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Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents


Abstract and Figures

As a traditionally underserved population that faces numerous health disparities, youth who identify as transgender and gender diverse (TGD) and their families are increasingly presenting to pediatric providers for education, care, and referrals. The need for more formal training, standardized treatment, and research on safety and medical outcomes often leaves providers feeling ill equipped to support and care for patients that identify as TGD and families. In this policy statement, we review relevant concepts and challenges and provide suggestions for pediatric providers that are focused on promoting the health and positive development of youth that identify as TGD while eliminating discrimination and stigma.
Content may be subject to copyright.
Ensuring Comprehensive Care and
Support for Transgender and Gender-
Diverse Children and Adolescents
As a traditionally underserved population that faces numerous health
disparities, youth who identify as transgender and gender diverse (TGD)
and their families are increasingly presenting to pediatric providers
for education, care, and referrals. The need for more formal training,
standardized treatment, and research on safety and medical outcomes of ten
leaves providers feeling ill equipped to suppor t and care for patients that
identify as TGD and families. In this policy statement, we review
relevant concepts and challenges and provide suggestions for pediatric
providers that are focused on promoting the health and positive
development of youth that identify as TGD while eliminating discrimination
and stigma.
In its dedication to the health of all children, the American Academy of
Pediatrics (AAP) strives to improve health care access and eliminate
disparities for children and teenagers who identify as lesbian, gay,
bisexual, transgender, or questioning (LGBTQ) of their sexual or gender
2 Despite some advances in public awareness and legal
protections, youth who identify as LGBTQ continue to face disparities
that stem from multiple sources, including inequitable laws and policies,
societal discrimination, and a lack of access to quality health care,
including mental health care. Such challenges are often more intense for
youth who do not conform to social expectations and norms regarding
gender. Pediatric providers are increasingly encountering such youth and
their families, who seek medical advice and interventions, yet they may
lack the formal training to care for youth that identify as transgender and
gender diverse (TGD) and their families.3
This policy statement is focused specifically on children and youth that
identify as TGD rather than the larger LGBTQ population, providing
brief, relevant background on the basis of current available research
prehensive Care and Support for Transgender and Gender-
Diverse Children and Adolescents. Pediatrics. 2018;142(4):
Department of Pediatrics, Hasbro Childrens Hospital, Providence,
Rhode Island; Thundermist Health Centers, Providence, Rhode Island;
and Department of Child Psychiatry, Emma Pendleton Bradley Hospital,
East Providence, Rhode Island
Dr Rafferty conceptualized the statement, drafted the initial
manuscript, reviewed and revised the manuscript, approved the final
manuscript as submitted, and agrees to be accountable for all aspects
of the work.
This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors have
filed conflict of interest statements with the American Academy
of Pediatrics. Any conflicts have been resolved through a process
approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
involvement in the development of the content of this publication.
Policy statements from the American Academy of Pediatrics benefit
from expertise and resources of liaisons and internal (AAP) and
external reviewers. However, policy statements from the American
Academy of Pediatrics may not reflect the views of the liaisons or the
organizations or government agencies that they represent.
The guidance in this statement does not indicate an exclusive course
of treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
All policy statements from the American Academy of Pediatrics
automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
Organizational Principles to Guide and Define the Child Hea lth Care System
and/or Improve the Health of all Children
PEDIATRICS Volume 142, number 4, October 2018:e20182162 FROM THE AMERICAN ACADEMY OF PEDIATRICS
by guest on September 19, from
and expert opinion from clinical and
research leaders, which will serve
as the basis for recommendations.
It is not a comprehensive review of
clinical approaches and nuances to
pediatric care for children and youth
that identify as TGD. Professional
understanding of youth that
identify as TGD is a rapidly evolving
clinical field in which research on
appropriate clinical management is
limited by insufficient funding.3,
To clarify recommendations and
discussions in this policy statement,
some definitions are provided.
However, brief descriptions of
human behavior or identities may not
capture nuance in this evolving field.
Sex, or natal gender, is a label,
generally male or female, that
is typically assigned at birth on
the basis of genetic and anatomic
characteristics, such as genital
anatomy, chromosomes, and sex
hormone levels. Meanwhile, gender
identity is ones internal sense of
who one is, which results from a
multifaceted interaction of biological
traits, developmental influences,
and environmental conditions. It
may be male, female, somewhere
in between, a combination of both,
or neither (ie, not conforming to a
binary conceptualization of gender).
Self-recognition of gender identity
develops over time, much the same
way as a childs physical body does.
For some people, gender identity
can be fluid, shifting in different
contexts. Gender expression
refers to the wide array of ways
people display their gender through
clothing, hair styles, mannerisms, or
social roles. Exploring different ways
of expressing gender is common
for children and may challenge
social expectations. The way others
interpret this expression is referred
to as gender perception
(Table 1).5,
These labels may or may not be
congruent. The term cisgender
is used if someone identifies and
expresses a gender that is consistent
with the culturally defined norms of
the sex that was assigned at birth.
Gender diverse is an umbrella term
to describe an ever-evolving array of
labels that people may apply when
their gender identity, expression, or
even perception does not conform
TABLE 1 Relevant Terms and Definitions Related to Gender Care
Term Definition
Sex An assignment that is made at birth, usually male or female, typically on the basis of external genital anatomy but sometimes on the
basis of internal gonads, chromosomes, or hormone levels
Gender identity A persons deep internal sense of being female, male, a combination of both, somewhere in between, or neither, resulting from a
multifaceted interaction of biological traits, environmental factors, self-understanding, and cultural expectations
Gender expression The external way a person expresses their gender, such as with clothing, hair, mannerisms, activities, or social roles
Gender perception The way others interpret a persons gender expression
Gender diverse A term that is used to describe people with gender behaviors, appearances, or identities that are incongruent with those culturally
assigned to their birth sex; gender-diverse individuals may refer to themselves with many different terms, such as transgender,
nonbinary, genderqueer,
7 gender fluid, gender creative, gender independent, or noncisgender. Gender diverse is used to
acknowledge and include the vast diversity of gender identities that exists. It replaces the former term, gender nonconforming,
which has a negative and exclusionary connotation.
Transgender A subset of gender-diverse youth whose gender identity does not match their assigned sex and generally remains persistent,
consistent, and insistent over time; the term transgender also encompasses many other labels individuals may use to refer to
Cisgender A term that is used to describe a person who identifies and expresses a gender that is consistent with the culturally defined norms of
the sex they were assigned at birth
Agender A term that is used to describe a person who does not identify as having a particular gender
Affirmed gender When a persons true gender identity, or concern about their gender identity, is communicated to and validated from others as
MTF; affirmed female;
trans female
Terms that are used to describe individuals who were assigned male sex at birth but who have a gender identity and/or expression
that is asserted to be more feminine
FTM; affirmed male;
trans male
Terms that are used to describe individuals who were assigned female sex at birth but who have a gender identity and/or expression
that is asserted to be more masculine
Gender dysphoria A clinical symptom that is characterized by a sense of alienation to some or all of the physical characteristics or social roles of ones
assigned gender; also, gender dysphoria is the psychiatric diagnosis in the DSM-5, which has focus on the distress that stems from
the incongruence between ones expressed or experienced (affirmed) gender and the gender assigned at birth.
