In the last 5 years, many clinicians have faced tough questions about how best to serve transgender youth while doing no harm. They are aided in this task by the recent explosion in clinical research on best practices for supporting and treating the transgender community. However, at the same time, the increase in access to gender-affirming hormone therapy and puberty suppressors has led transgender individuals to seek medical transition at younger ages, raising important questions about the risks and benefits of early transition.
What Is Transition?
Transgender young people often seek out health professionals because of a strong, persistent conflict between the way they feel about and think of themselves (referred to as “experienced” or “expressed gender”) and their physical or assigned sex. When this conflict is accompanied by significant distress and/or problems functioning, the person can be diagnosed with gender dysphoria.
A gender dysphoria diagnosis opens the gateway to gender-affirming treatments such as puberty suppression and cross-sex hormone therapy that allow a patient to better align their body with their internal sense of identity. Puberty suppressors, such as GnRH agonists leuprolide acetate and histrelin, halt the progression of puberty in adolescents. GnRH agonists prevent the development of sex-specific characteristics such as breast growth, virilized hair patterns, voice deepening, and skeletal changes that would require more extensive surgery later in life.1 Because their effects are not permanent, suppressors offer additional time for a young person and their family to decide whether cross-sex hormone therapy is the right choice for them.
If the young person persists in a desire for transition, cross-sex hormone therapy then allows for the development of primary and secondary sex characteristics in the transgender person’s gender of choice. Transgender girls may use estrogen supplements to encourage the development of breast buds and rounder hips, whereas transgender boys may take testosterone to lengthen the clitoris, deepen the voice, and grow facial hair.
What If It’s Just a Phase?
Although hormone therapy can be incredibly beneficial for many transgender youth, clinicians may question whether it is appropriate for their patient: “Is my client’s distress part of the normal ups and downs of adolescence, or is it truly dysphoria?”
These anxieties are exacerbated by a commonly cited statistic that 80% of children expressing cross-sex identity issues will not “persist” in identifying as transgender into adulthood. However, the basis of this statistic is quite misleading, as study authors classified children who were lost to follow-up as “desisters.” The authors also used medical intervention as the outcome variable indicating gender persistence, which problematically conflates gender identity with a desire for hormone therapy or surgery.2 This study design creates undue panic over the supposed instability of transgender identification in young children.
Stacey Karpen, PhD, senior manager of behavioral health at Whitman-Walker Health, Washington, DC, says that clinical preoccupation with desisters misses the point of gender-affirming care. “I can’t tell you how your child will identify in 10 years, or even tomorrow. If you’re looking for someone to tell you concretely about your child’s identity, then I’m not a good fit. But I say, look I want your child alive. If they feel differently at 18 then they do at 14, at least we got them to 18.”
Transgender young people often present with severe depression, anxiety, and even suicidal ideation related to their gender dysphoria. Although some clinicians might consider these diagnoses as a contraindication for a major medical procedure such as hormone therapy, frequently their symptoms are significantly alleviated by social and physical transition. Even major psychiatric disorders such as major depressive disorder and bipolar disorder are frequently “cured” when gender identity issues are addressed.1
Dr Karpen explains that gender identity can be fluid and she cannot promise that transition is “the right thing to do” for every patient. But all the research to date shows that transition improves mental health and quality of life for transgender young people, and that’s what matters. She continues, “I care about these kids being happy in their skin. I care about their ability to thrive. Some kids are really struggling in school, in friendships, struggling with social isolation. Transition helps them engage in life and figure out who they are and what they want.”
Dr Karpen notes that her approach acknowledges and seeks to remedy the history of mental health professionals as gatekeepers to care. She says, “I’m trying to name the power dynamic between clinician and client. When someone comes to me and wants a letter for hormone therapy, it’s never a question of yes or no, but a question of when. I tell a patient that, and you can see their whole body relax, because they see our interaction as a conversation instead of a test.”
That doesn’t mean everyone Dr Karpen sees is immediately referred for hormone therapy. She follows an assessment procedure that mirrors the guidelines of the Endocrine Society. Mental health providers should assess their patient’s current degree of gender dysphoria and their history of gender identity development, as well as standard psychosocial issues such as psychiatric history; experiences with bullying, school, and peer groups; and body image.
Zoe, a 13-year-old transgender girl who recently started puberty blockers, explains that her therapist regularly assesses how she is dealing with social elements of her transition and helps her develop coping skills. “My therapist is always trying to talk about how to handle difficult situations, like bullying at school. She’s helped me deal with my gender dysphoria, including difficult things that cause dysphoria. She’s been an advocate for me 100% of the time.”
