What Is the Aim of PEDIATRIC "Gender-Affirming" Care?

The original "Dutch Protocol"-the treatment model comprised of puberty blockers, cross-sex hormones, and surgery-was intended to improve the mental and physical health of pediatric patients experiencing distress over their sexed bodies. Consequently, both researchers and clinicians have couched eligibility for treatment and measures of treatment efficacy in terms of the interventions' effects on outcomes such as gender dysphoria, depression, anxiety, and suicide. However, recent systematic reviews have concluded that the scientific evidence supporting these interventions is uncertain, leading to significant international differences in what treatments are offered to youth. Against this backdrop, a different argumentative approach has emerged in support of gender-affirming care. This approach appeals not to reductions in patient morbidity or mortality but to patient autonomy, where medical intervention is pursued as a means to the satisfaction of a patient's "embodiment goals." In this article, I raise objections to autonomy-based justifications for pediatric gender-affirming care, concluding that these arguments misunderstand the place of autonomy in clinical decision-making and, consequently, put patients at risk of medical harm.

The role of the pediatrician in the management of the child and adolescent with gender dysphoria.

Gender dysphoria is a clinical condition characterized by significant distress due to the discordance between biological sex and gender identity. Currently, gender dysphoria is also found more frequently in children and adolescents, thanks to greater social sensibleness and new therapeutic possibilities. In fact, it is estimated that the prevalence of gender dysphoria in pediatric age is between 0.5% and 2% based on the statistics of the various countries. Therefore, the pediatrician cannot fail to update himself on these issues and above all should be the reference figure in the management of these patients. Even if the patient must be directed to a referral center and be followed up by a multidisciplinary team, the treating pediatrician will care to coordinate the clinical and therapeutic framework. The aim of the present report is therefore to integrate literature data with our clinical experience to propose a new clinical approach in which the pediatrician should be the reference in the care of these patients, directing them towards the best therapeutic approach and staying in contact with the specialists of the referral center.

Editorial Perspective: Medical body modification in youth with gender dysphoria or body dysmorphic disorder - is current practice coherent and evidence-based?

In recent decades, there has been a steady increase in the number of people, including adolescents, undergoing medical body modification (MBM) to alter their physically healthy bodies in invasive and nearly irreversible ways through medical treatment (e.g. surgery). While MBM is often recommended for youth with persisting gender dysphoria (GD), in body dysmorphic disorder (BDD) it has been considered contraindicated. Here, we outline the current controversies surrounding MBM practice and recommendations in adolescents with GD versus those with BDD in order to better understand under what circumstances we may or may not support adolescents who want to change their bodies medically and often irreversibly. We compare the two disorders in terms of the overlap and uniqueness of their behavioural and psychological features. In doing so, we discuss limitations of the existing (often low-quality) evidence for and against MBM in young patients. We conclude that the currently available evidence is too preliminary and far from conclusive to make any robust recommendations in terms of benefits and harms of MBM in youth with persisting GD or BDD. However, we strongly recommend further urgent scientific discussions and systematic research efforts into more robust evaluations and the identification of more precise psychological characteristics that may serve as decision criteria for or against MBM - particularly in those adolescents who did not respond to non-MBM, that is, psychiatric/psychological treatment and psychosocial support, if available at all. This will greatly benefit youth healthcare professionals in their challenging clinical practice of making decisions regarding MBM today and in the future.

The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence.

It has been a quarter of a century since Dutch clinicians proposed puberty suppression as an intervention for "juvenile transsexuals," which became the international standard for treating gender dysphoria. This paper reviews the history of this intervention and scrutinizes the evidence adduced to support it. The intervention was justified by claims that it was reversible and that it was a tool for diagnosis, but these claims are increasingly implausible. The main evidence for the Dutch protocol came from a longitudinal study of 70 adolescents who had been subjected to puberty suppression followed by cross-sex hormones and surgery. Their outcomes shortly after surgery appeared positive, except for the one patient who died, but these findings rested on a small number of observations and incommensurable measures of gender dysphoria. A replication study conducted in Britain found no improvement. While some effects of puberty suppression have been carefully studied, such as on bone density, others have been ignored, like on sexual functioning.

Hematologic concerns in transgender patients.

Patients with gender dysphoria are increasingly seeking gender-affirming therapies, which can have adverse hematologic effects. For example, estrogen can increase the risk for arterial and venous thrombosis, whereas testosterone can cause erythrocytosis. This article reviews the hematologic issues associated with gender-affirming hormone therapies and discusses ways to lessen and monitor the risks. Common consult scenarios are also addressed.

Winning The Battle - A Success Story Of Managing Gender Dysphoria.

The DSM 5 defines Gender Dysphoria (GD) as a marked incongruence between one's biological gender and experienced gender. Individuals with GD face increased discrimination in the form of decreased job opportunities, healthcare facilities and increased violence. The definitive treatment for GD is sex reassignment surgery (SRS). The case we present follows a 24-year-old biological male, self-identifying as a female. His experience seeking treatment made him a target for misdiagnoses and mistreatment by healthcare professionals (including psychiatrists, endocrinologists and plastic surgeons) and family resulting in mental agony. After struggling for a long time, he was able to move abroad for SRS. Upon her return to Pakistan as a female she presented as being finally content with her gender and life. The article places emphasis on creating inclusive healthcare plans for individuals with GD and raising awareness among healthcare professional and general population regarding the issue.