Gender identity
A psychiatric diagnosis defined previously in the DSM-IV (changed to gender dysphoria in the DSM-5); the primary criteria include a
strong, persistent cross-sex identification and significant distress and social impairment. This diagnosis is no longer appropriate
for use and may lead to stigma, but the term may be found in older research.
Sexual orientation A persons sexual identity in relation to the gender(s) to which they are attracted; sexual orientation and gender identity develop
This list is not intended to be all inclusive. The pronouns they and their are used intentionally to be inclusive rather than the binary pronouns he and she and his and her.
Adapted from Bonifacio HJ, Rosenthal SM. Gender variance and dysphoria in children and adolescents. Pediatr Clin North Am. 2015;62(4):10011016. Adapted from Vance SR Jr, Ehrensaft
D, Rosenthal SM. Psychological and medical care of gender nonconforming youth. Pediatrics. 2014;134(6):11841192. DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; FTM, female to male; MTF, male to female.
by guest on September 19, from
to the norms and stereotypes
others expect of their assigned sex.
Transgender is usually reserved
for a subset of such youth whose
gender identity does not match their
assigned sex and generally remains
persistent, consistent, and insistent
over time. These terms are not
diagnoses; rather, they are personal
and often dynamic ways of describing
ones own gender experience.
Gender identity is not synonymous
with sexual orientation, which
refers to a persons identity in
relation to the gender(s) to which
they are sexually and romantically
attracted. Gender identity and
sexual orientation are distinct but
interrelated constructs.8 Therefore,
being transgender does not imply a
sexual orientation, and people who
identify as transgender still identify
as straight, gay, bisexual, etc, on the
basis of their attractions. (For more
information, The Gender Book, found
at www. thegenderbook. com, is a
resource with illustrations that are
used to highlight these core terms
and concepts.)
In population-based surveys,
questions related to gender identity
are rarely asked, which makes
it difficult to assess the size and
characteristics of the population
that is TGD. In the 2014 Behavioral
Risk Factor Surveillance System of
the Centers for Disease Control and
Prevention, only 19 states elected to
include optional questions on gender
identity. Extrapolation from these
data suggests that the US prevalence
of adults who identify as transgender
or gender nonconforming is
0.6% (1.4 million), ranging from
0.3% in North Dakota to 0.8%
in Hawaii.9 On the basis of these
data, it has been estimated that
0.7% of youth ages 13 to 17 years
(150 000) identify as transgender.10
This number is much higher than
previous estimates, which were
extrapolated from individual states
or specialty clinics, and is likely an
underestimate given the stigma
regarding those who openly identify
as transgender and the difficulty in
defining transgender in a way that
is inclusive of all gender-diverse
There have been no large-scale
prevalence studies among children
and adolescents, and there is no
evidence that adult statistics reflect
young children or adolescents. In
the 2014 Behavioral Risk Factor
Surveillance System, those 18 to
24 years of age were more likely
than older age groups to identify
as transgender (0.7%).9 Children
report being aware of gender
incongruence at young ages. Children
who later identify as TGD report first
having recognized their gender as
different at an average age of
8.5 years; however, they did not
disclose such feelings until an
average of 10 years later.12
Adolescents and adults who identify
as transgender have high rates of
depression, anxiety, eating disorders,
self-harm, and suicide.13
20 Evidence
suggests that an identity of TGD
has an increased prevalence among
individuals with autism spectrum
disorder, but this association is
not yet well understood.21, 22 In 1
retrospective cohort study, 56% of
youth who identified as transgender
reported previous suicidal ideation,
and 31% reported a previous
suicide attempt, compared with
20% and 11% among matched
youth who identified as cisgender,
respectively.13 Some youth who
identify as TGD also experience
gender dysphoria, which is a
specific diagnosis given to those
who experience impairment in peer
and/or family relationships, school
performance, or other aspects of
their life as a consequence of the
incongruence between their assigned
sex and their gender identity.23
There is no evidence that risk
for mental illness is inherently
attributable to ones identity of
TGD. Rather, it is believed to be
multifactorial, stemming from an
internal conflict between ones
appearance and identity, limited
availability of mental health services,
low access to health care providers
with expertise in caring for youth
who identify as TGD, discrimination,
stigma, and social rejection.24 This
was affirmed by the American
Psychological Association in 200825
(with practice guidelines released in
20158) and the American Psychiatric
Association, which made the
following statement in 2012:
Being transgender or gender variant
implies no impairment in judgment,
stability, reliability, or general social or
vocational capabilities; however, these
individuals often experience discrimination
due to a lack of civil rights protections
for their gender identity or expression.
