Alessandra Daphne Fisher

Purpose: Transgender and gender diverse (TGD) individuals have various medical needs, but limited healthcare professionals’ expertise remains a major barrier to care. Data on the preparedness of Italian endocrinologists to provide TGD care are scarce. This study assessed Italian endocrinologists’ knowledge, clinical practice, and educational needs in gender-affirming care. Methods: A nationwide survey developed by the Association of Medical Endocrinologists (AME), with support from the Italian Society for Gender, Identity and Health, was distributed to all AME members in 2023. Multivariable logistic regression identified factors associated with knowledge, self-reported ability to manage gender-affirming hormone therapy (GAHT) and interest in further education. Results: Overall, 703 endocrinologists completed the survey. Only 8.4% reported frequent clinical involvement with TGD patients, and fewer than 15% considered themselves able to initiate and monitor GAHT. Previous education in gender-affirming care was the strongest determinant of knowledge (OR 14.3) and self-reported ability to manage GAHT (OR 4.4). Younger age was associated with greater knowledge but not with perceived clinical competence. Nevertheless, 90.4% expressed interest in further education. Conclusion: Italian endocrinologists show substantial gaps in preparedness for transgender care. Structured education in gender-affirming care is strongly associated with greater knowledge and self-reported ability to manage GAHT, supporting the implementation of educational programs to improve access to competent endocrine care for TGD individuals.

The sample size and data collection period of the original publication

Purpose: There is a paucity of data on the safety and efficacy of long-term testosterone (T)-based gender-affirming hormone therapy (GAHT) on anthropometric parameters, body composition, and glycolipid metabolism in assigned female at birth (AFAB) persons. The purpose of this study was to provide an updated meta-analysis on this topic. Methods: We searched PubMed, Scopus, and Cochrane Library for relevant studies. Pre-/post-therapy changes in body mass index (BMI), waist-to-hip ratio (WHR), body composition, lipid glycemic/insulinemic profiles were combined as mean differences (MD) with 95% confidence interval (CI), using random-effect models. Results: Thirty-nine studies ( N =1949) were analyzed. At pooled estimates, GAHT was associated with significant decrease in fat mass (MD: −1.29 kg; 95% CI: −2.52 to −0.05; p =0.04) and increase in lean mass (4.12 kg; 95% CI: 3.07–5.16; p 2 ; 95% CI: 0.50–1.07; p p =0.003) in the absence of heterogeneity ( I ² =0%). T therapy was also accompanied by unfavorable effects on lipid profile, including increases in total cholesterol (4.95 mg/dL; 95% CI: 1.53–8.37; p =0.005), LDL (11.15 mg/dL; 95% CI: 7.57–14.74; p p =0.0003) and decrease in HDL concentration (−7.52 mg/dL; 95% CI: −9.38 to −5.67; p p =0.002), with no significant effects on homeostatic model assessment index of insulin resistance. Conclusion: T-based GAHT in AFAB people is associated with androgenic changes in body composition and body fat distribution, accompanied by the acquisition of a more unfavorable cardiovascular lipid profile.

Transgender and gender-diverse (TGD) individuals continue to experience harassment and discrimination across various aspects of life, significantly impacting their physical and mental health. The scarcity of data on their general health, particularly regarding dietary habits, remains a challenge in developing effective healthcare strategies for this population. To address this gap, we analyzed selected dietary habits, physical activity (PA), and body mass index (BMI) among Italian TGD adults compared to the Italian general population (IGP). An online anonymous survey was conducted via the Computer Assisted Web Interviewing technique from June 2020 to June 2021. Participants were enrolled through clinical centers and TGD organizations. Data from 959 TGD adults were analyzed using chi-squared tests and logistic regression models. Key findings indicated that approximately 70% of TGD individuals consumed fewer servings of fruit and vegetables (FV) than recommended (five or more servings per day). Although red meat consumption was lower overall, a greater percentage of TGD individuals reported consuming more than three servings per week. Additionally, 58% of TGD participants indicated that they did not engage in any PA, compared to 36% of the IGP. Notably, significant differences in BMI were identified, with higher rates of overweight and obesity among TGD individuals assigned female at birth. These results underscore the urgent need for tailored nutritional guidelines and inclusive public health strategies to meet the specific health needs of the Italian TGD population. Expanding access to targeted interventions could contribute to improving overall well-being in this marginalized group.

