Endocrine Society updates guidelines

The Endocrine Society has updated its guidelines for providing gender-affirming treatment to transgender individuals, published online in the Journal of Clinical Endocrinology & Metabolism.

The Society simultaneously issued a position statement.

This asks US federal and private insurers to cover physician-prescribed medical interventions for transgender individuals and highlights the need for increased funding and prioritization of research on transgender medical care.

The guidelines were last updated in 2009.

In particular, they provide detailed advice on the appropriate age for teens to start treatment. They also emphasize standard fertility preservation counseling for all individuals deciding about puberty suppression or hormone therapy.

Diagnosing clinicians, mental-health providers for adolescents, and mental-health professionals for adults should all be knowledgeable about the diagnostic criteria for gender-affirming treatment, have sufficient training and experience in assessing related mental-health conditions, and be willing to participate in the ongoing care throughout the endocrine transition.

--Wylie Hembree, MD, Columbia University

The new guideline is cosponsored by the American Association of Clinical Endocrinologists, American Society of Andrology, European Society for Paediatric Endocrinology, European Society of Endocrinology, Pediatric Endocrine Society, and the World Professional Association for Transgender Health.

The guidelines focus on gender-affirming hormone therapy, which can reduce the suffering experienced by gender-dysphoric/gender-incongruent individuals whose physical characteristics do not match their assigned birth sex.

Hormone therapy suppresses the body's sex hormones, which cause many of the physical changes seen at puberty. Treatment should be safe and effective, and sex hormone levels should be kept within the normal range for gender affirmation, say the guidelines.

Because gender-affirming therapy is partially irreversible, it should be provided only after confirming the persistence of gender dysphoria/gender incongruence in individuals with sufficient mental capacity to give informed consent.

Most people can do that by age 16, write the authors, while recognizing that some individuals may have compelling reasons to start therapy before age 16. However, minimal published evidence exists regarding treatment before ages 13.5 to 14 years. Gender-affirming surgery and removal of gonads or the uterus should not be performed before age 18 or the legal age of majority in the individual's country.

Recommendations include:

Hormone therapy is not advised for prepubertal individuals with gender dysphoria or gender incongruence.

Clinicians should inform and counsel all individuals seeking gender-affirming medical treatment about the options for fertility preservation before starting puberty suppression in adolescents and before starting hormonal therapy in both adolescents and adults.

In adolescents who meet diagnostic and treatment criteria, pubertal hormone suppression using GnRH analogues should start after girls and boys first exhibit the physical changes of puberty.

In adults, clinicians should evaluate and address medical conditions that can be exacerbated by hormone depletion and treatment before starting hormone therapy.

Surgical removal of gonads may be considered when high doses of sex steroids are needed to suppress the body's own secretion of sex steroids and/or in advanced age.

All individuals receiving hormone therapy should have regular monitoring for prolactin; bone loss; cardiovascular, lipid, and metabolic disorders; and cancer screening.

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