Children & Adolescents

There are a number of differences in the developmental course and management of transgender patients depending on their age. While it is within a primary care physician’s scope of practice to perform an initial assessment of all patients presenting with concerns regarding gender identity, all children and adolescent patients should be referred to a qualified pediatric mental health professional or endocrinologist for further assessment and management. Management should not be carried out independently by a primary care physician.

Children


Highlights

  • Features of gender dysphoria can be present as early as two years old and can vary in severity from mild to extremely distressing.
  • The majority of children with gender dysphoria will not have gender dysphoria that persists into adolescence/adulthood.
  • The decision of whether or not to allow children to undergo a social transition to a different gender role is a controversial one that should be supported by mental health professionals.

 

Overview

Research on childhood gender development proposes that by age three, most children have a sense of what it means to be male or female and by age five to six, most children will declare a gender identity of male or female. Children as young as age two can show features that could indicate gender dysphoria. Most commonly these features manifest as gender non-conforming behaviors as opposed to an expressed desire to be the opposite gender. Children with gender variance may express unhappiness with their physical sex characteristics and function; may prefer clothes, toys, and games that are commonly associated with the other sex; or may prefer to play with other-sex peers. The prominence of these behaviours varies amongst children and ranges from occasional to constant and distressing. The prevalence of gender dysphoria in children is difficult to estimate. However one study found that 1% of parents had children that expressed an interest to be the opposite sex.

Notably, gender dysphoria in childhood usually disappears before or early in puberty. Studies have shown that only 6-27% of pre-pubertal children who experience gender dysphoria had the dysphoria persist into adulthood. Strong indicators that children will have gender dysphoria that persists into adulthood include: an older age at the time of diagnosis, a higher intensity of gender dysphoria, female natal gender, social transitioning, cross-gender identification, and a tendency to assert their gender cognitively versus affectively (i.e., “I am a girl” versus “I feel like a girl”). In cases where gender dysphoria subsides, the majority of children have been found to later identify as gay or lesbian.

The decision of whether or not to allow children to undergo a social transition to a different gender role is a controversial one that should be supported by mental health professionals. There have not been adequate studies to predict the long term outcomes of early social transition. Proponents of social transitioning argue that children allowed to transition to their affirmed gender will experience less social distress and, because the transition occurs solely at the social level (i.e., without medical intervention), these children can fully revert to their birth-assigned gender should gender dysphoria desist. Opponents of social transitioning argue that it can contribute to gender dysphoria persistence, thereby increasing one’s likelihood to identify as transgender in adolescence. Given the high desistance of childhood gender dysphoria in adolescence, there is concern that children may undergo premature or entirely contraindicated social transitioning. Families may decide to allow no social transition, a partial transition (e.g., clothing but not pronouns), or a full social transition. Compromises could also be discussed (e.g., only on vacations).  If a transition is allowed and later on the child feels they no longer identify with their new gender role (the most likely scenario), a change back to the original gender role can be distressing and may result in a delay of this second transition. In children who undergo a social transition it is important to frame it as a period of exploration, and ensure that children understand that it does not have to be a permanent change and that they can always transition back.

Recommended qualities needed to diagnose gender dysphoria in children and adolescents (American Endocrine Society clinical guidelines):

  • Training in child and adolescent developmental psychology and psychopathology;
  • Competence in using the DSM for diagnostic purposes;
  • The ability to make a distinction between gender dysphoria/gender incongruence and conditions that have similar features (e.g., body dysmorphic disorder);
  • Training in diagnosing psychiatric conditions;
  • The ability to undertake or refer for appropriate treatment;
  • The ability to psychosocially assess the person’s understanding and social conditions that can impact gender-affirming hormone therapy;
  • A practice of regularly attending relevant professional meetings;
  • Knowledge of the criteria for puberty blocking and gender-affirming hormone treatment in adolescents.