Sommario: La terapia ormonale di affermazione di genere ha la finalità di allineare, per quanto possibile, le caratteristiche corporee con l’identità di genere e gli specifici obiettivi delle persone transgender (trans) o gender diverse (GD) che ne esprimano la necessità. Il cardine della terapia virilizzante e de-femminilizzante nelle persone trans/GD assegnate al genere femminile alla nascita (AFAB) è rappresentato dal testosterone (T), in grado di indurre modificazioni corporee quali l’amenorrea, l’aumento della distribuzione pilifera del corpo e del volto, l’aumento della massa muscolare, l’abbassamento del timbro vocale, l’aumento delle dimensioni del clitoride. L’acne, l’alopecia con pattern maschile, la policitemia e il peggioramento dell’assetto lipidico sono i principali effetti collaterali della terapia con T, che richiede un attento monitoraggio clinico-biochimico. Alcune persone trans/GD AFAB desiderano una mascolinizzazione e/o de-femminilizzazione parziale, per cui potrebbero essere proposte terapie con dosaggi ridotti di T in associazione ad altre strategie non ormonali di affermazione di genere, valutando il rapporto tra benefici e possibili rischi di tale trattamento. La terapia femminilizzante e de-mascolinizzante nelle persone trans/GD assegnate al genere maschile alla nascita (AMAB) si basa sull’uso di estrogeni (in varie formulazioni) e antiandrogeni, nella fattispecie ciproterone acetato (CPA), analoghi dell’ormone di rilascio delle gonadotropine (GnRHa) o, in alternativa, spironolattone. Tra i principali effetti attesi della terapia con estrogeni e antiandrogeni, sono previsti l’aumento del volume mammario, la riduzione della distribuzione pilifera del volto e del corpo, dell’oleosità della cute, delle erezioni spontanee e del volume testicolare e la ridistribuzione del grasso corporeo in aree ginoidi. La terapia con estrogeni può essere associata a un aumentato rischio di tromboembolismo venoso, mentre la terapia con antiandrogeni è associata a specifici – per quanto rari – effetti collaterali che impongono un regolare monitoraggio clinico e biochimico. Alcune persone trans/GD AMAB potrebbero richiedere una terapia finalizzata alla parziale femminilizzazione e/o de-mascolinizzazione del corpo; pertanto, può essere presa in considerazione una terapia con bassi dosaggi di estrogeni e/o di antiandrogeni secondo gli specifici obiettivi della persona, effettuando un bilancio tra benefici e rischi, soprattutto sotto il profilo della salute ossea e cardiovascolare.

Background: Despite the increasing interest in transgender health research, to date little is known about the size of the transgender and gender diverse (TGD) population. Methods: A web-based questionnaire survey was developed, including a collection of socio-demographic characteristics and disseminated online through social media. Gender incongruence was evaluated by using a 2-item approach assessing gender recorded at birth and gender identity. The primary objective of the present population-based study was to estimate the proportion of TGD people across ages among a large sample of people who answered a web-based survey. The secondary endpoints were to identify gender-affirming needs and possible barriers to healthcare access. Results: A total of 19,572 individuals participated in the survey, of whom 7.7% reported a gender identity different from the sex recorded at birth. A significantly higher proportion of TGD people was observed in the youngest group of participants compared with older ones. Among TGD people who participated in the study, 58.4% were nonbinary, and 49.1% experienced discrimination in accessing health care services. Nonbinary TGD participants reported both the need for legal name and gender change, along with hormonal and surgical interventions less frequently compared to binary persons. Conclusions: Being TGD is not a marginal condition In Italy. A large proportion of TGD persons may not need medical and surgical treatments. TGD people often experience barriers to healthcare access relating to gender identity.

Context: The role of body modifications induced by gonadal suppression in transgender and gender diverse adolescents on psychological functioning has not yet been evaluated. Objective: The main aim of the present study was to explore several hormone, physical and psychological functioning changes during gonadotropin-releasing hormone analog (GnRHa) treatment in transgender and gender diverse adolescents (TGDAs). The potential relationship between the physical and hormone effects of GnRHa and psychological well-being, along with its magnitude, was assessed for the first time. Methods: This prospective multidisciplinary study included 36 TGDA (22 assigned female at birth, and 14 assigned male at birth) who received psychological assessment followed by triptorelin prescription after referring to the Florence Gender Clinic. This study consisted of 3 time points: first referral (T0), psychological assessment (T1); and treatment with intramuscular injections of triptorelin for 3 up to 12 months (T2). Psychometric questionnaires were administered at each time point, and clinical and biochemical evaluations were performed at T1 and T2. Results: The following results were found: (1) GnRHa showed efficacy in inhibiting puberty progression in TGDAs; (2) an increase in psychopathology was observed before starting GnRHa (T1) compared with baseline levels; (3) during GnRHa treatment (T2), a significant improvement in psychological functioning, as well as decrease in suicidality, body uneasiness, depression, and anxiety levels were observed; (4) hormone and physical changes (in terms of gonadotropin and sex steroid levels, height and body mass index percentiles, waist–hip ratio, and acne severity) observed during triptorelin treatment significantly correlated with a reduction in suicidal ideation, anxiety, and body image concerns. Conclusion: Psychological improvement in TGDA on GnRHa seems to be related to the objective body changes induced by a GnRHa. Therefore, the rationale for treatment with a GnRHa may not only be considered an extension of the evaluation phase, but also the start of a medical (even if reversible) gender-affirming path, especially in TGDAs whose puberty has already progressed.

In Italy, studies investigating gender identity and expression in gender non-conforming adults are lacking, as well as data regarding the non-binary population. The present study aimed at dimensionally exploring how transgender and non-binary Italian adults identify and express their gender. The Gender Diversity Questionnaire (GDQ) was administered to a sample of 112 adult subjects aged 18–60 years accessing a gender-specialized service in Rome. The majority of the participants were aged 18–24 years (53.6%), whereas fewer subjects were aged 25–35 years (32%) and 35 years and older (14.3%). Most participants (83.9%) identified themselves as trans binary, while the remaining (16.1%) identified as non-binary. Trans binary participants reported a stable gender identity, whereas non-binary participants reported a more fluid gender identity over time and across contexts. Younger subjects recognized the use of chosen names, pronouns, and clothes as important for their gender expression, whereas older subjects attributed more importance to physical appearance and emotions. Differences regarding gender-affirmative interventions emerged between non-binary and transbinary participants. Findings evidence that gender non-conforming adults accessing gender-specialized services have unique needs and features, thus it is essential to shed light on this population by providing greater visibility and recognition.