Care for Transgender Young People

Puberty suppression in adolescents with gender dysphoria: an emerging issue with multiple implications

Controversy exists over puberty suppression (PS) in adolescents with gender dysphoria (GD). PS is preferentially achieved with GnRH analogues. By preventing the development of secondary sex characteristics, PS may improve psychological functioning, well-being, quality of life, emotional and behavioral (especially internalizing) problems and depressive symptoms, thus decreasing suicidality. PS can also extend the diagnostic period and give transgender adolescents time to explore their gender identity. GnRHa may also decrease the need for feminization/masculinization surgery. However, 2-year treatment with GnRHa may result in bone mass accrual retardation (decrease in BMD/BMAD z-scores), growth velocity deceleration (decrease in height SDS), increase in fat mass, temporary pause in oocyte/sperm maturation. The most common side effects of GnRHa are hot flashes, mood fluctuations, fatigue and headache. They are usually mild and rarely lead to GnRHa discontinuation. Based on current scientific evidence, PS could be recommended to adolescents who meet the diagnostic criteria of gender incongruence (by DSM-5 and/or ICD-11) and have long-lasting intense GD, which aggravates with puberty onset. Before initiating PS, possible mental issues should be addressed and informed consent (by the adolescent/caregiver) should be given, after counseling on probable reproductive effects of GnRHa. GnRHa can only be started after the adolescent has entered Tanner stage 2. Nevertheless, published studies are inadequate in number, small in size, uncontrolled and relatively short-term, so that it is difficult to draw safe conclusions on efficacy and safety of GnRHa. Large long-term randomized controlled trials are needed to expand knowledge on this controversial issue and elucidate the benefit and risks of PS.

Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future

In this essay, we consider the clinical and ethical implications of puberty blockers for pediatric gender dysphoria through the lens of "the child's right to an open future," which refers to rights that children do not have the capacity to exercise as minors, but that must be protected, so they can exercise them in the future as autonomous adults. We contrast the open future principle with the beliefs underpinning the gender affirming care model and discuss implications for consent. We evaluate claims that puberty blockers are reversible, discuss the scientific uncertainty about long-term benefits and harms, summarize international developments, and examine how suicide has been used to frame puberty suppression as a medically necessary, lifesaving treatment. In discussing these issues, we include relevant empirical evidence and raise questions for clinicians and researchers. We conclude that treatment pathways that delay decisions about medical transition until the child has had the chance to grow and mature into an autonomous adulthood would be most consistent with the open future principle.

No Bones About It: Sex Is Binary

Anthropologists have led the way in formulating techniques that reveal skeletal differences between males and females. Understanding of physical differences in the pelvis related to childbirth, hormonal impacts on bones, and extensive comparative studies have provided anthropologists with an array of traits and measurements that help them estimate sex using just bones. Forensic anthropologists and bioarcheologists are improving their ability to differentiate males and females by increasing research on a variety of postcranial bones and through the use of molecular data, especially new methods called proteomics, to identify sex in prepubescent juveniles. As remains from more cultures and time periods are studied, sex identification will continue to improve, because skeletal sex differences are in large part biologically determined. Yet, anthropologists have also been at the forefront of arguing that sex lies on a spectrum. Anthropologists who view sex as on a spectrum may deter sex identification progress; from their perspective, an individual of an undetermined sex may just be a nonbinary individual. Anthropologists who consider sex is on a spectrum are coming to this conclusion in part because they are looking for anatomical ideals, mistaking pathology for variation, and confusing independent variables with dependent variables. Nonetheless, anthropologists need to continue to improve sex identification techniques to reconstruct the past accurately, which may reveal less strict sex roles than previously presumed and help with the identification of crime victims. Forensic anthropologists should also increase their efforts to identify whether individuals have undergone medical procedures intended to change one's gender due to the current rise in transitioning individuals.

