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The participants include an Endocrine Society—appointed task force of nine experts, a methodologist, and a medical writer. 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.

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. Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Those clinicians who recommend gender-affirming endocrine treatments—appropriately trained diagnosing clinicians requireda 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.

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 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. We suggest maintaining physiologic levels of gender-appropriate hormones and Adult seeking hot sex Millers falls Massachusetts 1349 for known risks and complications.

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. Ungraded Good Practice Statement. We recommend that clinicians inform and counsel all individuals seeking gender-affirming medical treatment regarding options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy of the affirmed gender in both adolescents and adults.

We suggest that clinicians begin pubertal hormone suppression after girls and boys first exhibit physical changes of puberty. We recommend that, where indicated, GnRH analogues are used to suppress pubertal hormones. We suggest monitoring clinical pubertal development every 3 to 6 months and laboratory parameters every 6 to 12 months during sex hormone treatment.

We recommend that clinicians evaluate and address medical conditions that can be exacerbated by hormone depletion and treatment with sex hormones of the affirmed gender before beginning treatment. We suggest that clinicians measure hormone levels during treatment to ensure that endogenous sex steroids are suppressed and administered sex steroids are maintained in the normal physiologic range for the affirmed gender.

We suggest that endocrinologists provide education to transgender individuals undergoing treatment about the onset and time course of physical changes induced by sex hormone treatment. We suggest regular clinical evaluation for physical changes and potential adverse changes in response to sex steroid hormones and laboratory monitoring of sex steroid hormone levels every 3 months during the first year of hormone therapy for transgender males and females and then once or twice yearly.

We suggest periodically monitoring prolactin levels in transgender females treated with estrogens. We recommend that clinicians obtain bone mineral density BMD measurements when risk factors for osteoporosis exist, specifically in those who stop sex hormone therapy after gonadectomy.

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We suggest that transgender females with no known increased risk of breast cancer follow breast-screening guidelines recommended for non-transgender females. We suggest that transgender females treated with estrogens follow individualized screening according to personal risk for prostatic disease and prostate cancer. We advise that clinicians determine the medical necessity of including a total hysterectomy and oophorectomy as part of gender-affirming surgery. We advise that clinicians approve genital gender-affirming surgery only after completion of at least 1 year of consistent and compliant hormone treatment, unless hormone therapy is not desired or medically contraindicated.

We advise that the clinician responsible for endocrine treatment and the primary care provider ensure appropriate medical clearance of transgender individuals for genital gender-affirming surgery and collaborate with the surgeon regarding hormone use during and after surgery.

We recommend that clinicians refer hormone-treated transgender individuals for genital surgery when: 1 the individual has had a satisfactory social role change, 2 the individual is satisfied about the hormonal effects, and 3 the individual desires definitive surgical changes.

We suggest that clinicians determine the timing of breast surgery for transgender males based upon the physical and mental health status of the individual. There is insufficient evidence to recommend a specific age requirement. Both the current guideline and the one published in contain similar sections. The section on clinical evaluation of both youth and adults, defines in detail the professional qualifications required of those who diagnose and treat both adolescents and adults.

We advise that decisions regarding the social transition of prepubertal youth are made with the assistance of a mental health professional or similarly experienced professional. We recommend against puberty blocking followed by gender-affirming hormone treatment of prepubertal children. Clinicians should inform pubertal Adult seeking hot sex Millers falls Massachusetts 1349, adolescents, and adults seeking gender-confirming treatment of their options for fertility preservation. A multidisciplinary team, preferably composed of medical and mental health professionals, should monitor treatments.

Physicians should educate transgender persons regarding the time course of steroid-induced physical changes. Treatment should include periodic monitoring of hormone levels and metabolic parameters, as well as assessments of bone density and the impact upon prostate, gon, and uterus.

We also make recommendations for transgender persons who plan genital gender-affirming surgery. The task force followed the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation group, an international group with expertise in the development and implementation of evidence-based guidelines 1. A detailed description of the grading scheme has been published elsewhere 2. The task force used the best available research evidence to develop the recommendations.

The task force also used consistent language and graphical descriptions of both the strength of a recommendation and the quality of evidence. The task force has confidence that persons who receive care according to the strong recommendations will derive, on average, more benefit than harm. Linked to each recommendation is a description of the evidence and the values that the task force considered in making the recommendation.

In some instances, there are remarks in which the task force offers technical suggestions for testing conditions, dosing, and monitoring. These technical comments reflect the best available evidence applied to a typical person being treated. Often this evidence comes from the unsystematic observations of the task force and their preferences; therefore, one should consider these remarks as suggestions. In this guideline, the task force made several statements to emphasize the importance of shared decision-making, general preventive care measures, and basic principles of the treatment of transgender persons.

The intention of these statements is to draw attention to these principles.

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The Endocrine Society maintains a rigorous conflict-of-interest review process for developing clinical practice guidelines. All task force members must declare any potential conflicts of interest by completing a conflict-of-interest form. The CGS and the task force have reviewed all disclosures for this guideline and resolved or managed all identified conflicts of interest.

Conflicts of interest are defined as remuneration in any amount from commercial interests; grants; research support; consulting fees; salary; ownership interests [ e. Completed forms are available through the Endocrine Society office. The Endocrine Society provided the funding for this guideline; the task force received no funding or remuneration Adult seeking hot sex Millers falls Massachusetts 1349 commercial or other entities.

The task force commissioned two systematic reviews to support this guideline. The first one aimed to summarize the available evidence on the effect of sex steroid use in transgender individuals on lipids and cardiovascular outcomes. The review identified 29 eligible studies at moderate risk of bias.

In transgender males female to malesex steroid therapy was associated with a statistically ificant increase in serum triglycerides and low-density lipoprotein cholesterol levels. High-density lipoprotein cholesterol levels decreased ificantly across all follow-up time periods. In transgender females male to femaleserum triglycerides were ificantly higher without any changes in other parameters. Few myocardial infarction, stroke, venous thromboembolism VTEand death events were reported. These events were more frequent in transgender females.

However, the quality of the evidence was low. The second review summarized the available evidence regarding the effect of sex steroids on bone health in transgender individuals and identified 13 studies. In transgender males, there was no statistically ificant difference in the lumbar spine, femoral neck, or total hip BMD at 12 and 24 months compared with baseline values before initiating masculinizing hormone therapy.

In transgender females, there was a statistically ificant increase in lumbar spine BMD at 12 months and 24 months compared with baseline values before initiation of feminizing hormone therapy. There was minimal information on fracture rates. The quality of evidence was also low. Throughout recorded history in the absence of an endocrine disorder some men and women have experienced confusion and anguish resulting from rigid, forced conformity to sexual dimorphism. In modern history, there have been numerous ongoing biological, psychological, cultural, political, and sociological debates over various aspects of gender variance.

Magnus Hirschfeld and Harry Benjamin, among others, pioneered the medical responses to those who sought relief from and a resolution to their profound discomfort. Magnus Hirschfeld 6 and others 47 have described other types of trans phenomena besides transsexualism. These early researchers proposed that the gender identity of these people was located somewhere along a unidimensional continuum.

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Yet such a classification does not take into that people may have gender identities outside this continuum. For instance, some experience themselves as having both a male and female gender identity, whereas others completely renounce any gender classification 89. There are also reports of individuals experiencing a continuous and rapid involuntary alternation between a male and female identity 10 or men who do not experience themselves as men but do not want to live as women 11 In some countries, e.

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