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Betsi G, Goulia P, Sandhu S, Xekouki P. Puberty suppression in adolescents with gender dysphoria: an emerging issue with multiple implications. Front Endocrinol (Lausanne) 2024; 15:1309904. [PMID: 38988996 PMCID: PMC11235884 DOI: 10.3389/fendo.2024.1309904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 05/17/2024] [Indexed: 07/12/2024] Open
Abstract
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.
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Affiliation(s)
- Grigoria Betsi
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Heraklion, Greece
| | - Panagiota Goulia
- Department of Psychiatry, Cambridgeshire and Peterborough National Health Service (NHS) Foundation Trust, Cambridge, United Kingdom
| | - Sophia Sandhu
- General Practice, Bridge Street Medical Practice, Cambridge, United Kingdom
| | - Paraskevi Xekouki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Heraklion, Greece
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Jorgensen SCJ, Athéa N, Masson C. Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:1941-1956. [PMID: 38565790 PMCID: PMC11106199 DOI: 10.1007/s10508-024-02850-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024]
Abstract
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.
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Affiliation(s)
- Sarah C J Jorgensen
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada.
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | | | - Céline Masson
- Département de Psychologie, Université de Picardie Jules-Verne, Amiens, France
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Abbruzzese E, Levine SB, Mason JW. The Myth of "Reliable Research" in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies-and research that has followed. JOURNAL OF SEX & MARITAL THERAPY 2023:1-27. [PMID: 36593754 DOI: 10.1080/0092623x.2022.2150346] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Two Dutch studies formed the foundation and the best available evidence for the practice of youth medical gender transition. We demonstrate that this work is methodologically flawed and should have never been used in medical settings as justification to scale this "innovative clinical practice." Three methodological biases undermine the research: (1) subject selection assured that only the most successful cases were included in the results; (2) the finding that "resolution of gender dysphoria" was due to the reversal of the questionnaire employed; (3) concomitant psychotherapy made it impossible to separate the effects of this intervention from those of hormones and surgery. We discuss the significant risk of harm that the Dutch research exposed, as well as the lack of applicability of the Dutch protocol to the currently escalating incidence of adolescent-onset, non-binary, psychiatrically challenged youth, who are preponderantly natal females. "Spin" problems-the tendency to present weak or negative results as certain and positive-continue to plague reports that originate from clinics that are actively administering hormonal and surgical interventions to youth. It is time for gender medicine to pay attention to the published objective systematic reviews and to the outcome uncertainties and definable potential harms to these vulnerable youth.
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Affiliation(s)
- E Abbruzzese
- Society for Evidence-Based Gender Medicine, Twin Falls, ID, United States
| | - Stephen B Levine
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, United States
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Levine SB, Abbruzzese E, Mason JW. What Are We Doing to These Children? Response to Drescher, Clayton, and Balon Commentaries on Levine et al., 2022. JOURNAL OF SEX & MARITAL THERAPY 2022; 49:115-125. [PMID: 36267050 DOI: 10.1080/0092623x.2022.2136117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Stephen B Levine
- Case Western Reserve University Department of Psychiatry, 6415 Gates Mills Blvd, Mayfield Heights, 44124, United States
| | - E Abbruzzese
- Society for Evidence-Based Gender Medicine, Twin Falls, 83301-5235, United States
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Levine SB, Abbruzzese E, Mason JW. Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults. JOURNAL OF SEX & MARITAL THERAPY 2022; 48:706-727. [PMID: 35300570 DOI: 10.1080/0092623x.2022.2046221] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In less than a decade, the western world has witnessed an unprecedented rise in the numbers of children and adolescents seeking gender transition. Despite the precedent of years of gender-affirmative care, the social, medical and surgical interventions are still based on very low-quality evidence. The many risks of these interventions, including medicalizing a temporary adolescent identity, have come into a clearer focus through an awareness of detransitioners. The risks of gender-affirmative care are ethically managed through a properly conducted informed consent process. Its elements-deliberate sharing of the hoped-for benefits, known risks and long-term outcomes, and alternative treatments-must be delivered in a manner that promotes comprehension. The process is limited by: erroneous professional assumptions; poor quality of the initial evaluations; and inaccurate and incomplete information shared with patients and their parents. We discuss data on suicide and present the limitations of the Dutch studies that have been the basis for interventions. Beliefs about gender-affirmative care need to be separated from the established facts. A proper informed consent process can both prepare parents and patients for the difficult choices that they must make and can ease professionals' ethical tensions. Even when properly accomplished, however, some clinical circumstances exist that remain quite uncertain.
