry, for those who want more detail on how to conduct these assessments. On the theme of supporting parents, I would highlight the value of taking a three-stage approach. In the first stage, a clinician meets with an adolescent alone to collect their gender history and discuss important considerations regarding the medical intervention. In stage two, the same information about the medical intervention is shared with parents, along with a summary of what the adolescent shared with the clinician (with the adolescent’s consent, of course). Often there will be some areas of disconnect. We make a list of these areas of disconnect that are addressed in stage three, in which the full family is brought together to get everyone on the same page and understanding each other’s perspectives.

Common disconnects include gender dysphoria seeming to “come out of nowhere” from the parents’ perspective, necessitating the young person to recount an early life experience in which they were harassed for expressing gender nonconformity, leading them to act stereotypically in line with their sex assigned at birth for years to avoid being “outed” and harassed more. Conversations around fertility preservation can be particularly complex. Young people and their parents also sometimes have different conceptualizations of gender identity and require a shared framework for talking about gender identity (which I offer in my forthcoming book). This list of family therapy topics can be diverse and highly dependent on the family. An additional resource for this phase of the family therapy is The Family Acceptance Project, which has created culturally tailored materials to help parents understand their sexual and gender minority children.

In summary, fostering healthy family functioning is essential for the care of transgender and gender diverse youth, and parents require support in addition to their children needing support. I encourage all gender providers to incorporate the vital element of family therapy into their practice.

 

Dr. Turban is director of the Gender Psychiatry Program at the University of California, San Francisco, where he is an assistant professor of child & adolescent psychiatry and affiliate faculty at the Philip R. Lee Institute for Health Policy Studies. He is on X @jack_turban.

Recent newspaper headlines have focused almost exclusively on gender-affirming medical interventions for transgender youth (eg, puberty blockers and gender-affirming hormones like estrogen and testosterone). It is true that these are important treatments that are consistently tied to improvements in mental health. However, an additional powerful predictor of good mental health outcomes for transgender youth is parental support and acceptance.

It is essential that clinicians consider this when creating treatment plans for transgender youth. While transgender young people are struggling with gender dysphoria, their parents are often struggling as well. Sadly, they are often afraid to share their own struggles, despite working through these being essential for their children’s thriving and well-being. I have a few key tips for combating this issue. My upcoming book Free to Be: Understanding Kids & Gender Identity provides much more context for parents and providers, but I will highlight a few big takeaways here.

Stanford Lucille Packard Children&#039;s Hospital.

Give Parents Their Own Space

Many parents have never encountered a transgender person in their life and have a lot of questions. At times, they may be “thinking out loud” and say things in passing that aren’t their final thoughts or opinions on a matter. This can, unfortunately, be damaging to their children. I often speak with adult transgender people whose parents said something they no longer believe (eg, “being trans is just a mental illness – you need therapy to fix it”), but these comments stick in the person’s mind and drive shame and self-esteem challenges later in life, sometimes for decades. Parents need to have a safe space, with a trained professional with expertise in gender, to work through their concerns and questions away from their children, so that when they talk to their kids about gender, they are presenting their fully formed thoughts.

Validate Parents’ Difficult Experiences

As pediatric providers, we are often focused on the difficult experiences of our transgender pediatric patients. However, their parents tend to be struggling as well, and that struggling predicts adverse mental health outcomes for their children.

The most common reaction a parent has upon learning their child is transgender is fear. It’s important to validate this fear (and other feelings that come out), so that parents know they can share with you what’s really going on in their minds.

There are some common themes we see for parents. Some are big fears: fear that their child will be victimized or fear that their child will later regret taking gender-affirming hormones and blame the parents for giving permission to take them. Parents often say they had a gendered vision for what their child’s future would be like, and their child coming out as transgender changes that (it can be helpful to gently remind parents that children almost never grow up exactly how we predict).