Gender Dysphoria in Children (DSM 5)

  1. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least six of the following (one of which must be Criterion A1):
    1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender).
    2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire: or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
    3. A strong preference for cross-gender roles in make-believe play or fantasy play.
    4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.
    5. A strong preference for playmates of the other gender.
    6. In boys (assigned gender), a strong rejection of typically masculine toys, games, 
and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.
    7. A strong dislike of one’s sexual anatomy.
    8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.
  2. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Role of the Primary Care Physician

Primary care physicians may safely assure prepubertal children with possible gender dysphoria and their families that specialized medical care (i.e. hormone blockers) is not yet needed. The physician has a duty to take a thorough history, including assessing for safety at home and school, substance abuse, and sexual and mental health. These children should be referred to a qualified mental health professional to cope with stigma, clarify preferred gender expression, and manage relationships and expectations. Referrals may need to be made on a more urgent basis if there are concerns for a patient’s safety.

Adolescents


Highlights

  • Gender dysphoria in adolescents is much more likely to persist into adulthood, compared to gender dysphoria in children. Diagnostic criteria are the same as that in adults.
  • Early medical treatment in adolescents consists of GnRH analogues to suppress puberty and irreversible secondary sex characteristics. This is normally started (by a specialist) during Tanner stage II-III.
  • Puberty suppression can allow more time for adolescents to explore their gender identity, but can have negative consequences for fertility and can limit some options for future gender confirming surgery.
  • Refusing timely medical intervention in adolescents may prolong or worsen their gender dysphoria and contribute to abuse and stigmatization.

 

Overview

It is difficult to estimate the prevalence of gender dysphoria in adolescents. However one survey found that 1.2% of adolescents identified as transgender and another 2.5% were unsure about their gender. Not all adolescents (or adults) presenting with gender dysphoria will recall a childhood of gender non-conforming behaviours. Adolescents with gender dysphoria may experience intense body aversion as secondary sex characteristics begin to develop and may have a strong desire for hormones and surgery. Increasing numbers of adolescents have started living in their desired gender role by the time they enter high school.

Gender dysphoria in adolescents appears to be much more likely to persist into adulthood. A study of 70 adolescents diagnosed with gender dysphoria and given puberty-suppressing hormones demonstrated that all patients continued on with cross-hormone therapy.

Before any physical interventions are considered, psychological work should be done to explore psychological, family, and social issues. In some forms of gender incongruence, psychological interventions may be sufficient to manage the feelings of distress. Co-morbid psychosocial issues are more prevalent in the transgender population, the most common of which are: bullying, depression, self-harm, and suicide attempts. It is still unknown if the increased mental health burden is a result of being stigmatized as transgender or if the mental health disorders are a risk factor for developing gender dysphoria or both. Currently, there is a move toward the former explanation (distress secondary to discrimination, stigmatization, and prejudice).

Family support is highly protective for trans youth. Physicians should seek to nurture and sustain supportive relationships between trans youth and their families. Ideally, decisions regarding medical treatment are made collaboratively between the care provider, the youth, and their family. However, during times when parental involvement is not possible, the risks and benefits of providing treatment in the absence of parental support must be weighed against the risks and benefits of withholding treatment. The New Brunswick Medical Consent of Minors Act assures that minors 16 years or older have the same right to refuse or consent to medical treatment as adults do. The New Brunswick Act also provides that a minor under the age of 16 can make decisions about medical treatment if the minor is deemed capable of understanding the nature and consequences of the medical treatment and the treatment and procedures are in the best interests of the minor.

Early medical treatment in adolescents consists of gonadotropin-releasing hormone (GnRH) analogues (e.g. Lupron) that suppress puberty by providing a nonpulsatile, continuous release of a GnRH analogue that desensitizes the GnRH receptors in the pituitary gland and thereby inhibits the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Given their agonist effects, GnRH analogues may temporarily increase natal pubertal signs in the first few weeks after initiation (e.g., increased moodiness, increased breast development, hot flashes, and vaginal bleeding in natal females; increased aggressiveness in natal males). Such effects will reverse once secretion of LH, FSH, and the gonadal sex steroids are reduced. During GnRH analogue treatment, slight development of natal secondary sex characteristics may regress, and in a later phase of pubertal development, it will stop. In natal females, breast tissue will become atrophic, and menses will stop. In natal males, virilization will stop, and testicular volume may decrease. In MtF patients, hormone alternatives include progestins or spironolactone which decrease the effect of the androgens secreted by the testicles. In FtM patients, progestins can also be used as an alternative, and continuous oral contraceptives can be used to suppress menses. The effects of these aforementioned interventions are completely reversible, enabling full pubertal development in the natal gender, after cessation of treatment, if desired.

