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There is a significant increase in people who self-diagnose as having gender dysphoria and gender incongruence. The number of people with gender dysphoria and gender incongruence who seek assessment, support and treatment at gender identity clinic services has increased substantially over the years globally, and in Europe, North America and Australia in particular. Many countries lack appropriate transgender healthcare services. This book gives an overview regarding mental health and quality of life issues across the life span within the evolving interdisciplinary field of transgender healthcare. The book is written for professionals who in their day-to-day job may encounter people with gender dysphoria and gender incongruence; and for students, teachers, educators, academics, and members of the public at large with an interest in this timely topic. This book was originally published as a special issue of the International Review of Psychiatry.


The largest study involving transgender people is providing long-sought insights about their health

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Gender-affirming treatment of transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological, and mental health.

The Endocrine Society guidelines for transgender women include estrogens in combination with androgen-lowering medications. Feminizing treatment with estrogens and antiandrogens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth, and fat redistribution in a female pattern.

Possible side effects should be discussed with patients, particularly those at risk for venous thromboembolism. The Endocrine Society guidelines for transgender men include testosterone therapy for virilization with deepening of the voice, cessation of menses, and increases of muscle mass and facial and body hair. Owing to the lack of evidence, treatment of gender nonbinary people should be individualized. Young people may receive pubertal suspension, consisting of GnRH analogs, later followed by sex steroids.

Options for fertility preservation should be discussed before any hormonal intervention. Morbidity and cardiovascular risk with cross-sex hormones is unchanged among transgender men and unclear among transgender women. Sex steroid—related malignancies can occur but are rare. Mental health problems such as depression and anxiety have been found to reduce considerably following hormonal treatment. Future studies should aim to explore the long-term outcome of hormonal treatment in transgender people and provide evidence as to the effect of gender-affirming treatment in the nonbinary population.

Transgender people before gender-affirming treatment present with higher levels of mental health problems, particularly depression, anxiety, and self-harm, than do cisgender people. Gender-affirming treatment has been found to reduce mental health problems in transgender people. Long-term estrogen and androgen-lowering medications may be associated with increased risk of thromboembolism, which can be mitigated by changing the formulation and route of estrogen therapy.

Testosterone treatment in transgender men is seen as safe regarding cardiovascular and oncological disease in the short-term and mid-term, but long-term effects need to be elucidated. The endocrine treatment of adolescents with gender dysphoria consists of two phases, first pubertal suppression followed by the addition of hormones. The few somatic data available in adolescents are favorable and hitherto support the fact that the proven psychological benefits of early medical intervention outweigh the potential medical risks.

In well-informed transgender people regrets of gender-confirming treatment are very rare. The acceptance by society, reflected in the media, that gender identity may not always match the assigned sex at birth has provided the option and permission for individuals to question their gender identity more freely.

Consequently, in some countries, transgender health services have expanded and developed so that gender-diverse people wanting physical change are able to access gender-affirming medical interventions. Hormone treatment, pivotal for those who wish to transition into their affirmed gender that differs from their sex that is assigned at birth, is ideally prescribed under the supervision of endocrinologists.

However, many endocrinologists may feel uneasy and unskilled when working with the transgender population because the field of transgender medicine is relatively new. This review aims to summarize the endocrine treatment of transgender people wishing to undergo gender-affirmation therapies.

The review first describes the terminology used in the field of transgender medicine, followed by a critical review of the diagnostic criteria currently in use, and it summarizes the mental health difficulties that transgender people may present with and the benefits of gender-affirming treatment on well-being. Finally, the major focus of this paper is to provide a critical review of the published literature on the hormonal treatment and long-term monitoring for transgender children and adults.

Transgender is used as an umbrella term to describe individuals whose gender identity differs from the assigned sex at birth.

Transgender males are people assigned female at birth but who self-identify as male. Transgender females are people assigned male at birth, but who self-identify as female. This can be used as an umbrella term to include people with no gender agender , two genders bigender , multiple genders pangender , or with a fluid gender gender fluid 2 , 3 , among others.

Terminology changes all the time, and terms used in the past may become outdated and can be perceived as pejorative. For example, the term transsexual, which has been used since 4 , is largely now confined to the legal and medical literature. Not every transgender person suffers from gender dysphoria, and the urgency for medical intervention among transgender people may vary 1. For some people, social change may be enough without the need for further physical intervention.