Some themes are more mundane but nonetheless distressing for parents, such as not wanting to throw away meaningful souvenirs from past vacations that have their child’s birth name on them. Clinicians can and should validate these thoughts and feelings, while also providing additional context and education. I often recommend the book Found in Transition by Pariah Hassouri, a pediatrician who goes through many of these common struggles after her daughter comes out as transgender.

 

Take a Three-Stage Approach When Adolescents Are Considering Gender-Affirming Medical Interventions

We recently outlined our process for conducting a biopsychosocial assessment for adolescents considering pubertal suppression for adolescent gender dysphoria in The Journal of the American Academy of Child & Adolescent Psychiatry, for those who want more detail on how to conduct these assessments. On the theme of supporting parents, I would highlight the value of taking a three-stage approach. In the first stage, a clinician meets with an adolescent alone to collect their gender history and discuss important considerations regarding the medical intervention. In stage two, the same information about the medical intervention is shared with parents, along with a summary of what the adolescent shared with the clinician (with the adolescent’s consent, of course). Often there will be some areas of disconnect. We make a list of these areas of disconnect that are addressed in stage three, in which the full family is brought together to get everyone on the same page and understanding each other’s perspectives.

Common disconnects include gender dysphoria seeming to “come out of nowhere” from the parents’ perspective, necessitating the young person to recount an early life experience in which they were harassed for expressing gender nonconformity, leading them to act stereotypically in line with their sex assigned at birth for years to avoid being “outed” and harassed more. Conversations around fertility preservation can be particularly complex. Young people and their parents also sometimes have different conceptualizations of gender identity and require a shared framework for talking about gender identity (which I offer in my forthcoming book). This list of family therapy topics can be diverse and highly dependent on the family. An additional resource for this phase of the family therapy is The Family Acceptance Project, which has created culturally tailored materials to help parents understand their sexual and gender minority children.

In summary, fostering healthy family functioning is essential for the care of transgender and gender diverse youth, and parents require support in addition to their children needing support. I encourage all gender providers to incorporate the vital element of family therapy into their practice.

 

Dr. Turban is director of the Gender Psychiatry Program at the University of California, San Francisco, where he is an assistant professor of child & adolescent psychiatry and affiliate faculty at the Philip R. Lee Institute for Health Policy Studies. He is on X @jack_turban.

TOPLINE:

Mental health distress increased disproportionately among transgender and gender-nonconforming US adults between 2014 and 2021 compared with their cisgender counterparts, a new study suggested. Investigators said the findings among an historically marginalized segment of society point to a need to address a growing inequality in mental health.

METHODOLOGY:

• Investigators drew on 2014-2021 US Behavioral Risk Factor Surveillance System (BRFSS) survey data, using logistic and ordinary least squares regression to document temporal trends in the transgender-cisgender disparity in self-reports of the number of poor mental health days in the past month and frequent mental distress.
• They included 43 states that implemented the optional sexual orientation and gender identity module in the BRFSS.
• Outcomes included the number of poor mental health days in the past month, as well as frequent mental distress (≥ 14 poor mental health days in the past month).

TAKEAWAY:

• Even in 2014, there was a discrepancy between cisgender and transgender and gender-nonconforming individuals in the reported mean of poor mental health days (3.68 vs 5.42).
• The size of this disparity, adjusted by differences in observable characteristics, increased by 2.75 days (95% CI, 0.58-4.91) over the study period.
• The inequality in mental health status between cisgender and transgender and nonconforming adults grew from 11.4% vs 18.9% in 2014, respectively, to 14.6% vs 32.9% in 2021, respectively.

IN PRACTICE:

“Our findings demonstrate sizable and worsening inequities in mental health across gender identity,” the authors wrote. “Mental health and primary care providers must be prepared to address the unique psychosocial needs of gender minority adults. Furthermore, our findings highlight the need for action to reduce these disparities.”

SOURCE:

Samuel Mann, PhD, of the RAND Corporation, was the corresponding author of the study. It was published online on April 10 in the American Journal of Public Health.

LIMITATIONS:

Measures of mental health were derived from self-reports. In addition, data from seven states were missing because these states did not include sexual orientation and gender identity in the BRFSS. And the BRFSS does not survey people who are unhoused, incarcerated, or in group living quarters.

