TRxans

The medical care of transgender adolescents and adults

By Carly Guss

Blockers. TE binding. Packing. These are all terms that may be familiar to you. But what about GnRH agonist? Or sexual maturity rating? Medical jargon can be difficult to interpret. Transgender individuals wishing to have medical treatment to match their expressed gender may choose to speak with their primary care doctor, a specialist, or both. It is important to understand the medical and surgical options and the terminology being used. Medical providers may use the expression “gender dysphoria” when exploring medical treatment for transition. Gender dysphoria is defined as distress that individuals may experience when their expressed gender does not match their assigned birth sex (for example, periods in a trans man).

There are a few places that doctors look to for guidelines and recommendations on the medical management of transgender youth and adults: The Endocrine Society and the World Professional Association for Transgender Health (WPATH). More and more research is being done in this area of medicine, so as time goes on these may guidelines change.

The medical management of transgender children or adolescents depends on where they are in puberty. Medical providers judge puberty development based on a physical exam which determines a person’s sexual maturity rating (also known as Tanner Staging). If the person is in early puberty, a medication called a GnRH agonist may be used. These medications are commonly known as “blockers” because they prevent puberty from progressing. It can be given as a shot or as an implant in the body that slowly releases medicine. One benefit of this medication is that it allows the child to have time to explore their gender identity without developing secondary sex characteristics (i.e, breasts for girls, facial hair for boys). This medication is also reversible, meaning that once it is discontinued, puberty will progress. When taking these medications it is important for patients to have a good relationship with their physician, as there are certain vital signs and blood work that should be monitored. The medical provider may also monitor bone density with the use of special imaging tools.

If an adolescent presents with gender dysphoria later in puberty, blockers can be used potentially to allow the physician to use lower doses of cross-sex hormones. The age at which cross-sex hormones will be started varies by provider. The Endocrine Society recommends initiating cross-sex hormones around age 16, but some places start earlier with a slow increase of hormones over two to three years.

Cross-sex hormones are used when individuals want to achieve a feminizing or masculinizing physical appearance, so that it will be more aligned with their gender identity. For trans women, the main medication used is estrogen. This medication can be taken as a pill, a patch, or a shot. Other medications may also be used to suppress the body’s production of testosterone, such as spironolactone or finasteride. For trans men, testosterone is used. This tends to be administered as a weekly injection into the leg or buttocks. Once the individual is on an appropriate dose of testosterone, it is possible to change the dosing to a patch or a gel.

It is always important to know what the side effects of the medications are. For those on estrogen, this may entail high risk of a blood clot or issues with your body’s insulin. Testosterone may cause cystic acne, changes in blood counts, high blood pressure, changes in cholesterol, and issues with insulin. Also, for trans men, testosterone may impair fertility but should not be used as a birth control method alone.

Studies show that gender dysphoria improves after cross-sex hormonal therapy and gender affirming surgery.

Unfortunately, there are several barriers to care for transgender individuals who desire medical management. One barrier is access to a specialist who has experience in hormone management. Fortunately, in Boston, there are several options, such as the Gender Management Service clinic at Boston Children’s Hospital or the Fenway Health Center. Insurance coverage is another barrier. Here in the United States, the use of blockers and cross-sex hormones is considered “offlabel”, meaning that their use is not approved by the Food and Drug Administration. Insurance companies can therefore deny coverage of these otherwise costly medications. Luckily, Massachusetts Medicaid now covers medical services for gender dysphoria.

You may read online about medications that are available in other countries and not in the United States. It is not recommended to purchase medications from the internet or off the street, as you may receive an unsafe product. It is important to make the decision that is right for you with regard to blockers, hormones, or surgery, as well as to feel that your doctor is on your side and can refer you to a specialist, who can discuss these treatments further.

Dr. Carly Guss is a first year fellow in Adolescent Medicine at Boston Children’s Hospital. As a pediatrics resident, she worked with Dr. Michelle Forcier at Brown University, providing primary care and hormones for transgender adolescents. She is interested in sexual and reproductive health, contraception, and health care for transgender and gender nonconforming youth.

Studies show that gender dysphoria improves after cross-sex hormonal therapy and gender affirming surgery.