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Demystifying Transgender Healthcare

December 4, 2023

Fueled by misinformation, transgender healthcare has become a flashpoint of political controversy in recent years. Here at Charged, we’re going to debunk the myths and get down to the science to understand how transgender healthcare works, why it’s important, and what political messages are scientifically supported.

 

Activists from the National Center for Transgender EqualityActivists from the National Center for Transgender Equity

Activists from the National Center for Transgender Equality (Health Coverage Guide)

 

Terminology

Cisgender: “People whose gender identity is congruent with what is traditionally expected based on their sex assigned at birth” (Streed et al., 2021).

Transgender: People “whose gender identity, gender expression, or behavior does not conform to that typically associated with the sex to which they were assigned at birth” (American Psychological Association, 2023).

Gender Dysphoria: “Intense, persistent gender incongruence” (American Psychological Association, 2023).

Gender Affirming Care (GAC): “Psychosocial and medical support” that allows people to live in alignment with their gender identity (Lepore, Alstott, McNamara, 2022).

 

How Does Transgender Healthcare Work?

Transgender healthcare involves many steps and processes, not all of which are pursued by all transgender patients. The most common form of GAC for transgender patients is exogenous hormone therapy.

During hormone therapy, transgender men use testosterone to suppress feminizing characteristics and develop masculinizing characteristics (Unger, 2016). Transgender women use anti-androgens to suppress masculinizing characteristics and use estrogen to develop feminizing characteristics (Unger, 2016).

Hormone therapy is a strongly positive force in many transgender patients’ lives. Patients that have undergone hormone therapy have shown positive physical and psychological changes, including improvements in sexual function and mood, and a reduction in stress and cortisol levels (Unger, 2016). For these reasons, hormone therapy is considered a core element of GAC.

 

Myth 1: Only Transgender People Seek GAC

Many arguments against the availability of GAC base themselves on the myth that only transgender people seek GAC. This is false. In fact, both cisgender and transgender individuals seek GAC, including such instances as “estrogen for menopause, breast surgery, genital surgery for sexual development disorders, etc.” (Lepore, Alstott, McNamara, 2022). Gender affirming care is not limited to transgender patients, and should be viewed as a general standard of care for patients, rather than a requirement specific to transgender people.

 

Myth 2: GAC is Experimental

Arguments in favor of legal bans against GAC for transgender patients state that GAC is experimental and unsafe, and thus not yet ready for use. This is another myth. GAC is used by cisgender people without legal complaints, involving the “same medications as used in [transgender] hormone therapy, like estrogen, testosterone, and spirolactone” (Lepore, Alstott, McNamara, 2022). Furthermore, puberty and androgen blockers, used by transgender patients to lower the effects of other types of hormones, are also used by cisgender people for “developmental disorders and general medical procedures” (Lepore, Alstott, McNamara, 2022). Evidently, both transgender and cisgender patients take GAC, and cisgender patients have been taking GAC without complaint. Thus, GAC cannot be experimental, and even if it was, it should not be blocked from transgender patients specifically, but from both transgender and cisgender patients, as they both benefit from GAC.

 

Myth 3: GAC is Entirely Irreversible

Another argument against the use of GAC for transgender patients, especially in the case of hormone replacement therapy (HRT) is the myth that GAC is entirely irreversible. While the effects of HRT are irreversible in the long term, patients are “only offered reversible treatments first,” and only take further hormonal treatments for long term symptoms of gender dysphoria (Lepore, Alstott, McNamara, 2022). Beyond treatment, transgender individuals are still able to conceive, and all individuals considering hormone therapy are recommended fertility preservation methods (Lepore, Alstott, McNamara, 2022). Furthermore, irreversible genital surgeries are only reserved for adults who have “adhered to their new identities for at least a year” (Lepore, Alstott, McNamara, 2022). Thus, it can be observed that GAC is not entirely irreversible, and all irreversible decisions are made after long-term, reversible treatment has already begun. To assuage the fears of youth taking irreversible, rash decisions, let it be known that young people seeking GAC are not capable of making irreversible medical decisions within the current guidelines.