DISCLOSURES:

No source of study funding was listed. The authors disclosed no relevant financial relationships.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Mental health distress increased disproportionately among transgender and gender-nonconforming US adults between 2014 and 2021 compared with their cisgender counterparts, a new study suggested. Investigators said the findings among an historically marginalized segment of society point to a need to address a growing inequality in mental health.

METHODOLOGY:

• Investigators drew on 2014-2021 US Behavioral Risk Factor Surveillance System (BRFSS) survey data, using logistic and ordinary least squares regression to document temporal trends in the transgender-cisgender disparity in self-reports of the number of poor mental health days in the past month and frequent mental distress.
• They included 43 states that implemented the optional sexual orientation and gender identity module in the BRFSS.
• Outcomes included the number of poor mental health days in the past month, as well as frequent mental distress (≥ 14 poor mental health days in the past month).

TAKEAWAY:

• Even in 2014, there was a discrepancy between cisgender and transgender and gender-nonconforming individuals in the reported mean of poor mental health days (3.68 vs 5.42).
• The size of this disparity, adjusted by differences in observable characteristics, increased by 2.75 days (95% CI, 0.58-4.91) over the study period.
• The inequality in mental health status between cisgender and transgender and nonconforming adults grew from 11.4% vs 18.9% in 2014, respectively, to 14.6% vs 32.9% in 2021, respectively.

IN PRACTICE:

“Our findings demonstrate sizable and worsening inequities in mental health across gender identity,” the authors wrote. “Mental health and primary care providers must be prepared to address the unique psychosocial needs of gender minority adults. Furthermore, our findings highlight the need for action to reduce these disparities.”

SOURCE:

Samuel Mann, PhD, of the RAND Corporation, was the corresponding author of the study. It was published online on April 10 in the American Journal of Public Health.

LIMITATIONS:

Measures of mental health were derived from self-reports. In addition, data from seven states were missing because these states did not include sexual orientation and gender identity in the BRFSS. And the BRFSS does not survey people who are unhoused, incarcerated, or in group living quarters.

DISCLOSURES:

No source of study funding was listed. The authors disclosed no relevant financial relationships.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Mental health distress increased disproportionately among transgender and gender-nonconforming US adults between 2014 and 2021 compared with their cisgender counterparts, a new study suggested. Investigators said the findings among an historically marginalized segment of society point to a need to address a growing inequality in mental health.

METHODOLOGY:

• Investigators drew on 2014-2021 US Behavioral Risk Factor Surveillance System (BRFSS) survey data, using logistic and ordinary least squares regression to document temporal trends in the transgender-cisgender disparity in self-reports of the number of poor mental health days in the past month and frequent mental distress.
• They included 43 states that implemented the optional sexual orientation and gender identity module in the BRFSS.
• Outcomes included the number of poor mental health days in the past month, as well as frequent mental distress (≥ 14 poor mental health days in the past month).

TAKEAWAY:

• Even in 2014, there was a discrepancy between cisgender and transgender and gender-nonconforming individuals in the reported mean of poor mental health days (3.68 vs 5.42).
• The size of this disparity, adjusted by differences in observable characteristics, increased by 2.75 days (95% CI, 0.58-4.91) over the study period.
• The inequality in mental health status between cisgender and transgender and nonconforming adults grew from 11.4% vs 18.9% in 2014, respectively, to 14.6% vs 32.9% in 2021, respectively.

IN PRACTICE:

“Our findings demonstrate sizable and worsening inequities in mental health across gender identity,” the authors wrote. “Mental health and primary care providers must be prepared to address the unique psychosocial needs of gender minority adults. Furthermore, our findings highlight the need for action to reduce these disparities.”

SOURCE:

Samuel Mann, PhD, of the RAND Corporation, was the corresponding author of the study. It was published online on April 10 in the American Journal of Public Health.

