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1.
J Adolesc Health ; 2020 May 13.
Artigo em Inglês | MEDLINE | ID: mdl-32417098

RESUMO

PURPOSE: The purpose of this study was to describe baseline physical and laboratory characteristics of participants in the largest prospective study of transgender and gender-diverse (TGD) youth in the United States. METHODS: Participants were recruited from four clinics which specialize in the care of TGD youth before starting either GnRH analogs for pubertal suppression or gender-affirming hormone treatment. Anthropometric and laboratory measurements were abstracted from the medical chart. Baseline characteristics including height, weight, body mass index, blood pressure, and laboratory measurements were compared with those of age-matched National Health and Nutritional Examination Survey comparison group. RESULTS: Seventy-eight TGD youth with a median age of 11 years (range 8-14 years) were recruited before pubertal suppression, of whom 41 (53%) were designated male at birth, and 296 participants with a median age of 16 years (range 12-20 years) were recruited before beginning gender-affirming hormones, of whom 99 (33%) were designated male at birth. The mean high-density lipoprotein cholesterol was lower in the study participants when compared with that of National Health and Nutritional Examination Survey participants (50.6 ± 12.3 mg/dL vs. 53.3 ± 13.3 mg/dL, p = .001). Otherwise, the study cohorts were similar in terms of body mass index, proportion of overweight and obesity, blood pressure, and baseline laboratory variables. CONCLUSIONS: Before starting gender-affirming treatment, TGD youth are physiologically similar to the general population of children and adolescents in the United States, with the exception of slightly lower high-density lipoprotein cholesterol. Evaluation of this cohort over time will define the physiological effects of pubertal blockade and gender-affirming hormone treatment.

5.
J Clin Endocrinol Metab ; 102(11): 3869-3903, 2017 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-28945902

RESUMO

Objective: To update the "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline," published by the Endocrine Society in 2009. Participants: The participants include an Endocrine Society-appointed task force of nine experts, a methodologist, and a medical writer. Evidence: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. Consensus Process: Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines. Conclusion: Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person's genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person's affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments-appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)-should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.


Assuntos
Endocrinologia/métodos , Endocrinologia/normas , Disforia de Gênero/terapia , Transexualidade/terapia , Adolescente , Adulto , Fatores Etários , Endocrinologia/organização & administração , Medicina Baseada em Evidências , Feminino , Humanos , Assistência de Longa Duração/normas , Masculino , Sociedades Médicas , Pessoas Transgênero , Adulto Jovem
6.
Curr Opin Pediatr ; 29(4): 475-480, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28562420

RESUMO

PURPOSE OF REVIEW: The purpose of this Position Statement is to emphasize the importance of an affirmative approach to the health care of transgender individuals, as well as to improve the understanding of the rights of transgender youth. RECENT FINDINGS: Transgender youth have optimal outcomes when affirmed in their gender identity, through support by their families and their environment, as well as appropriate mental health and medical care. SUMMARY: The Pediatric Endocrine Society Special Interest Group on Transgender Health joins other academic societies involved in the care of children and adolescents in supporting policies that promote a safe and accepting environment for gender nonconforming/transgender youth, as well as adequate mental health and medical care. This document provides a summary of relevant definitions, information and current literature on which the medical management and affirmative approach to care of transgender youth are based.


Assuntos
Serviços de Saúde do Adolescente/normas , Serviços de Saúde da Criança/normas , Serviços de Saúde para Pessoas Transgênero/normas , Serviços de Saúde Mental/normas , Pessoas Transgênero , Transexualidade , Adolescente , Serviços de Saúde do Adolescente/ética , Atitude do Pessoal de Saúde , Criança , Serviços de Saúde da Criança/ética , Disforia de Gênero/diagnóstico , Disforia de Gênero/psicologia , Disforia de Gênero/terapia , Serviços de Saúde para Pessoas Transgênero/ética , Humanos , Serviços de Saúde Mental/ética , Direitos do Paciente , Distância Social , Apoio Social , Pessoas Transgênero/psicologia , Transexualidade/psicologia , Estados Unidos
7.
J Adolesc Health ; 60(4): 425-430, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28065519

