A PRISMA systematic review of adolescent gender dysphoria literature: 3) treatment

Puberty blockers for gender dysphoria in youth: A systematic review and meta-analysis

AIM

Gender dysphoria (GD) refers to the psychological distress associated with the incongruence between one's sex and one's gender identity. To manage GD, individuals may delay the development of primary and secondary sex characteristics with the use of puberty blockers. In this systematic review, we assess and summarise the certainty of the evidence about the effects of puberty blockers in individuals experiencing GD.

METHODS

We searched Medline, Embase, PsychINFO, Social Sciences Abstracts, LGBTQ+ Source and Sociological Abstracts from inception to September 2023. We included observational studies comparing puberty blockers with no puberty blockers in individuals aged <26 years experiencing GD, as well as before-after and case series studies. Outcomes of interest included psychological and physical outcomes. Pairs of reviewers independently screened articles, abstracted data and assessed risk of bias. We performed a meta-analysis and assessed the certainty of a non-zero effect using the grading of recommendations assessment, development and evaluation (GRADE) approach.

RESULTS

We included 10 studies. Comparative observational studies (n=3), comparing puberty blockers versus no puberty blockers, provided very low certainty of evidence on the outcomes of global function and depression. Before-after studies (n=7) provided very low certainty of evidence addressing gender dysphoria, global function, depression, and bone mineral density.

CONCLUSIONS

There remains considerable uncertainty regarding the effects of puberty blockers in individuals experiencing GD. Methodologically rigorous prospective studies are needed to understand the effects of this intervention.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42023452171.

Treatment trajectories among children and adolescents referred to the Norwegian National Center for Gender Incongruence

AIM

We aimed to describe treatment trajectories, detransition and mortality rate among children and adolescents referred to the Norwegian National Center for Gender Incongruence (NCGI).

METHODS

The cohort included all 1258 persons under 18 years at referral to the NCGI from 2000 to 2020. Trajectories were registered until end of 2023.

RESULTS

In total, 861/1258 (68.4%) were assigned female gender at birth (AFAB). Mean age at referral was 14.4 years. Puberty suppression with gonadotropin-releasing hormone agonists (GnRHa) was initiated among 135/1258 (10.7%), significantly more persons assigned male gender at birth (AMAB) than AFAB (p < 0.001). Gender-affirming hormonal treatment (GAHT) was initiated in 783/1258 (62.2%). The continuation rate from GnRHa to GAHT was 97%. Discharge rate from NCGI without gender-affirming medical treatment among those who attended at least one appointment, was 264/1198 (22.0%). Eighteen AFAB detransitioned after initiated GAHT, eleven due to a cessation of transgender identity. Mortality rate in the cohort until end of 2023 was 11/1258 (0.9%).

CONCLUSION

Different trajectories including medical pathways and assessments without gender-affirming treatment were observed. GAHT was initiated in 783/1258 (62.2%), including eighteen AFAB detransitioning after testosterone treatment. There was a high continuation rate from GnRHa to GAHT. Various trajectories highlights the need for long-term follow-up in care.

Influence of the Timing of Gender Dysphoria Presentation and Suicidal Behaviors on Internalizing Symptoms, Emotion Dysregulation, and Body Investment in Adolescents Seeking Gender Affirmation

Studies have consistently shown that gender-diverse youth experience higher rates of internalizing disorders and self-harm behaviors (SH) compared to their cisgender peers. However, there is limited research on how body investment and emotion regulation influence these symptoms, especially in relation to the age of gender dysphoria (GD) presentation.

OBJECTIVES

This study aimed to explore the relationship between the timing of GD presentation (early vs. late) and psychological distress in adolescents seeking gender affirmation (GA), specifically focusing on internalizing symptoms, emotion regulation, and body investment. The study also investigated how SH during the year preceding the request for gender affirmation might have impacted these factors.

METHODS

On a total of 80 adolescents (mean age: 14.88 years) at their first request for GA, participants were divided into two groups: early-presentation GD (EP-GD; mean age: 14.93 years) and late-presentation GD (LP-GD; mean age: 14.83 years). Among the sample, 60% exhibited SH. Internalizing symptoms, emotion regulation, and body investment were assessed using the Youth Self-Report (YSR), the Difficulties in Emotion Regulation Scale (DERS), and the Body Investment Scale (BIS).

RESULTS

Results revealed that LP-GD adolescents had significantly higher emotion dysregulation (ED), particularly in the Strategies domain of the DERS (p = 0.040), and more social problems in the YSR (p = 0.047) compared to EP-GD ones. SH were associated with higher internalizing symptoms, including anxiety, withdrawal, and somatic complaints (p < 0.03), as well as increased body dissatisfaction, particularly in the BIS Care and Protection dimensions (p = 0.044; p = 0.034).