LIMITATIONS:

Measures of mental health were derived from self-reports. In addition, data from seven states were missing because these states did not include sexual orientation and gender identity in the BRFSS. And the BRFSS does not survey people who are unhoused, incarcerated, or in group living quarters.

DISCLOSURES:

No source of study funding was listed. The authors disclosed no relevant financial relationships.
 

A version of this article appeared on Medscape.com.

On May 5, 2023, the director of the Centers for Disease Control and Prevention (CDC), Rochelle Walensky, in announcing her resignation after more than 2 years of dedicated service, wrote that she “took on this role … with the goal of leaving behind the dark days of the pandemic and moving the CDC — and public health — forward into a much better and more trusted place.”

Three times in the past 3 years I have written a Beyond the White Coat column emphasizing the importance of trust. Trust in the expertise of scientists. Trust in the integrity of medical research and public health institutions. Trust in the commitment of providers — doctors, nurses, therapists, and first responders — to shepherd us through the pandemic and other medical crises in our lives. This column is take four.

All human institutions have human imperfections. However, imperfect humans working together in community are more productive and more reliable than nihilism and political polarization. Underlying all of healthcare are compassion and honesty. Honesty means the truth, the whole truth, and nothing but the truth. Honesty is such a simple concept in the moral formation of children, but the concept has evolved aberrantly in the world of woke adults. There appear to be irresistible temptations to shade that truth for political gain. The dominant current mutation is the half-truth. One tells the part of the truth that appears to advance one’s own political aspirations and at the same time one omits or censors other viewpoints.

On April 17, 2023, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American Psychiatric Association wrote an open letter to Congressional leaders advocating for transgender female students’ participation in girl’s and women’s sports. The letter was written “On behalf of the more than 165,000” members of those organizations, though public opinion polls show a majority of those members likely oppose the opinion expressed. The letter goes on to extol the benefits that sports might bring to transgender students, but it contains not one word acknowledging the negative impact that participation has on others. That is a half-truth.

The same half-truth methodology distorts dialogue about various therapies for gender dysphoria in children and young adults.

In April 2022, U.S. Assistant Secretary for Health Rachel Levine in an NPR interview declared that, “There is no argument about the value and importance of gender-affirming care.” That might be a half-truth, since I could not locate U.S. specialists who dare to go on record questioning the party line of the World Professional Association for Transgender Health. However, Dr. Levine’s dismissal of any dissent is bizarre since in the prior 2 years multiple countries, including Australia, New Zealand, Sweden, Finland, and the United Kingdom had all issued reports questioning and even rescinding the practices that evolved since the 2012 WPATH guidance. Their main concerns included 1) the marked increase in incidence of gender dysphoria first manifesting in tween and early teenage girls, 2) the inadequate access to mental health screening before considering transitioning, 3) the long-term risks of puberty blockers particularly to bone density, and 4) the low quality of evidence supporting a measurable reduction in suicide rates. There may be reasonable counterarguments to each of those concerns, but a high ranking U.S. government official labeling all those international reports as “no argument” does not produce high quality decision making and does not foster the public’s trust.

Indeed, the public in many cases has decided its elected legislators are more trustworthy on these topics than the medical organizations. As I wrote the first draft of this column, the Missouri state legislators had passed a bill banning gender-affirming health care for transgender minors. They also passed a bill preventing participation of transgender females in women’s sports. Per reckoning by CBS News in the summer of 2023, 16 states had recently enacted laws restricting gender-affirming care and 22 states had restricted transgender participation in sports.

In 2022, I wrote a column claiming that suppressing viewpoints and debate leads to exploding spaceships. I believe the current legislative carnage is just such an explosion. It harms children.

The AAP has experts in advocacy. I am no expert in political advocacy. Perhaps politics has to be played by different rules where half-truths are normalized. Criminal law and advertising use those rules. But this explosion of vitriol and legislative intrusion into medicine should prompt everyone to reassess the use of one-sided advocacy in public and professional circles in healthcare. I want to be associated with a profession that uses evidence-based medicine that is not corrupted with political agendas. I want to be associated with a profession known for telling the whole truth.