Managing Long-term Risks
Many clinicians worry that transgender youth interested in hormone therapy may not fully appreciate the risks that come with their medication regimen. The effects of puberty suppressors are not well studied, but could potentially cause stunted bone mass and cognitive developmental changes from delaying or preventing primary puberty.4 Cross-sex hormones in young people who have not undergone puberty prevent the development of primary sex characteristics, rendering transgender young people infertile. Although there are some options for fertility preservation at this stage, only about 5% of youth in gender-care clinics undertake the process.3
Experienced gender therapists recommend ongoing conversations about the effects of hormone therapy, using an informed consent model, so that a young person better understands the risks, rewards, and reversibility of a proposed medication. Therapists can also help assess readiness and mediate expectations about the effects of hormone therapy. Similar to with any other medication, patients should know that a prescription is not a magic pill that will fix everything, and they should have a plan in place for how to store and take their medication safely. Longer-term, process-oriented conversations such as these create an opportunity for the healthcare provider to better assess their patient’s maturity and decision-making capacity.2
Most adolescents state that the lack of long-term safety data and the loss of fertility would not stop them from pursuing puberty suppression and hormone therapy. Any negative consequences are offset by a significant improvement in their quality of life. As one young transgender boy described, “I would rather live 10 years shorter but live a very happy life being myself, than live 10 years longer and be unhappy my whole life.”4
Access to Care
Even when hormone therapy or puberty suppression is clearly the right course of action, accessing gender-affirming care can be a struggle for transgender young people. There is a dearth of experienced clinicians across specialties who serve transgender youth.
Dr Karpen notes that many of her patients say they already see a therapist regularly, but came to her because their primary therapist “doesn’t deal with gender.” She exhorts all mental health professionals, especially those providing care to young people, to invest in continuing education on this topic. “I don’t think we can say, ‘I don’t do gender.’ If you are providing care to young people, having knowledge about gender identity should be a priority for all patients, not just the trans kids, because it’s part of the picture of mental health and quality of life.”
Access to care comes with a significant price tag as well, and one not always covered by insurance. Zoe explains that her prescription for puberty blockers cost almost $28,000 a year. She says, “Thankfully, our medical plan covered it. My parents paid about $600 instead of the full cost. However, I’ve also learned from my parents that not all medical plans cover this. My parents and I are very thankful for our medical coverage.”
For young people who are on Medicaid or experiencing poverty, hormone care may be economically out of reach. One young person in foster care explained how the system made it nearly impossible to medically transition: “I think doing the transition in the group home was really hard, too, because of course you have to go through the court to start hormones and I think it’s really frustrating because it’s a whole long process. So I had to wait till I turned 18 to start hormones.”5
The good news is that transgender young people thrive when they can socially and medically transition. Transgender children who have support around their gender identity have normal levels of depression and only slightly elevated levels of anxiety compared with their cisgender peers. Their rates of stress, drug and alcohol abuse, and suicidal ideation are drastically lower than transgender youth who are not able to transition.6
For Zoe, social transition and puberty blockers have made a huge difference in her ability to be herself in school and with her friends. Her biggest concern right now? “Someone should make larger size shoes for girls!”
- Edwards-Leeper L, Spack N. Psychological evaluation and medical treatment of transgender youth in an interdisciplinary “Gender Management Service” (GeMS) in a major pediatric center. J Homosex. 2012;59(3):321-336.
- Chen D, Edwards-Leeper L, Stancin T, Tishelman A. Advancing the practice of pediatric psychology with transgender youth: state of the science, ongoing controversies, and future directions. Clin Pract Pediatr Psychol. 2018;6(1):73-83.
- Chen D, Simons L. Ethical considerations in fertility preservation for transgender youth: a case illustration. Clin Pract Pediatr Psychol. 2018;6(1):93-100.
- Vrouenraets L, Fredriks A, Hannema S, Cohen-Kettenis P, de Vries M. Perceptions of sex, gender, and puberty suppression: a qualitative analysis of transgender youth. Arch Sex Behav. 2016;45(7):1697-1703.
- Mountz S, Capous-Desyllas M, Pourciau E. ‘Because we’re fighting to be ourselves:’ voices from former foster youth who are transgender and gender expansive. Child Welfare. 2018;96(1):103-125.
- Olson K, Durwood L, DeMeules M, McLaughlin K. Mental health of transgender children who are supported in their identities. Pediatrics. 2016;137(3):e20153223.