Estimated that the prevalence of transgender or transsexual individuals in the United States is 1-1.4 million.

Prevalence ranges from 0.5 to 8.4%  percent of the population.

Estimates of the proportion of transgender and gender diverse individuals worldwide range from 0.6% to 3% and have increased in recent years, particularly among adolescents and young adults.

The proportion of adults who identify as transgender worldwide ranges from 0.3 to 0.5% and it is estimated that 0.5% to 4.5% of adults self identify as gender diverse, with the variability reported across geographical regions and depending on inclusion criteria.

In a population based study, transgender and gender diverse participants, self report, a mean poor mental health of 14.8 days per month compared with 6 for cisgender participants (Feldman JL).

Estimated transgender and non-binary youth compromise 2 to 9% of high school aged persons in the United States.

Approximately 25 million people worldwide identify as transgender.

Sex refers to anatomy based on one’s chromosomal phenotype.

Sex is the biological phenotype present at birth.

Sexuality of a person is the gender of the person to whom they are attractive.

Gender refers to how an individual wants to be viewed by the world around them.

Gender identity describes a persons sense of being male, female, neither, or some combination of both.

Transgender/transsexual- circumstance in which the person’s birth sex does not match his/her gender.

Transgender men have male gender identity and were recorded as female at birth.

Transgender women have a female gender identity and have been recorded as male at birth.

Gender non-binary persons may identify as neither male nor female or as having features of both sexes.

Gender expression relates to have a person communicates gender identity.

The effort to align physical characteristics with gender identification is known as transition, gender affirmation or gender confirmation.

Gender dysphoria is a mental health diagnosis describing an individual’s sense of discomfort when gender identity and sex recorded at birth do not align.

Mental health providers often initially identify and address gender dysphoria and support patients through hormone and surgical therapy and interact with family, colleagues, friends, employers and institutions.

Transgender women have higher rates of mood disorders, substance abuse, sexually transmitted infections then non-transgender women, yet they receive less preventive care.

Endocrinologists recommend regimens to suppress endogenous sex hormones and increase target hormone concentrations.

There are higher risks of thrombosis in transwomen with at least one of the following risk factors: smoking, genetic predisposition, prolonged mobility, or use of ethinyl estradiol or conjugated estrogens.

Estrogen suppress androgen production through essential feedback mechanism while causing feminization and protecting bone health.

Transgendered women who receive hormone therapy may be at it increase risk with deep vein thrombosis, pulmonary embolism, stroke, and myocardial infarction as compared with expected rates among cisgendered persons.

The feminizing effects of estrogen occur both directly and through negative feedback on the hypothalamus pituitary testicular hormonal access, leading to a reduction in testosterone levels.

The use of estrogen can result in the development of secondary sexual characteristics, causing breast growth and redistribution of body fat.

Estrogens are usually combined with anti-androgen therapy for suppression of secondary sex characteristics, such as body hair.

Hormone levels are routinely followed to ensure suppression of testosterone and avoid supraphysiological levels of estrogen.

Arterial thrombosis and venous thromboembolism is more frequent with the use of estrogens and the incidence of myocardial infarction is increased twofold.

Ethinyl estradiol is not recommended because it appears to be particularly thrombogenic.

Testosterone lowering agents are also considered measures.

Spironolactone is a commonly used adjunctive agent to reduce androgen levels, as it blocks the action of androgen at its receptor and decreases testosterone levels.

Identical twin siblings of transgender persons are more likely than fraternal twin siblings of transgender person to be transgender.

Cyproterone May suppress gonadotropins and act as androgen receptor antiagonist.

GnRH Agonists can suppress testosterone levels but are second line therapy owing to the high cost.

Approximately 0.6% of adults, or 1.4 million persons, identify as transgender.

Approximately 25% of transgender persons report denial of medical services, and 30% report be they avoided care owing to fear of discrimination.

Children may label genders and articulate gender identity by two years of age.

Up to 2.7% of children report gender incongruence, but many of such children do not continue to do so later in life.

The majority of transgender patients present in late adolescence or early adulthood.

Change gender identity is established on the basis of historical aspects alone: gender in congruence is persistent, typically present for years.

Increasingly, transgender and non-binary youth receive medical care to alleviate, gender dysphoria, including gonadotropin, releasing hormone agonists to suppress, gender incongruent, puberty and gender affirming hormones, testosterone, or estradiol, to foster the gender, congruent, secondary sex characteristics.

The goal of such treatment is to attenuate, gender, dysphoria by increasing appearance, congruence, the degree to which youth experience alignment between their gender in the physical appearance.

In a two-year study involving transgender and non-binary youth, gender affirming hormones, improved appearance congruence, and psychosocial functioning (Chen D).

Patients should have social and sexual history obtained, screening for infections based on sexual history, assessment of anxiety, depression, and suicidality, all of which are more common among sch patients.

Goals for transfeminine hormone treatment or to reduce growth of facial hair, induce breast development, and induce fat and muscle redistribution to a more feminine pattern.

The initiation of hormone therapy after puberty does not affect height or a voice.

Terminal hair on the face continues to grow without androgen stimulation, and transgender women may require electrolysis or laser hair removal.

Testosterone levels are moved from the male range of 300-1000 ng/dL to the female range of less than 50 ng/dL and targeting estradiol levels in the range of 100-200 pg/mL while avoiding superphysiologic levels of greater than 200 pg/mL.

Physical changes are generally observed in 6-18 months.

Orchiectomy is the most effective means of decreasing testosterone levels, but many transgender women opt for medical treatment instead.

The goal in transmasculine hormone therapy is the bring physical changes that match gender identity through administration of testosterone, raising hormone levels to male physiologic range.

After approximately 3-6 months of treatment transgender men can anticipate cessation of menses, the development of a deeper voice, increase in facial and body hair, increase muscle mass, and increased sexual desire.

Acne may develop with testosterone dosing, and overtime the development of male hair pattern and clitoral enlargement may occur.

Testosterone esters, gels, patches, and injectables may be utilized.

Androgens stimulate erythropoiesis and this may be associated with polycythemia, making treated individuals at risk for elevated hematocrit, and sleep apnea.


Monitoring hormone levels in transgender patients for need of adjustment in hormone doses is suggested every three months during the first year and then once or  twice a year whenever the dose is changed.

Transgender patients should undergo bone density testing.

Transgender hormone therapy may reduce fertility and transgender women may consider cryopreservation of sperm, and transgender men cryopreservation of oocytes.

Children identified for transgender identity problems should be assessed for mood disorders, and risk of suicide.

Transgender populations have a high baseline cardiovascular risk, higher rates of mental health disorders and substance abuse then the general population, with high rates of undiagnosed and untreated comorbidities, such as hypertension and dyslipidemia, that increase risk for cardiovascular disease.

In a Danish population based, retrospective study, transgender individuals, had significantly higher rates of suicide attempt, suicide mortality, suicide unrelated mortality, and all cause mortality compared with non-transgender population (Erlansen A).






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