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Affiliation(s)
- Stephen B Levine
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, USA
| | - E Abbruzzese
- Society for Evidence-based Gender Medicine (SEGM), Twin Falls, ID, USA
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Vrouenraets LJ, de Vries MC, Hein IM, Arnoldussen M, Hannema SE, de Vries AL. Perceptions on the function of puberty suppression of transgender adolescents who continued or discontinued treatment, their parents, and clinicians. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2021; 23:428-441. [PMID: 36324881 PMCID: PMC9621271 DOI: 10.1080/26895269.2021.1974324] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Purpose: Treatment of transgender adolescents with puberty suppression (PS) was developed to provide time for exploration before pursuing gender affirming medical treatment (GAMT) with irreversible effects. It may also result in a more satisfactory physical outcome for those who continue with GAMT. Despite being the current first choice treatment, little research has examined the function of PS from the perspectives of transgender adolescents, their parents, and clinicians. Insight into the perceived functions of PS will help to adequately support adolescents in their decision-making process and give them the care they need. Methods: Qualitative study using interviews with eight transgender adolescents who proceeded with GAMT after PS ("continuers"), six adolescents who discontinued PS ("discontinuers") and 12 parents, and focus groups with ten clinicians. Results: All informants considered inhibition of development of secondary sex characteristics an important function of PS. Most continuers saw PS as the first step of GAMT. Nevertheless, some were glad that the effects were reversible even if they didn't expect to change their minds. Some discontinuers did experience PS as an expanded diagnostic phase. One continuer used the time on PS to get used to living in the affirmed gender role, and several parents found the time helpful to adapt to their child's new gender role. PS provided clinicians more time for diagnostic assessment. Conclusions: Adolescents, parents and clinicians do not all report the same functions of PS. Although international guidelines emphasize providing time for exploration of gender identity as an important reason for PS, many adolescents nowadays seem to have clear ideas about their gender identity and treatment wishes, and experience PS as the first step of GAMT. For some discontinuers however, PS offered a valued period of exploration. Guidelines could be modified to provide more customized care, taking adolescents' and parents' ideas about the functions of PS into account.
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Affiliation(s)
- Lieke J.J.J. Vrouenraets
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Oegstgeest, The Netherlands
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Martine C. de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Irma M. Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
| | - Marijn Arnoldussen
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location VUmc, VU Universiteit, Amsterdam, The Netherlands
| | - Sabine E. Hannema
- Department of Paediatric Endocrinology, Amsterdam University Medical Centers, Location VUmc, VU Universiteit, Amsterdam, the Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Annelou L.C. de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location VUmc, VU Universiteit, Amsterdam, The Netherlands
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Littman L. Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:3353-3369. [PMID: 34665380 PMCID: PMC8604821 DOI: 10.1007/s10508-021-02163-w] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 05/04/2023]
Abstract
The study's purpose was to describe a population of individuals who experienced gender dysphoria, chose to undergo medical and/or surgical transition and then detransitioned by discontinuing medications, having surgery to reverse the effects of transition, or both. Recruitment information with a link to an anonymous survey was shared on social media, professional listservs, and via snowball sampling. Sixty-nine percent of the 100 participants were natal female and 31.0% were natal male. Reasons for detransitioning were varied and included: experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clinicians that they had detransitioned. There are many different reasons and experiences leading to detransition. More research is needed to understand this population, determine the prevalence of detransition as an outcome of transition, meet the medical and psychological needs of this population, and better inform the process of evaluation and counseling prior to transition.