A retrospective review of the use of bicalutamide in transfeminine youth; a single center experience

Background: Androgen blockers are an essential part of gender affirming care in post-pubertal transfeminine patients. Bicalutamide is a highly potent androgen receptor blocker that is used primarily in adults. We aimed to review our experience with the use of bicalutamide in transgender adolescents who were assigned male at birth. Methods: A retrospective review of medical records of transfeminine patients treated with bicalutamide during an 8-year period was conducted. Results: Forty patients, aged 15.5 ± 1.55 years were identified, of whom 21 (53%) were started on bicalutamide alone and 19 were started concurrently on estrogen. In patients on bicalutamide alone, 90.4% reported breast development at their first follow up visit, which occurred at a median of 7.1 months. Patients were treated for 29.4 ± 18.2 months. No episodes of liver toxicity related to bicalutamide were seen. Conclusions: Although these results are preliminary, bicalutamide appears to be a safe option for androgen blockade in transgender girls.

Adherence to Gender Affirming Hormone Therapy in Transgender Adolescents and Adults: A Retrospective Cohort Study

CONTEXT

Transgender and gender diverse (TGD) individuals often seek gender-affirming hormone therapy (GAHT). While receipt of GAHT has been associated with improved well-being, the risk of GAHT discontinuation and its reasons are not well known.

OBJECTIVE

There were two main objectives: (1) To investigate the proportion of TGD individuals who discontinue therapy after an average of 4 years (maximum 19 years) since GAHT initiation; and (2) to explore reasons for GAHT discontinuation. This was a retrospective cohort study at academic centers providing care to TGD adolescents and adults. TGD individuals prescribed estradiol or testosterone between January 1, 2000, and January 1, 2019, were included. GAHT continuation was ascertained using a 2-phase process. In phase 1, Kaplan-Meier survival analyses were used to examine likelihood of GAHT discontinuation and compare discontinuation rates by age and sex assigned at birth. In phase 2, reasons for stopping GAHT were investigated by reviewing records and by contacting study participants who discontinued therapy. The main outcome measures were incidence and determinants of GAHT discontinuation.

RESULTS

Among 385 eligible participants, 231 (60%) were assigned male at birth and 154 (40%) were assigned female at birth. Less than one-third of participants (n = 121) initiated GAHT prior to their 18th birthday, constituting the pediatric cohort (mean age 15 years), and the remaining 264 were included in the adult cohort (mean age 32 years). In phase 1, 6 participants (1.6%) discontinued GAHT during follow-up, and of those only 2 discontinued GAHT permanently (phase 2).

CONCLUSION

GAHT discontinuation is uncommon when therapy follows Endocrine Society guidelines. Future research should include prospective studies with long-term follow-up of individuals receiving GAHT.

Headache prevalence in transgender and gender diverse youth: A single-center case-control study

OBJECTIVE

Assess the prevalence of headache in transgender and gender-diverse adolescents, comparing prevalence with and without exposure to gender-affirming hormone therapy.

BACKGROUND

Transgender and gender-diverse youth are an understudied group in whom we can study the effects of sex steroids on adolescents' development of headache. We hypothesized that transfeminine adolescents treated with estrogen would have higher odds of headache than those not treated, and that transmasculine adolescents treated with testosterone would have lower odds of headache than those not treated.

METHODS

This retrospective case-control study analyzed all patients seen at the Boston Children's Hospital Gender Multispecialty Service clinic from 2007 to 2017. Cases were defined as patients with headache, controls as those without headache, and exposure as treatment with gender-affirming hormone therapy (i.e., estrogen or testosterone). A computerized search identified cases that were then validated by chart review.

RESULTS

Fifty-two of the 763 transgender and gender-diverse patients seen were confirmed to have headache. Of 273 transfeminine patients 45% (123/273) received estrogen treatment. Transfeminine patients receiving estrogen were more likely to have headache than those not receiving estrogen (7% [9/123] vs. 1% [2/150]; odd ratio [OR] 5.84 (95% confidence interval [CI] 1.24-27.6), p = 0.026). Of 490 transmasculine patients, 46% (227/490) received testosterone. Transmasculine patients receiving testosterone were more likely to have headache than those not receiving testosterone (12% [28/227] vs. 5% (13/263); OR 2.71 (95% CI 1.37-5.4), p = 0.005).

CONCLUSION

Among transfeminine and transmasculine youth, those who received gender-affirming hormone therapy had higher odds of headache compared to those not taking gender-affirming hormone therapy. Further prospective studies to guide headache care of transgender and gender-diverse youth and adults are needed. Our results could be generalizable to other pediatric gender management clinics and may be worth discussing with patients considering treatment.