Impact of Hormone Treatment on Psychosocial Functioning in Gender-Diverse Young People

Purpose: Few studies have assessed the effects of hormonal treatments such as gonadotropin-releasing hormone agonists (GnRHa) and gender-affirming hormones (GAH) on mental health outcomes in clinically referred gender-diverse young people from a younger age. Where this research has been conducted, findings have been mixed. This study investigated a cohort of young people before treatment, 1 year into GnRHa, and 1 year into GAH treatment to understand psychological and behavioral impacts over time. Methods: Thirty-eight young people (28 assigned female and 10 assigned male) referred to endocrinology, younger than 15 years at/beyond Tanner stage two, who received GnRHa followed by GAH treatment, were assessed in a retrospective analysis study. Young people completed the Youth Self Report (YSR), the Body Image Scale, and the Utrecht Gender Dysphoria Scale, while caregivers completed the Child Behavior Checklist (CBCL) and the Social Responsiveness Scale-2 at all time points. Results: Dissatisfaction with primary sexual characteristics (p = 0.02), gender dysphoria (p = 0.01), and social motivation (p = 0.04) improved significantly over time. Self-harm and suicidality also showed a general decrease. Caregivers reported a significant reduction in internalizing (p = 0.03) behaviors on the CBCL after GnRHa. Other subcategories of the YSR and CBCL were within normal ranges with no significant difference (p > 0.05). Conclusion: These findings demonstrate some improvements in psychological and behavioral outcomes in young people concurrently receiving psychosocial support and hormone treatment. Future research with larger and more diverse samples is warranted to further understand generalizability.

Just as Tall on Testosterone; a Neutral to Positive Effect on Adult Height of GnRHa and Testosterone in Trans Boys

CONTEXT

Growth is an important topic for many transgender boys. However, few studies have investigated the impact of puberty suppression (PS) and gender-affirming hormone treatment (GAHT) on growth and adult height.

OBJECTIVE

To evaluate the effect of PS and GAHT on growth and adult height.

DESIGN

Retrospective cohort study.

SETTING

Specialized gender identity clinic.

PARTICIPANTS

A total of 146 transgender boys treated with GnRH analogues and testosterone who reached adult height.

MAIN OUTCOME MEASURES

Growth, bone age (BA), adult height, and difference between adult height and predicted adult height (PAH) and midparental height.

RESULTS

In those with BA ≤14 years at start (n = 61), a decrease in growth velocity and bone maturation during PS was followed by an increase during GAHT. Adult height was 172.0 ± 6.9 cm; height SD score was similar to baseline (0.1; 95% CI, -0.2 to 0.4). Adult height was 3.9 ± 6.0 cm above midparental height and 3.0 ± 3.6 cm above PAH at start of PS. A younger BA at start PS was associated with an adult height significantly further above PAH.

CONCLUSION

During PS, growth decelerated followed by an acceleration during GAHT. Although adult height SD score was similar to baseline, adult height was taller than predicted based on BA at baseline, especially in those who started treatment at a younger BA. It is reassuring that PS and GAHT do not have a negative impact on adult height in transgender boys and might even lead to a slightly taller adult height, especially in those who start at a younger age.

Impact of gender-affirming treatment on bone health in transgender and gender diverse youth

Both in the United States and Europe, the number of minors who present at transgender healthcare services before the onset of puberty is rapidly expanding. Many of those who will have persistent gender dysphoria at the onset of puberty will pursue long-term puberty suppression before reaching the appropriate age to start using gender-affirming hormones. Exposure to pubertal sex steroids is thus significantly deferred in these individuals. Puberty is a critical period for bone development: increasing concentrations of estrogens and androgens (directly or after aromatization to estrogens) promote progressive bone growth and mineralization and induce sexually dimorphic skeletal changes. As a consequence, safety concerns regarding bone development and increased future fracture risk in transgender youth have been raised. We here review published data on bone development in transgender adolescents, focusing in particular on differences in age and pubertal stage at the start of puberty suppression, chosen strategy to block puberty progression, duration of puberty suppression, and the timing of re-evaluation after estradiol or testosterone administration. Results consistently indicate a negative impact of long-term puberty suppression on bone mineral density, especially at the lumbar spine, which is only partially restored after sex steroid administration. Trans girls are more vulnerable than trans boys for compromised bone health. Behavioral health measures that can promote bone mineralization, such as weight-bearing exercise and calcium and vitamin D supplementation, are strongly recommended in transgender youth, during the phase of puberty suppression and thereafter.

