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Evidence-Based Transgender Medicine

"Published transgender-specific level 1 evidence is essentially non-existent. [...] Long-term, prospective studies for most transgender-specific health issues are lacking, thus resulting in variable preventive care recommendations based primarily on expert opinion. However, by utilizing an increasing body of peer-reviewed, scientific research on transgender health, along with relevant data from the general population, one can develop an evidence-based approach to preventive care for patients who are transgendered or transsexual." -- Jamie Feldman, M.D. (Feldman, J [2007])

Many thousands of transgender and transsexual people have been treated with cross-sex hormones (see section Hormone Administration) and surgical procedures for over 70 years in Western Europe and over 60 years in America. Yet because of the stigma of gender-variance and sex reassignment (also called sex affirmation, or gender confirmation) which discourages funding for research, and because of the difficulty of conducting randomized trials involving cross-sex treatments, very little specific information about treatment actually exists beyond case reports and small scale studies on specific clinical issues.

Data collection weaknesses further impacting the marginalization of transgender and transsexual people include lack of researcher access to the population, lack of cohesive community networks within the population, disagreement with terminology used to refer to the population (which affects community trust and impacts researcher effectiveness; e.g., referring to transwomen as "male transsexuals" or "men who have sex with men (MSM)" alienates potential subjects), and researchers' use of definitions to describe both transgender and transsexual people (see section Transgender Terminology) that artificially circumscribe the pool of available research subjects (e.g., describing transsexual people as only those who have previously undergone genital reconstruction). The UCSF Center of Excellence for Transgender Health offers recommendations for data collection.

To address the health care needs of their transgender and transsexual patients, clinicians have extrapolated from studies based on non-transgender populations, and adapted findings from the few long-term cross-sex hormonal assessments done in the Netherlands by Gooren, et al., combined with their own clinical experience, to support clinical judgments regarding basic health care with general success.(Gooren, LJ [2008])

The Center of Excellence for Transgender Health's Medical Advisory Board (MAB), consisting of eight physicians and one nurse practitioner, came together to develop a common-sense approach to transgender care. The MAB members are predominantly based in California (one physician is in Arizona) because the project to develop this protocol was originally targeted to California-based practitioners. Medicine is often practiced differently based on geographic region, and the CoE is interested to learn how physicians in other regions adapt our recommendations to their own practices. Please write to the CoE with comments.

This protocol is based on a critical review of the medical literature that exists on transgender health care, and on the physicians' many combined years of clinical practice. In evaluating their recommendations, the MAB members employed the Strength-of-Recommendation Taxonomy (SORT) used by the American Academy of Family Physicians. We applied this taxonomy to transgender-related practice using the following grade definitions and notation to indicate strength of recommendations and the basis on which the recommendations are made:

Grade Definitions
ARelatively low quality transgender-specific retrospective or observational study data
BInconsistent, or limited-quality patient oriented evidence obtained from other disciplines that the experts have adapted to transgender contexts
CExpert opinion, derived from clinical experience, study of prior publications, and consensus among the providers serving on the Medical Advisory Board

This protocol emphasizes the areas of special consideration in which transgender-related medical treatments may have an impact on a patient's well-being.