Providing gender-affirming hormone therapy through primary care: service users.

INTRODUCTION Primary health care providers are playing an increasingly important role in providing gender-affirming health care for gender diverse people. This article explores the experiences of a primary care-based pilot clinic providing gender-affirming hormone therapy in Wellington, New Zealand. AIM To evaluate service users' and health professionals' experiences of a pilot clinic at Mauri Ora (Victoria University of Wellington's Student Health and Counselling Service) that provided gender-affirming hormones through primary care. METHODS In-depth interviews were conducted with four (out of six) service users and four health professionals about their perspectives on the clinic. Interviews were transcribed verbatim and analysed using thematic analysis. RESULTS Three themes were identified in service users' interviews, who discussed receiving affirming care due to the clinic's accessibility, relationship-centred care and timeliness. Three themes were identified in the health professionals' interviews, who described how the clinic involves partnership, affirms users' gender and agency, and is adaptable to other primary care settings. Both service users and health professionals discussed concerns about the lack of adequate funding for primary care services and the tensions between addressing mental health needs and accessing timely care. DISCUSSION The experiences of service users and health professionals confirm the value of providing gender-affirming hormone therapy in primary care. Models based in primary care are likely to increase accessibility, depathologise gender diversity and reduce wait times.

European Society for Sexual Medicine Position Statement "Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction".

BACKGROUND: There is a general lack of recommendations for and basic information tailored at sexologists and other health-care professionals for when they encounter trans people in their practice. AIM: We present to clinicians an up-to-date overview of clinical consensus statements on trans health care with attention for sexual function and satisfaction. METHODS: The task force consisted of 7 clinicians experienced in trans health care, selected among European Society for Sexual Medicine (ESSM) scientific committee. The consensus was guided by clinical experience and a review of the available literature and by interactive discussions on trans health, with attention for sexual function and satisfaction where available. OUTCOMES: The foci of the study are assessment and hormonal aspects of trans health care. RESULTS: As the available literature for direct recommendations was limited, most of the literature was used as background or indirect evidence. Clinical consensus statements were developed based on clinical experiences and the available literature. With the multiple barriers to care that many trans people experience, basic care principles still need to be stressed. We recommend that health-care professionals (HCPs) working with trans people recognize the diversity of genders, including male, female, and nonbinary individuals. In addition, HCPs assessing gender diverse children and adolescents should take a developmental approach that acknowledges the difference between prepubescent gender diverse children and pubescent gender diverse adolescents and trans adults. Furthermore, trans people seeking gender-affirming medical interventions should be assessed by HCPs with expertise in trans health care and gender-affirming psychological practice. If masculinization is desired, testosterone therapy with monitoring of serum sex steroid levels and signs of virilization is recommended. Similarly, if feminization is desired, we recommend estrogens and/or antiandrogen therapy with monitoring of serum sex steroid levels and signs of feminization. HCPs should be aware of the influence of hormonal therapy on sexual functioning and satisfaction. We recommend HCPs be aware of potential sexual problems during all surgical phases of treatment. CLINICAL IMPLICATIONS: This is an up-to-date ESSM position statement. STRENGTHS & LIMITATIONS: These statements are based on the data that are currently available; however, it is vital to recognize that this is a rapidly changing field and that the literature, particularly in the field of sexual functioning and satisfaction, is limited. CONCLUSION: This ESSM position statement provides relevant information and references to existing clinical guidelines with the aim of informing relevant HCPs on best practices when working with transgender people. T'Sjoen G, Arcelus J, De Vries ALC, et al. European Society for Sexual Medicine Position Statement "Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction". J Sex Med 2020;17:570-584.

Assessment of Gender-Affirming Hormone Therapy Requirements.

PURPOSE: There are currently no recommendations regarding the starting doses of hormone therapy for individuals with gender dysphoria. The purpose of this study was to assess the hormone dose needed to achieve target hormone levels in transgender men and transgender women, and whether body mass index (BMI) affects these doses. METHODS: A retrospective chart review of subjects seeking gender-affirming hormone therapy was performed. Height, weight, hormone doses, and serum hormone levels were collected from charts. Data were analyzed for a correlation between BMI and effective hormone dosing (dose that achieved hormone levels in the target range). RESULTS: Charts from 319 subjects were reviewed; however, only 84 transgender women and 71 transgender men had serum hormone levels available and only 40 transgender women and 54 transgender men had plasma hormone levels in the target range (normal range for affirmed gender). For transgender women, there was a significant negative correlation between BMI and effective estradiol dose (r = -0.337, p = 0.04). For transgender men, there was a positive correlation between BMI and effective testosterone dose (r = 0.409, p = 0.002). CONCLUSION: Increased BMI was associated with lower estrogen dose requirements in transgender women. In transgender men, an increase in BMI was associated with increased testosterone dose requirements. These results suggest that BMI may influence effective gender-affirming hormone dosing; however, further studies are needed to examine its utility in determining the initial hormone dose.

Exogenous sex steroid hormones and asthma in females: protocol for a population-based retrospective cohort study using a UK primary care database.