[Such] discrimination and lack of equal
civil rights is damaging to the mental
health of transgender and gender variant
Youth who identify as TGD often
confront stigma and discrimination,
which contribute to feelings of
rejection and isolation that can
adversely affect physical and
emotional well-being. For example,
many youth believe that they
must hide their gender identity
and expression to avoid bullying,
harassment, or victimization. Youth
who identify as TGD experience
disproportionately high rates of
homelessness, physical violence
(at home and in the community),
substance abuse, and high-risk
sexual behaviors.5,
31 Among
the 3 million HIV testing events that
were reported in 2015, the highest
percentages of new infections were
among women who identified as
transgender32 and were also at
particular risk for not knowing their
HIV status.30
PEDIATRICS Volume 142, number 4, October 2018 3
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In a gender-affirmative care model
(GACM), pediatric providers offer
developmentally appropriate
care that is oriented toward
understanding and appreciating the
youths gender experience. A strong,
nonjudgmental partnership with
youth and their families can facilitate
exploration of complicated emotions
and gender-diverse expressions
while allowing questions and
concerns to be raised in a supportive
environment.5 In a GACM, the
following messages are conveyed:
transgender identities and
diverse gender expressions do not
constitute a mental disorder;
variations in gender identity
and expression are normal
aspects of human diversity, and
binary definitions of gender do not
always reflect emerging gender
gender identity evolves as an
interplay of biology, development,
socialization, and culture; and
if a mental health issue exists,
it most often stems from stigma
and negative experiences
rather than being intrinsic to
the child.27,
The GACM is best facilitated
through the integration of medical,
mental health, and social services,
including specific resources
and supports for parents and
families.24 Providers work together
to destigmatize gender variance,
promote the childs self-worth,
facilitate access to care, educate
families, and advocate for safer
community spaces where children
are free to develop and explore
their gender.5 A specialized
gender-affirmative therapist,
when available, may be an asset in
helping children and their families
build skills for dealing with gender-
based stigma, address symptoms of
anxiety or depression, and reinforce
the childs overall resiliency.34,
There is a limited but growing body
of evidence that suggests that using
an integrated affirmative model
results in young people having
fewer mental health concerns
whether they ultimately identify
as transgender.24,
In contrast, conversion or
reparative treatment models
are used to prevent children and
adolescents from identifying as
transgender or to dissuade them
from exhibiting gender-diverse
expressions. The Substance
Abuse and Mental Health Services
Administration has concluded
that any therapeutic intervention
with the goal of changing a youths
gender expression or identity
is inappropriate.33 Reparative
approaches have been proven to
be not only unsuccessful38 but also
deleterious and are considered
outside the mainstream of
traditional medical practice.29,
The AAP described reparative
approaches as unfair and
43 At the time of this
* conversion therapy was
banned by executive regulation
in New York and by legislative
statutes in 9 other states as well
as the District of Columbia.44
Pediatric providers have an
essential role in assessing gender
concerns and providing evidence-
based information to assist youth
and families in medical decision-
making. Not doing so can prolong
or exacerbate gender dysphoria
and contribute to abuse and
stigmatization.35 If a pediatric
provider does not feel prepared to
address gender concerns when they
occur, then referral to a pediatric or
mental health provider with more
expertise is appropriate. There is
little research on communication
and efficacy with transfers in care
for youth who identify as TGD,
* For more information regarding state-specific
laws, please contact the AAP Division of State
Government Affairs at stgov@
particularly from pediatric to adult
Acknowledging that the capacity
for emerging abstract thinking
in childhood is important to
conceptualize and reflect on identity,
gender-affirmation guidelines are
being focused on individually tailored
interventions on the basis of the
physical and cognitive development
of youth who identify as TGD.45
Accordingly, research substantiates
that children who are prepubertal
and assert an identity of TGD know
their gender as clearly and as
consistently as their developmentally
equivalent peers who identify as
cisgender and benefit from the
same level of social acceptance.46
This developmental approach to
gender affirmation is in contrast to
the outdated approach in which a
childs gender-diverse assertions
are held as possibly true until an
arbitrary age (often after pubertal
onset) when they can be considered
valid, an approach that authors of
the literature have termed watchful
waiting. This outdated approach
does not serve the child because
critical support is withheld. Watchful
waiting is based on binary notions of
gender in which gender diversity and
fluidity is pathologized; in watchful
waiting, it is also assumed that
notions of gender identity become
fixed at a certain age. The approach
is also influenced by a group of
early studies with validity concerns,
methodologic flaws, and limited
follow-up on children who identified
as TGD and, by adolescence,
did not seek further treatment
47 More robust and
current research suggests that,
rather than focusing on who a child
will become, valuing them for who
they are, even at a young age, fosters
secure attachment and resilience,
not only for the child but also for the
whole family.5,
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Pediatric primary care providers
are in a unique position to routinely
inquire about gender development
in children and adolescents as part of
recommended well-child visits50 and
to be a reliable source of validation,
support, and reassurance. They
are often the first provider to be
aware that a child may not identify
as cisgender or that there may be
distress related to a gender-diverse
identity. The best way to approach
gender with patients is to inquire
directly and nonjudgmentally about
their experience and feelings before
applying any labels.27,
Many medical interventions can be
offered to youth who identify as TGD
and their families. The decision of
whether and when to initiate gender-
affirmative treatment is personal
and involves careful consideration
of risks, benefits, and other factors
unique to each patient and family.
Many protocols suggest that clinical
assessment of youth who identify
as TGD is ideally conducted on an
ongoing basis in the setting of a
collaborative, multidisciplinary
approach, which, in addition to the
patient and family, may include the
pediatric provider, a mental health
provider (preferably with expertise
in caring for youth who identify as
TGD ), social and legal supports,
and a pediatric endocrinologist
or adolescent-medicine gender
specialist, if available.6,
28 There is
no prescribed path, sequence, or
end point. Providers can make every
effort to be aware of the influence of
their own biases. The medical options
also vary depending on pubertal and
developmental progression.
Clinical Setting
In the past year, 1 in 4 adults who
identified as transgender avoided a
necessary doctors visit because of
fear of being mistreated.31 All clinical
office staff have a role in affirming
a patients gender identity. Making
flyers available or displaying posters
related to LGBTQ health issues,
including information for children
who identify as TGD and families,
reveals inclusivity and awareness.
Generally, patients who identify as
TGD feel most comfortable when
they have access to a gender-neutral
restroom. Diversity training that
encompasses sensitivity when
caring for youth who identify as
TGD and their families can be
helpful in educating clinical and
administrative staff. A patient-
asserted name and pronouns are
used by staff and are ideally reflected
in the electronic medical record
without creating duplicate charts.52,
The US Centers for Medicare and
Medicaid Services and the National
Coordinator for Health Information
Technology require all electronic
health record systems certified
under the Meaningful Use incentive
program to have the capacity to
confidentially collect information
on gender identity.54, 55 Explaining
and maintaining confidentiality
procedures promotes openness and
trust, particularly with youth who
identify as LGBTQ.1 Maintaining a
safe clinical space can provide at
least 1 consistent, protective refuge
for patients and families, allowing
authentic gender expression and
exploration that builds resiliency.
Pubertal Suppression
Gonadotrophin-releasing hormones
have been used to delay puberty
since the 1980s for central
precocious puberty.56 These
reversible treatments can also be
used in adolescents who experience
gender dysphoria to prevent
development of secondary sex
characteristics and provide time up
until 16 years of age for
the individual and the family to
explore gender identity, access
psychosocial supports, develop
coping skills, and further define
appropriate treatment goals. If
pubertal suppression treatment is
suspended, then endogenous puberty
will resume.20,
Often, pubertal suppression creates
an opportunity to reduce distress
that may occur with the development
of secondary sexual characteristics
and allow for gender-affirming care,
including mental health support
for the adolescent and the family.
It reduces the need for later surgery
because physical changes that are
otherwise irreversible (protrusion
of the Adams apple, male pattern
baldness, voice change, breast
growth, etc) are prevented. The
available data reveal that pubertal
suppression in children who identify
as TGD generally leads to improved
psychological functioning in
adolescence and young
Pubertal suppression is not
without risks. Delaying puberty
beyond ones peers can also be
stressful and can lead to lower
self-esteem and increased risk
taking.60 Some experts believe that
genital underdevelopment may
limit some potential reconstructive
options.61 Research on long-term
risks, particularly in terms of bone
metabolism62 and fertility,
is currently limited and provides
varied results.57,
65 Families often
look to pediatric providers for help
in considering whether pubertal
suppression is indicated in the
context of their childs overall well-
being as gender diverse.
