Consumer Health: Hormone therapy for people who are transgender. A gender affirmative approach is the first step to counterbalancing the negativity youth face both in their external environments and within self (i.e., internalized transphobia, dysphoria). | (Photo: Reuters) Parents of transgender-identified youth are speaking out against the American Academy of Pediatrics' recent guideline affirming the use of hormone therapy for transgender children, saying that it could "worsen the harm" brought to their children. Staff and provider inquiry about, and consistent use of appropriate pronouns and name is the first, and potentially most important step toward creating a culturally sensitive and welcoming environment. TGE youth face minority stress and are often experiencing dysphoria, stressors that can lead to increased mental health problems, including depression, anxiety, and suicidality. Transgender and gender-diverse children might choose to temporarily suppress puberty through the use of prescription medications called pubertal blockers. 125-140). Washington, DC: American Psychological Association. Despite increasing visibility and acceptance, TGNC youth are likely to experience transphobia and its negative consequences, and may benefit from ongoing support. House Bill 1399 would have banned gender-confirmation surgery, hormone therapy and puberty suppression treatments for Texas' transgender children. Since the start of the 2020 legislative session, at least six states have proposed to restrict transgender minors' access to gender reassignment treatments, including surgery and hormone therapy. The utility of escalating doses of spironolactone (to decrease side effects including blood pressure instability or dizziness) is unclear, but because of the diuretic effect, it may be useful to start at 25 mg bid and taper up each week to a final dose of 200 mg BID. If both parents maintain medical decision-making for the youth then it becomes the task of the medical and mental health providers to help both parents understand the necessity of medical interventions. For those youth who struggle with emotional lability at that age, they do so in a relatively protected environment, regulated by parents/caregivers, and without access to potential dangers such as motor vehicles, drugs, alcohol and adult (or almost adult) peers and sexual partners. [13] While current guidelines recommend laboratory tests every three months to assess adequate suppression of the hypothalamic-pituitary-gonadal (HPG) axis,[11] repeated blood draws can be expensive and traumatizing for TGNC children. (2013). For children 16 and older, we provide gender-affirming hormone therapy, which brings about physical and emotional changes that better match their gender identity. As outlined in a recent review by Rosenthal [12] escalation of estrogen can be achieved in the following manner: Monitoring for safety of estradiol is outlined elsewhere in these guidelines (link to testosterone administration), and the Endocrine Society have also published guidelines for estrogen administration. This issue of Endocrinology and Metabolism Clinics, Guest Edited by Dr. Vin Tangpricha, will focus on Transgender Medicine. This issue is one of four issues selected per year by the series Consulting Editor, Adriana Ioachimescu. Psychotherapy with Transgender and Gender Nonconforming Clients. [3] Often young people are engaged in mental health services long before presenting for care related to phenotypic gender transition. Hormone therapy is a horrible risk for kids. The gender affirmative model: What we know and what we aim to learn. For people interested in feminizing hormones, estrogen is the main hormone used. Check levels, and adjust in 25 mg increments accordingly. In order to avoid the development of undesired secondary sexual characteristics, GnRH analogues ideally are initiated at the earliest stages of puberty (Tanner 2-3). Therapists also can work closely with parents to help them understand what their child is experiencing, and will likely need from their parents and/or caregivers. Social transition typically includes coming out to others and choosing clothing, hairstyle, name, and pronouns that feel congruent with the youthâs gender identity. Supporting transgender youth and their families in therapy: Facing challenges and harnessing strengths. Despite advances in youth care that include the use of puberty blockers and hormones in adolescence, many transgender youth (particularly transfeminine youth) often experience genital dysphoria that results in significant anxiety and depression, and has been reported by many youth as a barrier to quality of life. Pediatric endocrinologists have been treating gender dysphoric adolescents with puberty-suppressing drugs and, to a lesser extent, with cross-sex hormone therapies for more than twenty years. Subcutaneous dosing must be weekly as the testosterone level decreases significantly by a weeks' time, whereas intramuscular testosterone lasts longer and may be dosed either weekly or every other week. The CoE is unable to respond to individual patient requests for medical guidance. While the current Endocrine Society guidelines recommend starting gender-affirming hormones at about age 16,[11] some specialty clinics and experts now recommend the decision to initiate gender-affirming hormones be individually determined, based more on state of development rather than a specific chronological age. Deb A. Coolhart, PhD, LMFT, is an AAMFT Clinical Fellow and Approved Supervisor. It can improve mental health, confidence, body image and overall quality of life. Hormone agonist therapy disrupts bone density in transgender youth. Increasing numbers of young