In a society that is increasingly polarized, I want to embrace the advice of John Stuart Mill, a 19th century English philosopher best known for utilitarianism, which is often expressed as “the greatest good for the greatest number.” Mr. Mill also wrote on social theory, liberty, and even some early feminist theory. His 1859 work, On Liberty, chapter II, asserts: “He who knows only his own side of the case, knows little of that. His reasons may be good, and no one may have been able to refute them. But if he is equally unable to refute the reasons on the opposite side; if he does not so much as know what they are, he has no ground for preferring either opinion.”

Mr. Mill did not like half-truths.
 

It’s About Trust

My column is not the instrument to debate the use of hormones as puberty blockers or the fairness of transgender women participating in women’s sports. Those judgments will be rendered by others. I may report on those deliberations, but my column’s emphasis is on how professionals, and their organizations, go about making those determinations

For instance, the National Health Service in the United Kingdom spent 2 years reassessing transgender care for children and in October 2022 released a draft proposal to reduce and limit the aggressive therapies. On June 9, 2023, the NHS fully enacted those changes. Puberty blockers for gender dysphoria would be used only in experimental trials. In April 2024 the NHS began implementing those changes, joining other European countries that have imposed similar restrictions.

Similarly, the debate about transgender participation in women’s sports has continued to rage for years. On April 8, 2024, the National Association of Intercollegiate Athletics passed a resolution that bans almost all transgender participation in NAIA-regulated intercollegiate women’s sports. Dance and cheerleading are exceptions. Participation is still permissible at the intramural level. The NCAA has different rules.

Go to those sources to learn more substance for those debates. This column is about trust.

A major problem currently facing medicine is the public’s trust in expertise. That trust had been seriously weakened before the pandemic and was repeatedly wounded during the pandemic with arguments over masks, vaccines, and shutdowns. It needs repair.

A parent bringing a baby to a pediatrician’s office needs to trust that physician for the relationship to work. This is especially true for pediatric hospitalists that do not have the opportunity that office-based pediatricians have to build rapport with a family over years. At a recent university conference on diversity, equity, and inclusivity, one female rabbi stated, “I cannot be rabbi to everybody.” I agreed, but as a medical professional, sometimes I must be.

Telling half-truths harms the public’s trust in their personal physicians and in the medical establishment. Once people suspect an organization is making decisions based on ideology rather than science, credibility is lost and difficult to recover.

Let us stop telling half-truths. Let us stop suppressing dialogue. Truth can never be completely captured by humans, but if one side of an issue is suppressed by cancel culture, censorship, accusations of homophobia, or threat of cultural war, the search for truth is severely impaired.

Let us, as medical professionals, adopt Stephen Covey’s habit number 5, “Seek first to understand, then to be understood.” Empower voices. Listen to all stakeholders. And when we finally do speak, remember John Stuart Mill and tell the whole truth.
 

Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

On May 5, 2023, the director of the Centers for Disease Control and Prevention (CDC), Rochelle Walensky, in announcing her resignation after more than 2 years of dedicated service, wrote that she “took on this role … with the goal of leaving behind the dark days of the pandemic and moving the CDC — and public health — forward into a much better and more trusted place.”

Three times in the past 3 years I have written a Beyond the White Coat column emphasizing the importance of trust. Trust in the expertise of scientists. Trust in the integrity of medical research and public health institutions. Trust in the commitment of providers — doctors, nurses, therapists, and first responders — to shepherd us through the pandemic and other medical crises in our lives. This column is take four.

All human institutions have human imperfections. However, imperfect humans working together in community are more productive and more reliable than nihilism and political polarization. Underlying all of healthcare are compassion and honesty. Honesty means the truth, the whole truth, and nothing but the truth. Honesty is such a simple concept in the moral formation of children, but the concept has evolved aberrantly in the world of woke adults. There appear to be irresistible temptations to shade that truth for political gain. The dominant current mutation is the half-truth. One tells the part of the truth that appears to advance one’s own political aspirations and at the same time one omits or censors other viewpoints.