For others, owing to their personal circumstances, physical intervention may not be opportune or appropriate. Research in the field of transgender medicine has primarily focused on transgender people accessing transgender health services 7. Owing to the requirement in certain countries to provide funded health services only to those with a medical diagnosis, terms describing the gender-related suffering of transgender people have remained part of current diagnostic criteria 5 , 8.

In this review, the term transgender is used throughout to describe individuals who seek access to medical treatment in order for their bodies to become more congruent to their identified gender. A summary of some of the terms used in transgender health can be found in Table 1. Studies were selected only when participants were described as transgender whether self-identified or diagnosed by health professionals and they had empirical data relating to the hormonal treatment in this population.

This is a critical review with a focus on recent and original data. This paper describes and reviews the available literature since the last published review study by one of the coauthors of the current review 9.

Additionally, reference sections of identified articles and Google Scholar were examined for further relevant publications. Articles of interest were those that included the transgender population and had empirical data relating to hormonal treatment within this population.

Articles describing the effects of treatment, side effects, risk, and long-term outcome were also collected and reviewed to help with the discussion in this review.

If information was only to be retrieved from case reports, such as oncology, both the case reports and recent reviews on the specific topic were examined. The results of the present review are presented by describing the treatment in adults transgender women and men first, followed by the treatment in adolescents. It is expected that the new edition of the ICD ICD will change this term and move it out of the mental health chapter.

The desire to de-pathologize being transgender and the importance of securing access to health care has been a dilemma in both the development of the current edition of the Diagnostic and Statistical Manual of Mental Disorders DSM-5 and the ICD This diagnosis aims to classify the symptoms dysphoria and not the individual. If reaching a consensus to develop terms to classify transgender adults has been complicated, creating criteria for children has been even more complex.

The ICD is proposing the diagnosis of gender incongruence in children 10 whereas the DSM-5 uses the diagnosis of gender dysphoria in children. More than 20 studies have sought to investigate prevalence rates of transgender people. Although more recently prevalence rates of transgender identities have been reported using population studies, most of the available literature has extrapolated prevalence rates from people attending transgender health clinics 7.

Some of the first epidemiological studies, which focused on individuals seeking services to undergo gender-affirming genital surgery 12 , found prevalence rates of 0. The ratio between male assigned at birth and female assigned at birth was found to be 4 to 1 Other European studies, based on people attending transgender health services, provide different prevalence rates over time: 1. Once again, rates of male assigned at birth transgender people have been found to be higher than female assigned at birth transgender people at a ratio of 3 to 1.

Studies looking at more recent periods between and provide higher prevalence rates of 3. Studies have also examined the number of people who have petitioned governmental agencies to change their gender status legally.

Those studies have described prevalence rates ranging from 2. A recent meta-analysis found an overall prevalence for transsexualism as this is the diagnosis and term used in the published papers of 4. To identify the overall prevalence of transgender people including those not accessing services population studies may be more representative of the transgender community. Population-based studies have found a considerably higher prevalence rate than those reported in clinical studies.

For example, a study asking a sample of community participants in the United States 28, aged 18 to 64 years as to whether they considered themselves transgender found a prevalence rate of 0. Studies from the Netherlands and Belgium described that 0. Most of the epidemiological studies have been conducted in Western countries, particularly in Europe and the United States. Societies that are more egalitarian and open will facilitate the expression of gender diversity, and hence prevalence rates in those countries may be reported higher than in more restrictive societies.

Low prevalence rates in certain societies may need to be regarded with caution, as they may reflect a symptom of repression. A ban on gender identity expression for personal, cultural, or religious reasons may manifest itself as distress and profound unhappiness and may lead to the development of mental health problems Studies investigating rates of mental health diagnoses in the transgender population, once again, have focused on those attending transgender health services The few studies that compared their findings to the general cisgender population controlled by age and sex found certain mental health diagnoses, such as anxiety disorders, are threefold more prevalent among transgender people compared with cisgender people There are some discrepancies as to whether mental health diagnoses are more common among transgender men or among transgender women.

