Current approach to the clinical care of adolescents with gender dysphoria

Assessment of sociodemographic and psychiatric characteristics of transgender adults seen at a Midwest tertiary medical center

Background

The National Academy of Medicine has formally identified transgender adults as an understudied population in critical need of health research. While national surveys, like the US Transgender survey, have characterized higher rates of depression, anxiety, suicidality and socioeconomic need in the transgender community, studies have not examined the impact of sociodemographic and clinical characteristics on mental health related outcomes.

Objective

To describe the sociodemographic and mental health characteristics of transgender adults seen at a large Midwest transgender clinic and to determine factors associated with self-reported mental health conditions.

Methods

Descriptive, retrospective, cross-sectional study of new transgender patients 18 years and older seen at a large Midwest transgender clinic between December 2019 and June 2022.

Results

A total of 482 charts were reviewed. During their initial evaluation, 11.6% (56/482) reported having a history of suicide attempt and 81.3% (392/482) reported a mental health diagnosis with the most common being depression, anxiety, attention deficit disorder, and post-traumatic stress disorder. Multivariable logistic regression results show no single factor was significantly associated with mental health diagnosis after adjusting for the effect of age and race. Patients who were new to gender affirming hormone therapy (54%, 254/468) are 2.0 (95% CI 1.4-2.9) times more likely to report having a mental health care provider than patients who were seen for continuation of therapy (46%, 214/468). Ten records with race not disclosed, 3 records with gender identity "other" and 2 records with gender identity not disclosed were excluded from analysis.

Conclusion

This study reinforces the finding that transgender adults have an increased lifetime prevalence of mental health conditions. The higher prevalence of mental health conditions in our clinic was not associated with sociodemographic factors included in the study. Furthermore, transgender patients are less likely to have seen mental healthcare providers after initiation of gender affirming hormone therapy.

Update on bioethical, medical and fertility issues in gender incongruence during transition age

PURPOSE

Many issues still remain unresolved in the management of pubertal patients with gender incongruence (GI). The aim of this review is to discuss the main aspects of the treatment of these patients to provide a practical approach for clinicians.

METHODS

A comprehensive literature search within PubMed was performed to provide updates of available evidence regarding the impact on bioethical, medical and fertility issues in gender incongruence during transition age.

RESULTS

Gender Affirming Hormone Treatment (GAHT) and Gender Affirming Surgery (GAS) can induce unsatisfaction with change, future regrets, and the risk of infertility. This raises ethical issues especially in the management of pubertal patients that remain unresolved. Therapy with GnRH analogues (GnRHa) is intended to delay puberty, so as to give the adolescent a longer period of time to decide whether to continue with the treatments. At the level of physical changes, this therapy may have an effect on bone mineralization and body composition; however, long-term longitudinal data are not yet available. An important feature related to the use of GnRHa is the risk of fertility. Gamete cryopreservation is the most established method of fertility preservation (FP) and should be counselled to transgender adolescents. However, these patients are not always interested in having biological children.

CONCLUSION

Based on the current evidence, there is a need to conduct further research to clarify certain issues and to standardize clinical practice and improve counselling in transgender adolescent decision making and avoid regrets in the future.

Gender Dysphoria in Young People: A Model of Chronic Stress

BACKGROUND

Gender dysphoria (GD) refers to the distress that may accompany gender incongruence, often heightened at the onset of puberty, with the development of secondary sex characteristics. Children and adolescents may be especially vulnerable to severe stressors, including GD, with potentially irreversible effects if these exposures occur during critical periods of development and brain maturation.

SUMMARY

We describe the evidence for GD as a chronic stressor, drawing parallels to other established models of stress, activating both innate psychological and biological stress responses. As well as being an inherently distressing experience, a person who experiences GD may also experience minority stress. Minority stress has been demonstrated in young people who experience GD with higher rates of social rejection and internalized stigma and shame. The biological stress response in young people with GD is illustrated through the activation of the hypothalamic-pituitary-adrenal axis, autonomic nervous system, and pro-inflammatory response. The number of young people who report experiencing GD has increased exponentially worldwide in the past decade, demanding a change in the clinic infrastructure. Paediatric endocrinologists and specialists in mental health work together to both support psychosocial well-being and offer individualized treatment to align the phenotype with gender identity with the aim of alleviating the distress of GD. Medical interventions may include puberty suppression and gender-affirming hormones. Ongoing monitoring is required prior to initiation and during treatment to ensure that the goals of treatment are being achieved.

An appraisal of current service delivery and future models of care for young people with gender dysphoria

The clinical needs of young people with gender dysphoria (GD) have outpaced the capacity of health services to provide appropriate care. The study aimed to explore the interface of Paediatric Endocrinology and young people with GD, detailing the clinical characteristics and the clinical care provided, in order to inform future service development. Medical records of all young people with GD (n=91, 59 (65%) birth-assigned females and 32 (35%) birth-assigned males) referred to Paediatric Endocrinology during 2011-2019 for puberty suppression were reviewed. Median age at initial assessment was 14.6 years (range 8.8-17.6 years). There was a threefold increase from 2016 (n=22) to 2019 (n=73). Mental health disorders were present in 34 (37%) and autistic spectrum disorder in 21 (23%), while 54 (59%) had at least one comorbidity. Sixty-four (70%) young people fulfilled the criteria for consideration of fertility preservation, with 6 (9%) of them preserving their gametes. Seventy-nine (87%) young people commenced treatment with gonadotrophin-releasing hormone analogue, at a median age of 14.8 years (range 9.7-18.0 years). Six (8%) of those discontinued treatment, following a median duration of 6 months (range 6-18 months). Forty-one young people commenced gender-affirming hormones. One (2%) of those who started gender-affirming hormones discontinued treatment.Conclusions: We have witnessed increasing numbers of young people with GD attending Paediatric Endocrinology, with an over-representation of comorbidities, necessitating provision of an individualised approach to treatment. Addressing young people's acceptability of fertility services and ongoing close collaboration between endocrinology and mental health professionals require innovative models of multidisciplinary care. What is Known: • A worldwide increase in presentation of gender dysphoria has been mirrored in our service, with majority assigned female at birth and post-pubertal. • An over-representation of comorbidities exists, notably mental health disorders and autistic spectrum disorder. What is New: • Coordination of interprofessional care to meet complex needs, at an individual level, while improving efficiency of working, at a systemic level, can be met by the development of specialist centres. • The reasons for low uptake of fertility services demand further exploration.

Cardiovascular Risk Associated With Gender Affirming Hormone Therapy in Transgender Population

Transgender men and women represent about 0.6 -1.1%% of the general population. Gender affirming hormone therapy (GAHT) helps ameliorate gender dysphoria and promote well-being. However, these treatments' cardiovascular (CV) effects are difficult to evaluate due to the limited number of extensive longitudinal studies focused on CV outcomes in this population. Furthermore, these studies are mainly observational and difficult to interpret due to a variety of hormone regimens and observation periods, together with possible bias by confounding factors (comorbidities, estrogen types, smoking, alcohol abuse, HIV infection). In addition, the introduction of GAHT at increasingly earlier ages, even before the full development of the secondary sexual characteristics, could lead to long-term changes in CV risk compared to current data. This review examines the impact of GAHT in the transgender population on CV outcomes and surrogate markers of CV health. Furthermore, we review available data on changes in DNA methylation or RNA transcription induced by GAHT that may translate into changes in metabolic parameters that could increase CV risk.