Care of the Child with the Desire to Change Gender – Part I

Bethany Gibson; Anita J. Catlin


Pediatr Nurs. 2010;36(1):53-59. 

In This Article

Pubertal Delay

The primary goals of hormone use for those children who believe they need sex reassignment are twofold. The first is to eliminate, to the degree possible, the hormonally induced sex characteristics of the birth-assigned gender, and secondly, to induce those of the desired gender (Gooren, 1999). Discussion of the first goal, suppression of the puberty-induced secondary sex characteristics of natal sex, will be discussed in this section. According to the Netherlands protocol, adolescents diagnosed with GID who "have suffered with extreme lifelong gender dysphoria, are psychologically stable and live in a supportive environment" are considered eligible for puberty suppression (Delemarre-van de Waal & Cohen-Kettenis, 2006, p. 132). A letter of recommendation from a psychiatrist outlining the adolescent's identifying characteristics, gender and/or other psychiatric diagnoses, length of psychotherapeutic relationship, verification of eligibility criteria for hormone therapy and/or sex reassignment surgery, and whether the client has followed recommendations from the organization is required to initiate endocrine treatment (Meyer et al., 2006).

The suppression of puberty using gonadotropin-releasing hormone analogs (GnRHa) may be prescribed for adolescents aged 12 to 16 years old who have 1) fulfilled the criteria mentioned above, 2) reached Tanner stage 2 or 3, and 3) reached pubertal levels of sex hormones (Delemarrevan de Waal & Cohen-Kettenis, 2006). Early hormonal treatment can reduce the amount of invasive surgical procedures that may be required with later sex reassignment because irreversible physical development secondary to puberty can be avoided. Female-to-male transitions might avoid the need for mastectomy, and male-to-females might avoid the need for reduction thyroid chondroplasty and voice modification therapy. Initiating pubertal delay at an early age will "most certainly result in high percentages of individuals who will more easily pass into the opposite gender role than when treatment commenced well after the development of secondary sexual characteristics," which will likely result in better quality of life and perhaps decreased reports of post-operative regret due to poor functioning (Delemarre-van de Waal & Cohen-Kettenis, 2006, p. 133).

As previously discussed, puberty in the birth-assigned gender can cause the transgender adolescent significant distress and discomfort, potentially leading to many negative emotional and psychological outcomes. While initial administration of GnRHa results in increased levels of circulating luteinizing hormone (LH) and follicle-stimulating hormone (FSH), continuous administration results in decreased secretion of LH and FSH from the pituitary gland to levels of a castrated man or menopausal woman (Skidmore-Roth, 2007). Inhibition of LH and FSH inhibits the gonadal production of the sex hormones testosterone and estrogen. GnRHa administered prior to puberty will completely prevent puberty, and when administered after the start of puberty will halt the progression of puberty, effectively putting it on hold (Brill & Milazzo, 2008; Cohen-Kettenis & van Goozen, 1998; Cohen-Kettenis et al., 2008). Other drugs, such as progestins, antiandrogens (males only), and luteinizing hormone-releasing hormone (LHRH) agonists, may also be used to suppress the physical changes of puberty (Cohen-Kettenis & van Goozen, 1998; Cohen-Kettenis et al., 2008; Gooren, 1999; Meyer et al., 2006). Patients born as girls will experience a weakening of breast tissue, which may disappear completely, while those born as males will have a reduction in testicular volume. If this treatment is begun later in pubertal development, changes such as later stage breast growth in girls and deepening of the voice and facial hair growth in boys will recede, although not completely, while any further progression of puberty will be halted (Delemarre-van de Waal & Cohen-Kettenis, 2006).

This treatment is fully reversible, and cessation of the GnRH analog will result in the adolescent resuming puberty in their birth-assigned gender (Cohen-Kettenis et al., 2008). Pubertal delay can provide respite for the psychosocial pain of the transgender adolescent while simultaneously allowing time for the therapist and adolescent to further explore their gender identity and wish for sex reassignment, contributing to greater diagnostic precision (Cohen-Kettenis & van Goozen, 1998; Cohen-Kettenis et al., 2008). This can serve to satisfy any doubts the parents and doctor may have about proceeding with sex reassignment treatment, allow time for parents/family to get counseling and support as needed, notify and educate school personnel, and explore the full range of treatment options.

Clinics in Boston, Gent, Oslo, and Toronto, all very experienced in treating gender dysphoric youth, have begun providing these interventions and/or referrals prior to 16 years of age as long as hormonal puberty has progressed to at least Tanner stage 2 (Cohen-Kettenis et al., 2008). Other criteria noted for initiation of GnRHa therapy include persistent GID since early childhood, exacerbated GID following early pubertal development, no comorbid psychiatric issues that impede diagnosis or treatment, parental consent, and a social support network throughout the treatment. Additionally, the adolescent can use this time to learn about the effects of sex reassignment treatment, as well as the social consequences of that course, including GnRH analogs, cross-sex hormones, and surgery (Cohen-Kettenis et al., 2008).

GnRH analogs have long been used in medical treatment of precocious puberty in children, with the exact same purpose and effect, halting puberty (Skidmore-Roth, 2007). GnRH analogs used for pubertal delay include leuprolide (Lupron® [subcutaneous injection; 50 mcg/kg/day, may increase by 10 mcg/kg/day as needed] and Lupron® Depot [intramuscular injection; 15 mg every 4 weeks in children more than 37.5 kg or 22.5 mg IM every 3 months]) and histrelin (Supprelin® LA and Vantas® [yearly subcutaneous implant]) (Milazzo, 2008; Skidmore-Roth, 2007). LHRH agonist depot triptorelin is a 3.75 mg intramuscular injection given monthly (Skidmore-Roth, 2007) that has been safely used with good results in Dutch clinics (Cohen-Ketenis & van Goozen, 1998). Spironolactone (up to 100 mg twice daily, if tolerated) is a diuretic with antiandrogenic properties that has been used to suppress the effects of testosterone effectively (Gooren, Giltay, & Bunck, 2008; Milazzo, 2008). Cyproterone acetate (initial dose of 50 mg twice daily, reduced to 50 mg daily when testosterone levels are effectively suppressed) is a progesterone with antiandrogenic properties and is the most widely used drug for this purpose in Europe (Gooren, 1999; Gooren et al., 2008). Medroxyprogesterone acetate (5 to 10 mg daily) may be used if cyproterone acetate is unavailable, although it has been found to be less effective (Gooren, 1999; Gooren et al., 2008). Finasteride (1 mg) is a 5-reductase inhibitor that can be used as well (Gooren, 1999; Gooren et al., 2008).

A follow-up protocol has been developed to investigate the efficacy and safety of GnRHa treatment in adolescents suffering from gender dysphoria. Blood work should be done prior to the initiation of therapy to establish baseline levels of gonadotropins and sex hormones, and metabolic determinants, including fasting glucose, insulin, cholesterol, high and low-density lipoprotein levels, and renal and hepatic studies. Additionally, anthropomorphic measurements, such as height, weight, sitting height, hip and waist circumferences, and Tanner pubertal stage can be recorded initially and re-evaluated periodically to ensure normal growth and development. Follow-up protocol includes appointments with psychiatrist or psychologist every three months and laboratory measurements of factors described above (Delemarre-van de Waal & Cohen-Kettenis, 2006).


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