RESUMO

PURPOSE: To enhance pediatric trainees' and students' knowledge of the psychosocial and medical issues facing transgender youth through a comprehensive curriculum. METHODS: During the 2015-2016 academic year, we administered a transgender youth curriculum to fourth-year medical students, pediatric interns, psychiatry interns, and nurse practitioner students on their 1-month adolescent and young adult medicine rotation. The curriculum included six interactive, online modules and an observational experience in a multidisciplinary pediatric gender clinic. The online modules had a primary care focus with topics of general transgender terminology, taking a gender history, taking a psychosocial history, performing a sensitive physical examination, and formulating an assessment, psychosocial plan, and medical plan. At the completion of the curriculum, learners completed an evaluation that assessed change in perceived awareness and knowledge of transgender-related issues and learner satisfaction with the curriculum. RESULTS: Twenty learners participated in the curriculum with 100% completing the curriculum evaluations, 100% reporting completing all six online modules, and 90% attending the gender clinic. Learners demonstrated a statistically significant improvement in all pre-post knowledge/awareness measures. On a Likert scale where 5 indicated very satisfied, learners' mean rating of the quality of the curriculum was 4.5 ± .7; quality of the modules was 4.4 ± .7; and satisfaction with the observational experience was 4.5 ± .8. CONCLUSIONS: A comprehensive curriculum comprised interactive online modules and an observational experience in a pediatric gender clinic was effective at improving pediatric learners' perceived knowledge of the medical and psychosocial issues facing transgender youth. Learners also highly valued the curriculum.


Assuntos
Educação Médica/métodos , Disforia de Gênero/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Profissionais de Enfermagem Pediátrica/educação , Pediatria/educação , Psiquiatria/educação , Estudantes de Medicina/psicologia , Pessoas Transgênero/psicologia , Centros Médicos Acadêmicos , Adolescente , Currículo , Feminino , Disforia de Gênero/terapia , Humanos , Estudos Interdisciplinares/normas , Estudos Interdisciplinares/tendências , Internato e Residência/métodos , Masculino , Pediatria/métodos , Avaliação de Programas e Projetos de Saúde , Psiquiatria/métodos , São Francisco
9.
Curr Opin Endocrinol Diabetes Obes ; 23(2): 172-9, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26825472

RESUMO

PURPOSE OF REVIEW: The review summarizes relevant research focused on prevalence and natural history of gender nonconforming/transgender youth, and outcomes of currently recommended clinical practice guidelines. This review identifies gaps in knowledge, and provides recommendations foci for future research. RECENT FINDINGS: Increasing numbers of gender nonconforming youth are presenting for care. Clinically useful information for predicting individual psychosexual development pathways is lacking. Transgender youth are at high risk for poor medical and psychosocial outcomes. Longitudinal data examining the impact of early social transition and medical interventions are sparse. Existing tools to understand gender identity and quantify gender dysphoria need to be reconfigured to study a more diverse cohort of transgender individuals. Increasingly, biomedical data are beginning to change the trajectory of scientific investigation. SUMMARY: Extensive research is needed to improve understanding of gender dysphoria, and transgender experience, particularly among youth. Recommendations include identification of predictors of persistence of gender dysphoria from childhood into adolescence, and a thorough investigation into the impact of interventions for transgender youth. Finally, examining the social environments of transgender youth is critical for the development of appropriate interventions necessary to improve the lives of transgender people.


Assuntos
Pesquisa Biomédica , Assistência à Saúde , Identidade de Gênero , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Grupos Minoritários/psicologia , Saúde das Minorias , Pessoas Transgênero/psicologia , Transexualidade/psicologia , Feminino , Prioridades em Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Masculino , Determinação de Necessidades de Cuidados de Saúde , Procedimentos de Readequação Sexual , Transexualidade/terapia
10.
Ann Pediatr Endocrinol Metab ; 21(4): 185-192, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28164070

RESUMO

In many countries throughout the world, increasing numbers of gender nonconforming/transgender youth are seeking medical services to enable the development of physical characteristics consistent with their experienced gender. Such medical services include use of agents to block endogenous puberty at Tanner stage II with subsequent use of cross-sex hormones, and are based on longitudinal studies demonstrating that those individuals who were first identified as gender dysphoric in early or middle childhood and continue to meet the mental health criteria for being transgender at early puberty are likely to be transgender as adults. This review addresses terms and definitions applicable to gender nonconforming youth, studies that shed light on the biologic determinants of gender identity, current clinical practice guidelines for transgender youth, challenges to optimal care, and priorities for research.