Association between pre-treatment IQ and educational achievement after gender-affirming treatment including puberty suppression in transgender adolescents

BACKGROUND

Concerns exist regarding effects of puberty suppression on neurodevelopment. Intelligence is strongly correlated with educational achievement in the general population. This study aimed to examine the association between pre-treatment intelligence and educational achievement after gender-affirming treatment including puberty suppression in transgender adolescents to contribute to the emerging understanding of the effect that gender-affirming treatment including puberty suppression may have on cognitive development.

METHODS

IQ was measured in 72 adolescents (45 trans boys, 27 trans girls) at clinical entry (mean age 12.78 years), educational achievement was evaluated after gender-affirming treatment (mean age 20.40 years).

RESULTS

IQ pre-treatment and educational achievement post-treatment were positively associated (Nagelkerke R = 0.71).

DISCUSSION

The association between IQ pre-treatment and educational achievement post-treatment in transgender adolescents who received gender-affirming medical treatment including puberty suppression appears to be similar to the general population. This may reflect that gender-affirming medical treatment including puberty suppression does not negatively affect the association between IQ and educational achievement.

Puberty Suppression in Transgender and Gender-Diverse Adolescents: Timely Care for Optimal Outcomes

In this perspective, we argue that pubertal suppression with gonadotropin-releasing hormone analogues is a safe reversible intervention that should be made available to transgender and gender-diverse youth starting at early puberty. Recent data suggest puberty suppression is generally initiated among individuals once puberty has significantly progressed, thus reducing the effectiveness of the intervention. Delays and barriers to such care may systematically introduce permanent avoidable disadvantages for this vulnerable and marginalized group.

Gynecomastia in a Transgender Boy: A Case Report

Objective

To describe the case of a 17-year-old transgender boy who experienced breast development while on testosterone, having been suppressed with a gonadotropin-releasing hormone (GnRH) agonist prior to testosterone therapy

Case report

A 17-year-old transgender boy presented with breast development after having been on a GnRH agonist and then testosterone since the age of 11 years, having never experienced breast development before, which was consistent with pubertal gynecomastia. A small decrease in the testosterone dose resulted in a significant reduction of gynecomastia. Despite the improvement, he went on to undergo chest surgery with the removal of the breast tissue.

Discussion

Pubertal gynecomastia is a common phenomenon in the cisgender male population. However, it has not been previously described in transgender boys. The potential mechanisms for its occurrence were discussed.

Conclusion

Transgender boys who undergo GnRH agonist treatment for puberty suppression and subsequently receive testosterone therapy for puberty induction may develop gynecomastia. Judicious adjustment of the testosterone therapy may lead to an improvement.

Perceptions on the function of puberty suppression of transgender adolescents who continued or discontinued treatment, their parents, and clinicians

Purpose: Treatment of transgender adolescents with puberty suppression (PS) was developed to provide time for exploration before pursuing gender affirming medical treatment (GAMT) with irreversible effects. It may also result in a more satisfactory physical outcome for those who continue with GAMT. Despite being the current first choice treatment, little research has examined the function of PS from the perspectives of transgender adolescents, their parents, and clinicians. Insight into the perceived functions of PS will help to adequately support adolescents in their decision-making process and give them the care they need. Methods: Qualitative study using interviews with eight transgender adolescents who proceeded with GAMT after PS ("continuers"), six adolescents who discontinued PS ("discontinuers") and 12 parents, and focus groups with ten clinicians. Results: All informants considered inhibition of development of secondary sex characteristics an important function of PS. Most continuers saw PS as the first step of GAMT. Nevertheless, some were glad that the effects were reversible even if they didn't expect to change their minds. Some discontinuers did experience PS as an expanded diagnostic phase. One continuer used the time on PS to get used to living in the affirmed gender role, and several parents found the time helpful to adapt to their child's new gender role. PS provided clinicians more time for diagnostic assessment. Conclusions: Adolescents, parents and clinicians do not all report the same functions of PS. Although international guidelines emphasize providing time for exploration of gender identity as an important reason for PS, many adolescents nowadays seem to have clear ideas about their gender identity and treatment wishes, and experience PS as the first step of GAMT. For some discontinuers however, PS offered a valued period of exploration. Guidelines could be modified to provide more customized care, taking adolescents' and parents' ideas about the functions of PS into account.

