- •
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.
Advances in the Care of Transgender Children and Adolescents
Section snippets
Key points
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.
References (93)
- et al.
The preparation of the crystalline follicular ovarian hormone: Theelin
J Biol Chem
(1930) - et al.
Crystalline progestin
J Biol Chem
(1934) - et al.
Development of feminizing genitoplasty for gender dysphoria
J Sex Med
(2007) - et al.
Gender identity disorder in twins: a review of the case report literature
J Sex Med
(2012) - et al.
Sexual differentiation of human behavior: effects of prenatal and pubertal organizational hormones
Front neuroendocrinology
(2011) Hormones, context, and “brain gender”: a review of evidence from congenital adrenal hyperplasia
Soc Sci Med
(2012)- et al.
Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study
J Am Acad Child Adolesc Psychiatry
(2013) - et al.
Baseline physiologic and psychosocial characteristics of transgender youth seeking care for gender dysphoria
J Adolesc Health
(2015) - et al.
Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study
J Adolesc Health
(2015) - et al.
Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study
J Sex Med
(2011)
A simple intervention raised resident-physician willingness to assist transgender patients seeking hormone therapy
Endocr Pract
Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7
Int J Transgend
Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline
J Clin Endocrinol Metab
Transgender representation in offline and online media: LGBTQ youth perspectives
J Hum Behav Soc Environ
Transgender today
Monitor on Psychology
Children and adolescents with gender identity disorder referred to a pediatric medical center
Pediatrics
Approach to the patient: transgender youth: endocrine considerations
J Clin Endocrinol Metab
Child and Adolescent Gender Center: a multidisciplinary collaboration to improve the lives of gender nonconforming children and teens
Pediatr Rev
Clinical management of gender dysphoria in children and adolescents: the Dutch approach
J Homosex
Is gender identity disorder in adolescents coming out of the closet?
J Sex Marital Ther
Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education
JAMA
Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding
Current management of gender identity disorder in childhood and adolescence: guidelines, barriers and areas of controversy
Curr Opin Endocrinol Diabetes Obes
Diagnostic and statistical manual of mental disorders
Diagnostic and statistical manual of mental disorders
An epidemiological and demographic study of transsexuals in The Netherlands
Arch Sex Behav
Transgender health in Massachusetts: results from a household probability sample of adults
Am J Public Health
Note on the effects produced on man by subcutaneous injections of a liquid obtained from the testicles of animals
Lancet
On crystalline male hormone from testicles (testosterone) effective as from urine or from cholesterol
Hoppe Seylers Z Physiol Chem
Sexualhormone VII. Über die künstliche Herstellung des Testikelhormons Testosteron (Androsten-3-on-17-ol)
Helv Chim Acta
Über 'Progynon' ein krystallisiertes weibliches Sexualhormon
Naturwissenschaften
The chemistry of oestrin
Biochem J
Reindarstellung der Hormone aus dem Corpus luteum (II. Mitteil.)
Ber Dtsch Chem Ges
Sex hormone series
Ber Dtsch Chem Ges
Neue per os-wirksame weibliche Keimdrüsenhormon-Derivate: 17-Aethinyl-oestradiol und Pregnen-in-on-3-ol-17
Naturwissenschaften
Long-term treatment of transsexuals with cross-sex hormones: extensive personal experience
J Clin Endocrinol Metab
Man into woman: an authentic record of a change of sex
Ein Transvestit
Z Kriminalistische Wissen
Transvestism: hormonal, psychiatric, and surgical treatment
JAMA
The transsexual phenomenon: a scientific report on transsexualism and sex conversion in the human male and female
As nature made him: the boy who was raised as a girl
Long-Term treatment of central precocious puberty with a long-acting analogue of luteinizing hormone-releasing hormone
N Engl J Med
Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent
Eur Child Adolesc Psychiatry
Cited by (58)
Debunking Myths of Gender Informed Care: What Every Pediatric Surgeon Should Know
2023, Journal of Pediatric SurgeryThe care of transgender children and adolescents in France: Recent controversies and ethical issues
2022, Neuropsychiatrie de l'Enfance et de l'AdolescenceGroups in the support of children who are transgender or questioning their gender identity: A review of the literature and presentation of an innovative group
2021, Neuropsychiatrie de l'Enfance et de l'AdolescenceThe Nurse Practitioner's Role in the Management of Gender Dysphoria Among Youth
2021, Journal for Nurse PractitionersCitation Excerpt :Unfortunately, health care providers and members of the general public receive very little education to support transgendered youth.2 NPs must expand their scope of practice and enhance their therapeutic knowledge regarding the management of gender dysphoria.2 In addition, NPs need to advocate for professional development and education strategies regarding the needs of the transgender community.
Support for transgender adolescents and preadolescents: the role of the pediatric endocrinologist
2021, Soins Pediatrie/Puericulture