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Affiliation(s)
- Lisa Littman
- The Institute for Comprehensive Gender Dysphoria Research, 489 Main Street, Warren, RI, 02885, USA.
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D'Angelo R, Syrulnik E, Ayad S, Marchiano L, Kenny DT, Clarke P. One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:7-16. [PMID: 33089441 PMCID: PMC7878242 DOI: 10.1007/s10508-020-01844-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 09/17/2020] [Accepted: 09/19/2020] [Indexed: 05/04/2023]
Affiliation(s)
- Roberto D'Angelo
- Institute of Contemporary Psychoanalysis, Los Angeles, CA, 90064, USA.
- Society for Evidence-Based Gender Medicine, Twin Falls, ID, USA.
| | - Ema Syrulnik
- Society for Evidence-Based Gender Medicine, Twin Falls, ID, USA
| | - Sasha Ayad
- Society for Evidence-Based Gender Medicine, Twin Falls, ID, USA
| | - Lisa Marchiano
- Society for Evidence-Based Gender Medicine, Twin Falls, ID, USA
| | | | - Patrick Clarke
- Society for Evidence-Based Gender Medicine, Twin Falls, ID, USA
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Brik T, Vrouenraets LJJJ, de Vries MC, Hannema SE. Trajectories of Adolescents Treated with Gonadotropin-Releasing Hormone Analogues for Gender Dysphoria. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:2611-2618. [PMID: 32152785 PMCID: PMC7497424 DOI: 10.1007/s10508-020-01660-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 02/09/2020] [Accepted: 02/10/2020] [Indexed: 05/12/2023]
Abstract
Gonadotropin-releasing hormone analogues (GnRHa) are recommended as initial treatment for adolescents diagnosed with gender dysphoria, providing time to follow gender identity development and consider further treatment wishes without distress caused by unwanted pubertal changes. This has been described as an extended diagnostic phase. However, there are also concerns about the physical, neurocognitive, and psychosocial effects of this treatment. In this retrospective study, we document trajectories after the initiation of GnRHa and explore reasons for extended use and discontinuation of GnRHa. Treatment was considered appropriate in 143 (67%) of the 214 adolescents eligible for GnRHa treatment by virtue of their age/pubertal status, and all started GnRHa (38 transgirls, 105 transboys; median age, 15.0 years [range, 11.1-18.6] and 16.1 years [range, 10.1-17.9]). After a median duration of 0.8 years (0.3-3.8) on GnRHa, 125 (87%) started gender-affirming hormones (GAH). Nine (6%) discontinued GnRHa, five of whom no longer wished gender-affirming treatment. Thirteen had used GnRHa for longer than required by protocol for reasons other than logistics and regularly met with a mental health professional during this time, supporting the use of GnRHa treatment as an extended diagnostic phase. In conclusion, the vast majority who started GnRHa proceeded to GAH, possibly due to eligibility criteria that select those highly likely to pursue further gender-affirming treatment. Due to the observational character of the study, it is not possible to say if GnRHa treatment itself influenced the outcome. Few individuals discontinued GnRHa, and only 3.5% no longer wished gender-affirming treatment.
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Affiliation(s)
- Tessa Brik
- Department of Pediatrics, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Lieke J J J Vrouenraets
- Department of Pediatric and Adolescent Psychiatry, Curium-Leiden University Medical Centre, Leiden, The Netherlands
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Centre, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
- Department of Paediatric Endocrinology, Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands.