Gender Affirmation
As youth who identify as TGD
reflect on and evaluate their gender
identity, various interventions
may be considered to better align
their gender expression with their
underlying identity. This process of
reflection, acceptance, and, for some,
intervention is known as gender
affirmation. It was formerly referred
to as transitioning, but many
view the process as an affirmation
and acceptance of who they have
always been rather than a transition
PEDIATRICS Volume 142, number 4, October 2018 5
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from 1 gender identity to another.
Accordingly, some people who have
gone through the process prefer to
call themselves affirmed females,
males, etc (or just females, males,
etc), rather than using the prefix
trans-. Gender affirmation is also
used to acknowledge that some
individuals who identify as TGD
may feel affirmed in their gender
without pursuing medical or surgical
Supportive involvement of parents
and family is associated with
better mental and physical health
outcomes.67 Gender affirmation
among adolescents with gender
dysphoria often reduces the
emphasis on gender in their lives,
allowing them to attend to other
developmental tasks, such as
academic success, relationship
building, and future-oriented
planning.64 Most protocols for
gender-affirming interventions
incorporate World Professional
Association of Transgender
Health35 and Endocrine Society68
recommendations and include 1 of
the following elements (Table 2):
1. Social Affirmation: This is a
reversible intervention in which
children and adolescents express
partially or completely in their
asserted gender identity by
adapting hairstyle, clothing,
pronouns, name, etc. Children
who identify as transgender and
socially affirm and are supported
in their asserted gender show no
increase in depression and only
minimal (clinically insignificant)
increases in anxiety compared
with age-matched averages.48
Social affirmation can be
complicated given the wide range
of social interactions children
have (eg, extended families, peers,
school, community, etc). There
is little guidance on the best
approach (eg, all at once, gradual,
creating new social networks,
or affirming within existing
networks, etc). Pediatric providers
can best support families by
anticipating and discussing such
complexity proactively, either
in their own practice or through
enlisting a qualified mental health
2. Legal Affirmation: Elements of
a social affirmation, such as a
name and gender marker, become
official on legal documents, such
as birth certificates, passports,
identification cards, school
documents, etc. The processes
for making these changes depend
on state laws and may require
specific documentation from
pediatric providers.
3. Medical Affirmation: This is
the process of using cross-sex
hormones to allow adolescents
who have initiated puberty
to develop secondary sex
characteristics of the opposite
biological sex. Some changes are
partially reversible if hormones
are stopped, but others become
TABLE 2 The Process of Gender Affirmation May Include 1 of the Following Components
Component Definition General Age RangeaReversibilitya
Social affirmation Adopting gender-affirming hairstyles, clothing,
name, gender pronouns, and restrooms and
other facilities
Any Reversible
Puberty blockers Gonadotropin-releasing hormone analogues,
such as leuprolide and histrelin
During puberty (Tanner stage 25)bReversiblec
Cross-sex hormone therapy Testosterone (for those who were assigned
female at birth and are masculinizing);
estrogen plus androgen inhibitor (for those
who were assigned male at birth and are
Early adolescence onward Partially reversible (skin texture,
muscle mass, and fat deposition);
irreversible once developed
(testosterone: Adams apple
protrusion, voice changes, and male
pattern baldness; estrogen: breast
development); unknown reversibility
(effect on fertility)
Gender-affirming surgeries Top surgery (to create a male-typical
chest shape or enhance breasts);
bottom surgery (surgery on genitals or
reproductive organs); facial feminization
and other procedures
Typically adults (adolescents on case-
by-case basisd)
Not reversible
Legal affirmation Changing gender and name recorded on
birth certificate, school records, and other
Any Reversible
a Note that the provided age range and reversibility is based on the little data that are currently available.
b There is limited benefit to starting gonadotropin-releasing hormone after Tanner stage 5 for pubertal suppression. However, when cross-sex hormones are initiated with a gradually
increasing schedule, the initial levels are often not high enough to suppress endogenous sex hormone secretion. Therefore, gonadotropin-releasing hormone may be continued in
accordance with the Endocrine Society Guidelines.68
c The effect of sustained puberty suppression on fertility is unknown. Pubertal suppression can be, and often is indicated to be, followed by cross-sex hormone treatment. However, when
cross-sex hormones are initiated without endogenous hormones, then fertility may be decreased.68
d Eligibility criteria for gender-affirmative surgical interventions among adolescents are not clearly defined between established protocols and practice. When applicable, eligibility is
usually determined on a case-by-case basis with the adolescent and the family along with input from medical, mental health, and surgical providers.68
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irreversible once they are fully
developed (Table 2).
4. Surgical Affirmation: Surgical
approaches may be used to
feminize or masculinize features,
such as hair distribution, chest, or
genitalia, and may include removal
of internal organs, such as ovaries
or the uterus (affecting fertility).
These changes are irreversible.
Although current protocols
typically reserve surgical
interventions for adults,
68 they
are occasionally pursued during
adolescence on a case-by-case
basis, considering the necessity
and benefit to the adolescents
overall health and often including
multidisciplinary input from
medical, mental health, and
surgical providers as well as from
the adolescent and family.69
For some youth who identify as
TGD whose natal gender is female,
menstruation, breakthrough
bleeding, and dysmenorrhea can
lead to significant distress before
or during gender affirmation. The
American College of Obstetrics
and Gynecology suggests that,
although limited data are
available to outline management,
menstruation can be managed
without exogenous estrogens by
using a progesterone-only pill,
a medroxyprogesterone acetate
shot, or a progesterone-containing
intrauterine or implantable device.72
If estrogen can be tolerated, oral
contraceptives that contain both
progesterone and estrogen are more
effective at suppressing menses.73
The Endocrine Society guidelines
also suggest that gonadotrophin-
releasing hormones can be used for
menstrual suppression before the
anticipated initiation of testosterone
or in combination with testosterone
for breakthrough bleeding (enables
phenotypic masculinization at a
lower dose than if testosterone
is used alone).68 Masculinizing
hormones in natal female patients
may lead to a cessation of menses,
but unplanned pregnancies have
been reported, which emphasizes
the need for ongoing contraceptive
counseling with youth who identify
as TGD.72
In addition to societal challenges,
youth who identify as TGD face
several barriers within the health
care system, especially regarding
access to care. In 2015, a focus
group of youth who identified as
transgender in Seattle, Washington,
revealed 4 problematic areas related
to health care:
1. safety issues, including the lack
of safe clinical environments
and fear of discrimination by
2. poor access to physical health
services, including testing for
sexually transmitted infections;
3. inadequate resources to address
mental health concerns; and
4. lack of continuity with
This study reveals the obstacles many
youth who identify as TGD face in
accessing essential services, including
the limited supply of appropriately
trained medical and psychological
providers, fertility options, and
insurance coverage denials for
gender-related treatments.74
Insurance denials for services related
to the care of patients who identify
as TGD are a significant barrier.