12.
Pediatr Clin North Am ; 62(4): 1001-16, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26210629

RESUMO

Gender variant and transgender youth are seeking medical care at younger ages. Pediatricians and other primary care physicians are often the first professionals who encounter such youth and their families. The goals of this article are to provide information on the epidemiology and natural history of gender variant and transgender youth, current clinical practice guidelines regarding the use of puberty blockers and cross-sex hormones for transgender youth, and limitations and challenges to optimal care.


Assuntos
Identidade de Gênero , Relações Médico-Paciente , Pessoas Transgênero/psicologia , Adaptação Psicológica , Adolescente , Comportamento do Adolescente , Criança , Comportamento Infantil , Comorbidade , Feminino , Humanos , Masculino , Encaminhamento e Consulta
14.
J Adolesc Health ; 56(2): 251-3, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25620310

RESUMO

PURPOSE: To explore providers' clinical experiences, comfort, and confidence with and barriers to providing care to transgender youth. METHODS: An online survey was administered to members of the Society for Adolescent Health and Medicine and the Pediatric Endocrine Society with items querying about clinical exposure to transgender youth, familiarity with and adherence to existing clinical practice guidelines, perceived barriers to providing transgender-related care, and comfort and confidence with providing transgender-related care. The response rate was 21.9% (n = 475). RESULTS: Of the respondents, 66.5% had provided care to transgender youth, 62.4% felt comfortable with providing transgender medical therapy, and 47.1% felt confident in doing so. Principal barriers to provision of transgender-related care were lack of the following: training, exposure to transgender patients, available qualified mental health providers, and insurance reimbursement. CONCLUSIONS: This study suggests that more training in transgender-related care, available qualified mental health providers, and insurance reimbursement for transgender-related care are needed.


Assuntos
Atitude do Pessoal de Saúde , Assistência à Saúde , Pessoal de Saúde/psicologia , Pessoas Transgênero/psicologia , Adolescente , Criança , Feminino , Identidade de Gênero , Humanos , Masculino , Inquéritos e Questionários , Adulto Jovem
15.
J Clin Invest ; 125(1): 448-55, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25500887

RESUMO

BACKGROUND: Previous efforts to preserve ß cell function in individuals with type 1 diabetes (T1D) have focused largely on the use of single immunomodulatory agents administered within 100 days of diagnosis. Based on human and preclinical studies, we hypothesized that a combination of low-dose anti-thymocyte globulin (ATG) and pegylated granulocyte CSF (G-CSF) would preserve ß cell function in patients with established T1D (duration of T1D >4 months and <2 years). METHODS: A randomized, single-blinded, placebo-controlled trial was performed on 25 subjects: 17 subjects received ATG (2.5 mg/kg intravenously) followed by pegylated G-CSF (6 mg subcutaneously every 2 weeks for 6 doses) and 8 subjects received placebo. The primary outcome was the 1-year change in AUC C-peptide following a 2-hour mixed-meal tolerance test (MMTT). At baseline, the age (mean ± SD) was 24.6 ± 10 years; mean BMI was 25.4 ± 5.2 kg/m²; mean A1c was 6.5% ± 1.1%; insulin use was 0.31 ± 0.22 units/kg/d; and length of diagnosis was 1 ± 0.5 years. RESULTS: Combination ATG/G-CSF treatment tended to preserve ß cell function in patients with established T1D. The mean difference in MMTT-stimulated AUC C-peptide between treated and placebo subjects was 0.28 nmol/l/min (95% CI 0.001-0.552, P = 0.050). A1c was lower in ATG/G-CSF-treated subjects at the 6-month study visit. ATG/G-CSF therapy was associated with relative preservation of Tregs. CONCLUSIONS: Patients with established T1D may benefit from combination immunotherapy approaches to preserve ß cell function. Further studies are needed to determine whether such approaches may prevent or delay the onset of the disease. TRIAL REGISTRATION: Clinicaltrials.gov NCT01106157. FUNDING: The Leona M. and Harry B. Helmsley Charitable Trust and Sanofi.