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10
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Giovanardi G, Morales P, Mirabella M, Fortunato A, Chianura L, Speranza AM, Lingiardi V. Transition memories: experiences of trans adult women with hormone therapy and their beliefs on the usage of hormone blockers to suppress puberty. J Endocrinol Invest 2019; 42:1231-1240. [PMID: 30953318 DOI: 10.1007/s40618-019-01045-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/29/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE In recent years, an increasing number of specialized gender clinics have been prescribing gonadotropin-releasing hormone (GnRH) analogs to adolescents diagnosed with gender dysphoria (GD) to suppress puberty. This paper presents qualitative research on the hormone therapy (HT) experiences of older trans-people and their views on puberty suppression. The main aim of this research was to explore the psychological aspects of hormonal treatments for gender non-conforming adults, including the controversial use of puberty suppression treatments. METHODS Using a semi-structured interview format, ten adult trans-women were interviewed (mean age: 37.4) to explore their personal histories regarding GD onset and development, their HT experiences, and their views on the use of GnRH analogs to suppress puberty in trans-children and adolescents. RESULTS the interview transcripts were analyzed using the consensual qualitative research method from which several themes emerged: the onset of GD, childhood experiences, experiences with puberty and HT, views on the puberty suspension procedure, and the effects of this suspension on gender identity and sexuality. CONCLUSIONS The interviews showed that overall, the participants valued the new treatment protocol due to the opportunity to prevent the severe body dysphoria and social phobia trans-people experience with puberty. It seems that the risk of social isolation and psychological suffering is increased by the general lack of acceptance and stigma toward trans-identities in the Italian society. However, during gender transitions, they highlight the need to focus more on internal and psychological aspects, rather than over-emphasize physical appearance. This study gives a voice to an under-represented group regarding the use of GnRH analogs to suppress puberty in trans-individuals, and collected firsthand insights on this controversial treatment and its recommendations in professional international guidelines.
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Affiliation(s)
- G Giovanardi
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Via degli Apuli 1, 00185, Rome, Italy.
- Department of Psychology, University of Campania "Luigi Vanvitelli", Caserta, Italy.
| | - P Morales
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Via degli Apuli 1, 00185, Rome, Italy
| | - M Mirabella
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Via degli Apuli 1, 00185, Rome, Italy
| | - A Fortunato
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Via degli Apuli 1, 00185, Rome, Italy
| | | | - A M Speranza
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Via degli Apuli 1, 00185, Rome, Italy
| | - V Lingiardi
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Via degli Apuli 1, 00185, Rome, Italy
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Kaltiala-Heino R, Bergman H, Työläjärvi M, Frisén L. Gender dysphoria in adolescence: current perspectives. Adolesc Health Med Ther 2018; 9:31-41. [PMID: 29535563 PMCID: PMC5841333 DOI: 10.2147/ahmt.s135432] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Increasing numbers of adolescents are seeking treatment at gender identity services in Western countries. An increasingly accepted treatment model that includes puberty suppression with gonadotropin-releasing hormone analogs starting during the early stages of puberty, cross-sex hormonal treatment starting at ~16 years of age and possibly surgical treatments in legal adulthood, is often indicated for adolescents with childhood gender dysphoria (GD) that intensifies during puberty. However, virtually nothing is known regarding adolescent-onset GD, its progression and factors that influence the completion of the developmental tasks of adolescence among young people with GD and/or transgender identity. Consolidation of identity development is a central developmental goal of adolescence, but we still do not know enough about how gender identity and gender variance actually evolve. Treatment-seeking adolescents with GD present with considerable psychiatric comorbidity. There is little research on how GD and/or transgender identity are associated with completion of developmental tasks of adolescence.