Although the Office for Civil Rights
of the US Department of Health and
Human Services explicitly stated in
2012 that the nondiscrimination
provision in the Patient Protection
and Affordable Care Act includes
people who identify as gender
76 insurance claims for
gender affirmation, particularly
among youth who identify as
TGD, are frequently denied.54,
In 1 study, it was found that
approximately 25% of individuals
who identified as transgender
were denied insurance coverage
because of being transgender.31
The burden of covering medical
expenses that are not covered
by insurance can be financially
devastating, and even when expenses
are covered, families describe high
levels of stress in navigating and
submitting claims appropriately.78
In 2012, a large gender center in
Boston, Massachusetts, reported
that most young patients who
identified as transgender and were
deemed appropriate candidates for
recommended gender care were
unable to obtain it because of such
denials, which were based on the
premise that gender dysphoria was
a mental disorder, not a physical
one, and that treatment was not
medically or surgically necessary.24
This practice not only contributes to
stigma, prolonged gender dysphoria,
and poor mental health outcomes,
but it may also lead patients to seek
nonmedically supervised treatments
that are potentially dangerous.24
Furthermore, insurance denials can
reinforce a socioeconomic divide
between those who can finance the
high costs of uncovered care and
those who cannot.24,
The transgender youth group in
Seattle likely reflected the larger TGD
population when they described how
obstacles adversely affect self-esteem
and contribute to the perception
that they are undervalued by society
and the health care system.74,
Professional medical associations,
including the AAP, are increasingly
calling for equity in health care
provisions regardless of gender
identity or expression.1,
8, 23,
There is a critical need for
investments in research on the
prevalence, disparities, biological
underpinnings, and standards of
care relating to gender-diverse
populations. Pediatric providers
who work with state government
and insurance officials can play
an essential role in advocating for
PEDIATRICS Volume 142, number 4, October 2018 7
by guest on September 19, from
stronger nondiscrimination policies
and improved coverage.
There is a lack of quality research on
the experience of youth of color who
identify as transgender. One theory
suggests that the intersection of
racism, transphobia, and sexism may
result in the extreme marginalization
that is experienced among many
women of color who identify as
79 including rejection
from their family and dropping out
of school at younger ages (often in
the setting of rigid religious beliefs
regarding gender),
80 increased levels
of violence and body objectification,
3 times the risk of poverty compared
with the general population,
and the highest prevalence of HIV
compared with other risk groups
(estimated as high as 56.3% in 1
meta-analysis).30 One model suggests
that pervasive stigma and oppression
can be associated with psychological
distress (anxiety, depression,
and suicide) and adoption of risk
behaviors by such youth to obtain
a sense of validation toward their
complex identities.79
Research increasingly suggests that
familial acceptance or rejection
ultimately has little influence on the
gender identity of youth; however, it
may profoundly affect young peoples
ability to openly discuss or disclose
concerns about their identity.
Suppressing such concerns can affect
mental health.82 Families often find it
hard to understand and accept their
childs gender-diverse traits because
of personal beliefs, social pressure,
and stigma.49,
83 Legitimate fears
may exist for their childs welfare,
safety, and acceptance that pediatric
providers need to appreciate and
address. Families can be encouraged
to communicate their concerns
and questions. Unacknowledged
concerns can contribute to shame
and hesitation in regard to offering
support and understanding,
which is essential for the childs
self-esteem, social involvement, and
overall health as TGD.48,
87 Some
caution has been expressed that
unquestioning acceptance per se may
not best serve questioning youth or
their families. Instead, psychological
evidence suggests that the most
benefit comes when family members
and youth are supported and
encouraged to engage in reflective
perspective taking and validate their
own and the others thoughts and
feelings despite divergent views.49, 82
In this regard, suicide attempt rates
among 433 adolescents in Ontario
who identified as trans were
4% among those with strongly
supportive parents and as high as
60% among those whose parents
were not supportive.85 Adolescents
who identify as transgender and
endorse at least 1 supportive person
in their life report significantly
less distress than those who only
experience rejection. In communities
with high levels of support, it was
found that nonsupportive families
tended to increase their support
over time, leading to dramatic
improvement in mental health
outcomes among their children who
identified as transgender.88
Pediatric providers can create a
safe environment for parents and
families to better understand and
listen to the needs of their children
while receiving reassurance and
education.83 It is often appropriate to
assist the child in understanding the
parents concerns as well. Despite
expectations by some youth with
transgender identity for immediate
acceptance after coming out,
family members often proceed
through a process of becoming more
comfortable and understanding of
the youths gender identity, thoughts,
and feelings. One model suggests
that the process resembles grieving,
wherein the family separates from
their expectations for their child to
embrace a new reality. This process
may proceed through stages of shock,
denial, anger, feelings of betrayal,
fear, self-discovery, and pride.89 The
amount of time spent in any of these
stages and the overall pace varies
widely. Many family members also
struggle as they are pushed to reflect
on their own gender experience
and assumptions throughout this
process. In some situations, youth
who identify as TGD may be at
risk for internalizing the difficult
emotions that family members may
be experiencing. In these cases,
individual and group therapy for the
family members may be helpful.49,
Family dynamics can be complex,
involving disagreement among legal
guardians or between guardians
and their children, which may
affect the ability to obtain consent
for any medical management or
interventions. Even in states where
minors may access care without
parental consent for mental health
services, contraception, and sexually
transmitted infections, parental
or guardian consent is required
for hormonal and surgical care of
patients who identify as TGD.72,
Some families may take issue with
providers who address gender
concerns or offer gender-affirming
care. In rare cases, a family may deny
access to care that raises concerns
about the youths welfare and safety;
in those cases, additional legal or
ethical support may be useful to
consider. In such rare situations,
pediatric providers may want to
familiarize themselves with relevant
local consent laws and maintain their
primary responsibility for the welfare
of the child.
Youth who identify as TGD are
becoming more visible because
gender-diverse expression is
increasingly admissible in the
media, on social media, and
in schools and communities.
Regardless of whether a
youth with a gender-diverse
FROM THE AMERICAN ACADEMY OF PEDIATRICS8 by guest on September 19, from
identity ultimately identifies as
transgender, challenges exist in
nearly every social context, from
lack of understanding to outright
rejection, isolation, discrimination,
and victimization. In the US
Transgender Survey of nearly
28 000 respondents, it was found
that among those who were out
as or perceived to be TGD between
kindergarten and eighth grade,
54% were verbally harassed,
24% were physically assaulted,
and 13% were sexually assaulted;
17% left school because of
maltreatment.31 Education
and advocacy from the medical
community on the importance
of safe schools for youth who
identify as TGD can have a
significant effect.
