Caring for Transgender and Gender Diverse Youth

Recent years have seen an increasing recognition of the human and medical rights of transgender and gender diverse (TGD) people in the United States. As such, there has been an effort in the medical community to increase awareness and knowledge of optimal care for TGD individuals, including young people. TGD people, and particularly TGD people of color, bear a disproportionate burden of morbidity and mortality. It behooves us to do a better job medically, as one step toward a more equitable society. This article will focus on the care of TGD youth, but the reader interested in more detailed care guidelines for both the adult and pediatric populations is encouraged to examine the Endocrine Society’s Clinical Practice Guideline (Hembree, 2017) and the website of UC San Francisco’s Center of Excellence for Transgender Health (UCSF Center of Excellence for Transgender Health, n.d.). Due to the necessarily short format of this article, an in-depth review of the diagnosis and management of gender dysphoria (GD) is not possible. The focus here will be: 1) to define GD and discuss the rationale for treatment; 2) to review the specific modalities of medical treatment for children and adolescents; and 3) to touch briefly on ethical and other considerations the practitioner should attend to when caring for this group of young people.

Gender Dysphoria

GD is defined as the distress experienced due to a conflict between one’s sex assigned at birth and one’s gender identity. It is important to emphasize here that it is the distress which is pathologic and treatable. TGD identity is not a pathology; it is an identity factor. But if there is associated distress (i.e. GD is present) and it goes untreated, there is significant risk for morbidity and mortality. TGD individuals experience substantially higher rates of anxiety, depression, substance use disorder, self-injury, and suicidal thinking and attempts (Olson K. e., 2015). Forty percent of transgender adults report having ever attempted suicide (James, 2016). Among TGD youth, estimates of the prevalence of suicide attempts range from 25-32%. (Olson J., 2015) These mental health comorbidities do not arise from the TGD identity itself, but rather they likely result from a combination of GD and minority stress, as these youth experience a significant amount of peer and family rejection, harassment, homelessness and verbal and physical abuse, among other external stressors and stigma. In the section on treatment below, we will discuss how, even in the absence of pharmacologic interventions, we can help mitigate a significant portion of the mental health burden by simple social interventions such as using preferred names and pronouns.

Modalities of Treatment

Before discussing medical treatment of GD, it is critical to pause and point out that TGD identity does not presume the presence of GD. While some TGD individuals experience GD and desire treatment, a significant proportion do not desire any intervention. It is, therefore, critical for the medical provider to listen to their patients. Explicitly ask about the presence or absence of distress around gender incongruence. Ask about goals of treatment. Do not presume that an individual desires an outward appearance consistent with our society’s prevailing image of “masculinity” or “femininity.” What matters for your patient is what makes them feel whole, with an aligned body-mind existence, thereby reducing or eliminating mental health comorbidities and improving quality of life. Once it is established that the TGD pediatric patient is experiencing GD and does desire treatment, then the treatment offered will depend on their pubertal status and age. Once again, it is critical to listen to the youth and their parents regarding goals of treatment, and not to presume to know the desired outcome based solely on stated gender identity.

