The effect of early puberty suppression on treatment options and outcomes in transgender patients

In the past 10-15 years, paediatric transgender care has emerged at the forefront of several general practice and subspecialty guidelines and is the topic of continuing medical education for various medical disciplines. Providers in specialties ranging from family medicine, paediatrics and adolescent medicine to endocrinology, gynaecology and urology are caring for transgender patients in increasing numbers. Current and evolving national and international best practice guidelines recommend offering a halt of endogenous puberty for patients with early gender dysphoria, in whom impending puberty is unacceptable for their psychosocial health and wellness. Pubertal blockade has implications for fertility preservation, transgender surgical care and psychosocial health, all of which must be considered and discussed with the patient and their family and/or legal guardian before initiation.

Medical Options for Care of Gender Diverse and Transgender Youth

Increasing numbers of transgender and gender diverse (TGD) youth are presenting for medical care, including seeking more information and access to services from gynecologic and reproductive health experts. Such experts are well positioned to provide affirming, comprehensive services, including education, hormonal interventions, menstrual management, contraception, and various gynecological procedures. Early medical guidance and support for the TGD community has been associated with long-term positive emotional and physical health outcomes. In this article medical interventions that reproductive health experts can offer to their TGD patients are discussed.

Psychosocial Overview of Gender-Affirmative Care

Transgender and gender-diverse youth and their families are increasingly presenting to adolescent gynecological providers for education, care, and referrals. These youth more often face mental health and social disparities that frequently go unrecognized or unaddressed by providers. A gender-affirmative approach focuses on providing emotional validation, psychological safety, and support to young patients and their families. With better understanding of the unique needs of transgender and gender-diverse populations, gynecological care can be personalized and delivered in a nuanced fashion to better address the sexual and reproductive needs of gender minority patients. In this article we review essential psychological and social considerations in caring for transgender and gender-diverse youth, including concepts relating to gender identity, affirmative approaches, means of assessing for risk and resiliency, and family dynamics. Ultimately, adolescent gynecological providers have an important role in promoting the emotional health and positive development of transgender and gender-diverse youth.

Medroxyprogesterone Acetate in Gender-Affirming Therapy for Transwomen: Results From a Retrospective Study

CONTEXT

Medroxyprogesterone acetate (MPA) is a widely used progestin in feminizing hormone therapy. However, the side effects and hormonal changes elicited by this drug have never been investigated in the transgender population.

OBJECTIVE

We evaluated the incidence of self-reported effects among transwomen using MPA and this drug's impact on hormonal and metabolic parameters.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively collected data from 290 follow-up visits (FUVs) of transwomen treated at Rhode Island Hospital from January 2011 to July 2018 (mean duration of therapy 3.4 ± 1.7 years). FUVs followed regimens of estradiol (E) and spironolactone, with MPA (n = 102) or without MPA (n = 188).

MAIN OUTCOME MEASURES

We assessed the incidence of self-reported effects after MPA treatment. We also compared blood levels of E, testosterone, and various laboratory parameters between MPA and non-MPA groups.

RESULTS

Mean weighted E level was 211 ± 57 pg/mL after MPA treatment and 210 ± 31 pg/mL otherwise; this difference was nonsignificant [t(274) = 0.143, P = 0.886]. Mean weighted testosterone level was 79 ± 18 ng/dL after MPA treatment and 215 ± 29 ng/dL otherwise; testosterone levels were significantly lower in the MPA group [t(122) = 32.4, P < 0.001]. There were minimal changes in other laboratory parameters. Of 39 patients receiving MPA, 26 reported improved breast development and 11 reported decreased facial hair. Five patients experienced mood swings on MPA.

CONCLUSIONS

In our cohort of transwomen, we found minimal side effects, unchanged E levels, and a decline in testosterone associated with MPA, outcomes consistent with feminization. Prospective studies are needed to confirm our findings.