Not just a tragic compromise: The positive case for adolescent access to puberty-blocking treatment

Within bioethics as well as in broader clinical practice, support for transgender and gender-questioning adolescent access to pubertal suppression has often relied heavily on the desire to prevent risky, self-destructive, and suicidal behavior. We argue that framing justifications for access to puberty suppression in this way can actually be harmful to both individual patients as well as to the broader trans population. This justification for access to care makes such access precarious, limits its scope, and introduces perverse incentives to the patient population that is being served. We go on to offer an alternative, positive defense of access to puberty-blocking treatment for transgender youth grounded in the child's right to an open future. We argue that decisions related to pubertal suppression are both importantly weighty and potentially irreversible, and show why this justification is preferable to so-called "informed consent" approaches.

Bell v Tavistock: Why the Assent Model Is Most Appropriate for Decisions Regarding Puberty Suppression for Transgender and Gender Diverse Youth

The decision of the High Court of England and Wales in Bell v Tavistock [2020] EWHC 3274 (Admin) raises important questions regarding best care for transgender and gender diverse (TGD) youth. In this section, I describe this case, its ruling, and its implications. The ruling is underpinned by the position that puberty suppression can only be ethically and legally permissible where the young person has not only provided their assent but has also been deemed capable to provide valid consent. I challenge this position on three grounds. First, it overlooks the key ethical question of whether puberty suppression is in the individual's best interests. Second, withholding puberty suppression until the young person can consent will likely result in harmful, irreversible consequences for them. Finally, puberty suppression is not sufficiently potentially harmful to justify the additional protection offered by requiring patient consent and court authorisation. For these reasons, I argue that an assent model should govern decisions about puberty suppression for TGD youth.

Effectiveness of Puberty Suppression with Gonadotropin-Releasing Hormone Agonists in Transgender Youth

Purpose: To analyze the effectiveness of gonadotropin-releasing hormone agonists (GnRHa) in suppressing the hypothalamic-pituitary gonadal (HPG) axis in transgender adolescents. Methods: Retrospective review of electronic medical records of transgender youth and children with central precocious puberty (CPP) treated with GnRHa. Blood levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, and/or estradiol at baseline and during treatment were compared between groups. Results: Data from 30 transgender and 30 patients with CPP were analyzed. Transgender patients were older with a mean age of 13.0±2.1 years versus 7.7±2.3 years in the CPP group, p<0.001. There were more patients assigned male at birth (AMAB) in the transgender group (56.7%) than males in the CPP group (30%), p<0.001. The transgender group had more patients with advanced puberty with 56% of patients having a Tanner stage of IV-V, versus none in the CPP group, p<0.01. GnRHa treatment resulted in LH, FSH, and testosterone levels that were similar in males with CPP versus transgender patients AMAB; suppression of LH and FSH levels was similar in females with CPP versus transgender patients assigned female at birth, but estradiol levels were higher in the latter (1.8±1.8 pg/mL vs. 9.4±9.7 pg/mL, respectively, p<0.001). FSH levels were lower in the transgender group treated with histrelin (0.8±0.8 mIU/mL vs. 1.9±1.2 mIU/mL in the leuprolide group, p=0.004). Conclusions: GnRHa are effective in suppressing the HPG axis in transgender youth, similar to that observed in children with CPP.