 

Myth 4: GAC is Unsafe

Many argue that GAC for transgender patients is unsafe and too dangerous to be medically prescribed. However, dangerous chemicals have been removed from GAC prescriptions for many years, and the risks of cardiovascular disease, which is more prevalent among transgender people, are reviewed before any medication is prescribed (Lepore, Alstott, McNamara, 2022).

In particular, transgender patients face an excess risk to cardiovascular disease, which can be attributed to “psychological stressors” such as discrimination and structural violence, rather than lower standards of care (Streed et al., 2021). Rates of cardiovascular disease are heightened for people suffering from HIV and AIDS, which are conditions more prevalent among transgender populations for reasons outside of medically prescribed GAC (Streed et al., 2021). While GAC has been shown to increase risks of cardiovascular disease, it is by no means the sole cause of transgender patients’ increased risk, nor is it likely the major cause of it (Streed et al., 2021).

While GAC is a risk, it is by no means a risk too dangerous to be medically prescribed, and is not a prescription that distorts standards of care.

 

Conclusion

As transgender healthcare remains a sensitive political topic, it’s important to keep the science in mind. Gender affirming care does come with risk, but is not too dangerous to be prescribed, and is shown to be psychologically helpful and at times medically necessary for transgender patients (Unger, 2016).

 

Sources

Lepore C, Alstott A, McNamara M. Scientific Misinformation Is Criminalizing the Standard of Care for Transgender Youth. JAMA Pediatr. 2022;176(10):965–966. doi:10.1001/jamapediatrics.2022.2959

Streed, C. G., Beach, L. B., Caceres, B. A., Dowshen, N. L., Moreau, K. L., Mukherjee, M., Poteat, T., Radix, A., Reisner, S. L., & Singh, V. (2021). Assessing and addressing cardiovascular health in people who are transgender and gender diverse: A scientific statement from the American Heart Association. Circulation, 144(6). https://doi.org/10.1161/cir.0000000000001003

American Psychological Association. (2023, March 9). Answers to your questions about transgender people, gender identity, and gender expression. Understanding transgender people, gender identity and gender expression. https://www.apa.org/topics/lgbtq/transgender-people-gender-identity-gender-expression

Unger CA. Hormone therapy for transgender patients. Transl Androl Urol. 2016 Dec;5(6):877-884. doi: 10.21037/tau.2016.09.04. PMID: 28078219; PMCID: PMC5182227.

Health Coverage Guide, National Center for Transgender Equality, transequality.org/health-coverage-guide. Accessed 4 Dec. 2023.

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  Timothy Durham was convicted of rape when a test showed his DNA genotype matched the DNA recovered from the crime scene. Eye witnesses testified that Durham was in a different state at the time of the incident, but he wasn’t exonerated from his 3000 year sentence until follow up DNA analysis showed that the preliminary forensic analysis used in the trial was misinterpreted (Thomas et al.). DNA testing serves an invaluable part in our criminal justice system, but it comes with complications and bias that can lead to wrongful convictions and misinformed juries.  

Background:

Forensic genetics aims to identify the origin of a biological sample. It can be traced back to Karl Landsteiner who discovered human ABO blood groups. With blood groups, suspects could be eliminated based on their blood type. For example, if a suspect had type A blood and there was type B blood left at the scene by the perpetrator, the investigators could rule out the suspect. Unfortunately, the reverse didn’t work. If the suspect and perpetrator both had the same blood type, it can’t be concluded that the suspect was guilty. Blood identifiers evolved into 8 distinct categories which improved the ability to eliminate suspects, but could only conclude that (if the system matched) it might be the perpetrator or this person might be related to the perpetrator (Jobling and Gill). The field evolved in the 1980s with the discovery of Minisatellites, lines of repetitive DNA that don’t encode proteins. Minisatellite patterns in DNA create what we know today as the DNA fingerprint, and it has a much higher accuracy rate than previous methods (Augustyn et al.). Around the same time, a breakthrough for victims of sexual assault was discovered. In the case of assault, bodily fluids of both the victim and the assaulter can get mixed. A process called differential lysis was created which could selectively increase the concentration of sperm in a fluid sample thereby allowing for accurate DNA testing (Jobling and Gill). Forensics evolved to use single-locus probe testing after several years because of its ease of interpretation. It looked at specific minisatellites that had high variability between subjects. This was the first DNA-based method to be used in a criminal investigation. Two murder homicides from several years apart were connected using DNA evidence. The evidence was then used to exonerate an innocent man, and the guilty party was found when he tried to evade mandatory DNA testing for all men in the small town. His guilt was then reinforced when the DNA profiles matched, and he gave a confession (Jobling and Gill). Finding DNA at a crime scene doesn’t guarantee that you’ll find a murderer. There are issues with non-pure samples and limited samples that make DNA work difficult, and accreditation of facilities and new techniques and take time (Jobling and Gill).  

