Medicine (Austin & Northern Health) - Theses
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ItemThe effect of gender-affirming hormone therapy on the health and well-being of transgender Australians( 2021)There is increasing demand for gender-affirming hormone therapy, used by transgender individuals to align physical characteristics with their gender identity. Although hormone therapy improves quality of life and psychological functioning, significant barriers to accessing appropriate healthcare persist. Hormone therapy is often started at a young age and continued lifelong, yet little is known about the long-term effects on metabolic and bone health, both highly regulated by sex hormones. Our aim was to understand the sociodemographic characteristics of transgender Australians, the level of training and confidence of Endocrinologists in transgender health, and the prescribing practices of experienced medical practitioners. We report findings from a series of surveys. Transgender adults (n=928) reported alarmingly high rates of self-harm (63%), attempted suicide (43%) and discrimination within healthcare settings (26%). Barriers included difficulties navigating the healthcare system and finding doctors to prescribe. Better training for doctors was a priority with only 4% of Endocrinologists and trainees (n=147) reporting any training in transgender health during medical school, 91% desired more training. Experienced prescribers (n=35) displayed uniformity in prescribing practices, despite a lack of local guidelines. We then investigated the effects of hormone therapy on cardiovascular risk and bone microstructure. Transgender individuals face higher metabolic risk due to sex hormone mediated changes in body composition and insulin resistance. Bone morphology may be compromised as estradiol is a key regulator of bone remodelling. Transgender adults on established hormone therapy, and control participants, underwent body composition scanning (dual energy X-ray absorptiometry) and quantification of bone microstructure (high-resolution peripheral quantitative CT). Trans men (n=43) had higher mean lean mass, +7.8kg (4.0, 11.5) p<0.001, similar total fat mass but higher android:gynoid fat ratio when compared to female controls (n=48). Insulin resistance was similar, indicating a protective effect of higher lean mass. Conversely, trans women (n=41) had lower mean lean mass, -6.9kg (-10.6, -3.1), p<0.001, higher fat mass, +9.8kg (3.9, 14.5), p=0.001, and lower android:gynoid fat ratio when compared to male controls (n=30). Although android fat correlated more strongly with insulin resistance, trans women had higher insulin resistance likely due to higher overall fat mass. Bone microarchitecture was not compromised in trans men (n=41), as aromatisation of administered testosterone to estradiol likely prevented bone loss. Trans men had higher distal tibial total volumetric bone density (vBMD), 0.71 SD (0.30, 1.12), p<0.01, preserved cortical morphology and trabecular bone volume fraction relative to female controls (n=71). Despite estradiol administration, trans women (n=40) were not protected from microarchitectural deterioration, indicating the dose was insufficient to offset reduced aromatisable testosterone. Trans women had -0.55 SD lower distal tibial total vBMD (-1.01, -0.08), p=0.02 due to higher cortical porosity, 0.63 SD (0.19, 1.07), p=0.01 and lower trabecular bone volume fraction relative to male controls (n=51). Our survey findings informed new Australian clinical practice guidelines and a new gender service. Our cross-sectional study not only provide new and important insights into sex hormone action but are also highly clinically significant, given proactive measures can be implemented to mitigate fat gain and bone loss, particularly in trans women.