At the time of this writing,
* only
18 states and the District of
Columbia had laws that prohibited
discrimination based on gender
expression when it comes to
employment, housing, public
accommodations, and insurance
benefits. Over 200 US cities have
such legislation. In addition to
basic protections, many youth
who identify as TGD also have to
navigate legal obstacles when it
comes to legally changing their
name and/or gender marker.54
In addition to advocating and
working with policy makers
to promote equal protections
for youth who identify as TGD,
pediatric providers can play an
important role by developing a
familiarity with local laws and
organizations that provide social
work and legal assistance to youth
who identify as TGD and their
School environments play a
significant role in the social and
emotional development of children.
Every child has a right to feel safe
* For more information regarding state-specific
laws, please contact the AAP Division of State
Government Affairs at stgov@
and respected at school, but for
youth who identify as TGD, this can
be challenging. Nearly every aspect
of school life may present safety
concerns and require negotiations
regarding their gender expression,
including name/pronoun use, use
of bathrooms and locker rooms,
sports teams, dances and activities,
overnight activities, and even peer
groups. Conflicts in any of these
areas can quickly escalate beyond
the schools control to larger debates
among the community and even on a
national stage.
The formerly known Gay, Lesbian,
and Straight Education Network
(GLSEN), an advocacy organization
for youth who identify as LGBTQ,
conducts an annual national survey
to measure LGBTQ well-being in
US schools. In 2015, students who
identified as LGBTQ reported high
rates of being discouraged from
participation in extracurricular
activities. One in 5 students who
identified as LGBTQ reported
being hindered from forming or
participating in a club to support
lesbian, gay, bisexual, or transgender
students (eg, a gay straight alliance,
now often referred to as a genders
and sexualities alliance) despite such
clubs at schools being associated
with decreased reports of negative
remarks about sexual orientation
or gender expression, increased
feelings of safety and connectedness
at school, and lower levels of
victimization. In addition, >20% of
students who identified as LGBTQ
reported being blocked from writing
about LGBTQ issues in school
yearbooks or school newspapers
or being prevented or discouraged
by coaches and school staff from
participating in sports because of
their sexual orientation or gender
One strategy to prevent conflict
is to proactively support policies
and protections that promote
inclusion and safety of all students.
However, such policies are far from
consistent across districts. In 2015,
GLSEN found that 43% of children
who identified as LGBTQ reported
feeling unsafe at school because of
their gender expression, but only
6% reported that their school had
official policies to support youth
who identified as TGD, and only
11% reported that their schools
antibullying policies had specific
protections for gender expression.91
Consequently, more than half of
the students who identified as
transgender in the study were
prevented from using the bathroom,
names, or pronouns that aligned with
their asserted gender at school.
A lack of explicit policies that
protected youth who identified as
TGD was associated with increased
reported victimization, with
more than half of students who
identified as LGBTQ reporting verbal
harassment because of their gender
expression. Educators and school
administrators play an essential
role in advocating for and enforcing
such policies. GLSEN found that
when students recognized actions
to reduce gender-based harassment,
both students who identified as
transgender and cisgender reported
a greater connection to staff and
feelings of safety.91 In another study,
schools were open to education
regarding gender diversity and
were willing to implement policies
when they were supported by
external agencies, such as medical
Academic content plays an
important role in building a
safe school environment as well.
The 2015 GLSEN survey revealed
that when positive representations
of people who identified as LGBTQ
were included in the curriculum,
students who identified as LGBTQ
reported less hostile school
environments, less victimization
and greater feelings of safety,
fewer school absences because
of feeling unsafe, greater feelings
of connectedness to their school
PEDIATRICS Volume 142, number 4, October 2018 9
by guest on September 19, from
community, and an increased
interest in high school graduation
and postsecondary education.91
At the time of this writing,
* 8 states
had laws that explicitly forbade
teachers from even discussing
LGBTQ issues.54
One of the most important ways
to promote high-quality health
care for youth who identify as TGD
and their families is increasing
the knowledge base and clinical
experience of pediatric providers
in providing culturally competent
care to such populations, as
recommended by the recently
released guidelines by the
Association of American Medical
Colleges.93 This begins with the
medical school curriculum in areas
such as human development, sexual
health, endocrinology, pediatrics,
and psychiatry. In a 20092010
survey of US medical schools, it was
found that the median number of
hours dedicated to LGBTQ health
was 5, with one-third of US medical
schools reporting no LGBTQ
curriculum during the clinical
During residency training, there
is potential for gender diversity to
be emphasized in core rotations,
especially in pediatrics, psychiatry,
family medicine, and obstetrics and
gynecology. Awareness could be
promoted through the inclusion of
topics relevant to caring for children
who identify as TGD in the list of
core competencies published by
the American Board of Pediatrics,
certifying examinations, and
relevant study materials. Continuing
education and maintenance of
certification activities can include
topics relevant to TGD populations
as well.
* For more information regarding state-specific
laws, please contact the AAP Division of State
Government Affairs at stgov@
The AAP works toward all children
and adolescents, regardless of
gender identity or expression,
receiving care to promote optimal
physical, mental, and social well-
being. Any discrimination based on
gender identity or expression, real
or perceived, is damaging to the
socioemotional health of children,
families, and society. In particular,
the AAP recommends the following:
1. that youth who identify as TGD
have access to comprehensive,
gender-affirming, and
developmentally appropriate
health care that is provided in a
safe and inclusive clinical space;
2. that family-based therapy
and support be available to
recognize and respond to the
emotional and mental health
needs of parents, caregivers,
and siblings of youth who
identify as TGD;
3. that electronic health records,
billing systems, patient-centered
notification systems, and clinical
research be designed to respect
the asserted gender identity of
each patient while maintaining
confidentiality and avoiding
duplicate charts;
4. that insurance plans offer
coverage for health care that
is specific to the needs of
youth who identify as TGD,
including coverage for medical,
psychological, and, when
indicated, surgical gender-
affirming interventions;
5. that provider education, including
medical school, residency, and
continuing education, integrate
core competencies on the
emotional and physical health
needs and best practices for the
care of youth who identify as TGD
and their families;
6. that pediatricians have a role in
advocating for, educating, and
developing liaison relationships
with school districts and
other community organizations
to promote acceptance and
inclusion of all children without
fear of harassment, exclusion,
or bullying because of gender
7. that pediatricians have a role in
advocating for policies and laws
that protect youth who identify
as TGD from discrimination and
8. that the health care workforce
protects diversity by offering
equal employment opportunities
and workplace protections,
regardless of gender identity or
expression; and
9. that the medical field and federal
government prioritize research
that is dedicated to improving the
quality of evidence-based care for
youth who identify as TGD.
