Caring for Transgender Kids: Is Clinical Practice Outpacing the Science?

Becky McCall, BSc, MSc; Lisa Nainggolan

Disclosures

August 28, 2018

Treatment

Block Puberty and Introduce Cross-sex Hormones

At the Tavistock Centre, informed consent to treatment must be given by the child and one or both parents for patients who are 16 years of age or younger, except under exceptional circumstances. Patients older than 16 years of age who are deemed to have sufficient understanding of the treatment offered may give their own consent.

The first stage of physical intervention is suppression of puberty using fully reversible hormone blockers for a minimum of 12 months, which provides time for gender exploration without the pressure of ongoing pubertal development.

Then, when the young person reaches 15-16 years of age, the partially reversible cross-sex hormone treatment may begin. In trans-females (natal males), the hormone blocker is typically continued when the patient starts to take estrogen because it insufficiently blocks testosterone production. In trans-males, the blocker is often stopped because adult testosterone will usually block ovarian estrogen production sufficiently.

From the age of 18 years, patients may seek gender reassignment surgery to ensure that their physical features reflect their gender identity.

Suppressing Puberty: Implications for Fertility

Gary Butler, MD, FRCPCH, provides pediatric endocrinology services at GIDS and is a professor of pediatrics at University College London Hospitals. Reflecting on the 2016 NHS England clinical commissioning policy, he explains that a patient should have entered puberty before starting any intervention because gender dysphoria may resolve once puberty starts. This has been shown to happen in 73% to 88% of children who attend clinic.[4,5]

If puberty has reached at least Tanner stage 2, the patient can begin medical treatment, Butler explains. Gonadotropin-releasing hormone (GnRH) analogues block sex hormone production typical of natural puberty and provide a reversible option.

Blocking puberty has repercussions on fertility, however, the implications of which might seem far in the distant future for someone whose reproductive life has barely begun. Butler points out that GnRH analogue therapy stops gonadotropin and gonadal sex hormone secretion but also suspends gonocyte maturation. Oocytes remain dormant and spermatogenesis is halted. It is at this point that questions regarding future fertility arise. Young people and their families should receive counseling on loss of fertility as a result of treatment and discuss medical options to revert to birth gender if desired later in life.

"In boys, if puberty is under way, then by Tanner stage 3, ejaculation can take place. Even if sperm count is low, it may be sufficient for preservation for future assisted conception," Butler explains.

In girls, it's more complex. "Before menarche, ovarian biopsy is possible but not routinely available, and mature oocyte harvesting post menarche is more complicated."

Once a young person wishes to transition to the preferred sex, therapeutic regimens for gender-affirming (cross-sex) hormone treatment with testosterone or estradiol can start.

2017 Endocrine Society Guidelines Update

The rapid increase in referrals coupled with new evidence triggered a revision of the Endocrine Society guidelines in 2017 for the treatment of transgender individuals, as reported on Medscape Medical News .

Of note, the changes include detailed advice on the appropriate age for teens to start treatment. Pubertal blockers are to be used only in patients who have entered puberty and who meet certain criteria, which include marked incongruence between one's experienced/expressed gender and natal gender for at least 6 months, and clinically significant distress or impairment in social, occupational, or other important areas of functioning. Standard fertility preservation counseling for all individuals is also emphasized.

The guidelines focus on cross-sex hormone therapy and note that treatment should be safe and effective, with sex hormone levels kept within the normal range for gender affirmation. Because cross-sex therapy is partially irreversible, the persistence of gender dysphoria should be confirmed in individuals with sufficient mental capacity to give informed consent. This is usually done at the age of about 16 years, but the guidelines recognize that some people might have compelling reasons to start cross-sex hormones earlier.

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