Histrelin Implants for Suppression of Puberty in Youth with Gender Dysphoria: A Comparison of 50 mcg/Day (Vantas) and 65 mcg/Day (SupprelinLA)

Purpose: Development of incongruent secondary sex characteristics in transgender youth can intensify or trigger the onset of gender dysphoria. Guidelines from professional organizations recommend gonadotropin-releasing hormone agonists, including histrelin implants (Vantas and SupprelinLA) to suppress endogenous puberty. Although Vantas does not have a pediatric indication, it is anecdotally being used in pediatric gender centers throughout the United States because of its substantially lower cost. This retrospective study aimed to determine if both implants were effective in suppressing the hypothalamic-pituitary-gonadal axis in early-to-mid pubertal youth with gender dysphoria. Methods: Youth with gender dysphoria receiving care at the Center for Transyouth Health and Development at Children's Hospital Los Angeles (CHLA) or participants from an ongoing observational trial with a histrelin implant placed for pubertal suppression at Tanner stage 2 or 3 were included. Sex steroid (testosterone or estradiol) and gonadotropin measurements at baseline (T0) and then 2 to 12 months following implant placement (T1) were abstracted from medical records. Results: Of the 66 eligible participants, 52% were designated female at birth. Most participants were white (60.6%). Twenty participants (30.3%) had a Vantas implant and 46 (69.7%) had a SupprelinLA implant. Mean age of insertion was 11.3 years. Gonadotropin and sex steroid levels were significantly decreased at T1 (2-12 months after insertion of implant), with no differences between implants. Conclusion: These results indicate that both implants are effective in suppressing puberty in early-to-mid pubertal youth with gender dysphoria. These data may inform decisions about insurance coverage of Supprelin and/or Vantas for youth with gender dysphoria.

Transgender Dependent Adolescents in the U.S. Military Health Care System: Demographics, Treatments Sought, and Health Care Service Utilization

INTRODUCTION

Transgender and gender-diverse (TGD) youth are at greater risk for mental health and medical conditions than their cisgender peers; however, poor health outcomes and identity-based discrimination can be minimized in the context of optimal support. Approximately 1.7 million youth may be eligible for care covered by the Military Health System, which includes mental health and gender-affirming medications. The purpose of the current study is to identify sociodemographic characteristics, the psychosocial and behavioral risk profile, and health care utilization patterns of TGD dependent youth cared for in the U.S. military system to inform provider training and resource allocation.

MATERIALS AND METHODS

We performed a retrospective chart review by searching all medical records between July 1, 2014 and July 1, 2017 for diagnoses suggesting visits for TGD-services at a regional referral-based adolescent medicine clinic which cares for dependent children of active duty, activated selected reserve, and retired military service members between the ages of 9 and 24 years for a wide range of health care needs.

RESULTS

Fifty-three participants were included in this study. Sixty-four percent reported a transmasculine identity, 21% a transfeminine identity, and 15% a non-binary or undecided identity. The mean age at first gender-related visit was 14.5 years (SD 3.2). The mean number of primary care physicians and specialists seen by a given individual in a military treatment facility for any visit type since the implementation of the medical record system in 2005 was 12 (SD 6.8) and 10.2 (SD 7.8), respectively. Thirty-three percent of all patients assigned as female at birth were on testosterone therapy and 23% of all patients assigned as male at birth were on estrogen therapy at their most recent clinic visit. Twelve patients were undergoing pubertal suppression with an injectable or implantable gonadotropin-releasing hormone agonist. Seventy percent reported a history of suicidal ideation, 42% self-harm, 21% at least one suicide attempt, and 33% psychiatric hospitalization. Having strongly supportive parents was significantly associated with recognizing, disclosing and seeking treatment for gender nonconformity at an earlier age (ps ≤ 0.03) and marginally associated with less likelihood of current suicidal ideation (p = 0.06) compared to those with less supportive parents.

CONCLUSIONS

This study elucidated the sociodemographic and behavioral risk profile of a sample of TGD youth in the MHS. Military and non-military health care providers across a broad spectrum of specialties should be knowledgeable about the unique psychosocial and medical needs, requisite sensitivity, and available referral options in the care of TGD youth. Assumptions about one's gender identity, sexual orientation, gender expression, or behaviors cannot be made based on birth-assigned sex. Further research is needed to investigate the health and wellbeing of TGD military-affiliated youth over time and to determine quality transgender-related services in support of this vulnerable and underserved population.