Assuntos
Soro Antilinfocitário/uso terapêutico , Diabetes Mellitus Tipo 1/tratamento farmacológico , Fator Estimulador de Colônias de Granulócitos/uso terapêutico , Hipoglicemiantes/uso terapêutico , Células Secretoras de Insulina/fisiologia , Polietilenoglicóis/uso terapêutico , Adolescente , Adulto , Peptídeo C/sangue , Criança , Diabetes Mellitus Tipo 1/sangue , Combinação de Medicamentos , Feminino , Hemoglobina A Glicada/metabolismo , Humanos , Insulina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Método Simples-Cego , Resultado do Tratamento , Adulto Jovem
16.
Pediatrics ; 134(6): 1184-92, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25404716

RESUMO

Gender nonconforming (GN) children and adolescents, collectively referred to as GN youth, may seek care to understand their internal gender identities, socially transition to their affirmed genders, and/or physically transition to their affirmed genders. Because general pediatricians are often the first point of contact with the health care system for GN youth, familiarity with the psychological and medical approaches to providing care for this population is crucial. The objective of this review is to provide an overview of existing clinical practice guidelines for GN youth. Such guidelines emphasize a multidisciplinary approach with collaboration of medical, mental health, and social services/advocacy providers. Appropriate training needs to be provided to promote comprehensive, culturally competent care to GN youth, a population that has traditionally been underserved and at risk for negative psychosocial outcomes.


Assuntos
Identidade de Gênero , Papel do Médico , Pessoas Transgênero/psicologia , Transexualidade/psicologia , Transexualidade/terapia , Adolescente , Criança , Comportamento Cooperativo , Feminino , Hormônios Esteroides Gonadais/uso terapêutico , Serviços de Saúde para Pessoas Transgênero , Humanos , Comunicação Interdisciplinar , Masculino , Guias de Prática Clínica como Assunto , Puberdade/efeitos dos fármacos , Cirurgia de Readequação Sexual
17.
J Clin Endocrinol Metab ; 99(12): 4379-89, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25140398

RESUMO

Compelling studies have demonstrated that "gender identity"--a person's inner sense of self as male, female, or occasionally a category other than male or female--is not simply a psychosocial construct, but likely reflects a complex interplay of biological, environmental, and cultural factors. An increasing number of preadolescents and adolescents, identifying as "transgender" (a transient or persistent identification with a gender different from their "natal gender"--ie, the gender that is assumed based on the physical sex characteristics present at birth), are seeking medical services to enable the development of physical characteristics consistent with their affirmed gender. Such services, including the use of agents to block endogenous puberty at Tanner stage 2 and subsequent use of cross-sex hormones, are based on longitudinal studies demonstrating that those individuals who were first identified as gender-dysphoric in early or middle childhood and who still meet the mental health criteria for being transgender at early puberty are likely to be transgender as adults. Furthermore, onset of puberty in transgender youth is often accompanied by increased "gender dysphoria"--clinically significant distress related to the incongruence between one's affirmed gender and one's "assigned (or natal) gender." Studies have shown that such distress may be ameliorated by a "gender-affirming" model of care. Although endocrinologists are familiar with concerns surrounding gender identity in patients with disorders of sex development, many providers are unfamiliar with the approach to the evaluation and management of transgender youth without a disorder of sex development. The goals of this article are to review studies that shed light on the biological underpinnings of gender identity, the epidemiology and natural history of transgenderism, current clinical practice guidelines for transgender youth, and limitations and challenges to optimal care. Prospective cohort studies focused on long-term safety and efficacy are needed to optimize medical and mental health care for transgender youth.