On April 17, 2023, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American Psychiatric Association wrote an open letter to Congressional leaders advocating for transgender female students’ participation in girl’s and women’s sports. The letter was written “On behalf of the more than 165,000” members of those organizations, though public opinion polls show a majority of those members likely oppose the opinion expressed. The letter goes on to extol the benefits that sports might bring to transgender students, but it contains not one word acknowledging the negative impact that participation has on others. That is a half-truth.

The same half-truth methodology distorts dialogue about various therapies for gender dysphoria in children and young adults.

In April 2022, U.S. Assistant Secretary for Health Rachel Levine in an NPR interview declared that, “There is no argument about the value and importance of gender-affirming care.” That might be a half-truth, since I could not locate U.S. specialists who dare to go on record questioning the party line of the World Professional Association for Transgender Health. However, Dr. Levine’s dismissal of any dissent is bizarre since in the prior 2 years multiple countries, including Australia, New Zealand, Sweden, Finland, and the United Kingdom had all issued reports questioning and even rescinding the practices that evolved since the 2012 WPATH guidance. Their main concerns included 1) the marked increase in incidence of gender dysphoria first manifesting in tween and early teenage girls, 2) the inadequate access to mental health screening before considering transitioning, 3) the long-term risks of puberty blockers particularly to bone density, and 4) the low quality of evidence supporting a measurable reduction in suicide rates. There may be reasonable counterarguments to each of those concerns, but a high ranking U.S. government official labeling all those international reports as “no argument” does not produce high quality decision making and does not foster the public’s trust.

Indeed, the public in many cases has decided its elected legislators are more trustworthy on these topics than the medical organizations. As I wrote the first draft of this column, the Missouri state legislators had passed a bill banning gender-affirming health care for transgender minors. They also passed a bill preventing participation of transgender females in women’s sports. Per reckoning by CBS News in the summer of 2023, 16 states had recently enacted laws restricting gender-affirming care and 22 states had restricted transgender participation in sports.

In 2022, I wrote a column claiming that suppressing viewpoints and debate leads to exploding spaceships. I believe the current legislative carnage is just such an explosion. It harms children.

The AAP has experts in advocacy. I am no expert in political advocacy. Perhaps politics has to be played by different rules where half-truths are normalized. Criminal law and advertising use those rules. But this explosion of vitriol and legislative intrusion into medicine should prompt everyone to reassess the use of one-sided advocacy in public and professional circles in healthcare. I want to be associated with a profession that uses evidence-based medicine that is not corrupted with political agendas. I want to be associated with a profession known for telling the whole truth.

In a society that is increasingly polarized, I want to embrace the advice of John Stuart Mill, a 19th century English philosopher best known for utilitarianism, which is often expressed as “the greatest good for the greatest number.” Mr. Mill also wrote on social theory, liberty, and even some early feminist theory. His 1859 work, On Liberty, chapter II, asserts: “He who knows only his own side of the case, knows little of that. His reasons may be good, and no one may have been able to refute them. But if he is equally unable to refute the reasons on the opposite side; if he does not so much as know what they are, he has no ground for preferring either opinion.”

Mr. Mill did not like half-truths.
 

It’s About Trust

My column is not the instrument to debate the use of hormones as puberty blockers or the fairness of transgender women participating in women’s sports. Those judgments will be rendered by others. I may report on those deliberations, but my column’s emphasis is on how professionals, and their organizations, go about making those determinations

For instance, the National Health Service in the United Kingdom spent 2 years reassessing transgender care for children and in October 2022 released a draft proposal to reduce and limit the aggressive therapies. On June 9, 2023, the NHS fully enacted those changes. Puberty blockers for gender dysphoria would be used only in experimental trials. In April 2024 the NHS began implementing those changes, joining other European countries that have imposed similar restrictions.

Similarly, the debate about transgender participation in women’s sports has continued to rage for years. On April 8, 2024, the National Association of Intercollegiate Athletics passed a resolution that bans almost all transgender participation in NAIA-regulated intercollegiate women’s sports. Dance and cheerleading are exceptions. Participation is still permissible at the intramural level. The NCAA has different rules.

