In this issue of Reviews in Endocrine and Metabolic Disorders, several important topics in the rapidly evolving field of transgender medicine are presented. Gender dysphoria or gender incongruence is the feeling expressed by individuals who possess a gender identity that is different from the one assigned at birth. People who have gender dysphoria or gender incongruence are often categorized under the term “transgender”. Over the past decade, there has been increased understanding regarding the prevalence of transgender people and increased comfort with the efficacy and safety of gender affirming hormone therapy [1]. As reviewed by Nobili et al., transgender people have improved quality of life when undergoing gender affirming hormone therapy [2]. Transgender people seek hormone and/or surgical therapies to better align their physical and mental characteristics with their gender identity. Several professional associations, including the Endocrine Society and the World Professional Association for Transgender Health, have published evidence based guidelines for the health of transgender individuals [3,4,5].

Children who have gender dysphoria are at increased risk of depressive mood disorders and risk of self-harm compared to their cisgender peers [6]. Although further long term study is needed, children with gender dysphoria have improvement in social function and quality of life with the delay of puberty and initiation of gender affirming hormone therapy [7]. Delay of puberty with puberty blockers is generally the initial step in pre-pubertal children followed by gender affirming hormone therapy as children transition into adults as reviewed by Panagiotakopoulos [8] and Abramowitz [9]. Preservation of fertility should be addressed with all transgender children and adults prior to the initiation of hormone therapy. Many technologies exist that can preserve fertility in transgender people as reviewed by Mattawanon et al. [10]. In general, gender affirming hormone therapy is safe; however, there have been some concerns of cardiovascular disease, especially in transgender women as reviewed by Irwig [11]. There are also questions regarding how to adjust gender affirming hormone therapy, especially in older transgender people as reviewed Gooren and T’Sjoen [12]. Recent reports suggest that transgender women may be at increased risk of stroke and thromboembolic disease [13]. Large prospective studies are challenging to conduct in this population. However, novel techniques have been developed to obtain information from existing electronic medical records as described in this issue by Gerth et al. [14].

One of the biggest obstacles to receiving hormone affirming therapy is access to healthcare. A review by Korpaisarn and Safer discuss the gaps in medical education among physicians and trainees [15]. They found that there still remains a large majority of physicians who lack the expertise in transgender medicine and review several interventions that have been effective in reducing this gap. Continued medical education and research is necessary to further refine gender affirming medical therapies and to increase access to these therapies that not only improve quality of life but save lives.