Health considerations for transgender women and remaining unknowns: a narrative review

Abstract

Transgender (trans) women (TW) were assigned male at birth but have a female gender identity or gender expression. The literature on management and health outcomes of TW has grown recently with more publication of research. This has coincided with increasing awareness of gender diversity as communities around the world identify and address health disparities among trans people. In this narrative review, we aim to comprehensively summarize health considerations for TW and identify TW-related research areas that will provide answers to remaining unknowns surrounding TW’s health. We cover up-to-date information on: (1) feminizing gender-affirming hormone therapy (GAHT); (2) benefits associated with GAHT, particularly quality of life, mental health, breast development and bone health; (3) potential risks associated with GAHT, including cardiovascular disease and infertility; and (4) other health considerations like HIV/AIDS, breast cancer, other tumours, voice therapy, dermatology, the brain and cognition, and aging. Although equally deserving of mention, feminizing gender-affirming surgery, paediatric and adolescent populations, and gender nonbinary individuals are beyond the scope of this review. While much of the data we discuss come from Europe, the creation of a United States transgender cohort has already contributed important retrospective data that are also summarized here. Much remains to be determined regarding health considerations for TW. Patients and providers will benefit from larger and longer prospective studies involving TW, particularly regarding the effects of aging, race and ethnicity, type of hormonal treatment (e.g. different oestrogens, anti-androgens) and routes of administration (e.g. oral, parenteral, transdermal) on all the topics we address.

Transgender Women in Malaysia: A review of health related issues and challenges

“…In Malaysia, based on the data from Integrated Biological and Behavioural Surveillance studies showed increment from 4.8% -12.4% of transgender women were HIV positive, with higher estimation among those who engaged in sex work (Rutledge et al, 2018). HIV transmission risk in transgender women increases with various exposures such as violence victimization, polysubstance use, depression, frequent alcohol use, multiple partners, lack of knowledge in HIV/AIDS, negative attitude towards HIV/AIDS, transactional sex and history of sex with adults before the age of 18 years (Gibson et al, 2016;Samsul D et al, 2016;Iwamoto et al, 2019). Transactional sex or known as survival sex (sex in exchange for money), had been the main risk of HIV as they are at greater risk for engaging in unprotected receptive anal sex (condomless), which usually motivated by high payment (Parsons et al, 2018;Baral et al, 2013;Shan et al, 2018).…”

“…Despite the high prevalence of HIV among these community, they also contributed to low screening levels, most probably due to denial of having the illness (Gibson et al, 2016). HIV prevention, treatment and care should be priorities around the world, but these population experience many barriers to treatment ranging from incorrect pronoun use of their name, judgmental and insensitive statements, unwillingness to provide care, asked to change their appearance or felt they had to present as male to receive proper care, societal stigmatization, a lack of knowledge by the healthcare about transgender needs and the refusal of many national health systems or health insurance providers to cover their care (Gupta et al, 2016;Vijay et al, 2018;Iwamoto et al, 2019).…”

“…Cross-sex hormonal treatment usually being used to achieve the desired masculinization or feminization. Feminizing medications used in transgender women include Oestrogen and Spironolactone, which used to suppress serum testosterone levels and block the androgen action (Gupta et al, 2016;Iwamoto et al, 2019). The majority of feminizing oral hormones used were birth control pills which can be easily purchased at any pharmacy or obtained from friends or prescribed by a physician (Colby et al, 2016).…”

“…Breast enlargement is very important to transgender women because it represents their new gender (Draman S et al, 2018). To get the desired breast, these population usually will take a high dose of exogenous Oestrogen without knowing the complication of the medication (Braun et al, 2017;Iwamoto et al, 2019;Draman S et al, 2018). Several complications of these medications include depression, venous thrombo-embolism, myocardial infarction, stroke, hypertension and reduction in insulin sensitivity which in turn lead to diabetes Mellitus (Iwamoto et al, 2019;Draman S et al, 2018).…”

“…To get the desired breast, these population usually will take a high dose of exogenous Oestrogen without knowing the complication of the medication (Braun et al, 2017;Iwamoto et al, 2019;Draman S et al, 2018). Several complications of these medications include depression, venous thrombo-embolism, myocardial infarction, stroke, hypertension and reduction in insulin sensitivity which in turn lead to diabetes Mellitus (Iwamoto et al, 2019;Draman S et al, 2018). Hormone-related malignancies in transgender women can also occur due to the prolonged use of these high dose medication, especially breast and prostate cancer (Braun et al, 2017).…”