Treating Transgender, Gender-Nonconforming Youth

By Montano, Gerald | Clinical Psychiatry News, July 2016 | Go to article overview

Treating Transgender, Gender-Nonconforming Youth


Montano, Gerald, Clinical Psychiatry News


The clinical management of transgender and gender-nonconforming youth is a growing area in medicine with multiple questions and challenges. One of the many challenges relates to the decision-making process for transitioning to the self-identified gender. Many medical and ethical aspects surround this issue. What are the risks in delaying transition until adulthood? Can clinicians correctly diagnose gender dysphoria in childhood and adolescence? What are the long-term psychological and medical consequences of puberty suppression and cross-sex hormones? Each of these questions may pose a conundrum for patients, families, and clinicians to consider.

Risks of delaying transition

Available studies report the incidence of mental health problems among transgender and gender-nonconforming youth are higher than the incidence in cisgender youth. (1) This is especially true if they are unable to live as the gender with which they identify, de Vries et al. showed that transgender adults going through transition had worse baseline mental health problems than did transgender adolescents going through transition. (2) This makes sense, as transgender adults are less likely to have been living as their gender identity, compared with transgender adolescents. This exposes transgender adults to longer periods of gender dysphoria and to harassment and discrimination.

There are medical risks as well. Some surgical procedures are much more difficult to perform on a fully mature adult. For example, breast removal surgery for a transmale who has fully developed breasts may result in significant scarring, which could have been avoided if the surgery had been done when the patient was younger and had smaller breasts. (3) Furthermore, the secondary sex characteristics that develop during puberty can be much more difficult to remove in adulthood. These characteristics may result in an appearance that can provoke abuse and harassment. Patients can avoid this by the use of hormone blockers at an early age.

Gender dysphoria diagnoses

Because of the risks associated with pubertal suppression and cross-sex hormones, there is a concern about making the right diagnosis. Past studies have reported that, among children exhibiting gender dysphoria, about 10%-25% will continue to have gender dysphoria after the onset of puberty. (4,5) Because of this low rate of children with persistent gender dysphoria, many feel that making the diagnosis at such a young age, especially if the diagnosis is incorrect, will put these children through unnecessary risks.

One potential treatment for some prepubertal children with gender dysphoria is social transition--for example, using the child's preferred name and pronouns, having the child change clothing and hairstyle, and so on. These changes are reversible; however, there are no studies documenting the psychosocial outcomes of children whose gender dysphoria desists in adolescence.

Furthermore, the use of pubertal blockers does not begin until the patient reaches Tanner stage 2, (6,7) and the use of cross-sex hormones typically does not begin until age 16 years old. This allows time for the child to work with a mental health therapist to confirm gender identity. Finally, children with gender dysphoria beginning at puberty or persisting after puberty generally have persistent gender dysphoria in adulthood. (3)

Risks with pubertal suppression, cross-sex hormones

One of the risks for puberty suppression with a gonadotropin-releasing hormone agonist (GnRHa)--such as leuprolide--is reduced bone mineral density (BMD). (7) Most bone accretion occurs during adolescence and cannot be recovered in adulthood. There are no studies on how GnRHa may affect BMD in transgender children and adolescents. The best evidence comes from GnRHa treatment of central precocious puberty in children, which has mixed results. Some studies show that GnRHa may lead to lower BMD, (8) whereas other studies show no difference in BMD between those treated with GnRHa and those who were not treated with it, (9,10) especially after resumption of puberty. …

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