Eliminating parental consent for adolescents receiving human papillomavirus vaccination

Human papillomavirus (HPV) is a sexually transmitted infection (STI) causing nearly all cases of cervical carcinoma and genital condyloma worldwide. While HPV vaccination rates are higher in Rhode Island compared to other states, still 27% of female adolescents are not fully vaccinated. The requirement for parental consent for vaccination administration poses a barrier to HPV vaccine uptake and hinders adolescent autonomy. This requirement lies in stark contrast to the goals of the Family Planning Title X Program, which provides all adolescents with access to contraception and STI prevention and treatment without parental consent. In this commentary, we propose that HPV vaccination should be available to all pre-teens and adolescents as part of teen reproductive and sexual healthcare, and thus be exempt from parental consent in a similar way to other reproductive and sexual health services such as STI testing and contraception. [Full article available at http://rimed.org/rimedicaljournal-2018-09.asp].

Multidisciplinary care considerations for gender nonconforming adolescents with eating disorders: A case series

Gender nonconforming youth are at risk for body dissatisfaction and disordered eating. Currently, only a small body of literature addresses this high-risk group. The five cases in this series highlight important themes for this patient population from an interdisciplinary perspective. Identified themes include increased risk for self-harm/suicide, complex psychiatric, and medical implications of delay to treatment for either gender dysphoria or disordered eating, and the importance of collaborative management to maximize care and facilitate healthy development to adulthood. The purpose of this case series is to expand the interdisciplinary discussion regarding the breadth of presentation and management considerations for gender nonconforming adolescents with disordered eating. An interdisciplinary approach to care might enhance access to comprehensive, collaborative treatment for disordered eating, and gender dysphoria in this unique population.

Family Functioning and Mental Health of Transgender and Gender-Nonconforming Youth in the Trans Teen and Family Narratives Project

Transgender and gender-nonconforming (TGN) youth are at increased risk for adverse mental health outcomes, but better family functioning may be protective. This study describes TGN youth's mental health and associations with family functioning in a community-based sample. Participants were from 33 families (96 family members) and included 33 TGN youth, ages 13 to 17 years; 48 cisgender (non-transgender) caregivers; and 15 cisgender siblings. Participants completed a survey with measures of family functioning (family communication, family satisfaction) and mental health of TGN youth (suicidality, self-harm, depression, anxiety, self-esteem, resilience). TGN youth reported a high risk of mental health concerns: suicidality (15% to 30%), self-harm (49%), clinically significant depressive symptoms (61%); and moderate self-esteem (M = 27.55, SD = 7.15) and resiliency (M = 3.67, SD = 0.53). In adjusted models, better family functioning from the TGN youth's perspective was associated with better mental health outcomes among TGN youth (β ranged from -0.40 to -0.65 for self-harm, depressive symptoms, and anxious symptoms, and 0.58 to 0.70 for self-esteem and resiliency). Findings from this study highlight the importance of considering TGN youth's perspectives on the family to inform interventions to improve family functioning in families with TGN youth.

Transgender and Gender Nonconforming Youth: Psychosocial and Medical Considerations

Primary care providers are increasingly called upon to care for youth that are gender nonconforming. While these youth have the same health concerns as their cisgender peers, gender nonconforming youth face additional challenges. Traditionally, this has been an underserved and marginalized population at significant risk for multiple negative mental and physical health outcomes. Despite the history of disheartening health outcomes, there is hope in interventions that may serve to ameliorate the risks for transgender youth. Studies indicate that with collaborative multidisciplinary interventions by physicians and mental health professionals that promote early identification, emphasize parental support and directly address the patient's gender dysphoria with medical and psychological interventions, transgender youth can reach adulthood without psychological sequela. [Full article available at http://rimed.org/rimedicaljournal-2016-09.asp, free with no login].

Low vitamin D status among obese adolescents: prevalence and response to treatment

PURPOSE

To explore the prevalence of low vitamin D status among obese adolescents and to examine the effect of current management of low vitamin D status in these patients.

METHODS

A retrospective chart review of obese adolescents who had been screened for vitamin D status by serum total 25-hydroxyvitamin D (25(OH)D) level. Vitamin D deficiency was defined as 25(OH)D level of <20 ng/mL, vitamin D insufficiency as 25(OH)D level of 20-30 ng/mL, and vitamin D sufficiency as 25(OH)D level of >30 ng/mL. Adolescents with vitamin D deficiency were treated with 50,000 IU of vitamin D once a week for 6-8 weeks, whereas adolescents with vitamin D insufficiency were treated with 800 IU of vitamin D daily for 3 months. Repeat 25(OH)D was obtained after treatment.