Some studies have found that mental health diagnoses were not related to assigned or identified gender 30 , 31 , whereas other studies have demonstrated higher rates of mood disorders 23 , 32 , anxiety disorders 32 , adjustment disorders 18 , and substance abuse 24 among transgender women than among transgender men.

Most of those studies are biased by not controlling for factors known to influence mental health diagnoses, particularly hormone treatment. This means that people have been recruited for studies independently as to whether they are on hormone treatment or not, although research has confirmed that such treatment reduces mental health problems.

Interestingly, more recent large controlled studies involving only transgender people not on treatment have found that anxiety disorders were more prevalent among transgender men than among transgender women A similar study also found levels of self-harm were also higher among the same group Several factors have been found to predict mental health issues among the transgender population attending transgender health services, such as experiences of victimization or transphobic experiences , low self-esteem 27 , and interpersonal problems 28 , Lack of hormone treatment of those wanting physical change has been found to be the strongest predictor of mental health diagnoses 21 , 25 , A number of longitudinal studies have explored the role of hormonal treatment in mental health and quality of life among transgender people wanting gender-affirmation treatment.

Long-term follow-up studies and studies involving large groups of people are needed to evaluate whether these improvements remain. Hence, hormone treatment of those wanting physical change needs to be accessible, as this will reduce morbidity and improve quality of life of transgender people.

The literature on posttreatment regret is complex to interpret. Overall satisfaction after gender-affirming treatment is high. There are many causes of regret. Frequently dissatisfaction following gender-affirming surgery has been interpreted as regret regarding social and medical transition.

In one of the largest gender clinics Amsterdam , individuals received treatment between and Ten of these people subsequently indicated that they regretted their decision to have undergone the treatment nine transgender women and one transgender man Upon review in , the number of major and minor regrets increased by 5 out of a total of subjects.

In the total number of subjects treated had risen to , but there was no further increase in those expressing regret. The fact that fewer people have been having doubts about their treatment decisions over time may reflect the much-improved understanding of gender incongruence both by transgender people themselves and by the medical profession, as well as much greater acceptance of transgender people in society Mental health diagnoses are common in the transgender population, possibly owing to negative societal values, but they do improve once gender-affirming treatment is initiated.

This highlights the importance of hormone treatment and access to adequate transgender health care. Although state-funded health services, which are primarily available in Europe, may develop services where the needs of the transgender population can be provided for, including assessment, psychological support when needed , hormonal treatment, and gender-affirming surgery, other health care systems may not be so fortunate and transgender people may find themselves searching for professionals who are able to confidently prescribe and monitor hormone treatment.

Transgender women seek hormone therapy to change their physical appearance to better match their gender identity and expression 40 , Furthermore, transgender women experience improved quality of life and a decrease in gender dysphoria upon initiation of hormone therapy 42 , In the United States, Canada, and most of Europe, transgender women must seek medical professionals for hormone therapy because these medications are available only by prescription, but there is a black market also particularly for oral contraceptives.

Academic Bibliography

Benita Arren was the third person to join an innovative study of transgender individuals in Belgium. Credit: Bea Uhart. Benita Arren wishes that the human body came with instructions. About a decade ago, Arren was struggling with inner conflict.

He is particularly interested in transgender health, and will be presenting at a Meet the Expert session on the effects of hormone therapy on bone in transgender persons at ECE We interviewed him to find out more about his career, transgender research and what he is looking forward to at ECE During my training as an endocrinologist, I met a transgender woman and had the opportunity to talk to her.

Gender-affirming treatment of transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological, and mental health. The Endocrine Society guidelines for transgender women include estrogens in combination with androgen-lowering medications. Feminizing treatment with estrogens and antiandrogens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth, and fat redistribution in a female pattern.

Meet Professor Guy T’Sjoen, transgender health specialist and ECE speaker

Search publications Advanced search. Downloads Download. Transgenderism and reproduction. Van Caenegem, and K. Before, losing fertility was accepted as the price to pay for transitioning. Recent findings: The desire for children is present in many trans persons, as in the general population. Ethical concerns are sometimes raised against the preservation of fertility; however, the only unique aspect of this group is the gender transition of one of the parents. All other elements such as same sex parenthood, use of donor gametes, social stigma, etc.