CONCLUSIONS

These findings supported the hypothesis that LP-GD adolescents and youths with a history of SH showed more pronounced emotion regulation difficulties and internalizing symptoms, further emphasizing the need for early intervention programs targeting both GD and co-occurring mental health problems.

Critiques of the Cass Review: Fact-Checking the Peer-Reviewed and Grey Literature

The Cass Review's final report, published in April 2024, made recommendations to the UK's National Health Service regarding structuring of services for minors with gender-related distress. It recommended cautious use of hormonal interventions in this population and use of research protocols. Some clinician-researchers disagree with the Cass Review's recommendations and have written critiques. A critique of the Cass Review posted on Yale Law School's website in July 2024 has received extensive media coverage. Its references identified three other critiques. In these papers, there were multiple claims that were incorrect or that lacked essential clarification/contextualization. These claims involved (1) the Cass Review's contents and processes; (2) the pediatric transgender healthcare evidence base; (3) existing clinical practice guidelines, including claims that there is international medical consensus; (4) evidence-based medical practice and guideline development; and (5) conclusions regarding the validity of the Cass Review's findings. The Cass Review's careful, balanced investigations and judgments were a comprehensive, evidence-based response to the controversies in this pediatric clinical arena. Recently-published critiques of the Review have contained incorrect or inadequately contextualized claims. Because accurate information about medical interventions is essential to informed consent, it is important to correct errors in potentially influential publications.

Gender-affirming medical treatment for adolescents: a critical reflection on "effective" treatment outcomes

BACKGROUND

The scrutiny surrounding gender-affirming medical treatment (GAMT) for youth has increased, particularly concerning the limited evidence on long-term treatment outcomes. The Standards of Care 8 by the World Professional Association for Transgender Health addresses this by outlining research evidence suggesting "effective" outcomes of GAMT for adolescents. However, claims concerning what are considered "effective" outcomes of GAMT for adolescents remain implicit, requiring further reflection.

METHODS

Using trans negativity as a theoretical lens, we conducted a theory-informed reflexive thematic analysis of the literature cited in the "Research Evidence" section of the SOC8 Adolescents chapter. We selected 16 articles that used quantitative measures to assess GAMT outcomes for youth, examining how "effective" outcomes were framed and interpreted to uncover implicit and explicit normative assumptions within the evidence base.

RESULTS

A total of 44 different measures were used to assess GAMT outcomes for youth, covering physical, psychological, and psychosocial constructs. We identified four main themes regarding the normative assumptions of "effective" treatment outcomes: (1) doing bad: experiencing distress before GAMT, (2) moving toward a static gender identity and binary presentation, (3) doing better: overall improvement after GAMT, and (4) the absence of regret. These themes reveal implicit norms about what GAMT for youth should achieve, with improvement being the benchmark for "effectiveness."

DISCUSSION

We critically reflect on these themes through the lens of trans negativity to challenge what constitutes "effective" GAMT outcomes for youth. We explore how improvement justifies GAMT for youth and address the limitations of this notion.

CONCLUSIONS

We emphasize the need for an explicit discussion on the objectives of GAMT for adolescents. The linear narrative of improvement in GAMT for adolescents is limited and fails to capture the complexity of GAMT experiences. With currently no consensus on how the "effectiveness" of GAMT for adolescents is assessed, this article calls for participatory action research that centers the voices of young TGD individuals.

Care pathways of children and adolescents referred to specialist gender services: a systematic review

BACKGROUND

Increasing numbers of children and adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services. However, little is currently known about the proportions accessing different types of care and treatment following referral.

AIM

This systematic review examines the range of care pathways of children/adolescents (under 18) referred to specialist gender or endocrinology services.

METHODS

Database searches were performed (April 2022), with results assessed independently by two reviewers. Peer-reviewed articles providing data for numbers of children and/or adolescents at referral/assessment and their treatment pathways were included. A narrative approach to synthesis was used and where appropriate proportions were combined in a random-effects meta-analysis.

RESULTS

23 studies across nine countries were included, representing 6133 children and/or adolescents with a median age at assessment of 14-16 and overall a higher percentage of birth-registered females. Of those assessed, 36% (95% CI 27% to 45%) received puberty suppression, 51% (95% CI 40% to 62%) received masculinising or feminising hormones, 68% (95% CI 57% to 77%) received puberty suppression and/or hormones and 16% (95% CI 10% to 24%) received surgery. No study systematically reported information about the full pathway or psychological care received by children/adolescents. Follow-up in many studies was insufficient or unclear. Reasons for discontinuation were rarely provided.