Jason Richard Rafferty, MD, MPH, EdM, FAAP
Robert Garofalo, MD, FAAP
Michael Yogman, MD, FAAP, Chairperson
Rebecca Baum, MD, FAAP
Thresia B. Gambon, MD, FAAP
Arthur Lavin, MD, FAAP
Gerri Mattson, MD, FAAP
Lawrence Sagin Wissow, MD, MPH, FAAP
Sharon Berry, PhD, LP Society of Pediatric
Ed Christophersen, PhD, FAAP Society of
Pediatric Psychology
Norah Johnson, PhD, RN, CPNP-BC National
Association of Pediatric Nurse Practitioners
Amy Starin, PhD, LCSW National Association of
Social Workers
Abigail Schlesinger, MD American Academy of
Child and Adolescent Psychiatry
Karen S. Smith
James Baumberger
FROM THE AMERICAN ACADEMY OF PEDIATRICS10 by guest on September 19, from
Cora Breuner, MD, MPH, FAAP, Chairperson
Elizabeth M. Alderman, MD, FSAHM, FAAP
Laura K. Grubb, MD, MPH, FAAP
Makia E. Powers, MD, MPH, FAAP
Krishna Upadhya, MD, FAAP
Stephenie B. Wallace, MD, FAAP
Laurie Hornberger, MD, MPH, FAAP Section on
Adolescent Health
Liwei L. Hua, MD, PhD American Academy of
Child and Adolescent Psychiatry
Margo A. Lane, MD, FRCPC, FAAP Canadian
Paediatric Society
Meredith Loveless, MD, FACOG American College
of Obstetricians and Gynecologists
Seema Menon, MD North American
Society of Pediatric and Adolescent
CDR Lauren B. Zapata, PhD, MSPH Centers for
Disease Control and Prevention
Karen Smith
Lynn Hunt, MD, FAAP, Chairperson
Anne Teresa Gearhart, MD, FAAP
Christopher Harris, MD, FAAP
Kathryn Melland Lowe, MD, FAAP
Chadwick Taylor Rodgers, MD, FAAP
Ilana Michelle Sherer, MD, FAAP
Ellen Perrin, MD, MA, FAAP
Joseph H. Waters, MD AAP Section on Pediatric
Renee Jarrett, MPH
We thank Isaac Albanese, MPA, and
Jayeson Watts, LICSW, for their
thoughtful reviews and contributions.
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Address correspondence to Jason Rafferty, MD, MPH, EdM, FAAP. E-mail:
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2018 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
AAP:  American Academy of
GACM:  gender-affirmative care
GLSEN:  Gay, Lesbian, and
Straight Education
LGBTQ:  lesbian, gay, bisexual,
transgender, or
TGD:  transgender and gender
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FROM THE AMERICAN ACADEMY OF PEDIATRICS14 by guest on September 19, from
originally published online September 17, 2018; Pediatrics
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Ensuring Comprehensive Care and Support for Transgender and
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Background: This article provides a review and commentary on social transition of gender-expansive prepubertal youth, analyzing risks, and benefits based on a synthesis of research and clinical observation, highlighting controversies, and setting forth recommendations, including the importance of continued clinical research. Methods: This article involved: (1) a review and critique of the WPATH Standards of Care 7th edition guidelines on social transition; (2) a review and synthesis of empirical research on social transition in prepubertal children; (3) a discussion of clinical practice observations; (4) a discussion of continuing controversies and complexities involving early social transition; (5) a discussion of risks and benefits of social transition; and (6) conclusions and recommendations based upon the above. Results: Results suggest that at this point research is limited and that some of the earliest research on young gender-expansive youth is methodologically questionable and has not been replicated. Newer research suggests that socially transitioned prepubertal children are often well adjusted, a finding consistent with clinical practice observations. Analysis of both emerging research and clinical reports reveal evidence of a stable transgender identity surfacing in early childhood. Discussion: The authors make recommendations to support social transitions in prepubertal gender-expansive children, when appropriate, as a facilitator of gender health, defined as a child's opportunity to live in the gender that feels most authentic, acknowledging that there are limitations to our knowledge, and ongoing research is essential.
Full-text available
Transgender medicine presents a particular challenge for the development of evidence-based guidelines, due to limitations in the available body of evidence as well as the exclusion of gender identity data from most public health surveillance activities. The guidelines that have been published are often based on expert opinion, small studies, and data gathered outside the US. The existence of guidelines, however, helps legitimate the need for gender-affirming medical and surgical interventions. Research conducted on transgender populations should be grounded in gender-affirming methodologies and focus on key areas such as health outcomes after gender-affirming interventions.
Full-text available
Purpose: Transgender youth are at high risk for mental health morbidities. Based on treatment guidelines, puberty blockers and gender-affirming hormone therapy should be considered to alleviate distress due to discordance between an individual's assigned sex and gender identity. The goals of this study were to examine the: (1) prevalence of mental health diagnoses, self-injurious behaviors, and school victimization and (2) rates of insurance coverage for hormone therapy, among a cohort of transgender adolescents at a large pediatric gender program, to understand access to recommended therapy. Methods: An IRB-approved retrospective medical record review (2014-2016) was conducted of patients with ICD 9/10 codes for gender dysphoria referred to pediatric endocrinology within a large multidisciplinary gender program. Researchers extracted the following details: demographics, age, assigned sex, identified gender, insurance provider/coverage, mental health diagnoses, self-injurious behavior, and school victimization. Results: Seventy-nine records (51 transgender males, 28 transgender females) met inclusion criteria (median age: 15 years, range: 9-18). Seventy-three subjects (92.4%) were diagnosed with one or more of the following conditions: depression, anxiety, post-traumatic stress disorder, eating disorders, autism spectrum disorder, and bipolar disorder. Fifty-nine (74.7%) reported suicidal ideation, 44 (55.7%) exhibited self-harm, and 24 (30.4%) had one or more suicide attempts. Forty-six (58.2%) subjects reported school victimization. Of the 27 patients prescribed gonadotropin-releasing hormone analogues, only 8 (29.6%) received insurance coverage. Conclusion: Transgender youth face significant barriers in accessing appropriate hormone therapy. Given the high rates of mental health concerns, self-injurious behavior, and school victimization among this vulnerable population, healthcare professionals must work alongside policy makers toward insurance coverage reform.