Но мысли Сьюзан были далеко от политических последствий создания Цифровой крепости. Она пыталась осознать истинный смысл случившегося. Всю свою жизнь она посвятила взламыванию шифров, отвергая саму возможность разработки абсолютно стойкого шифра.

Любой шифр можно взломать - так гласит принцип Бергофского.

Этот новый стандарт шифрования означал бы, что АНБ может прослушивать кого угодно, где угодно и когда угодно. - Ты прав - и так и должно быть! - сурово отрезала Сьюзан.

Это полный абсурд. Танкадо ни за что не доверился бы Хейлу. - Коммандер, - напомнила Сьюзан, - Хейл однажды уже чуть не угробил нас - с Попрыгунчиком.

Должен быть какой-то другой выход. - Решайте! - крикнул Хейл и потащил Сьюзан к лестнице. Стратмор его не слушал. Если спасение Сьюзан равнозначно крушению его планов, то так тому и быть: потерять ее значило потерять все, а такую цену он отказывался платить.

Преступники, террористы и шпионы, которым надоело прослушивание их телефонов, с радостью встретили это новое средство глобальной коммуникации. Электронная почта соединила безопасность обычной почты со скоростью телефонной связи. С тех пор как сообщения стали передаваться по подземным волоконно-оптическим линиям, а не с помощью радиоволн, они оказались полностью защищенными от перехвата - таков по крайней мере был замысел. В действительности перехват электронных писем, передвигаемых по Интернету, был детской забавой для технических гуру из АНБ.

Интернет не был создан, как считали многие, в эру домашних персональных компьютеров. Он появился тремя десятилетиями ранее благодаря усилиям специалистов из министерства обороны и представлял собой громадную сеть компьютеров, призванных обеспечить безопасность правительственной связи на случай ядерной войны.

Стратмор повернулся, и Сьюзан сразу же его потеряла. В страхе она вытянула вперед руки, но коммандер куда-то исчез. Там, где только что было его плечо, оказалась черная пустота. Она шагнула вперед, но и там была та же пустота. Сигналы продолжались. Источник их находился где-то совсем близко. Сьюзан поворачивалась то влево, то вправо.

Apr 24, - Designated male at birth, she had secretly dressed up in her mother's clothes as a Guy T'Sjoen started the ENIGI study because there was no  Missing: partner ‎| Must include: partner.

Джабба отлично знал, что директор прав. Более трех тысяч узлов Независимой цифровой сети связывают весь мир с базой данных агентства. Каждый день военные оценивают моментальные спутниковые снимки всех передвижений по территории потенциальных противников.

Инженеры компании Локхид скачивают подробные чертежи новых систем вооружения. Оперативные агенты сообщают последние данные о ходе выполнения поставленных перед ними задач.

Такая прическа была у Табу в день гибели.  - Парень снова сплюнул.  - Поэтому все его последователи, достойные этого названия, соорудили себе точно такие. Беккер долго молчал.

Коммандер отпустил Сьюзан и повернулся к своему детищу стоимостью два миллиарда долларов. Глаза его расширились от ужаса. - Нет! - Он схватился за голову.

Я видел алгоритм. Уверяю вас, он стоит этих денег.

На экран выплыла надпись: КЛЮЧ К ШИФРУ-УБИЙЦЕ ПОДТВЕРЖДЕН - Укрепить защитные стены! - приказал Джабба. Но Соши, опередив его, уже отдала команду. - Утечка прекратилась! - крикнул техник. - Вторжение прекращено.

Не коснувшись краев, он вытащил из нее ключ Медеко. - Поразительно, - пробурчал он, - что сотрудникам лаборатории систем безопасности ничего об этом не известно. ГЛАВА 47 - Шифр ценой в миллиард долларов? - усмехнулась Мидж, столкнувшись с Бринкерхоффом в коридоре.

 - Ничего. - Клянусь, - сказал. Она смотрела на него с недоумением. - Надеюсь, это не уловка с целью заставить меня скинуть платье.

Только сейчас она поняла, почему он настаивал на том, чтобы ТРАНСТЕКСТ продолжал работать. Если Цифровой крепости суждено стать любимой игрушкой АНБ, Стратмор хотел убедиться, что взломать ее невозможно. - Ты по-прежнему хочешь уйти. Сьюзан посмотрела на .

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