CONCLUSIONS

Prospective studies with long-term follow-up reporting information about the full range of pathways are needed to understand what happens to children and adolescents referred to specialist gender services. Information about provision of psychological care is needed considering high rates of psychosocial difficulties in this population. PROSPERO registration number CRD42021289659.

Interventions to suppress puberty in adolescents experiencing gender dysphoria or incongruence: a systematic review

BACKGROUND

Treatment to suppress or lessen effects of puberty are outlined in clinical guidelines for adolescents experiencing gender dysphoria/incongruence. Robust evidence concerning risks and benefits is lacking and there is a need to aggregate evidence as new studies are published.

AIM

To identify and synthesise studies assessing the outcomes of puberty suppression in adolescents experiencing gender dysphoria/incongruence.

METHODS

A systematic review and narrative synthesis. Database searches (Medline, Embase, CINAHL, PsycINFO, Web of Science) were performed in April 2022, with results assessed independently by two reviewers. An adapted version of the Newcastle-Ottawa Scale for cohort studies was used to appraise study quality. Only moderate-quality and high-quality studies were synthesised. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines were used.

RESULTS

11 cohort, 8 cross-sectional and 31 pre-post studies were included (n=50). One cross-sectional study was high quality, 25 studies were moderate quality (including 5 cohort studies) and 24 were low quality. Synthesis of moderate-quality and high-quality studies showed consistent evidence demonstrating efficacy for suppressing puberty. Height increased in multiple studies, although not in line with expected growth. Multiple studies reported reductions in bone density during treatment. Limited and/or inconsistent evidence was found in relation to gender dysphoria, psychological and psychosocial health, body satisfaction, cardiometabolic risk, cognitive development and fertility.

CONCLUSIONS

There is a lack of high-quality research assessing puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development. Bone health and height may be compromised during treatment. More recent studies published since April 2022 until January 2024 also support the conclusions of this review.

PROSPERO REGISTRATION NUMBER

CRD42021289659.

Characteristics of children and adolescents referred to specialist gender services: a systematic review

BACKGROUND

Increasing numbers of children/adolescents experiencing gender dysphoria/incongruence are being referred to specialist gender services. Services and practice guidelines are responding to these changes.

AIM

This systematic review examines the numbers and characteristics of children/adolescents (under 18) referred to specialist gender or endocrinology services.

METHODS

Database searches were performed (April 2022), with results assessed independently by two reviewers. Peer-reviewed articles providing at least birth-registered sex or age at referral were included. Demographic, gender-related, mental health, neurodevelopmental conditions and adverse childhood experience data were extracted. A narrative approach to synthesis was used and where appropriate proportions were combined in a meta-analysis.

RESULTS

143 studies from 131 articles across 17 countries were included. There was a twofold to threefold increase in the number of referrals and a steady increase in birth-registered females being referred. There is inconsistent collection and reporting of key data across many of the studies. Approximately 60% of children/adolescents referred to services had made steps to present themselves in their preferred gender. Just under 50% of studies reported data on depression and/or anxiety and under 20% reported data on other mental health issues and neurodevelopmental conditions. Changes in the characteristics of referrals over time were generally not reported.

CONCLUSIONS

Services need to capture, assess and respond to the potentially co-occurring complexities of children/adolescents being referred to specialist gender and endocrine services. Agreement on the core characteristics for collection at referral/assessment would help to ensure services are capturing data as well as developing pathways to meet the needs of these children. PROSPERO registration number CRD42021289659.

Masculinising and feminising hormone interventions for adolescents experiencing gender dysphoria or incongruence: a systematic review

BACKGROUND

Clinical guidelines outline the use of hormones for masculinisation/feminisation in adolescents experiencing gender dysphoria or incongruence. Robust evidence concerning risks and benefits is lacking. There is a need to aggregate evidence as research becomes available.

AIM

Identify and synthesise studies assessing the outcomes of hormones for masculinisation/feminisation in adolescents experiencing gender dysphoria/incongruence.

METHODS

Systematic review and narrative synthesis. Database searches (MEDLINE, Embase, CINAHL, PsycINFO, Web of Science) were performed in April 2022, with results assessed independently by two reviewers. An adapted version of the Newcastle-Ottawa Scale for Cohort Studies was used to assess study quality. Moderate- and high-quality studies were synthesised.

