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When it comes to understanding transgender health, there are vast knowledge gaps, according to presenters at a congressional briefing hosted by the Endocrine Society.
Below are some of the key points that the experts emphasized.
More Than a 'Sex Change'
"It's not all about the genitalia," said Joshua Safer, MD, executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York City.
"We tend to be very genital-focused and think, 'Oh, [gender identity] is all about a sex-change operation,'" he explained. "It's aligning appearance and bodies with gender identity, heavily through hormones."
He pointed out that treatment for adult transgender men -- a female who is transitioning to a male -- does not focus primarily on surgery.
"Genital surgeries... have many pitfalls," for transgender men, Safer said.
He noted that chest reconstruction is common among all transgender patients. And for transgender women, facial feminization may be a desired change.
Also, estrogen and testosterone are not complete opposites, he said, explaining that "estrogen levels in men and women are not that different." Men have a lot of testosterone and women have less, he added. The transition for female-to-male may involve receiving androgen supplements with testosterone, potentially for life, he said.
Treatment for transgender women requires blocking hormones, and testosterone in particular. Estrogen or another agent may be used as a blocker, Safer stated. But one concern with estrogen is that it may increase clotting risks, which has been found in individuals using birth control or those receiving post-menopausal treatments.
Poorer Health Outcomes
One in three transgender individuals reported experiencing a negative reaction from a healthcare provider in a single year, according to a by the National Center for Transgender Equality. And approximately 55% of those who did seek coverage for a gender transition-related surgery were denied.
Additionally, the survey showed that 40% of transgender people have attempted suicide, which is almost 10 times the rate of the general population, said Rachel Levine, MD, the secretary of health for the Commonwealth of Pennsylvania, and a professor at Penn State College of Medicine in Hershey.
Transgender people also have higher rates of depression, anxiety, HIV infection, and substance use disorder, noted Levine, who is a transgender woman.
"The evidence suggests that there is nothing inherent with being transgender to have these negative outcomes," said Levine. Rather, the negative health outcomes are the result of bullying, harassment, discrimination, and violence inflicted on transgender individuals, she said.
'Transgender Is Biology'
Historically, the medical community has held gender identity to be environmentally determined, or a passive response to one's anatomy. But those views are shifting.
"Transgender is biology," said Robert Lash, MD, chief professional and clinical affairs officer for the Endocrine Society. There's a "durable, biological underpinning" to a person's own internal sense of his or her gender, he noted.
The evidence for this argument is found in studies of intersex children -- those born with ambiguous genitalia -- and in twin studies, Safer pointed out.
In a 2004 study of , those with congenital anomalies to their genitalia were assigned to the female gender, mainly because it was simpler for the doctors, Safer explained. But when the majority of children in the study learned of their medical history, they wanted their sex reversed, he said.
And in a 2016 of twin studies, nearly 40% of identical twins were concordant for gender dysphoria versus none of the non-identical twins.
However, Safer cast doubt on studies that have tied results on brain scans to gender identity. "Although those [studies] result in the , they are some of the weakest data," he said.
And while more research is needed, "we're quite certain there's this biological underpinning," to gender identity, he noted.
Puberty Blocking
The current medical approach to responding to gender identity issues in adolescents is to delay puberty through "puberty blockers," which were used in the past among those who started puberty earlier than normal.
They are an option available to transgender children or children who believe they might be transgender "while they're trying to work things out," Safer said. "If we could identify kids at younger ages, there are fundamental physical aspects that would be convenient to deal with, with hormones instead of surgery."
Those who identify later as the opposite gender can begin the process of aligning their gender with hormones or with surgery, depending on the individual's situation, he said.
Levine said she considers the use of puberty blockers as "extremely safe," with good outcomes for children who have supportive families and who live in a supportive environment with access to the appropriate standard of care.
However, children who lack these same supports and access have "significantly more mental health" problems, Levine noted.
One challenge is that most children are required to get parental consent before they are able to receive the hormone blockers, and puberty happens when the child is younger than the age of consent -- 16 or 18 years, depending on the state, Safer said. However, waiting until adulthood for puberty blockers obviously misses the point, he added.
"We don't routinely say it's your right to deny care to your kids," Safer said. Instead, he said he works to explain to parents what is known about transgender children, and what options are available. He added that he will often connect them to parents of other transgender children.
But it is undoubtedly a very difficult conversation and not something that can be resolved in one visit, Safer and Levine noted.
"Sometimes they view it as a loss," Levine said, "almost a death."
Provider Exemption?
Levine stressed that it would be unacceptable for a healthcare provider to refuse to treat a transgender person with a broken arm or a diagnosis of pneumonia. But she distinguished those cases from physicians who choose not to practice "transgender medicine."
Safer said he did not see the need for laws to obligate doctors to care for transgender patients. "It shouldn't be necessary... What doctor would deny care to somebody with a specific medical condition, and think that's somehow not a complete violation of the ethics of our medical professional community?" he said.
What is needed is education, he said. "Our understanding of physiology, of gender identity from the evidence that we have now in 2018, should be part of the standard curriculum ... It's not a big ask," he stated. "We need to create opportunities for trainees at various level to work with transgender individuals, and then they will see that it's not scary ... I think it will increase their confidence, which will increase access to care."