LAUSR

To the editors, We were pleased to see the article by Jue et al entitled “Kidney Transplantation in Transgender Patients;” however, we are concerned about their scientific interpretation regarding their recommendations for special preoperative assessment and counseling and enhanced consideration when it comes to screening transgender-identified kidney transplant candidates. The authors begin by using the rate of mental illness in the transgender community, a prolific research topic, to justify increased screening [1]. While the authors referenced the 2003 study by Hepp et al where 39% of those with gender identity disorder (GID) also met criteria for an undiagnosed concurrent psychiatric disorder and 71% concurrently or previously met diagnostic criteria for a psychiatric disorder, this study’s contemporary application is significantly limited. Hepp et al only reviewed 31 patients in Switzerland with GID. Due to the small sample size, location, and time (17 years ago) of the study, it is inaccurate to project these conclusions onto the current US and Canadian transgender population, particularly as larger and more complete assessments have been published in the literature which show very different results [1–3]. Additionally, while the authors correctly state that Gender Dysphoria (GD) took the place of Gender Identity Disorder in the DSM-Vmanual in 2013, it is incorrect to assume that they are interchangeable, as there are patients who fit the GID diagnosis who would not fit the GD diagnosis. Similarly, the authors included medical compliance of transgender individuals to inform their recommendation of increased screening for transgender individuals. Rotondi et al’s 2013 study on the rate of non-prescribed gender affirming hormones was utilized (26.8%), presumably to justify increased screening to ensure equivalent compliance to preand post-transplant care as cisgender transplant recipients. According to the most recent large National Center for Transgender Equality (NCTE) transgender survey published in 2015 (with 27,715 respondents), only 4% of transgender persons reported receiving hormones from unlicensed sources calling into question the broad applicability of Rotondi et al’s findings. Furthermore, recent reviews find similar rates (4%) of non-medical prescription opioid use in the US adult population in the past year, calling into question whether there is a true discrepancy in the risk of non-prescription medication use between cisgender and transgender populations [4]. Additionally, the authors use data from a “survey by the NCTE” stating that it “found that 17% of transgender patients refused medical care due to gender expression.” Because the existing NCTE study is not cited directly, and the authors’ present citation is incorrect in that it does not cite an NCTE study, we are unable to confirm from where this data point originates. Regardless, both NCTE studies (2011 and 2015) state that transgender individuals were denied service by medical professionals due to their gender identity (19 and 8%, respectively). Neither states that respondents refused medical care [5]. There is certainly a need for large-scale, controlled studies that assess the psychosocial environment of transgender individuals and their effects on medical compliance and mental This article is part of the Topical Collection on Kidney Diseases