RESULTS

12 cohort, 9 cross-sectional and 32 pre-post studies were included (n=53). One cohort study was high-quality. Other studies were moderate (n=33) and low-quality (n=19). Synthesis of high and moderate-quality studies showed consistent evidence demonstrating induction of puberty, although with varying feminising/masculinising effects. There was limited evidence regarding gender dysphoria, body satisfaction, psychosocial and cognitive outcomes, and fertility. Evidence from mainly pre-post studies with 12-month follow-up showed improvements in psychological outcomes. Inconsistent results were observed for height/growth, bone health and cardiometabolic effects. Most studies included adolescents who received puberty suppression, making it difficult to determine the effects of hormones alone.

CONCLUSIONS

There is a lack of high-quality research assessing the use of hormones in adolescents experiencing gender dysphoria/incongruence. Moderate-quality evidence suggests mental health may be improved during treatment, but robust study is still required. For other outcomes, no conclusions can be drawn. More recent studies published since April 2022 until January 2024 also support the conclusions of this review. PROSPERO registration number: CRD42021289659.

Clinical pharmacology in adolescent transgender medicine

Adolescent transgender medicine is a growing clinical field. Gender-affirming medications for transgender youth may include gonadotropin-releasing hormone (GnRH) agonists, gender-affirming hormones or both. To evaluate the potential effects of GnRH agonists (puberty suppression) on pharmacokinetic processes for transgender youth, we searched PubMed from inception to May 2024 for publications on the effects of GnRH agonists on drug absorption, distribution, metabolism or excretion for transgender adolescents or effects on hormones (including gonadotropins, adrenal androgens, sex steroids) that are associated with changes in drug metabolism during puberty in the general adolescent population. No publications discussed the effects of GnRH agonist treatment on pharmacokinetic processes for adolescent transgender people. Sixteen publications observed marked decreases in gonadotropins and sex steroids for both adolescent transgender men and adolescent transgender women and slight effects on adrenal androgens. During GnRH agonist treatment, changes in body composition and body shape were greater for adolescent transgender people than for cisgender adolescent people. Further research is needed to better understand the effects of GnRH agonists on drug metabolism and other pharmacokinetic processes for transgender adolescents receiving GnRH agonists and other gender-affirming medications.

Paediatric gender medicine: Longitudinal studies have not consistently shown improvement in depression or suicidality

AIM

Systematic literature reviews have found the evidence for hormonal interventions in paediatric-age patients with gender dysphoria is of low certainty. Studies in this field have all been observational, and generally of low quality. Nevertheless, some experts assert that the observational studies in this field have consistently found improvement in mental health, and therefore constitute sufficient evidentiary basis for hormonal interventions. The present review sought to characterise results of the longitudinal clinical research studies that have reported depression and suicidality outcomes.

METHODS

The present review collated, from examination of six existing reviews, 14 longitudinal clinical research studies that have specifically investigated depression and/or suicidality outcomes.

RESULTS

Significantly positive depression outcomes were reported in six studies, and significantly positive suicidality outcomes in two studies. Outcomes were negative in the largest study. Notably, some studies articulated positive conclusions about hormonal interventions even in the setting of insignificant, small or negative findings.

CONCLUSIONS

Analysis of longitudinal clinical research in this field showed inconsistent demonstration of benefit with respect to depression and suicidality. This analysis suggests that, contrary to assertions of some experts and North American professional medical organisations, the impact of hormonal interventions on depression and suicidality in this population is unknown.

Adolescent gender dysphoria management: position paper from the Italian Academy of Pediatrics, the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, the Italian Society of Adolescent Medicine and the Italian Society of Child and Adolescent Neuropsychiatry

BACKGROUND

In response to the imperative need for standardized support for adolescent Gender Dysphoria (GD), the Italian Academy of Pediatrics, in collaboration with the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, Italian Society of Adolescent Medicine and Italian Society of Child and Adolescent Neuropsychiatry is drafting a position paper. The purpose of this paper is to convey the author's opinion on the topic, offering foundational information on potential aspects of gender-affirming care and emphasizing the care and protection of children and adolescents with GD.

MAIN BODY

Recognizing that adolescents may choose interventions based on their unique needs and goals and understanding that every individual within this group has a distinct trajectory, it is crucial to ensure that each one is welcomed and supported. The approach to managing individuals with GD is a multi-stage process involving a multidisciplinary team throughout all phases. Decisions regarding treatment should be reached collaboratively by healthcare professionals and the family, while considering the unique needs and circumstances of the individual and be guided by scientific evidence rather than biases or ideologies. Politicians and high court judges should address discrimination based on gender identity in legislation and support service development that aligns with the needs of young people. It is essential to establish accredited multidisciplinary centers equipped with the requisite skills and experience to effectively manage adolescents with GD, thereby ensuring the delivery of high-quality care.