Creating the Trans Youth Research Network: A Collaborative Research Endeavor

Purpose: This article outlines the process of establishing the Trans Youth Care Research Network, composed of four academic clinics providing care for transgender and gender-diverse (TGD) youth. The Network was formed to design and implement research studies to better understand physiologic and psychosocial outcomes of gender-affirming medical care among TGD youth. Methods: Formed in response to both the Institute of Medicine's report recommendation for an increase of data concerning sexual and gender minority populations and a transgender-specific NIH program announcement, The Center for Transyouth Health and Development at Children's Hospital Los Angeles, the Gender Management Service at Boston Children's Hospital, the Child and Adolescent Gender Center Clinic at Benioff Children's Hospital in San Francisco, and the Gender and Sex Development Program at Lurie Children's Hospital of Chicago established a collaborative research network that subsequently designed a longitudinal observational study of TGD youth undergoing medical interventions to address gender dysphoria. Results: Two cohorts, youth starting puberty blockers and youth starting gender-affirming hormones, are participating. Psychosocial measures that span multiple domains of mental and behavioral health are collected from youth and parents. Physiologic data are abstracted from patient's charts. Baseline and follow-up data of this large cohort will be disseminated through conferences, abstracts, posters, and articles. Conclusion: Since initiation of funding in 2015, a total of 497 participants have been enrolled in TYC across the four sites; gonadotropin releasing hormone analogs (GnRHa) cohort youth (n=93), GnRHa cohort parents (n=93), and gender affirming hormone cohort youth (n=311). As the network moves toward data dissemination, its lessons learned have helped strengthen the current study, as well as inform future endeavors in this field.

Young adult psychological outcome after puberty suppression and gender reassignment

BACKGROUND

In recent years, puberty suppression by means of gonadotropin-releasing hormone analogs has become accepted in clinical management of adolescents who have gender dysphoria (GD). The current study is the first longer-term longitudinal evaluation of the effectiveness of this approach.

METHODS

A total of 55 young transgender adults (22 transwomen and 33 transmen) who had received puberty suppression during adolescence were assessed 3 times: before the start of puberty suppression (mean age, 13.6 years), when cross-sex hormones were introduced (mean age, 16.7 years), and at least 1 year after gender reassignment surgery (mean age, 20.7 years). Psychological functioning (GD, body image, global functioning, depression, anxiety, emotional and behavioral problems) and objective (social and educational/professional functioning) and subjective (quality of life, satisfaction with life and happiness) well-being were investigated.

RESULTS

After gender reassignment, in young adulthood, the GD was alleviated and psychological functioning had steadily improved. Well-being was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being.

CONCLUSIONS

A clinical protocol of a multidisciplinary team with mental health professionals, physicians, and surgeons, including puberty suppression, followed by cross-sex hormones and gender reassignment surgery, provides gender dysphoric youth who seek gender reassignment from early puberty on, the opportunity to develop into well-functioning young adults.

Puberty suppression in a gender-dysphoric adolescent: a 22-year follow-up

Puberty suppression by means of gonadotropin releasing hormone (GnRH) analogs is considered a diagnostic aid in gender dysphoric adolescents. However, there are also concerns about potential risks, such as poor outcome or post-surgical regret, adverse effects on metabolic and endocrine status, impaired increment of bone mass, and interference with brain development. This case report is on a 22-year follow-up of a female-to-male transsexual, treated with GnRH analogs at 13 years of age and considered eligible for androgen treatment at age 17, and who had gender reassignment surgery at 20 and 22 years of age. At follow-up, he indicated no regrets about his treatment. He was functioning well psychologically, intellectually, and socially; however, he experienced some feelings of sadness about choices he had made in a long-lasting intimate relationship. There were no clinical signs of a negative impact on brain development. He was physically in good health, and metabolic and endocrine parameters were within reference ranges. Bone mineral density was within the normal range for both sexes. His final height was short as compared to Dutch males; however, his body proportions were within normal range. This first report on long-term effects of puberty suppression suggests that negative side effects are limited and that it can be a useful additional tool in the diagnosis and treatment of gender dysphoric adolescents.