Go to those sources to learn more substance for those debates. This column is about trust.

A major problem currently facing medicine is the public’s trust in expertise. That trust had been seriously weakened before the pandemic and was repeatedly wounded during the pandemic with arguments over masks, vaccines, and shutdowns. It needs repair.

A parent bringing a baby to a pediatrician’s office needs to trust that physician for the relationship to work. This is especially true for pediatric hospitalists that do not have the opportunity that office-based pediatricians have to build rapport with a family over years. At a recent university conference on diversity, equity, and inclusivity, one female rabbi stated, “I cannot be rabbi to everybody.” I agreed, but as a medical professional, sometimes I must be.

Telling half-truths harms the public’s trust in their personal physicians and in the medical establishment. Once people suspect an organization is making decisions based on ideology rather than science, credibility is lost and difficult to recover.

Let us stop telling half-truths. Let us stop suppressing dialogue. Truth can never be completely captured by humans, but if one side of an issue is suppressed by cancel culture, censorship, accusations of homophobia, or threat of cultural war, the search for truth is severely impaired.

Let us, as medical professionals, adopt Stephen Covey’s habit number 5, “Seek first to understand, then to be understood.” Empower voices. Listen to all stakeholders. And when we finally do speak, remember John Stuart Mill and tell the whole truth.
 

Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].

On May 5, 2023, the director of the Centers for Disease Control and Prevention (CDC), Rochelle Walensky, in announcing her resignation after more than 2 years of dedicated service, wrote that she “took on this role … with the goal of leaving behind the dark days of the pandemic and moving the CDC — and public health — forward into a much better and more trusted place.”

Three times in the past 3 years I have written a Beyond the White Coat column emphasizing the importance of trust. Trust in the expertise of scientists. Trust in the integrity of medical research and public health institutions. Trust in the commitment of providers — doctors, nurses, therapists, and first responders — to shepherd us through the pandemic and other medical crises in our lives. This column is take four.

All human institutions have human imperfections. However, imperfect humans working together in community are more productive and more reliable than nihilism and political polarization. Underlying all of healthcare are compassion and honesty. Honesty means the truth, the whole truth, and nothing but the truth. Honesty is such a simple concept in the moral formation of children, but the concept has evolved aberrantly in the world of woke adults. There appear to be irresistible temptations to shade that truth for political gain. The dominant current mutation is the half-truth. One tells the part of the truth that appears to advance one’s own political aspirations and at the same time one omits or censors other viewpoints.

On April 17, 2023, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American Psychiatric Association wrote an open letter to Congressional leaders advocating for transgender female students’ participation in girl’s and women’s sports. The letter was written “On behalf of the more than 165,000” members of those organizations, though public opinion polls show a majority of those members likely oppose the opinion expressed. The letter goes on to extol the benefits that sports might bring to transgender students, but it contains not one word acknowledging the negative impact that participation has on others. That is a half-truth.

The same half-truth methodology distorts dialogue about various therapies for gender dysphoria in children and young adults.

In April 2022, U.S. Assistant Secretary for Health Rachel Levine in an NPR interview declared that, “There is no argument about the value and importance of gender-affirming care.” That might be a half-truth, since I could not locate U.S. specialists who dare to go on record questioning the party line of the World Professional Association for Transgender Health. However, Dr. Levine’s dismissal of any dissent is bizarre since in the prior 2 years multiple countries, including Australia, New Zealand, Sweden, Finland, and the United Kingdom had all issued reports questioning and even rescinding the practices that evolved since the 2012 WPATH guidance. Their main concerns included 1) the marked increase in incidence of gender dysphoria first manifesting in tween and early teenage girls, 2) the inadequate access to mental health screening before considering transitioning, 3) the long-term risks of puberty blockers particularly to bone density, and 4) the low quality of evidence supporting a measurable reduction in suicide rates. There may be reasonable counterarguments to each of those concerns, but a high ranking U.S. government official labeling all those international reports as “no argument” does not produce high quality decision making and does not foster the public’s trust.