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Affiliation(s)
- Riittakerttu Kaltiala-Heino
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- Department of Adolescent Psychiatry, Tampere University Hospital, Tampere, Finland
- Vanha Vaasa Hospital, Vaasa, Finland
| | - Hannah Bergman
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Marja Työläjärvi
- Department of Adolescent Psychiatry, Tampere University Hospital, Tampere, Finland
| | - Louise Frisén
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Giovanardi G. Buying time or arresting development? The dilemma of administering hormone blockers in trans children and adolescents. Porto Biomed J 2017; 2:153-156. [PMID: 32258611 PMCID: PMC6806792 DOI: 10.1016/j.pbj.2017.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 06/14/2017] [Indexed: 11/22/2022] Open
Abstract
In recent years, the use of gonadotropin-releasing hormone (GnRH) analogues in adolescents with gender dysphoria (GD) to suppress puberty has been adopted by an increasing number of gender clinics, generating controversial debate. This short essay provides an overview of the difficulties associated with this heterogeneous group of adolescents and discusses arguments for and against the suspension of puberty. Further, it reviews the main follow-up studies conducted in some of the world's largest clinical centres for gender-variant children and adolescents.
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Affiliation(s)
- Guido Giovanardi
- Department of Dynamic and Clinic Psychology, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
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13
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Joseph A, Cliffe C, Hillyard M, Majeed A. Gender identity and the management of the transgender patient: a guide for non-specialists. J R Soc Med 2017; 110:144-152. [PMID: 28382847 PMCID: PMC5407520 DOI: 10.1177/0141076817696054] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
In this review, we introduce the topic of transgender medicine, aimed at the non-specialist clinician working in the UK. Appropriate terminology is provided alongside practical advice on how to appropriately care for transgender people. We offer a brief theoretical discussion on transgenderism and consider how it relates to broader understandings of both gender and disease. In respect to epidemiology, while it is difficult to assess the exact size of the transgender population in the UK, population surveys suggest a prevalence of between 0.2 and 0.6% in adults, with rates of referrals to gender identity clinics in the UK increasing yearly. We outline the legal framework that protects the rights of transgender people, showing that is not legal for physicians to deny transgender people access to services based on their personal beliefs. Being transgender is often, although not always, associated with gender dysphoria, a potentially disabling condition in which the discordance between a person's natal sex (that assigned to them at birth) and gender identity results in distress, with high associated rates of self-harm, suicidality and functional impairment. We show that gender reassignment can be a safe and effective treatment for gender dysphoria with counselling, exogenous hormones and surgery being the mainstay of treatment. The role of the general practitioner in the management of transgender patients is discussed and we consider whether hormone therapy should be initiated in primary care in the absence of specialist advice, as is suggested by recent General Medical Council guidance.
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Affiliation(s)
- Albert Joseph
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Charlotte Cliffe
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
| | - Miriam Hillyard
- North West Thames Foundation School, Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
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14
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Vrouenraets LJJJ, Fredriks AM, Hannema SE, Cohen-Kettenis PT, de Vries MC. Perceptions of Sex, Gender, and Puberty Suppression: A Qualitative Analysis of Transgender Youth. ARCHIVES OF SEXUAL BEHAVIOR 2016; 45:1697-703. [PMID: 27251640 PMCID: PMC4987409 DOI: 10.1007/s10508-016-0764-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 03/14/2016] [Accepted: 03/29/2016] [Indexed: 05/21/2023]
Abstract
International guidelines recommend the use of Gonadotropin-Releasing Hormone (GnRH) agonists in adolescents with gender dysphoria (GD) to suppress puberty. Little is known about the way gender dysphoric adolescents themselves think about this early medical intervention. The purpose of the present study was (1) to explicate the considerations of gender dysphoric adolescents in the Netherlands concerning the use of puberty suppression; (2) to explore whether the considerations of gender dysphoric adolescents differ from those of professionals working in treatment teams, and if so in what sense. This was a qualitative study designed to identify considerations of gender dysphoric adolescents regarding early treatment. All 13 adolescents, except for one, were treated with puberty suppression; five adolescents were trans girls and eight were trans boys. Their ages ranged between 13 and 18 years, with an average age of 16 years and 11 months, and a median age of 17 years and 4 months. Subsequently, the considerations of the adolescents were compared with views of clinicians treating youth with GD. From the interviews with the gender dysphoric adolescents, three themes emerged: (1) the difficulty of determining what is an appropriate lower age limit for starting puberty suppression. Most adolescents found it difficult to define an appropriate age limit and saw it as a dilemma; (2) the lack of data on the long-term effects of puberty suppression. Most adolescents stated that the lack of long-term data did not and would not stop them from wanting puberty suppression; (3) the role of the social context, for which there were two subthemes: (a) increased media-attention, on television, and on the Internet; (b) an imposed stereotype. Some adolescents were positive about the role of the social context, but others raised doubts about it. Compared to clinicians, adolescents were often more cautious in their treatment views. It is important to give voice to gender dysphoric adolescents when discussing the use of puberty suppression in GD. Otherwise, professionals might act based on assumptions about adolescents' opinions instead of their actual considerations. We encourage gathering more qualitative research data from gender dysphoric adolescents in other countries.