RESULTS

The prevalence rate of low vitamin D status among 68 obese adolescents (53% females, 47% males, age: 17 ± 1 years, body mass index: 38 ± 1 kg/m(2), Hispanic: 45%, African American: 40%, Caucasian: 15%) was 100% in females and 91% in males. Mean (±SE) 25(OH)D level was significantly higher in summer (20 ± 8 ng/mL) than in spring (14 ± 4 ng/mL, p < .02), and significantly lower in winter (15 ± 7 ng/mL) than in fall (25 ± 15 ng/mL, p < .05). Although there was a significant (p < .00001) increase in mean 25(OH)D after the initial course of treatment with vitamin D, 25(OH)D levels normalized in only 28% of the participants. Repeat courses with the same dosage in the other 72% did not significantly change their low vitamin D status.

CONCLUSIONS

Increased surveillance and possibly higher vitamin D doses are warranted for obese adolescents whose total 25(OH)D levels do not normalize after the initial course of treatment.

Pediatric Residents' Attitudes and Practices Regarding Adolescent Dating Violence

OBJECTIVES

To examine pediatric residents' knowledge, attitudes, self-reported screening, and care of adolescents involved in violent dating relationships.

METHODS

Data were obtained by a cross-sectional survey of pediatrics and medicine-pediatrics residents at 4 pediatric and medicine-pediatric training programs in the United States during 1996-1997. We analyzed self-reported rates of screening for dating violence, resident responses to an adolescent report of dating violence, and barriers to caring for adolescent patients who report dating violence by descriptive statistics and bivariate analyses, chi(2) analysis, and prevalence ratios.

RESULTS

A survey was completed by 204 of 296 residents (69% response rate). Residents were knowledgeable about the prevalence of dating violence, but 91% did not routinely screen for dating violence in adolescent patients. Residents were more likely to ask about dating violence, be concerned, and refer for counseling when a teen was female or was involved in a physically versus emotionally violent relationship. Resident characteristics associated with responses were female sex, number of adolescent patients seen, and prior personal experience with intimate violence. Barriers to asking about dating violence mirror those for marital violence, with lack of time and insufficient training cited as major barriers.

CONCLUSIONS

Residents in pediatric training programs report that they would not routinely screen for or manage appropriately their adolescent patients in violent dating relationships. Residents believe that although it is a physician's role to discuss adolescent dating violence, they are not adequately trained to do so. Efforts are needed to properly prepare pediatricians to deal with this common adolescent health risk.

Epidemiology of depressive symptoms in the National Longitudinal Study of Adolescent Health

OBJECTIVE

To describe the range of depressive symptoms reported by adolescents in a nationally representative U.S. sample and to examine factors associated with persistent depressive symptoms.

METHOD

Secondary analysis was done on National Longitudinal Study of Adolescent Health (AddHealth) data from 13,568 adolescents who completed the initial survey in 1995 and follow-up 1 year later. Main outcomes of Center for Epidemiologic Studies-Depression Scale (CES-D) scores were analyzed by chi2 comparisons and sample-weighted logistic regression.

RESULTS

Over 9% of adolescents reported moderate/severe depressive symptoms at baseline (CES-D > or = 24). Females, older adolescents, and ethnic minority youths were more likely to report depressive symptoms at baseline. Only 3% of adolescents with low initial CES-D scores (CES-D < 16) developed moderate/severe depressive symptoms at follow-up. Factors associated with persistent depressive symptoms at 1-year follow-up included: female gender, fair/poor general health, school suspension, weaker family relationships, and health care utilization. Other factors, including race and socioeconomics, did not predict persistent depressive symptoms.

CONCLUSIONS

Depressive symptoms are common in adolescents and have a course that is difficult to predict. Most adolescents with minimal symptoms of depression maintain their status and appear to be at low risk for depression; however, adolescents with moderate/severe depressive symptoms warrant long-term follow-up and reevaluation.