Subjectivity of DNA Interpretation:

In a 2009 publication, the National Academy of Science discusses the possibility for subjective influence in lab based forensics. The interpretation bias happens in complex cases where, for example, there could be a mixture of DNA. A study published in 2011 looked specifically at this issue. A gang rape happened in Georgia, and the mixture in DNA from the case was used to prosecute one suspect after another suspect took a plea bargain to testify against him. With DNA mixtures, there are three possible conclusions: suspect excluded, suspect cannot be excluded, and inconclusive. If the suspect is excluded, it means that there’s little to no possibility that his DNA is part of the sample. If the suspect cannot be excluded, it means that there’s a possibility that his DNA is part of the sample. In the trial, the DNA examiners who knew the context of the case concluded that the suspect being prosecuted could not be excluded. The 2011 study gave the DNA evidence from this case and the DNA profiles of the suspects to 17 forensic examiners. These examiners had no context of the case, and they all worked independently. Of the 17, only 1 came to the same conclusion (suspect cannot be excluded) as the examiners who knew the context of the case. Twelve of the 17 concluded that the suspect who was prosecuted and convicted had no relation to the DNA found in the sample. Not only does this show that subjectivity occurs due to the context of the case, but the 17 examiners came up with different findings based on their past experiences meaning that not all DNA analysis is objective. Some organizations like the Scientific Working Group on DNA Analysis Methods say that quantitative statistical evidence should be presented with every categorical conclusion, but the US doesn’t require this (Dror and Hampikian).

False Positives:

There are two categories that cause wrongful identification in a DNA report: coincidental matches and false positives. Coincidental matches are DNA matches between two unrelated people. The probability of these matches is about 1 to 500,000 for white individuals and about 1 to 350,000 for black individuals. This small probability of coincidental matches makes people feel confident in DNA evidence. False positives, on the other hand, are matches between DNA and test DNA that result from issues in the forensics lab. There have been multiple cases of forensics labs accidentally switching victim and suspected rapist DNA which lead to convictions that were later overturned when the lab realized the error. There are also cases of misreading or misunderstanding a sample. In a case from 1993, a man was convicted of rape because someone interpreted a mixed sample of victim and perpetrator DNA as an individual sample. The conviction was again overturned. To prevent false convictions, retesting DNA is allowed, but it’s not an efficient solution. Many people are pushing for statistical information on the probability of false positives, so that the jurors can make accurate judgements based on DNA evidence (Thomas et al.).  

Conclusion:

DNA analysis is a useful tool for the criminal justice system, but subjectivity can be an issue in forensic testing. To combat wrongful convictions, there are organizations like The Innocence Project who use DNA testing to free the innocent, but reformed forensic testing standards should be put in place to prevent subjectivity and to ensure juries are correctly informed during trials. https://www.innocenceproject.org/    

Citation:

Augustyn , Adam, et al. “DNA Finerprinting.” Encyclopedia Britannica , 26 Apr. 2018, www.britannica.com/science/DNA-fingerprinting#ref153186. Dror, Itiel E., and Greg Hampikian. “Subjectivity and Bias in Forensic DNA Mixture Interpretation.” Science & Justice, vol. 51, no. 4, 2011, pp. 204–208., doi:10.1016/j.scijus.2011.08.004. Jobling, Mark A., and Peter Gill. “Encoded Evidence: DNA in Forensic Analysis.” Nature Reviews: Genetics, vol. 5, no. 10, Oct. 2004, pp. 739–751., doi:10.1038/nrg1455. Thompson, William C, et al. “How the Probability of a False Positive Affects the Value of DNA Evidence.” Journal of Forensic Sciences, vol. 48, no. 1, Jan. 2003, pp. 1–8., doi:10.1520/jfs2001171.