Indeed, the public in many cases has decided its elected legislators are more trustworthy on these topics than the medical organizations. As I wrote the first draft of this column, the Missouri state legislators had passed a bill banning gender-affirming health care for transgender minors. They also passed a bill preventing participation of transgender females in women’s sports. Per reckoning by CBS News in the summer of 2023, 16 states had recently enacted laws restricting gender-affirming care and 22 states had restricted transgender participation in sports.

In 2022, I wrote a column claiming that suppressing viewpoints and debate leads to exploding spaceships. I believe the current legislative carnage is just such an explosion. It harms children.

The AAP has experts in advocacy. I am no expert in political advocacy. Perhaps politics has to be played by different rules where half-truths are normalized. Criminal law and advertising use those rules. But this explosion of vitriol and legislative intrusion into medicine should prompt everyone to reassess the use of one-sided advocacy in public and professional circles in healthcare. I want to be associated with a profession that uses evidence-based medicine that is not corrupted with political agendas. I want to be associated with a profession known for telling the whole truth.

In a society that is increasingly polarized, I want to embrace the advice of John Stuart Mill, a 19th century English philosopher best known for utilitarianism, which is often expressed as “the greatest good for the greatest number.” Mr. Mill also wrote on social theory, liberty, and even some early feminist theory. His 1859 work, On Liberty, chapter II, asserts: “He who knows only his own side of the case, knows little of that. His reasons may be good, and no one may have been able to refute them. But if he is equally unable to refute the reasons on the opposite side; if he does not so much as know what they are, he has no ground for preferring either opinion.”

Mr. Mill did not like half-truths.
 

It’s About Trust

My column is not the instrument to debate the use of hormones as puberty blockers or the fairness of transgender women participating in women’s sports. Those judgments will be rendered by others. I may report on those deliberations, but my column’s emphasis is on how professionals, and their organizations, go about making those determinations

For instance, the National Health Service in the United Kingdom spent 2 years reassessing transgender care for children and in October 2022 released a draft proposal to reduce and limit the aggressive therapies. On June 9, 2023, the NHS fully enacted those changes. Puberty blockers for gender dysphoria would be used only in experimental trials. In April 2024 the NHS began implementing those changes, joining other European countries that have imposed similar restrictions.

Similarly, the debate about transgender participation in women’s sports has continued to rage for years. On April 8, 2024, the National Association of Intercollegiate Athletics passed a resolution that bans almost all transgender participation in NAIA-regulated intercollegiate women’s sports. Dance and cheerleading are exceptions. Participation is still permissible at the intramural level. The NCAA has different rules.

Go to those sources to learn more substance for those debates. This column is about trust.

A major problem currently facing medicine is the public’s trust in expertise. That trust had been seriously weakened before the pandemic and was repeatedly wounded during the pandemic with arguments over masks, vaccines, and shutdowns. It needs repair.

A parent bringing a baby to a pediatrician’s office needs to trust that physician for the relationship to work. This is especially true for pediatric hospitalists that do not have the opportunity that office-based pediatricians have to build rapport with a family over years. At a recent university conference on diversity, equity, and inclusivity, one female rabbi stated, “I cannot be rabbi to everybody.” I agreed, but as a medical professional, sometimes I must be.

Telling half-truths harms the public’s trust in their personal physicians and in the medical establishment. Once people suspect an organization is making decisions based on ideology rather than science, credibility is lost and difficult to recover.

Let us stop telling half-truths. Let us stop suppressing dialogue. Truth can never be completely captured by humans, but if one side of an issue is suppressed by cancel culture, censorship, accusations of homophobia, or threat of cultural war, the search for truth is severely impaired.

Let us, as medical professionals, adopt Stephen Covey’s habit number 5, “Seek first to understand, then to be understood.” Empower voices. Listen to all stakeholders. And when we finally do speak, remember John Stuart Mill and tell the whole truth.
 

Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at [email protected].