CONCLUSION

Maintaining an evidence-based approach is essential to safeguard the well-being of transgender and gender diverse adolescents.

[Beyond NICE: Updated Systematic Review on the Current Evidence of Using Puberty Blocking Pharmacological Agents and Cross-Sex-Hormones in Minors with Gender Dysphoria]

Beyond NICE: Updated Systematic Review on the Current Evidence of Using Puberty Blocking Pharmacological Agents and Cross-Sex-Hormones in Minors with Gender Dysphoria Abstract: Objective: The suppression of physiological puberty using puberty-blocking pharmacological agents (PB) and prescribing cross-sex hormones (CSH) to minors with gender dysphoria (GD) is a current matter of discussion, and in some cases, PB and CSH are used in clinical practice for this particular population. Two systematic reviews (one on PB, one on CSH treatment) by the British National Institute for Clinical Excellence (NICE) from 2020 indicated no clear clinical benefit of such treatments regarding critical outcome variables. In particular, these two systematic NICE reviews on the use of PB and CSH in minors with GD detected no clear improvements of GD symptoms. Moreover, the overall scientific quality of the available evidence, as discussed within the above-mentioned two NICE reviews, was classified as "very low certainty" regarding modified GRADE criteria. Method: The present systematic review presents an updated literature search on this particular topic (use of PB and CSH in minors with GD) following NICE principles and PICO criteria for all relevant new original research studies published since the release of the two above-mentioned NICE reviews (updated literature search period was July 2020-August 2023). Results: The newly conducted literature search revealed no newly published original studies targeting NICE-defined critical and important outcomes and the related use of PB in minors with GD following PICO criteria. For CSH treatment, we found two new studies that met PICO criteria, but these particular two studies had low participant numbers, yielded no significant additional clear evidence for specific and clearly beneficial effects of CSH in minors with GD, and could be classified as "low certainty" tfollowing modified GRADE criteria. Conclusions: The currently available studies on the use of PB and CSH in minors with GD have significant conceptual and methodological flaws. The available evidence on the use of PB and CSH in minors with GD is very limited and based on only a few studies with small numbers, and these studies have problematic methodology and quality. There also is a lack of adequate and meaningful long-term studies. Current evidence doesn't suggest that GD symptoms and mental health significantly improve when PB or CSH are used in minors with GD. Psychotherapeutic interventions to address and reduce the experienced burden can become relevant in children and adolescents with GD. If the decision to use PB and/or CSH is made on an individual case-by-case basis and after a complete and thorough mental health assessment, potential treatment of possibly co-occurring mental health problems as well as after a thoroughly conducted and carefully executed individual risk-benefit evaluation, doing so as part of clinical studies or research projects, as currently done in England, can be of value in terms of generation of new research data. The electronic supplement (ESM) 1 is an adapted and abreviated English version of this work.

All-cause and suicide mortalities among adolescents and young adults who contacted specialised gender identity services in Finland in 1996-2019: a register study

BACKGROUND

All-cause and suicide mortalities of gender-referred adolescents compared with matched controls have not been studied, and particularly the role of psychiatric morbidity in mortality is unknown.

OBJECTIVE

To examine all-cause and suicide mortalities in gender-referred adolescents and the impact of psychiatric morbidity on mortality.

METHODS

Finnish nationwide cohort of all <23 year-old gender-referred adolescents in 1996-2019 (n=2083) and 16 643 matched controls. Cox regression models with HRs and 95% CIs were used to analyse all-cause and suicide mortalities.

FINDINGS

Of the 55 deaths in the study population, 20 (36%) were suicides. In bivariate analyses, all-cause mortality did not statistically significantly differ between gender-referred adolescents and controls (0.5% vs 0.3%); however, the proportion of suicides was higher in the gender-referred group (0.3% vs 0.1%). The all-cause mortality rate among gender-referred adolescents (controls) was 0.81 per 1000 person-years (0.40 per 1000 person-years), and the suicide mortality rate was 0.51 per 1000 person-years (0.12 per 1000 person-years). However, when specialist-level psychiatric treatment was controlled for, neither all-cause nor suicide mortality differed between the two groups: HR for all-cause mortality among gender-referred adolescents was 1.0 (95% CI 0.5 to 2.0) and for suicide mortality was 1.8 (95% CI 0.6 to 4.8).

CONCLUSIONS

Clinical gender dysphoria does not appear to be predictive of all-cause nor suicide mortality when psychiatric treatment history is accounted for.

CLINICAL IMPLICATIONS

It is of utmost importance to identify and appropriately treat mental disorders in adolescents experiencing gender dysphoria to prevent suicide.