Transgender endocrinology

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INDIAN REALITY Transgender health is a fast-growing field of interdisciplinary endocrinology, and rightfully so. India, with the largest population of transgender people in the world,[1] should be the trans-healthcare capital of the world. Transgender people are a visible, and important, part of Indian society and are numbered separately in the census, though most likely an underestimation. They are legally recognized as a third gender and are protected by progressive legislation.[2] Till recently, the major transgender presence was in the form of conventional, transfeminine, or “hijra” community.[3] The changing trans-friendly legal environment has helped the gender dysphoric individuals in the society at large to come out of the closet and demand medical help, but the healthcare ecosystem may not necessarily be so welcoming. Many transgender persons go for inappropriate procedures by untrained and unqualified individuals and do not seek medical help because of prevailing doubts about the benefits of modern medicine. THE CHALLENGE WE FACE Primary care physicians are not trained in handling the unique needs, preferences, and wishes of transgender individuals.[4] Most healthcare providers are unaware of the complexity and heterogeneity of the transgender spectrum and the risks associated with nonintervention. The lack of clarity regarding the procedures to be followed reinforces the need of country-specific guidelines and training of medical professionals. The curriculum for endocrinology training does not include adequate focus on transgender health, while that for internal medicine makes no mention of this important subject. Thus, few physicians and endocrinologists possess the skills necessary for transgender care. Busy healthcare settings also mean that the sensitivity and privacy required for optimal transgender care may not always be available. The high burden of endocrine and metabolic diseases, and complications, relative to the availability of qualified endocrinologists,[5] limits the spread of trans-healthcare across the country. OUR RESPONSIBILITY As responsible endocrinologists, it becomes our duty to ensure optimal endocrine health for the transgender community. This can be done only if we understand their health-related needs and challenges. Gender incongruence is a spectrum disorder with variable concerns and treatment requirements even from endocrine perspective. Cross sex hormone therapy (CSHT) in gender incongruent individuals facilitates changes in secondary sex characteristics that are consistent with the desired sex. Safe and effective CSHT regimen suppresses endogenous hormone secretion and maintains physiologic levels of desired sex hormone. When appropriately prescribed CSHT can greatly improve mental health and quality of life for gender incongruent individuals. Once this is done, we need to leverage our subject expertise, along with that of relevant medical/surgical specialties and nonhealth-related professions, to create an integrated team-based healthcare delivery system. Optimal trans-healthcare delivery will be possible only if we move away from the one-size-fits-all concept to a more individualized person-centered care, learn patient–provider communication skills, and practice informed, shared decision-making.[6] These ideas have been paraphrased as the four core competencies of professional responsibility, caregiver/care-receiver relationship, interdisciplinary practice, and content knowledge, by the World Professional Association for Transgender Health (WPATH).[7] OUR ACTIVITIES Indian endocrinology has been working toward improving the quality of care provided to its transgender patient population. Specialized clinics offering excellent standard-of-care services exist across the country: in Kochi, Bengaluru, Chennai, and Kolkata. Continuing medical education programs on transgender endocrinology are conducted at regular intervals and the topic finds space in major endocrinology conferences (ESICON Nagpur 2019).[8] An active professionals' WhatsApp group (Frendos Transgender Forum) promotes a healthy discussion on the clinical aspects of transgender care. Endocrinologists serve as advisories to several nongovernmental organizations and are actively involved in social work with the transgender community. Our fraternity works with Indian Professional Active in Transgender care (IPATH) and WPATH. Endocrinologists serve as faculty at IPATH conferences to highlight the endocrine aspects of transgender care. A comprehensive good practice guide to Gender-Affirmative Care has been published by Sappho for Equality, Kolkata, West Bengal, India. This includes chapters on Indian law, transgender identify and gender transition, therapeutic approaches to gender affirmation, mental healthcare, hormone therapy, surgery, and voice transformation. This has been coauthored by a multi-professional team including prominent endocrinologists from Kolkata.[9] The Indian Journal of Endocrinology and Metabolism advocates transgender health and rights through its strongly-worded editorials[10] and thought-provoking communications.[3] The concepts of endocrine hygiene[11] and community endocrinology[12] provide affirmative support to the needs of transgender people. OUR PLANS Much more needs to be done, however. Transgender medicine should be highlighted in undergraduate medical, nursing, and psychology curricula. Transgender endocrinology must be made an essential part of postgraduate endocrine training. The Endocrine Society of India should work in collaboration with allied specialties to advocate for the health rights of the transgender community. Country-specific and patient-centered management guidelines are need of the hour. An MHP should provide inputs in the ongoing care during the endocrine transition and decision for surgical sex reaffirmation. Regular monitoring for adverse drug reactions and monitoring for known physical risks are the keys to the successful endocrine therapy. Academic endocrine departments should start and strengthen regular clinics for transgender people. If possible, integrated services, including medical, surgical, dermatologic, psychological/psychiatric, and endocrine care, should be provided under one roof. This is already being done at centers like St John's Medical College, Bengaluru, and IPGMER and KPC Medical College, Kolkata. If we work together, we should be able to create a healthy future for our transgender community and serve as an example for the rest of the world.

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