The minimum criteria for puberty suppressing hormones (WPATH):

  • The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed);
  • Gender dysphoria emerged or worsened with the onset of puberty;
  • Any co-existing psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment;
  • The adolescent has sufficient mental capacity to give informed consent to this (reversible) treatment;
  • The adolescent has been informed of the effects and side effects of treatment (including potential loss of fertility if the individual subsequently continues with sex hormone treatment) and options to preserve fertility;
  • The adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process;
  • The pediatric endocrinologist or other specialist agrees with the indication for GnRH agonist treatment, has confirmed that puberty has started, and has verified that there are no medical contraindications to treatment.

Puberty suppression is ideally started by a specialist during Tanner stage II-III, at which time any physical changes are usually still reversible. Physical puberty is often a valuable experience in adolescents with gender dysphoria as it may become clearer whether or not the gender dysphoria will persist. Studies evaluating this approach have only included adolescents of at least 12 years of age, although some patients may reach Tanner stage II significantly earlier.  The American Endocrine Society clinical practice guidelines recommend that adolescents who maintain a strong and consistent cross-gender identification should be considered for GnRH analogues at Tanner stage II to III, independent of chronologic age.

Adolescents with more advanced Tanner staging may proceed directly to cross-hormone therapy, or may still benefit from puberty-suppression to prevent further development of natal secondary sex characteristics as it will allow the patient time to consolidate their gender identity, and may potentially lower the dose of cross-sex hormones needed for future feminization/masculinization. In FtM patients puberty-suppression can stop menses and in MtF patients it can prevent facial hair growth. However, physical sex characteristics such as more advanced breast development in FtMs and lowering of the voice and outgrowth of the jaw and brow in MtFs are not reversible.

Puberty-suppressing interventions have both pros and cons, and withholding medical therapy in adolescents is not a neutral option. Refusing timely medical interventions may prolong or worsen gender dysphoria and may result in many negative psychosocial outcomes including: depression, anxiety, social withdrawal, self-harming behavior, suicidal ideation, suicide attempts, sexual behavioral risks, substance use, bullying/abuse, and stigmatization.

Puberty-suppression allows adolescents more time to explore their gender identity and will facilitate a possible transition in the future by preventing the development of secondary sex characteristics that are difficult or impossible to reverse. Gender-related abuse is strongly associated with the degree of psychiatric distress in adolescence. Studies have shown that adolescents with gender dysphoria that undergo puberty suppression along with psychosocial support have significantly improved global psychosocial functioning.

The downsides to puberty suppression are:

  • Infertility: While hormone suppression itself is reversible and does not lead to infertility, adolescents who are put on hormone blockers early in puberty immediately followed by cross-sex hormones will never develop the reproductive function of their natal sex, rendering them infertile. Delaying or temporarily discontinuing GnRH analogues to promote gamete maturation is an option. However it is often undesired because mature gamete production is associated with later stages of puberty and with the significant development of secondary sex characteristics. There is no data in this population concerning the time required for sufficient gametogenesis to allow for sperm banking or egg cryopreservation. Inferences made from other evidence suggests that it could take 6 months-3 years for adequate spermatogenesis to collect enough sperm for sperm banking.
  • Limited surgical options: MtF patients undergoing early pubertal suppression may end up with insufficient penile tissue for inversion vaginoplasty techniques in the future. However, alternative techniques are available.

During pubertal suppression, adolescents’ physical development should be monitored closely, preferably by a pediatric endocrinologist.  While the safety of short term use of GnRH analogues has been demonstrated in patients undergoing treatment for precocious puberty, the long term consequences of GnRH analogues on physical development, especially height and bone development, are unknown. Adolescents taking GnRH analogues will have lower bone density compared to their peers until treatment is stopped or cross-sex hormones are started, at which time the bone density has been shown to normalize. Patients should be encouraged to participate in regular exercise. Vitamin D should also be prescribed if deficient. Calcium supplements may help optimize bone health.