Importance Transmasculine youth, who are assigned female at birth but have a gender identity along the masculine spectrum, often report considerable distress after breast development (chest dysphoria). Professional guidelines lack clarity regarding referring minors (defined as people younger than 18 years) for chest surgery because there are no data documenting the effect of chest surgery on minors. Objective To examine the amount of chest dysphoria in transmasculine youth who had had chest reconstruction surgery compared with those who had not undergone this surgery. Design, Setting, and Participants Using a novel measure of chest dysphoria, this cohort study at a large, urban, hospital-affiliated ambulatory clinic specializing in transgender youth care collected survey data about testosterone use and chest distress among transmasculine youth and young adults. Additional information about regret and adverse effects was collected from those who had undergone surgery. Eligible youth were 13 to 25 years old, had been assigned female at birth, and had an identified gender as something other than female. Recruitment occurred during clinical visits and via telephone between June 2016 and December 2016. Surveys were collected from participants who had undergone chest surgery at the time of survey collection and an equal number of youth who had not undergone surgery. Main Outcomes and Measures Outcomes were chest dysphoria composite score (range 0-51, with higher scores indicating greater distress) in all participants; desire for chest surgery in patients who had not had surgery; and regret about surgery and complications of surgery in patients who were postsurgical. Results Of 136 completed surveys, 68 (50.0%) were from postsurgical participants, and 68 (50.0%) were from nonsurgical participants. At the time of the survey, the mean (SD) age was 19 (2.5) years for postsurgical participants and 17 (2.5) years for nonsurgical participants. Chest dysphoria composite score mean (SD) was 29.6 (10.0) for participants who had not undergone chest reconstruction, which was significantly higher than mean (SD) scores in those who had undergone this procedure (3.3 [3.8]; P < .001). Among the nonsurgical cohort, 64 (94%) perceived chest surgery as very important, and chest dysphoria increased by 0.33 points each month that passed between a youth initiating testosterone therapy and undergoing surgery. Among the postsurgical cohort, the most common complication of surgery was loss of nipple sensation, whether temporary (59%) or permanent (41%). Serious complications were rare and included postoperative hematoma (10%) and complications of anesthesia (7%). Self-reported regret was near 0. Conclusions and Relevance Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age.
Background: A rising number of female-affirmed transgender adolescents are being treated with gonadotropin-releasing hormone analogues and subsequently cross-sex hormones at early or mid-puberty, with vaginoplasty as the presumed final step in their physical transition. But, despite the minimum age of 18 years defining eligibility to undergo this irreversible procedure, anecdotal reports have shown that vaginoplasties are being performed on minors by surgeons in the United States, thereby contravening the World Professional Association for Transgender Health (WPATH) standards of care (SOC). Aim: To explore surgeons' attitudes toward ethical guidelines in the SOC; any professional experiences of performing vaginoplasty on transgender minors; views of surgical risks, benefits, and harm reduction measures; and perceptions of future challenges and concerns in this area of surgical practice. Methods: A qualitative semistructured interview approach was used to collect data from 13 male and 7 female surgeons who perform transgender vaginoplasty in the United States. Outcomes: Professional experiences and attitudes toward vaginoplasty in transgender minors were analyzed using the constant comparative method applied to 20 individual interview transcripts. Results: While there was close agreement concerning surgical techniques, proper patient selection, and predictive elements of postoperative success, attitudes toward the SOC and the reliance on the guidelines varied. The sole practitioner model is gradually giving way to a more holistic team approach, with patient responsibility dispersed among different professionals. Different approaches to surgical training, professional standards, and fellowship programs were suggested. Several participants expressed a need for centralized data collection, patient tracking, and increased involvement of the WPATH as a sponsor of studies in this emergent population. Clinical implications: Drawing on surgeons' attitudes and experiences is essential for the development of standards and practices. A more precise and transparent view of this surgical procedure will be essential in contributing to the updated version 8 of the WPATH SOC. Strengths and limitations: The abundant data elicited from the interviews address several meaningful research questions, most importantly patient selection criteria, surgical methods, and issues critical to the future of the profession. Nevertheless, the limited sample might not be representative of the surgical cadre at large, particularly when exploring experiences and attitudes toward vaginoplasty in minors. A larger participant pool representing WPATH-affiliated surgeons outside the United States would improve the generalizability of the study. Conclusion: Taken together, the study and its findings make a significant contribution to the planned revision of the WPATH SOC. Milrod C, Karasic DH. Age Is Just a Number: WPATH-Affiliated Surgeons' Experiences and Attitudes Toward Vaginoplasty in Transgender Females Under 18 Years of Age in the United States. J Sex Med 2017;14:624-634.
Puberty is highly important for the accumulation of bone mass. Bone turnover and bone mineral density (BMD) can be affected in transgender adolescents when puberty is suppressed by gonadotropin-releasing hormone analogues (GnRHa), followed by treatment with cross-sex hormone therapy (CSHT). We aimed to investigate the effect of GnRHa and CSHT on bone turnover markers (BTMs) and bone mineral apparent density (BMAD) in transgender adolescents. Gender dysphoria was diagnosed based on diagnostic criteria according to the DSM-IV (TR). Thirty four female-to-male persons (transmen) and 22 male-to-female persons (transwomen)were included. Patients were allocated to a young (bone age of < 15 years in transwomen or < 14 in transmen) or old group (bone age of ≥ 15 years in transwomen or ≥ 14 years in transmen). All were treated with GnRHa triptorelin and CSHT was added in incremental doses from the age of 16 years. Transmen received testosterone esters (Sustanon, MSD) and transwomen received 17-β estradiol. P1NP, osteocalcin, ICTP and BMD of lumbar spine (LS) and femoral neck (FN) were measured at three time points. In addition, BMAD and Z-scores were calculated. We found a decrease of P1NP and 1CTP during GnRHa treatment, indicating decreased bone turnover (young transmen 95% CI − 74 to − 50%, p = 0.02, young transwomen 95% CI − 73 to − 43, p = 0.008). The decrease in bone turnover upon GnRHa treatment was accompanied by an unchanged BMAD of FN and LS, whereas BMAD Z-scores of predominantly the LS decreased especially in the young transwomen. Twenty-four months after CSHT the BTMs P1NP and ICTP were even more decreased in all groups except for the old transmen. During CSHT BMAD increased and Z-scores returned towards normal, especially of the LS (young transwomen CI 95% 0.1 to 0.6, p = 0.01, old transwomen 95% CI 0.3 to 0.8, p = 0.04). To conclude, suppressing puberty by GnRHa leads to a decrease of BTMs in both transwomen and transmen transgender adolescents. The increase of BMAD and BMAD Z-scores predominantly in the LS as a result of treatment with CSHT is accompanied by decreasing BTM concentrations after 24 months of CSHT. Therefore, the added value of evaluating BTMs seems to be limited and DXA-scans remain important in follow-up of bone health of transgender adolescents.