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Affiliation(s)
| | - A Miranda Fredriks
- Department of Pediatric and Adolescent Psychiatry, Curium-Leiden University Medical Centre, Endegeesterstraatweg 27, 2342 AK, Oegstgeest, The Netherlands
| | - Sabine E Hannema
- Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology, VU University Medical Centre, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Centre, Leiden, The Netherlands
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15
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Cohen-Kettenis PT, Schagen SEE, Steensma TD, de Vries ALC, Delemarre-van de Waal HA. Puberty suppression in a gender-dysphoric adolescent: a 22-year follow-up. ARCHIVES OF SEXUAL BEHAVIOR 2011; 40:843-7. [PMID: 21503817 PMCID: PMC3114100 DOI: 10.1007/s10508-011-9758-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Revised: 02/14/2011] [Accepted: 02/16/2011] [Indexed: 05/22/2023]
Abstract
Puberty suppression by means of gonadotropin releasing hormone (GnRH) analogs is considered a diagnostic aid in gender dysphoric adolescents. However, there are also concerns about potential risks, such as poor outcome or post-surgical regret, adverse effects on metabolic and endocrine status, impaired increment of bone mass, and interference with brain development. This case report is on a 22-year follow-up of a female-to-male transsexual, treated with GnRH analogs at 13 years of age and considered eligible for androgen treatment at age 17, and who had gender reassignment surgery at 20 and 22 years of age. At follow-up, he indicated no regrets about his treatment. He was functioning well psychologically, intellectually, and socially; however, he experienced some feelings of sadness about choices he had made in a long-lasting intimate relationship. There were no clinical signs of a negative impact on brain development. He was physically in good health, and metabolic and endocrine parameters were within reference ranges. Bone mineral density was within the normal range for both sexes. His final height was short as compared to Dutch males; however, his body proportions were within normal range. This first report on long-term effects of puberty suppression suggests that negative side effects are limited and that it can be a useful additional tool in the diagnosis and treatment of gender dysphoric adolescents.
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Affiliation(s)
- Peggy T Cohen-Kettenis
- Department of Medical Psychology and Medical Social Work, VU University Medical Center, Amsterdam, The Netherlands.
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16
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Jacobeit J, Wüsthof A. Irreversible physical changes. DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 106:318; author reply 318. [PMID: 19547648 PMCID: PMC2689593 DOI: 10.3238/arztebl.2009.0318a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Jens Jacobeit
- *Endokrinologikum Zentrum für Hormon- und Stoffwechselerkrankungen, Reproduktionsmedizin und Pränatale Medizin, Lornsenstr. 4–6, 22767 Hamburg, Germany,
| | - Achim Wüsthof
- *Endokrinologikum Zentrum für Hormon- und Stoffwechselerkrankungen, Reproduktionsmedizin und Pränatale Medizin, Lornsenstr. 4–6, 22767 Hamburg, Germany,
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