INTRODUCTION: Female sex steroid hormones have been implicated in sex-related differences in the development and clinical outcomes of asthma. The role of exogenous sex steroids, however, remains unclear. Our recent systematic review highlighted the lack of high-quality population-based studies investigating this subject. We aim to investigate whether the use of hormonal contraception and hormone replacement therapy (HRT), subtypes and route of administration are associated with asthma onset and clinical outcomes in reproductive age and perimenopausal/postmenopausal females. METHODS AND ANALYSIS: Using the Optimum Patient Care Research Database (OPCRD), a national primary care database in the UK, we will construct a retrospective longitudinal cohort of reproductive age (16-45 years) and perimenopausal/postmenopausal (46-70 years) females. We will estimate the risk of new-onset asthma using Cox regression and multilevel modelling for repeated asthma outcomes, such as asthma attacks. We will adjust for confounding factors in all analyses. We will evaluate interactions between the use of exogenous sex hormones and body mass index and smoking by calculating the relative excess risk due to interaction and the attributable proportion due to interaction. With 90% power, we need 23 700 reproductive age females to detect a 20% reduction (risk ratio 0.8) in asthma attacks for use of any hormonal contraception and 6000 perimenopausal/postmenopausal females to detect a 40% (risk ratio 1.40) increased risk of asthma attacks for use of any HRT. ETHICS AND DISSEMINATION: We have obtained approval (ADEPT1317) from the Anonymised Data Ethics and Protocol Transparency Committee which grants project-specific ethics approvals for the use of OPCRD data. Optimum Patient Care has an existing NHS Health Research Authority ethics approval for the use of OPCRD data for research (15/EM/150). We will present our findings at national and international scientific meetings and publish the results in international peer-reviewed journals. TRIAL REGISTRATION NUMBER: EUPAS22967.

The standardization of nonsterile compounding: a study in quality control and assessment for hormone compounding.

Sterile and nonsterile compounding of medication has attracted much attention over the last few years due to the onset of various infections and negative compounding practices. This paper reports on the standardization of compounded hormones utilizing the Wiley Protocol, which provides nonsynthetic bioidentical estradiol, progesterone, dehydroepiandrosterone, and testosterone in a transdermal topical cream base for women and men in a standardized dosing regimen. Here, we present data from 2008 through 2012, which details the process of standardization and quality testing of the hormones through submission of random compounded samples for quality control and assessment. Pharmacies delivering the Wiley Protocol were required to follow the same compounding formulation, as well as submit random samples for quarterly testing. Sample concentrations were tested using high-performance liquid chromatography. We found that pharmacies that submitted samples had a 91% passing rating with a percent of target of 98.6% +/- 8.4%. It was also determined that pharmacies that prepared more compounded cream had a higher passing rating than those that prepared limited quantities. We found that standardization across multiple pharmacies could be achieved through quarterly testing of submitted samples by a third-party laboratory when following necessary procedures as defined by the Wiley Protocol. It was also determined that experience and training were a critical factor in the mixing of compounded prescriptions, with high consistency and accuracy providing patient safety.

Exploration of functional health, mental well-being and cross-sex hormone use in a sample of Thai male-to-female transgendered persons (kathoeys).

Transgender people sometimes use cross-sex hormones without medical supervision. The use of cross-sex hormones, as well as the functional health and mental well-being, among male-to-female transgendered people ('kathoeys') in Chiang Mai, Thailand, was studied. Sixty kathoeys were interviewed regarding their use of cross-sex hormones and their family relationships. Individuals also completed the Life Orientation Test Revised (LOT-R) to assess dispositional optimism, the Social Functioning Questionnaire (SFQ) and the Short Form Health Survey 36 (SF-36). Three categories were established as follows: those who never cross-dress, those who sometimes cross-dress and those who always cross-dress in public. Of the 60 subjects, 44 had used hormones for prolonged periods (9.7±6.1 years). Their use was related to the permanence of cross-dressing but unrelated to functional health and mental well-being. Fifty percent of subjects had overdosed on commonly used oral contraceptives. Three people used injectable oestrogen in a higher-than-recommended dose. Self-acceptance was high or reasonably good (83%) compared to no acceptance (17%), and neither was related to the permanence of cross-dressing. Their acceptance by parents and siblings was also relatively high (85% and 89%, respectively). The permanence of cross-dressing had no effect on the scores of optimism, SF-36 scores and social functioning. Acceptance by oneself or one's parents did not seem to affect most aspects of functional health and mental well-being, but non-acceptance by siblings generated lower scores on the social functioning and general mental health subscales. Stressors tended to include physical rather than social factors. In conclusion, the unsupervised use of cross-sex hormones was common among kathoeys, and 50% of the sample had overdosed on them. Acceptance was relatively good, except by siblings. New strategies are needed for a more responsible use of cross-sex hormones.

Health care policies addressing transgender inmates in prison systems in the United States.

Inmates with gender identity disorders (GID) pose special challenges to policy makers in U.S. prison systems. Transgender persons are likely overrepresented in prisons; a reasonable estimate is that at least 750 transgender prisoners were in custody in 2007. Using the Freedom of Information Act, requests were mailed to each state, the District of Columbia, and the Federal Bureau of Prisons in 2007. The requests were for copies of policies, directives, memos, or other documents concerning placement and health care access of transgender inmates. By April 2008, 46 responses were received; 6 states did not reply. Information was qualitatively analyzed and summarized. There was substantial disparity in transgender health care for inmates with GID or related conditions. Most systems allowed for diagnostic evaluations. There was wide variability in access to cross-sex hormones, with some allowing for continuation of treatment and others allowing for both continuation and de novo initiation of treatment. There was uniformity in denial of surgical treatments for GID.

Injectable contraceptive synthesis: an example of international cooperation.

Since many contraceptives appropriate for use in developing countries are not of major interest to the pharmaceutical companies in developed countries, the World Health Organization has sponsored a program whereby contraceptives are developed outside the traditional pharmaceutical industry channels. This program might serve as a model for the develoment of other drugs or even pesticides.