How Gender-Affirming Care Is Provided to Adolescents in the US

"Texas investigates parents of transgender teen." "Court did not force dad to allow chemical castration of son." Headlines such as these are becoming more common as transgender adolescents and young adults, as well as their families, continue to come under attack from state and local governments. In the 2021 state legislative sessions, more than 100 anti-trans bills were filed across 35 state legislatures. Texas alone saw 13 anti-trans bills, covering everything from sports participation to criminalization of best-practice medical care.¹ Many of these bills are introduced under the guise of "protecting" these adolescents and young adults but are detrimental to their health. They also contain descriptions of gender-affirming care that do not reflect the evidence-based standards of care followed by clinicians across the country. Below is scientifically accurate information on gender-affirming care.

Gender Identity Development

Trajectories of gender identity are diverse. In a large sample of transgender adults (n = 27,715), 10% started to realize they were transgender at age 5 or younger, 16% between ages 6 and 10, 28% between 11 and 15, 29% between 16 and 20, and 18% at age 21 or older.² In childhood, cross-gender play and preferences are a normal part of gender expression and many gender-nonconforming children will go on to identify with the sex they were assigned at birth (labeled cisgender). However, some children explicitly identify with a gender different than the sex they were assigned at birth (labeled transgender). Children who are consistent, insistent, and persistent in this identity appear likely to remain so into adolescence and adulthood. It is important to note that there is no evidence that discouraging gender nonconformity decreases the likelihood that a child will identify as transgender. In fact, this practice is no longer considered ethical, as it can have damaging effects on self-esteem and mental health. In addition, not all transgender people are noticeably gender nonconforming in childhood and that lack of childhood gender nonconformity does not invalidate someone's transgender identity.

Gender-Affirming Care

For youth who identify as transgender, all steps in transition prior to puberty are social. This includes steps like changing hairstyles or clothing and using a different (affirmed) name and/or pronouns. This time period allows youth to explore their gender identity and expression. In one large study of 10,000 LGBTQ youth, among youth who reported "all or most people" used their affirmed pronoun, 12% reported a history of suicide attempt.³ In comparison, among those who reported that "no one" used their affirmed pronoun, the suicide attempt rate was 28%. Further, 14% of youth who reported that they were able to make changes in their clothing and appearance reported a past suicide attempt in comparison to 26% of those who were not able to. Many of these youth also are under the care of mental health professionals during this time.

At the onset of puberty, transgender youth are eligible for medical management, if needed, to address gender dysphoria (i.e., distress with one's sex characteristics that is consistent and impairing). It is important to recognize that not all people who identify as transgender experience gender dysphoria or desire a medical transition. For those who do seek medical care, puberty must be confirmed either by breast/testicular exam or checking gonadotropin levels. Standards of care suggest that prior to pubertal suppression with GnRH agonists, such as leuprolide or histrelin, adolescents undergo a thorough psychosocial evaluation by a qualified, licensed clinician. After this evaluation, pubertal suppression may be initiated. These adolescents are monitored by their physicians every 3-6 months for side effects and continuing evaluation of their gender identity. GnRH agonists pause any further pubertal development while the adolescent continues to explore his/her/their gender identity. GnRH agonists are fully reversible and if they are stopped, the child's natal puberty would recommence.

If an adolescent desires to start gender-affirming hormones, these are started as early as age 14, depending on their maturity, when they desire to start, and/or their ability to obtain parental consent. If a patient has not begun GnRH agonists and undergone a previous psychosocial evaluation, a thorough psychosocial evaluation by a qualified, licensed clinician would take place prior to initiating gender-affirming hormones. Prior to initiating hormones, a thorough informed-consent process occurs between the clinician, patient, and family. This process reviews reversible versus irreversible effects, as well of any side effects of the medication(s). Adolescents who begin hormonal treatment are then monitored every 3-6 months for medication side effects, efficacy, satisfaction with treatment, and by continued mental health assessments. Engagement in mental health therapy is not required beyond the initial evaluation (as many adolescents are well adjusted), but it is encouraged for support during the adolescent's transition.⁴ It is important to note that the decision to begin hormones, or not, as well as how to adjust dosing over time, is nuanced and is individualized to each patient's particular goals for his/her/their transition.

Care for transmasculine identified adolescents (those who were assigned female at birth) typically involves testosterone, delivered via subcutaneous injection, transdermal patch, or transdermal gel. Care for transfeminine individuals (those who were assigned male at birth) typically involves estradiol, delivered via daily pill, weekly or twice weekly transdermal patch, or intramuscular injection, as well as an androgen blocker. This is because estradiol by itself is a weak androgen inhibitor. Antiandrogen medication is delivered by daily oral spironolactone, daily oral bicalutamide (an androgen receptor blocker), or GnRH agonists similar to those used for puberty blockade.

Outcomes

At least 13 studies have documented an improvement in gender dysphoria and/or mental health for adolescents and young adults after beginning gender affirming medical care.⁵ A recent study by Turban et al. showed that access to gender affirming hormones during adolescence or early adulthood was associated with decreased odds of past month suicidal ideation than for those who did not have access to gender-affirming hormones.⁶ Tordoff et al. found that receipt of gender-affirming care, including medications, led to a 60% decrease in depressive symptoms and a 73% decrease in suicidality.⁷ One other question that often arises is whether youth who undergo medical treatment for their transition regret their transition or retransition back to the sex they were assigned at birth. In a large study at a gender clinic in the United Kingdom, they found a regret rate of only 0.47% (16 of 3,398 adolescents aged 13-20).⁸ This is similar to other studies that have also found low rates of regret. Regret is often due to lack of acceptance in society rather than lack of transgender identity.

The care of gender diverse youth takes place on a spectrum, including options that do not include medical treatment. By supporting youth where they are on their gender journey, there is a significant reduction in adverse mental health outcomes. Gender-affirming hormonal treatment is individualized and a thorough multidisciplinary evaluation and informed consent are obtained prior to initiation. There are careful, nuanced discussions with patients and their families to individualize care based on individual goals. By following established evidence-based standards of care, physicians can support their gender-diverse patients throughout their gender journey. Just like other medical treatments, procedures, or surgeries, gender-affirming care should be undertaken in the context of the sacred patient-physician relationship.

Cooper is assistant professor of pediatrics at University of Texas Southwestern, Dallas, and an adolescent medicine specialist at Children's Medical Center Dallas.

References

1. Equality Texas. Legislative Bill Tracker.

2. James SE et al. The Report of the 2015 U.S. Transgender Survey. 2016. Washington, DC: National Center for Transgender Equality.

3. The Trevor Project. 2020. National Survey on LGBTQ Mental Health.

4. Lopez X et al. Curr Opin Pediatrics. 2017;29(4):475-80.

5. Turban J. The evidence for trans youth gender-affirming medical care. Psychology Today. 2022 Jan 24.

6. Turban J et al. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLOS ONE. 2022;17(1).

7. Tordoff DM et al. Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA Network Open. 2022;5(2).

8. Davies S et al. Detransition rates in a national UK gender identity clinic. Inside Matters. On Law, Ethics, and Religion. 2019 Apr 11.

This article originally appeared on MDedge.com , part of the Medscape Professional Network.

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Cite this: How Gender-Affirming Care Is Provided to Adolescents in the US - Medscape - Apr 25, 2022.