The prepubertal youth does not require any medical intervention. Because they have not yet reached Tanner stage 2, they do not meet criteria for treatment with a puberty-blocking medication. But that does not mean we cannot, as medical providers, offer life-saving interventions. At this developmental stage, the child is in the midst of formative experiences that will shape how they perceive the world and its acceptance or rejection of them. If their parents, teachers and peers reject their gender identity, a crucial part of who they are, then they learn that they are unloved due to an inherent and immutable identity factor. If, on the other hand, we can help guide the parents to be unconditionally supportive, the child is likely to avoid the mental unhealth comorbidities described above. For example, Olson et al. described prepubescent youth who were socially supported (i.e. at home, school and in public, they used the names and pronouns that matched their gender identity—not their assigned sex). They were found to have depression measures on par with (and anxiety levels only slightly higher than) their cisgender siblings and age-matched non-sibling controls. (Olson K. e., 2015). The early pubertal child, who has reached at least Tanner stage 2, may be eligible for treatment with a puberty-blocking medication (commonly known as “blockers”). The first-line option for such treatment is a long-acting gonadotropin releasing hormone (GnRH) analogue (Hembree, 2017), the most common of which are leuprolide and histrelin. The GnRH analogues act at the level of the pituitary, desensitizing receptors and thereby halting downstream production of the sex steroids testosterone and estrogen. The result is the cessation of development of secondary sex characteristics. In natal males, virilization will stop. In natal females, breast tissue will become atrophic and menses will stop (or will not start in the premenarchal person). This results in significantly improved psychological and physical outcomes for the individual, reducing their present dysphoria and potentially minimizing or even precluding the need for future surgeries (de Vries, 2011) (Turban, 2020). Treatment with GnRH analogues is fully reversible, and if the patient desires to terminate treatment, they will resume their natal/ endogenous puberty (Hembree, 2017). Finally, in the older adolescent, we may begin to use hormone therapy (i.e. testosterone or estradiol) to initiate a puberty that aligns with their gender identity. Historically, the age of such initiation was 16 years, but this was a somewhat arbitrary threshold, and it certainly does not align with the timing of puberty onset in the vast majority of the population. The current guidelines acknowledge this fact and suggest that a lower limit of 13.5 years may be more appropriate. Using a gradually increasing dose of the respective sex steroids, the pubertal process yields secondary sex characteristics that align with the individual’s identified gender. Unlike with the GnRH agonists, which are fully reversible, the effects of sex steroids are considered partially reversible. For example voice deepening, clitoral enlargement, and scalp hair loss in those taking testosterone, and breast development in those taking estradiol, will not regress if the individual stops taking the medication. To the question of safety, hormone therapy has long been used in the treatment of adult transgender persons and has a track record of safety. A growing body of peer-reviewed literature is now emerging demonstrating that it is also safe in adolescents (Jarin, 2017).

Ethical and Other Considerations

First and foremost, see the human being in front of you. As humans, we all desire to be heard and respected. Your TGD patients are no different. Even if you do not feel comfortable with the medical management of GnRH agonists or hormones, you can still foster a trusting and supportive relationship with your young patients. You can use their preferred names and pronouns, and ensure that all your staff do the same. You can listen to your patients’ stories and validate their experiences. You can make appropriate referrals—to gender specialists, mental health providers, endocrinologists, surgeons, etc. But if you choose to ignore their experience, you risk missing the opportunity to prevent adverse medical and mental health outcomes, up to and including suicide. With respect to the healthcare team, the ideal scenario is to have a multidisciplinary team that includes medical and mental health providers. Of course, this is not possible in all settings. For the medical provider practicing without the benefit of an in-house mental health provider, it is advisable to have a list of gender-affirming therapists to whom you can refer your patients if needed. For one such list, readers may email a request to the author. Readers may also find additional resources at the website of RECLAIM, a Twin Cities mental health provider focused on queer and trans youth (RECLAIM–Resources for Queer and Trans Youth, n.d.).

Conclusion

As physicians, we are privileged to help guide our patients on a path to better health. We also have the responsibility to ensure that all people have access to that path, regardless of their race, gender identity, sexual orientation, or ability to pay. By becoming more familiar with the optimal management of TGD youth in your practice environment, you will better serve your patients’ health and better fulfill your duty to health equity.

Rhamy Magid, MD, FAAP, is a primary care pediatrician and the founder and Medical Director of the Pediatric Gender and Sexual Health Clinic (PGSHC) at Hennepin Healthcare. He is a graduate of the University of Minnesota Medical School, and did his postgraduate residency training in Pediatrics also at the University of Minnesota. The PGSHC is an interdisciplinary clinic focused on the health of LGBTQ+ youth. You can find more information on the PGSHC here: https://www.hennepinhealthcare.org/ specialty/pediatric-gender-sexual-health/. Emails to Dr. Magid can be sent to rhamy. magid@hcmed.org.