Assuntos
Sistema Endócrino/fisiologia , Pessoas Transgênero/psicologia , Adolescente , Feminino , Identidade de Gênero , Humanos , Masculino , Transtornos Mentais/complicações , Transtornos Mentais/psicologia
18.
BMC Health Serv Res ; 14: 319, 2014 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-25060235

RESUMO

BACKGROUND: The Theoretical Domains Framework (TDF) is a set of 14 domains of behavior change that provide a framework for the critical issues and factors influencing optimal knowledge translation. Considering that a previous study has identified optimal knowledge translation techniques for each TDF domain, it was hypothesized that the TDF could be used to contextualize and interpret findings from a behavioral and educational needs assessment. To illustrate this hypothesis, findings and recommendations drawn from a 2012 national behavioral and educational needs assessment conducted with healthcare providers who treat and manage Growth and Growth Hormone Disorders, will be discussed using the TDF. METHODS: This needs assessment utilized a mixed-methods research approach that included a combination of: [a] data sources (Endocrinologists (n:120), Pediatric Endocrinologists (n:53), Pediatricians (n:52)), [b] data collection methods (focus groups, interviews, online survey), [c] analysis methodologies (qualitative - analyzed through thematic analysis, quantitative - analyzed using frequencies, cross-tabulations, and gap analysis). Triangulation was used to generate trustworthy findings on the clinical practice gaps of endocrinologists, pediatric endocrinologists, and general pediatricians in their provision of care to adult patients with adult growth hormone deficiency or acromegaly, or children/teenagers with pediatric growth disorders. The identified gaps were then broken into key underlying determinants, categorized according to the TDF domains, and linked to optimal behavioral change techniques. RESULTS: The needs assessment identified 13 gaps, each with one or more underlying determinant(s). Overall, these determinants were mapped to 9 of the 14 TDF domains. The Beliefs about Consequences domain was identified as a contributing determinant to 7 of the 13 challenges. Five of the gaps could be related to the Skills domain, while three were linked to the Knowledge domain. CONCLUSIONS: The TDF categorization of the needs assessment findings allowed recommendation of appropriate behavior change techniques for each underlying determinant, and facilitated communication and understanding of the identified issues to a broader audience. This approach provides a means for health education researchers to categorize gaps and challenges identified through educational needs assessments, and facilitates the application of these findings by educators and knowledge translators, by linking the gaps to recommended behavioral change techniques.


Assuntos
Endocrinologia , Modelos Teóricos , Determinação de Necessidades de Cuidados de Saúde , Padrões de Prática Médica/normas , Medicina Baseada em Evidências , Pesquisa sobre Serviços de Saúde , Humanos
20.
Int J Pediatr Endocrinol ; 2012(1): 3, 2012 Feb 10.
Artigo em Inglês | MEDLINE | ID: mdl-22325688

RESUMO

Nephrogenic Syndrome of Inappropriate Antidiuresis (NSIAD) is a novel disease caused by a gain-of-function mutation in the V2 vasopressin receptor (V2R), which results in water overload and hyponatremia. We report the effect of water loading in a 3-year old boy with NSIAD, diagnosed in infancy, to assess urine aquaporin-2 (AQP2) excretion as a marker for V2R activation, and to evaluate the progression of the disease since diagnosis. The patient is one of the first known NSIAD patients and the only patient with a R137L mutation. Patient underwent a standard water loading test in which serum and urine sodium and osmolality, serum AVP, and urine AQP2 excretion were measured. The patient was also evaluated for ad lib fluid intake before and after the test. This patient demonstrated persistent inability to excrete free water. Only 39% of the water load (20 ml/kg) was excreted during a 4-hour period (normal ≥ 80-90%). Concurrently, the patient developed hyponatremia and serum hypoosmolality. Serum AVP levels were detectable at baseline and decreased one hour after water loading; however, urine AQP2 levels were elevated and did not suppress normally during the water load. The patient remained eunatremic but relatively hypodipsic during ad lib intake. In conclusion, this is the first demonstration in a patient with NSIAD caused by a R137L mutation in the V2R that urine AQP2 excretion is inappropriately elevated and does not suppress normally with water loading. In addition, this is the first longitudinal report of a pediatric patient with NSIAD diagnosed in infancy who demonstrates the ability to maintain eunatremia during ad lib dietary intake.

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