Transgender Medicine

Interview with Joshua D. Safer, MD, FACP

EndocrineWeb spoke with Joshua D. Safer, MD, FACP, who serves on The Endocrine Society’s Endocrine Treatment of Transsexual Persons Clinical Practice Guideline Task Force. Here, Dr. Safer provides clinicians an overview of gender identity and transgender medicine.

What is the appropriate terminology used in transgender medicine?
Dr. Safer:
Most of us are evolving to use the term transgender as an adjective that describes the entire range of individuals with gender identity different from their body parts.  For example: transgender men and transgender women.

The older term, gender identity disorder (GID), refers to a psychiatric diagnosis given when an individual exhibits strong and persistent cross-gender identification, including significant distress with their own biological gender. The emotional components, distress and conflict are now referred to as gender dysphoria —the replacement term.

Transsexual is the adjective for someone who has “completed the process,” including surgery (eg, transsexual man) but the term is losing favor because there is no clear definition of what “completing the process” means.  People choose multiple variations of hormones and strategies.

Transgender individuals want to live and be accepted as a member of their gender identity, which is different from their anatomical sex at birth (transfemale: male to female; transman: female to male).

Although the data on transgender individuals are considerably crude, clearly it is a biological entity. Simply put, when a baby is born, it enters the world with male or female biology—and, gender identity is biological and separate. While most of the population’s gender matches the physical body that is not the case with transgender individuals.

What is the endocrinologist’s role in treatment?
Dr. Safer:
Endocrinologists, who practice transgender medicine, use hormones to treat transgender individuals.

Generally speaking, what do you observe about transgender individuals?
Dr. Safer:
An example: Among my patients, there are young transgender men (female to male) who, maybe starting in high school, started to lead "tomboyish lives." Let’s say they see me after they’ve entered college. They are started on testosterone and start living as young men, and feel much better. It is helpful that these transgender men transition rather easily from an appearance perspective.

These transgender men had been following their biological default trajectory from childhood (puberty) to a female appearance. When testosterone is administered—even though given later in life—the switch to a very masculine look is relatively easy. Most of my young transgender men patients are quite happy. Many transgender men express relief when they can live as a man—what they always felt they were—and not be treated as female by the world.

Why do transgender individuals have difficulty finding clinical care?
Dr. Safer:
Broadly speaking, the number of endocrinologists who practice transgender medicine is shockingly small. Interestingly, endocrinologists use the same hormone therapies as those used in transgender medicine, they just don’t know how. Many transgender individuals travel great distances for appropriate care.

Transgender individuals report that barriers to care are either (1) lack of physician knowledge or (2) lack of physicians who are appropriately sensitive to the patients. Therefore, a key element to moving patient care forward is educating physicians.

Considering my own experience, I didn’t learn about transgender medicine in medical school, in residency, or during my fellowship. Therefore, it would make sense that physicians know very little about transgender medicine. To help remove the barriers to care, I took the necessary steps to develop the transgender medical program at Boston University School of Medicine.

Now gender identity/transgender medicine is taught at Boston University School of Medicine. It is a small, but important piece of the medical education program, and was easily incorporated into the standard curriculum. Furthermore, it could very easily be incorporated into the standard medical school curriculums across the United States.

Article Continues: Transgender Medicine: Clinical Care of Adolescents

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