people are presenting with nonbinary or gender queer identities, preferring gender-neutral pronouns as a more accurate way to be described. Hormone therapy can help a person's body align with their gender identity. If it feels emotionally safe for the youth, therapists can coach youth in talking to their parents about the impact on them when incorrect pronouns are used. GnRH analogues may be used in this situation, however access is often difficult for financial and other reasons, and these medications cannot be used without hormone replacement indefinitely. The law blocks doctors from providing pre-pubescent minors with gender-confirming treatment. For those youth assigned female at birth who identify on the transmasculine spectrum, testosterone is used for the development of masculine secondary sexual characteristics. Expertise in coordinating your hormone therapy with your overall health. Biro FM, Galvez MP, Greenspan LC, et al. In recent weeks RxISK has had several emails asking about possible links between transgender issues or Gender Dysphoria and antidepressants. The four primary authors for this youth protocol represent many years of expertise in clinical care and research, in both academic and community practice settings, and within the disciplines of adolescent medicine, pediatric endocrinology, family medicine, and advanced practice nursing. Colizzi et al. Providers should participate in appeal processes so that patients can undergo chest surgery. Lulu, a transgender girl, leans on a hammock at her home in Buenos Aires. More than that, however, Becoming Nicole is the story of an extraordinary girl who fought for the right to be herself. Systemic therapists, with their openness to understanding multiple perspectives, are in a unique position to support not only TGE youth, but also their parents. Ruble DN, Taylor LJ, Cyphers L, Greulich FK, Lurye LE, Shrout PE. A team of experts in the Netherlands at the Gender Identity Clinic at the VU University Medical Center in Amsterdam was the first to develop a protocol that presented the possibility of delaying, or avoiding altogether, the development of undesired secondary sex characteristics resulting from an unwanted endogenous pubertal process. Chest dysphoria is often very intense for transmasculine youth and chest reconstruction can often eliminate this distress. The emotional upheaval that occurs for youth undergoing puberty happens normally at 11 or 12 years of age. In C. Meier & D. Ehrendaftâs (Eds. Load Error Reisner SL, Vetters R, Leclerc M, et al. As youth take small steps in the process, therapists can then check in to make sure the steps taken are resulting in increased feelings of congruence. Both the Endocrine Society Guidelines and the World Professional Association of Transgender Health (WPATH) Standards of Care version 7.0 recommend deferring genital surgery for both transmasculine and transfeminine youth until the age of 18 years. Cultural sensitivity and awareness begins with front office staff, and other staff that are initial points of contact for parents and patients. Testosterone patches come in 2mg and 4mg strengths, testosterone gel is available in 1% and 1.62% concentrations. Experiences of ambiguous loss for parents of transgender male youth: A phenomenological exploration. Therapists can help parents understand why pronouns are so important and the pain it causes when one is misgendered. Disclaimer, National Library of Medicine This finding is subject to confounding, as youth who repress gender dysphoria due to safety or lack of basic language to express ones feelings may be no less likely to persist into adulthood, yet not present at an early age. These two cohorts often require different medical interventions; suppression of endogenous puberty, and/or the use of gender-affirming hormones for the development of masculinizing or feminizing features. Every individual is different, and guidance about hormone therapy should always be used flexibly in response to individual needs. Coolhart, D. (2012). Intramuscular dosing can be done every one or two weeks with an escalating schedule that is similar; 25 mg IM every week, or 50 mg IM every two weeks for 8-12 weeks, then increase to 50 mg every week or 100 mg IM every two weeks. [9] GnRH analogues offer a reversible intervention that allows youth temporary relief from an undesired, and potentially traumatic endogenous puberty. There is some evidence that LH/FSH levels are not necessarily reliable indicators of suppression in those with GnRH analogue implants, therefore more accurate assessment of adequate suppression might require gonadotropin response to a subcutaneous leuprolide acetate stimulation test. It is vital to follow the lead of youth and listen to what they need to feel congruent.Â. Covering everything from family life to school and mental health issues, as well as the physical, social, and emotional aspects of transition, this book is full of best practices to support trans kids. At Blank Children's Adolescent Medicine and Blank Children's Endocrinology, we provide education about medical care options for gender-variant and transgender youth in a comfortable and welcoming environment. When parents have particularly low attunement, therapists can use they/them pronouns and gender neutral language (i.e., âyour childâ) in order to respect both the parents and the youth in their processes. Gender-affirming hormones help make a person's physical body match their inner gender identity. In fact, the provider should consider deferring a genital or chest exam until a follow-up visit, after a positive rapport has hopefully been established. Here you will find care and support services ranging from mental health support