Many adolescents will desire cross-sex hormone therapy after puberty suppression. This again should be managed by a pediatric specialist as there are differences between adolescent and adult treatment, including different hormone doses and monitoring. Currently studies support treatment with cross-sex hormones beginning at 16 years old. However, some patients may incur potential risks by waiting until the age of 16, and it may be decided to start cross-sex hormones earlier.

GnRH analogues should be continued during cross-sex hormone treatment to ensure natal hormones are adequately suppressed and to potentially decrease the dose of cross-sex hormone needed. It is recommended that the GnRH analogues only be stopped post-gonadectomy. Alternatively, in FtM adolescents, GnRH analogues can be stopped once an adult dose of testosterone has been reached and the individual is well virilized. If uterine bleeding occurs, a progestin can be added. In MtF patients, an anti-androgen can be used as an alternative to ongoing GnRH analogues.

The minimum criteria for cross-sex hormones (WPATH):

  • Persistance of gender dysphoria;
  • Gender dysphoria emerged or worsened with the onset of puberty;
  • Any co-existing psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment;
  • The adolescent has sufficient mental capacity to estimate the consequences of the (partly) irreversible treatment, weight the risks and benefits, and give informed consent;
  • The adolescent has been informed of the (irreversible) effects and side effects of treatment (including potential loss of fertility and options to preserve fertility);
  • The adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process;
  • The pediatric endocrinologist or other specialist agrees with the indication for cross-sex hormone treatment, and has verified that there are no medical contraindications to treatment.

Patients may choose to undergo a social transition either before, after, or in parallel with cross-sex hormone therapy. Social transitioning is a period of time in which transgender individuals live full-time in their affirmed gender. The purpose of this is to help youth confirm their affirmed gender and evaluate their ability to function as a member of that gender. It also provides insight into the adequacy of social, economic, and psychological support. During social transitioning, the person’s feelings about the social transformation (including coping with the reaction of others) is a major focus of the counselling.

Fertility counselling prior to cross-sex hormone initiation is important. As mentioned above, patients that underwent puberty suppression early in puberty will not have developed their natal secondary sex characteristics and therefore are ineligible for sperm banking or egg cryopreservation, rendering them infertile in the future. Patients that have developed their natal secondary sex characteristics may be eligible for sperm banking or egg cryopreservation and these options should be discussed with all eligible patients.

Any surgical interventions that are undertaken are irreversible and are discussed in more detail here. Genital surgery should not be carried out until a patient reaches 18 years of age and has lived continuously for at least 12 months in the gender role that is congruent with their gender identity. Chest surgery in FtM patients could be carried out as early as 16 years of age provided they have had ample time to live in their desired gender role.

Role of the Primary Care Physician

Adolescents with gender dysphoria may not directly present with gender concerns. Instead, they may present with declining academic performance, behavioral problems at home and/or school, or drug use. Other gender dysphoric adolescents may present with disordered eating (e.g. FtM patients may restrict food intake to avoid a more feminine body type). Many youth may have been diagnosed and may be currently treated for depression, anxiety, or other mood disorders. Even if a physician asks, many youth may deny gender concerns. Therefore, physicians should incorporate gender inclusive questions as part of their adolescent screen to facilitate future disclosure of such gender issues and concerns. A gender-inclusive environment can also be created using the tips here.

If an adolescent discloses their feelings of gender dysphoria physicians should take a thorough history, including assessing for safety at home and school, substance abuse (including use of non-prescription hormones), and sexual and mental health. All adolescents should be referred to a qualified mental health professional to cope with stigma, clarify preferred gender expression, and manage relationships and expectations. It is also prudent that the primary care physician makes a timely referral to a specialist that can provide the medical management (puberty suppression or cross-gender hormones) if desired, as delaying this process can have negative consequences as outlined above.