Elsevier

Advances in Pediatrics

Volume 63, Issue 1, August 2016, Pages 79-102
Advances in Pediatrics

Advances in the Care of Transgender Children and Adolescents

https://doi.org/10.1016/j.yapd.2016.04.018Get rights and content

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Key points

  • Children and adolescents with gender dysphoria are presenting for medical attention at increasing rates.

  • Standards of care have been developed that outline appropriate mental health support and hormonal interventions for transgender youth.

  • Transgender issues have emerged from the periphery of the general conscious to a center stage cultural, human rights, and medical topic.

Definitions and epidemiology

Gender identity describes one’s internal feeling of gender, for example, boy or girl, man or woman; agender (identifying as having no gender); or a nonbinary understanding of one’s gender. This is in contrast to biologic sex, which describes the chromosomal, hormonal, and anatomic determinants that result in characterizing people as male or female. A transgender person feels a discrepancy between their sex assigned at birth and their gender identity [11]. The term cisgender has subsequently

Historical perspectives

Before the isolation of sex hormones, their development into an injectable or oral compound to be administered, and development of surgical techniques, there were no options to change one’s secondary sex characteristics. Charles-Édouard Brown-Séquard was among the first to conceptualize that hormones, or substances, may be secreted by a gland and enter the bloodstream to affect distant organs. He claimed to have injected himself with an extract derived from dog and guinea pig testes [17].

The development of gender identity

Expectant parents can now learn the chromosomal sex of their fetus with first trimester cell-free fetal DNA and the anatomic sex on the second trimester ultrasound examination [39]. Many parents then spend the next few months preparing a nursery adorned in pink or blue, excited to welcome their new son or daughter into the world. The baby is born into a gendered world, where boys and girls dress differently and are often encouraged to pursue gender-specific games or styles of play. Although

Mental health

Transgender persons continue to be disproportionately affected by bias, persecution, and harassment [60], and have alarmingly high rates of depression, anxiety, self-harm behaviors, and suicidality. A staggering 41% of transgender adults have attempted suicide. Rates of suicide attempt are higher among nonwhite transgender adults, those who are unemployed or underemployed, poor, less educated, and young [61]. Transgender youth who experience verbal and physical abuse are more likely to attempt

Sex differentiation and normal puberty

Testosterone and estrogen are produced in the testes and ovaries beginning in early fetal life. Testosterone production in the fetus, and its subsequent conversion to dihydrotestosterone, leads to virilization of genital tissues and development of male genitalia. Absence of testosterone results in female external genitalia [74].

After the “minipuberty” of infancy, sex hormone production within the gonads enters a quiescent stage [75]. There is little difference in the hormonal milieu between

Overview of medical management

The WPATH standards of care and The Endocrine Society clinical practice guidelines both recommend the diagnosis of gender dysphoria be made by a mental health professional with expertise in gender identity before considering a hormonal intervention [1], [2]. Some multidisciplinary gender programs employ mental health professionals to perform assessments for referred patients; other programs rely on community-based mental health providers to make the diagnosis of gender dysphoria [82]. Primary

Prevention of the development of unwanted secondary sex characteristics

Medical interventions that suppress sex hormone production or that block sex hormone action work to prevent the development of undesired secondary sex characteristics of the biologic sex (Table 2). These interventions include pubertal suppression using GnRH agonists, reduction in biologic hormone production using progestins, and use of androgen receptor antagonists such as spironolactone [6].

Use of a GnRH agonist to suppress puberty completely starting at SMR 2 followed by introduction of

Promotion of the development of desired secondary sex characteristics

The use of hormonal interventions, often referred to as cross-sex or gender affirming hormones, to promote the development of desired secondary sex characteristics in transgender persons can be considered in carefully screened and counseled adolescents with gender dysphoria (see Table 2). Specifically, the use of 17β-estradiol in MTF individuals, and testosterone in FTM individuals, are used to induce the development of the secondary sex characteristics of the affirmed gender. Broad goals of

Longitudinal screening and anticipatory guidance

Patients being treated with pubertal suppression, spironolactone, 17β-estradiol, and/or testosterone require continued support from a mental health professional, longitudinal follow-up to assess clinical response and development of untoward side effects of treatment, and laboratory monitoring. Rosenthal [6] suggests that patients undergoing pubertal suppression using GnRH agonist medication should have a physical examination, including monitoring of height, weight, and pubertal staging, as well

Gender affirmative surgery

Mental health and medical providers caring for transgender adolescents should become familiar with common surgical interventions used in the transgender patient population, and should be knowledgeable about what surgical resources are available in the community. Surgical interventions used in transgender persons for the purposes of transition are often referred to as gender affirmation surgeries. Procedures may include genital surgeries, chest surgeries, and a variety of other gender affirming

Outcomes

Treatment with pubertal suppression in transgender adolescents improves psychological functioning and decreases depressive symptoms; however, it does not seem to eliminate gender dysphoria [72]. Long-term outcomes data from the Netherlands suggests that transgender persons treated with pubertal suppression, followed by cross-sex hormones and finally gender affirmation surgery in young adulthood, yields positive outcomes with none regretting starting gender affirming medical treatments [73]. In

Challenges and barriers to care

The National Transgender Discrimination Survey Report on Health and Health Care in 2010 surveyed more than 6000 transgender adults in the United States and US territories, and found that transgender adults experience discrimination by medical providers, with 19% of respondents reporting that they have been refused care owing to their gender identity. More than one-quarter responded that they have been harassed verbally in a medical setting and more than one-half had to teach their provider

Current gender management programs in the United States and Canada

A recent report provides descriptions and contact information for 35 gender programs in the United States and Canada [93]. In addition to these programs, several other programs are known to exist by the authors. The descriptions of the various programs in this report makes clear that different centers have approached providing gender services to children and adolescents in diverse ways. For example, providers from the fields of pediatric endocrinology, adolescent medicine, gynecology, primary

Patient 1

An 11-year-old biologic male presented to the pediatrician with concerns regarding gender identity. The child had been interested in stereotypically feminine toys and play from a very young age, and the parents had assumed that the child would grow up to be a gay man. However, more recently the child has clearly expressed a female gender identity to the parents. The child has declared herself to be transgender and insisted on use of female pronouns at home. The parents noted that school

Acknowledgments

Thank you to the wonderful children, teenagers, and families who come to our clinics. Also thank you to the clinicians and staff at The Center for Transyouth Health and Development at Children’s Hospital Los Angeles for allowing Dr N.J. Nokoff to visit and gain insight into the wonderful care they provide for transgender and gender nonconforming youth.

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