Transgender (trans) people have a gender identity and/or gender expression that does not align with their sex assigned at birth (SAB). Many trans people experience associated distress known as gender dysphoria. Health care disparities among trans people are prevalent, related to gender dysphoria, fears of discrimination, access to medical/surgical care and other barriers. Among the many health care disparities faced by trans people, studies have reported on decreased physical activity and healthy eating habits as well as increased tobacco smoking, alcohol use and drug use. My quality improvement project during endocrine fellowship revealed higher rates of obesity among both trans women and trans men compared to the general adult population of Colorado. Research locally and around the world tries to better understand the basis for and evaluate solutions to reduce differential health outcomes based on gender identity.
As an early career endocrinologist at the University of Colorado School of Medicine (CUSOM), my academic trajectory is to explore the impacts of obesity, aging and gender-affirming hormone therapy (GAHT, or using sex hormones of the affirmed gender) on cardiometabolic risk in trans people. My current research compares vascular endothelial function and aging in trans women and men on chronic GAHT with the same parameters in cisgender (cis) women and men, individuals whose gender identity aligns with their SAB. These data will provide preliminary data for further investigations on the effects of sex steroids in trans and cis people. My interest in trans research has a foundation in years of volunteer work within the trans and other sexual/gender minority communities. Over the years, I have also heard from trans patients about continued stigma within medicine regarding access to culturally sensitive and comprehensive care. Trans patients deserve evidence-based best practices for health care delivery, particularly in the setting of GAHT, which has been associated with weight gain and an increased risk cardiovascular disease (CVD) and venous thromboembolism in trans women and possibly trans men. Whether gonadectomy (after GAHT, based on clinical practice guidelines) affects CVD risk is yet to be determined.
In September 2017, I co-founded the UCHealth Integrated Transgender Program (ITP) with my mentor, Dr. Micol Rothman, and other specialists in psychiatry, internal medicine, gynecology and plastics and reconstructive surgery, to provide safe and comprehensive care to our trans patients during a single clinic visit within the Endocrinology Clinic. ITP also educates providers, staff and learners across the hospital system and within the community. We received a 2018 University of Colorado President’s Diversity & Inclusive Excellence Grant, the 2019 University of Colorado Hospital Medical Staff Award for Excellence in Clinical Innovation and a 2019 One Colorado Ally Award. We are collecting qualitative (e.g., patient and provider needs assessments) and quantitative (e.g., Pap test and other cancer screening compliance, hormone monitoring, body mass index [BMI] and body composition changes, laboratory trends, pre-/post-Provider Education Day knowledge differences) data. We are establishing a Community Advisory Board to engage stakeholders in developing ideas for future research collaborations and participant recruitment. I am also spearheading the creation of a registry of trans patients at UCHealth and will collect prospective data on health outcomes. Working with the Division of Plastic and Reconstructive Surgery, a new plastic surgeon will join the ITP team in Sept 2019, increasing access to gender-affirming surgery to our patients.
To learn more about trans health research, I met Dr. Guy T’Sjoen (Ghent University Hospital, Belgium) and Dr. Martin den Heijer (Amsterdam University Medical Center, the Netherlands) as part of a 2017 American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) Dr. Lewis E. Braverman Educational Fund Travel Grant. Both are endocrinologists and primary investigators of the European Network for the Investigation of Gender Incongruence (ENIGI), the first collaboration to create a multicenter, multinational, standardized treatment and follow up protocol to prospectively investigate the effects of GAHT in trans people. Since then, we have collaborated on a workshop about GAHT outcomes at the European Professional Association for Transgender Health (EPATH) in April 2019 and wrote a narrative review on feminizing GAHT. I have also submitted a proposal to conduct subgroup analyses on existing ENIGI data to see if/how BMI and age influence various health outcomes in that cohort of patients. I am serving on the U.S. Professional Association for Transgender Health (USPATH) 2019 Conference Scientific Review and Awards Committees, while also part of a symposium on screening tests in trans people.
I have ongoing support of my mentorship committee and the CUSOM Department of Medicine, Division of Endocrinology, Metabolism & Diabetes to help achieve their vision of cultivating interdisciplinary trans research. Though early in my career, I have already established myself as a physician advocate dedicated to improving health care/outcomes for trans patients through interdisciplinary clinical translational research and international collaboration, with a focus on obesity and aging.