Addressing the Needs of Transgender Youth in Primary Care

Laurie Barclay, MD

February 14, 2011

February 14, 2011 — To minimize negative health outcomes and maximize positive futures for transgender adolescents, timely medical intervention to achieve gender/body congruence paired with affirmative mental health therapy is appropriate, according to a review in the February issue of the Archives of Pediatrics & Adolescent Medicine.

"Transgender is an umbrella term that is used to describe individuals whose gender self-identification or expression transgresses established gender norms," write Johanna Olson, MD; Catherine Forbes, PhD; and Marvin Belzer, MD, from Children's Hospital Los Angeles, in California.

"Specifically, it is the state of one's gender identity (self-identification as male, female, both, or neither) not matching one's assigned gender (identification by others as male or female based on natal sex). The identity and behavior of transgender individuals are socially and medically stigmatized, resulting in a notably underserved population at high risk for significant morbidity and mortality."

Support of Transgender Youth

Although the phenomenon of transgender is relatively uncommon, increasing media attention is resulting in more adolescents and young adults "coming out" at a younger age. Despite the highly specific medical and mental health needs of transgender adolescents, they continue to be an underserved and poorly studied group. Primary care clinicians are uniquely positioned to improve physical and mental health outcomes among transgender youth.

Most, but not all transgender adolescents wish to undergo phenotypic transition to match their gender and physical body. Because this process is complex, it mandates the involvement of a mental health therapist specializing in gender issues as well as a clinician, but it is often highly problematic for transgender youth to find needed comprehensive medical and mental health services.

Transgender youth are at increased risk for multiple psychosocial problems, including family and peer rejection, harassment and bullying, trauma, abuse, insufficient housing, legal problems, lack of financial support, and educational problems. "It is very important for primary care physicians to examine their own feelings, attitudes, and beliefs about gender-variant persons and consider how these affect their work with youth," the review authors write. "Using supportive, affirming language with gender-variant youth, such as using the patient's preferred name and pronouns, can make all the difference between a trustworthy physician and one that makes a youth feel misunderstood, rejected, and unwelcome. In addition, medical professionals can be effective advocates for their transgender patients' needs and rights in settings outside of the home, such as clinics and schools."

Phenotypic Transitioning

Phenotypic transitioning occurs in reversible, partially reversible, and irreversible phases. The reversible portion includes adopting preferred gender hairstyles, clothing, and play, and sometimes adopting a new name, which may occur before age 10 years. Puberty may be suppressed with gonadotropin-releasing hormone analogues, which may have adverse effects on height and bone density. Allowing transition before puberty begins is controversial and should be preceded by a careful assessment of the potential risks and benefits in a decision-making process involving healthcare professionals, parents, and children.

The partially reversible phase of transitioning involves using cross-gender hormone therapy. The Endocrine Society guidelines recommend deferring estrogen and testosterone therapy until the patient is 16 years old, but the reviewers note that "it is often not pragmatic to delay the initiation of treatment with cross-gender hormones." The reviewers suggest using age 16 years as a guideline and considering starting cross-gender hormones earlier on a case-by-case basis.

Before starting cross-gender hormone therapy, patients should be assessed for readiness by a mental health professional as well as by a clinician who can exclude medical contraindications. Testosterone administration is indicated for female-to-male patients. For male-to-female patients, estrogen, usually in combination with spironolactone or other androgen inhibitor, may be offered. Progesterone may be considered but may lead to unwanted weight gain. In general, the benefits of cross-gender hormone therapy must be carefully balanced against potential adverse effects, especially since very little is known about the use of hormones in this population.

Irreversible surgical procedures for sexual reassignment to create a more masculine or feminine appearance include vaginoplasty, labioplasty, tracheal shave, liposuction, breast implants, jaw shaping, and orchiectomy for transgender girls; and mastectomy, construction of neoscrotum, metoidioplasty, or phalloplasty for transgender boys. Later in adulthood, female-to-male patients may also opt for hysterectomy and oophorectomy.

"The low prevalence of children and adolescents seeking care, combined with the historical refusal of most insurance providers to pay for care, has led to inadequate research in the United States, thus making care for this population uncommon," the review authors conclude. "Due to the tremendous paucity of research in transgender youth, specific medication regimens are neither standardized nor approved by the Food and Drug Administration for treatment of GID [gender identity disorder]. The Amsterdam Gender Clinic has demonstrated reasonable safety and thus far good outcomes in a small cohort of white youth."

The study authors have disclosed no relevant financial relationships.

Arch Pediatr Adolesc Med. 2011;165:171-176. Abstract

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