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1.4% of American teenagers report identifying as transgender.
That figure comes from a report released in June by the Williams Institute at the University of California, Los Angeles School of Law after analyzing data from the US Centers for Disease Control and Prevention. This estimate doubles the figure for that age group from 2017, the organization said, and contributes to a total of 1.6 million people who identify as transgender in the country.
“For many people, having physical characteristics that do not match their inner feelings of sexuality is very unfortunate. Dr. Stuart WeinzimmerProfessor of Pediatrics and Director of Research at Yale School of Medicine Yale Gender Program. “We call it dysphoria – a feeling of extreme discomfort with yourself, that your body and identity are out of sync.”
This discomfort can grow during adolescence, when physical changes can trigger initial concerns about the gender assigned at birth or exacerbate long-term anxiety.
“One of the primary functions of adolescence is the development of identity, including gender identity,” Weinzimmer said. “Most people don’t think twice about their sexuality because they don’t have to, just like you don’t have to think about breathing. You just do it. However, for people who are physically out of sync with their inner feelings, this disconnect can be a hindrance to mental health. It is a hindrance to the creation of one’s own personality.
Gender dysphoria can cause life-threatening risks, including anxiety, depression, and suicide. Yale’s Children’s Gender Program offers in-depth psychological evaluations for those who have experienced this “disconnection” with their gender identity and need help. Individuals who are considering or undergoing social transition are seen with their parents or carers and given the opportunity to discuss and better understand these experiences. After a general consultation, next steps based on individual goals are discussed. In this context, gender-affirming hormone therapy (GAHT) may be offered as an option.
As is true with many medications, GAHT can present both risks and benefits to the individual. For example, patients treated with GAHT with testosterone may develop unfavorable cholesterol profiles, increasing the long-term risk of cardiovascular disease. Patients taking GAHT with estrogen may have an increased risk of blood clots. GAHT may also present other health risks that have not yet been fully investigated. However, despite being aware of potential risks, the experience of gender dysphoria can be so obvious and severe that GAHT may be preferred.
Hormones and bone strength
Bone is a living organism. On a continuous basis, the bones respond to weight stresses by strengthening themselves, just as a computerized bridge is emotionally and intellectually designed to somehow strengthen itself and support the traffic load above. Bones also act a bit like an individual pension plan, where people contribute throughout their lives (with minerals stored in their bones) so they can withdraw money to support themselves as they get older. The fastest time for such investments to increase bone strength is during late adolescence, before typically appearing in individuals in their 20s and 30s and generally beginning to decline in their 40s.
“You build bone strength in your early years, so you have that reserve,” he said Dr. Thomas CarpenterProfessor of Pediatrics and Orthopedics and Rehabilitation at Yale School of Medicine. “The presence of sex hormones during puberty plays an important role in building strength.”
Under the influence of the male hormone testosterone, the hard cylinder that surrounds the outer part of the bones, known as the periosteum, grows thicker. This is why cisgender adult males (assigned male at birth and who identify as male) have large, thick, and strong bones.
The female hormone estrogen tends to suppress or prevent bone loss, as some cells store calcium and other minerals and other cells dissolve bone cells by chewing them up. In this way, estrogen reduces bone loss. This is why transgender women who experience low estrogen levels during menopause are at a higher risk of fractures and fractures.
During puberty, normal patterns and timing of adolescent growth are altered in individuals taking GAHT, and the effect of these hormonal systems on the bone growth process is not fully understood.
A picture of better bone health
Standard bone density measurements use an X-ray machine (commonly called DXA), which cannot detect changes in the microstructure that affects bone quality.
“Bone structure is like a strong chain with many links,” Carpenter said. But if you have one thin link, that’s where your chain can break. You need to know if those weak spots exist.
With a grant from WHRY, Dr. Weinzimmer collaborated with Dr. Carpenter and the director and founder of the Yale Pediatric Gender Program. Dr. Christy OlezeskiIt is using more sophisticated methods to image the dynamic process of bone development, including bone density, quality, and architecture, and is evaluating bone changes in adolescents who identify as transgender during the first year of GAHT.
In addition, the study, building on work started by former postdoctoral fellow Apoorva Ravindranath Waiker, will catalog metabolic markers of bone health, as well as demographic, clinical and behavioral variables such as diet and exercise that may facilitate or hinder normal bone health. As they age in this population.
“This study represents an important step forward in looking for the first time at how these parameters change in people taking sex-affirming hormone therapy,” Weinzimmer said. “We don’t know what that looks like yet, and we probably find that these measures of variability are very different in this population.” If we find that, then we need to look at ways to reduce the risk in this population.
Possible strategies may include changes in diet and exercise or adjusting hormone systems.
The study will ultimately help inform central clinical questions in GAHT during adolescence, including: Are current treatments effective in improving bone health at the time of initiation of these hormonal treatments? What role do non-pharmacological influences such as physical activity and diet play in these parameters over time? And, how can we use these data to advise individuals and their families to make the healthiest decisions about when to start these treatments?
“We know GAHT saves lives,” Weinzimmer said. “Even if it’s effective, we know there are risks. The way to address the risks is not to say ‘it’s dangerous – don’t do it.’
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