GEnder Dysphoria Treatment in Sweden (GETS)

Phenotype Modulations Following Treatment With Contrary Sex Hormones

Gender dysphoria (DSM-5) or transsexualism (ICD10) is a condition in which a person's feeling of gender identity is not congruent with the physical body. The hormonal treatment includes inhibition of one's own sex hormone production followed by treatment with testosterone or estrogen levels that are normal for the opposite sex. Seen as experimental model, this is a process that provides an opportunity to study the sex hormone dependent influences that explain differences in morbidity in men and women respectively. The differences that are especially significant but not well known is 1) metabolic changes in the regulation of glucose homeostasis and lipid metabolism 2) regulation of vascular function and structural effects on the heart and arteries 3) regulation of skeletal muscle mass and fat tissue 4) morphological and functional effects on discrete areas of the brain.

Therefore, the investigators will follow these patients for a year to study how the heart, blood vessels, brain, and risk factors for cardiovascular disease affected by altered sex hormone patterns and studying what happens in the muscles and fat in both the short and long term with respect to particular gene expression and epigenetic changes and link it to metabolic changes and body composition.

Study Overview

• Status: Completed
• Conditions: Transsexualism
• Intervention / Treatment: Other: Genetic men treated with estrogen; Other: Genetic women treated with androgen

Detailed Description

At the Centre for andrology and sexual medicine at Karolinska University Hospital about 30 genetic males (MtF) and 25 genetic females (FtM) every year start hormone replacement therapy. This hormonal treatment includes inhibition of one's own sex hormone production (down regulation of the gonadal axis) followed by treatment with testosterone or estrogen levels that are normal for the opposite sex. Seen as experimental model, this is a process that provides an opportunity to study the sex hormone dependent influences that explain differences in morbidity in men and women respectively. Furthermore, the constitutional differences distinguish them from those that are dynamically addressable through change in the hormonal milieu. The differences that are especially significant but not well known is 1) metabolic changes in the regulation of glucose homeostasis and lipid metabolism 2) regulation of vascular function and structural effects on the heart and arteries 3) regulation of skeletal muscle mass and fat tissue 4) morphological and functional effects on discrete areas of the brain.

It is well known that testosterone has a dose-response effect on body composition in men while conditions are less well known in women. Thus, it is not known how the adult woman's body responds to male levels of testosterone, and if the dose response relation is similar or different than that of men. The clinical impression is that women have less effect of androgen on muscle mass than men. Furthermore, it is not known whether the qualitative properties are comparable, i.e. muscle force/unit area. The basic hypothesis is that there are no constitutional sex differences in androgen response. If there are differences, we are looking to identify differences in gene expression. Another hypothetical regulatory mechanism is epigenetic differences which are not dynamically modifiable by androgen exposition. Difference in cardiovascular morbidity between men and women is well known, but there is considerable confusion if and how radical changes of sex hormone levels affects the function of the cardiovascular system both with acute and chronic exposure. Radical change of estrogen and testosterone levels can also affect the risk for metabolic disorders (lipid, carbohydrate and protein metabolism) which can cause hazard for both metabolic diseases such as diabetes and cardiovascular disease in the long term but also be a risk for future muscle weakness and osteoporosis. Effects on the central nervous system as a result of changes of sex hormone profile are not well known. However, we have several observations indicating that changes in sex hormone levels have visual effects (shown by MRI and PET) on distinctive features of the central nervous system.

Therefore, we will follow these patients for a year to study how the heart, blood vessels, brain, and risk factors for cardiovascular disease affected by altered sex hormone patterns and studying what happens in the muscles and fat in both the short and long term with respect to particular gene expression and epigenetic changes and link it to metabolic changes and body composition. Forty volunteers with gender dysphoria, 20 MtF and 20 FtM, are studied before the onset of sex hormone therapy, after a four-week shutdown of endogenous sex hormones and during one year of sex hormone treatment.

• Study Type: Observational
• Enrollment (Actual): 40

Contacts and Locations

Study Locations

• Sweden
  • Stockholm, Sweden, 14186
    • Karolinska Institutet

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 20 years to 40 years (Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Probability Sample

Study Population

Subjects that are under investigation for gender dysphoria that have been accepted but not yet started their treatment with contrary sex hormones are asked if they want to participate.

Description

Inclusion Criteria:

• Otherwise healthy

Exclusion Criteria:

• Infectious disease
• Treatment with Warfarin or other anti coagulants.
• History of cardiovascular disease.
• Serious illness or mental disorder.
• Diabetes type 1
• Language difficulties

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Men with gender dysphoria; Genetic men treated with estrogen	Other: Genetic men treated with estrogen; Observational during estrogen treatment
Women with gender dysphoria; Genetic women treated with androgen	Other: Genetic women treated with androgen; Observational during androgen treatment

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Physiological changes in peripheral tissues	Expression level and changes in epigenetics in skeletal muscle, skin and adipose tissue and associate to metabolism, insulin sensitivity, muscle strength, adipokines and adipose tissue morphology changes and body composition.	5 years

Secondary Outcome Measures

Outcome Measure	Time Frame
Arterial stiffness, endothelial function and structural and functional effects of the heart	5 years
Regulation of skeletal muscle mass and fat tissue with effect on body composition	5 years
Systemic immune system changes	5 years
Metabolic changes in the regulation of glucose homeostasis and lipid metabolism	5 years
Morphological and functional effects on discrete areas of the brain	5 years

Collaborators and Investigators

• Sponsor: Karolinska Institutet
• Collaborators: Region Stockholm
• Investigators: Principal Investigator: Anna M Wiik, PhD, Karolinska Institutet

Publications and helpful links

General Publications

• Wiik A, Lundberg TR, Rullman E, Andersson DP, Holmberg M, Mandić M, Brismar TB, Dahlqvist Leinhard O, Chanpen S, Flanagan JN, Arver S, Gustafsson T. Muscle Strength, Size, and Composition Following 12 Months of Gender-affirming Treatment in Transgender Individuals. J Clin Endocrinol Metab. 2020 Mar 1;105(3). pii: dgz247. doi: 10.1210/clinem/dgz247.

Study record dates

Study Major Dates

• Study Start (Actual): April 1, 2015
• Primary Completion (Actual): December 1, 2021
• Study Completion (Actual): May 1, 2022

Study Registration Dates

• First Submitted: May 12, 2015
• First Submitted That Met QC Criteria: August 6, 2015
• First Posted (Estimate): August 7, 2015

Study Record Updates

• Last Update Posted (Actual): June 10, 2022
• Last Update Submitted That Met QC Criteria: June 9, 2022
• Last Verified: June 1, 2022

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Physiological Effects of Drugs; Hormones; Hormones, Hormone Substitutes, and Hormone Antagonists; Androgens; Estrogens
• Other Study ID Numbers: KI GETS

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Undecided