to hormone therapy. For some children this may include a social transition - changing of external appearance (clothing, hairstyle) and possibly name and pronouns to match one's internal gender. . Blood tests include ultrasensitive LH/FSH/total testosterone (in those with testes) or estradiol (in those with ovaries). The ability to develop skills and experience in social relationships is negatively impacted in those youth with genitals that do not correspond to their gender. Follow-up conversation with youth who are undergoing pubertal suppression should include an assessment of an ongoing desire for endogenous puberty suppression. This approach assumes that no gender identity or expression is pathological (Keo-Meier & Ehrensaft, 2018), that they are all natural variations of humanity (Coolhart & Shipman, 2017), and that any pathology that is present is a result of transphobia, homophobia, and sexism, rather than a disturbance in the child (Coolhart, 2012; Hidalgo et al., 2013). Careers. Hormone therapy before puberty is not needed because . Hormone therapy. gender hormones in order to address the psychological, social, and emotional concerns for children and adolescents faced with gender dysphoria. This book delivers robust, essential content from internationally recognized innovators and veterans in the field, including cutting-edge techniques for all gender transition surgeries. Subcutaneous dosing of testosterone with concurrent GnRH analogue use: Dosing schedules may start with 12.5 mg SC weekly for 8-12 weeks, increase to 25 mg SC weekly. Youth can be informed that the administration of progestogens alone have little if any feminizing effect. Learn more about the gender affirming hormone therapies in our sections on Masculinizing Hormone Therapy and Feminizing Hormone Therapy. Covering everything from family life to school and mental health issues, as well as the physical, social, and emotional aspects of transition, this book is full of best practices to support trans kids. Bathroom signs are temporary, but hormones are forever. Affirmative Mental Health Care for Transgender and Gender Diverse Youth: A Clinical Guide begins with three introductory chapters which contain practical information regarding assessment, psychological interventions, and the potential ... Because the cost of GnRH analogues is prohibitive for most families, gender-affirming hormones (in combination with other agents such as hormone blockers) are used to both suppress endogenous hormone production and masculinize or feminize bodies. Prior to the initiation of gender-affirming hormones, providers should review the expectations that patients have about the use of hormones in their phenotypic gender transition. The hospital will no longer accept patients who want hormone or puberty suppression therapy for gender dysphoria. Sun SS, Schubert CM, Chumlea WC, et al. When youth become clear about their binary identity, most wish to take steps towards gender transition in order to experience congruence. Rebecca Johnson meets the mothers navigating a new parenting landscape. In the absence of solid evidence, providers often must rely on the expert opinions of innovators and thought leaders in the field; many of these expert opinions are expressed in this youth guideline. Development of undesired secondary sex characteristics related to natal puberty can have profound negative psychosocial effects and for many, are a source of great distress. Parents of TGE youth often need accurate information about gender-related concepts (i.e., the differences between sex, gender identity, gender expression, and orientation) as well as TGE experiences (i.e., TGE kids can grow up to be healthy adults). Therapists can also educate parents about the importance of parental support, which can buffer youth from negative mental and physical health outcomes. as well as testosterone hormone therapy.12 In contrast to Leelah's tragic Some patients prefer to dose at other intervals such as every 10 days with adjusting of the dose. Continuation of GnRH analogs in tandem with gender-affirming hormones into late adolescence or even early adulthood may be beneficial. In order to achieve amenorrhea with testosterone alone, masculinization will likely occur, which may or may not be desirable. doi: 10.1542/peds.2019-1606. Youth with gender dysphoria often experience significant trauma at the onset of their endogenous pubertal process. Tennessee Governor Bill Lee signed a law that bans hormone therapy for transgender youth. Gender studies in non-transgender participants have found that children are aware of their gender by the age of five or six, and often earlier.[14]. This site needs JavaScript to work properly. Hormone Therapy For individuals seeking hormone treatment as part of their gender affirming process, we offer masculinizing and feminizing hormone treatment in a primary care setting. Posted: Sep 27, 2018 7:00 PM. Intramuscular dosing of testosterone with concurrent GnRH analogue use: Intramuscular dosing of testosterone weekly or bi-weekly with an escalating schedule that is similar; 25 mg IM every week for 8 weeks, then increase to 50 mg IM every week. Some youth are very clear about their identity as early as they can remember, while other youth may not understand their gender identity until adolescence. Long-term data on the health risks of hormonal intervention in youth are not available due to the relative newness of the gender affirmative approach. As youth are transitioning at increasingly younger ages, genital surgery is being performed on a case-by-case basis more frequently in minors, in order to address the issues mentioned above.
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