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Back in February, MedPage Today covered a study finding that transgender and gender nonconforming youth often have poorer overall physical and mental health compared with cisgender peers. This work extended the growing body of research indicating that the medical establishment hasn't yet mastered the care of these patients. In this follow-up feature, we review developments in transgender medicine since that story appeared.

New Policy Statement

"I think one of the highlights for transgender care that took place in 2018 was the release of a policy document on care for transgender and gender non-conforming (TGNC) youth by the American Academy of Pediatrics," Elizabeth Boskey, PhD, of Boston Children's Hospital, told MedPage Today. Released in September, this was the AAP's first policy statement focused on transgender youth, which urged pediatricians and other healthcare providers to provide a "safe and inclusive clinical space" for these patients.

"It emphasized the importance of integrating gender assessment into pediatric care as well as the role of interdisciplinary teams in taking care of TGNC youth. It also called for improved insurance coverage of gender-affirming care and better training of healthcare providers," Boskey added.

The statement also referenced the American Psychological Association's clinical practice guideline for psychological care of TGNC individuals, released back in 2015, as a valuable tool for healthcare providers.

This wasn't the only call for greater mental healthcare for transgender youth seen in 2018. Another study, published in April, identified a higher risk for experiencing anxiety, depression, attention deficits, and other mental conditions for TGNC youth. Specifically, this increased risk ranged from a threefold up to a 13-fold higher incidence for some of these mental health disorders compared with cisgender peers.

This study was later followed-up with a similar report published in September finding that high school students who self-reported themselves as gender non-conforming were more likely to experience feelings of sadness and hopelessness. These teens were also significantly more likely to seriously consider attempting suicide.

Calling the findings of this particular study "striking" and a highlight of research from this year, Deirdre Shires, PhD, MSW, MPH, of the Henry Ford Health System in Detroit, told MedPage Today, "This is one of the first studies to leverage electronic medical record data of transgender individuals seeking healthcare across several healthcare systems, and more studies like this are needed not only to specifically pinpoint gaps in care for transgender people, but also to determine how to best fill these gaps."

These findings were later confirmed with more data released in October which found that LGBT teens were around 3.5 times more likely to attempt suicide than heterosexual peers. Among sexual minorities, transgender teens experienced the highest risk for suicide, with a nearly six-times increased risk compared with heterosexual teens.

Advancements in Hormone Management

Research in 2018 wasn't focused just on mental health, new findings were also made in hormonal therapy. This kicked off with a new report in February of the first-ever case of non-puerperal induced lactation in a transgender woman following 6 years of hormone-replacement therapy. This was later followed by another study suggesting that transgender men don't need anti-estrogens or aromatase inhibitors, but only need testosterone therapy.

Another notable study published this year came in the form of a systematic review, which suggested that the typical practice of suspending hormone therapy prior to surgery for transgender patients might not be of much benefit in reducing perioperative risks.

Gaps in Care Still Remain

This past July, the Endocrine Society hosted a congressional briefing in which experts in the field tried to bring some of the knowledge gaps to light. "It's not all about the genitalia," Joshua Safer, MD, executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York City, explained at the briefing.

Knowledge gaps in medical care for transgender persons are still prevalent, however, with another study, released in November, reporting that a third of family medicine physicians didn't feel they were capable of providing care to transgender patients.

This survey of 163 physicans in the Midwest, conducted by Shires et al. also found that 15% of docs would refuse to care for a transgender patient. "Our findings, as well as the success of transgender speaker panels, point to the importance of integrating not only clinical but also personal exposure to transgender individuals into medical education," Shires' group highlighted.

Despite some of the advances in 2018, "there's still so much work that needs to be done," said Boskey, adding that she hopes to see additional research in fertility preservation for transgender youth prescribed puberty blockers.

"There have been suggestions that oncofertility techniques could be useful with this population, but there's very little data on how well those techniques work. We're seeing a growing call for better fertility assessment in transgender youth and young adults, but assessment would be more useful with better interventions."

What Might 2019 Hold?

"Looking forward, there is much to be hopeful about in transgender research," Boskey commented. "However, it's also important to be aware of ways in which research could be impeded by changes in the regulatory environment, such as through unscientific changes in the government's definition of gender."

"As researchers work to expand our evidence base on the subject of transgender medicine, we may need to advocate for the use of that evidence to advance a more scientific understanding of sex and gender in the public sphere," she concluded.

This sentiment was echoed in late December by Jocelyn Samuels, JD, of the University of California, Los Angeles, and Mara Keisling, BSS, of the National Center for Transgender Equality in Washington, D.C., in a New England Journal of Medicine Perspective piece.

"[The Department of Health and Human Services] has signaled its intent to try to rescind the rule's provisions regarding gender identity," they wrote, adding that "doing so would not only cause substantial harm to the health of transgender people; it would also conflict with the court holdings that gender identity discrimination is in fact prohibited under the law."

Under the ACA, Samuels and Keisling noted, "all patients, including transgender patients, deserve the same respect and dignity."