Detransition-Related Needs and Support: A Cross-Sectional Online Survey.

The aim of this study is to analyze the specific needs of detransitioners from online detrans communities and discover to what extent they are being met. For this purpose, a cross-sectional online survey was conducted and gathered a sample of 237 male and female detransitioners. The results showed important psychological needs in relation to gender dysphoria, comorbid conditions, feelings of regret and internalized homophobic and sexist prejudices. It was also found that many detransitioners need medical support notably in relation to stopping/changing hormone therapy, surgery/treatment complications and reversal interventions. Additionally, the results indicated the need for hearing about other detransitioners' experiences and meeting each other. A major lack of support was reported by the respondents overall, with a lot of negative experiences coming from medical and mental health systems and from the LGBT+ community. The study highlights the importance of increasing awareness and support given to detransitioners.

Psychosocial health in adolescents and young adults with gender dysphoria before and after gender-affirming medical interventions: a descriptive study from the Hamburg Gender Identity Service.

Empirical evidence concerning the psychosocial health outcomes after puberty suppression and gender-affirming (GA) medical interventions of adolescents with gender dysphoria (GD) is scarce. The aim of the present study was to describe how dimensions of psychosocial health were distributed among different intervention groups of adolescents with a GD diagnosis from the Hamburg Gender Identity Service before and after treatment. Participants included n = 75 adolescents and young adults from a clinical cohort sample, measured at their initial intake and on average 2 years later (M treatment duration = 21.4 months). All cases were divided into four different intervention groups, three of which received medical interventions. At baseline, both psychological functioning and quality of life scores were significantly below the norm mean for all intervention groups. At follow-up, adolescents in the gender-affirming hormone (GAH) and surgery (GAS) group reported emotional and behavioral problems and physical quality of life scores similar to the German norm mean. However, some of the psychosocial health outcome scores were still significantly different from the norm. Because this study did not test for statistically significant differences between the four intervention groups or before and after treatment, the findings cannot be generalized to other samples of transgender adolescents. However, GA interventions may help to improve psychosocial health outcomes in this sample of German adolescents. Long-term treatment decisions during adolescence warrant careful evaluation and informed, participatory decision-making by a multidisciplinary team and should include both medical interventions and psychosocial support. The present study highlights the urgent need for further ongoing longitudinal research.

[Role of the psychiatrist-psychotherapist in the assessment and treatment of gender dysphoria]. / Rôle du psychiatre-psychothérapeute dans la prise en charge de la dysphorie de genre.

This article is the result of the joint work of psychiatrists-psychotherapists working with patients with gender dysphoria (children, adolescents and adults) in Lausanne and Geneva university hospitals. It emphasizes the importance of their clinical interventions when hormone therapy and sex reassignment surgery are requested.

Cet article est issu d'une collaboration entre les psychiatres-psychothérapeutes et les pédopsychiatres-psychothérapeutes intervenant dans les deux consultations universitaires spécialisées pour la dysphorie de genre en Suisse romande et illustre l'importance de leur intervention dans la prise en charge des personnes qui sollicitent des traitements médicochirurgicaux de réassignation sexuelle.

Endocrine treatment of transgender individuals: current guidelines and strategies.

INTRODUCTION: This review summarizes gender affirming medical and surgical care available to transgender individuals, along with proposals to improve medically and culturally appropriate care. AREAS COVERED: Transgender individuals are those whose gender identity differs from that recorded at birth (usually based on visualization of external sexual anatomy). In order to align the body with the patient's gender identity, clinicians can provide hormone therapy (HT) to bring sex hormone levels to the range associated with the patient's gender identity. At steady state, monitoring for maintenance of levels, as well as for known risks and complications, is required. Treating clinicians should have knowledge of trans assessment criteria, hormone therapy, surgical options, primary care, and mental health needs of transgender patients. A narrative literature review was conducted using Pubmed and EMBASE with articles then selected for relevance. The initial search terms were: androgen suppression, antiandrogen, breast development, chest reconstruction, cisgender, estrogen, fertility preservation, gender-affirming surgery, gender identity, gender incongruence, genital reconstruction, hormone replacement, hyperlipidemia, orchiectomy, prolactin, prostate atrophy, spermatogenesis, spironolactone, testosterone, thrombogenesis, transgender, and virilization. EXPERT OPINION: Although guidelines exist and examples of training are available, systematic formal training must be implemented to truly mainstream high-quality gender-affirming health care .

The effect of early puberty suppression on treatment options and outcomes in transgender patients.

In the past 10-15 years, paediatric transgender care has emerged at the forefront of several general practice and subspecialty guidelines and is the topic of continuing medical education for various medical disciplines. Providers in specialties ranging from family medicine, paediatrics and adolescent medicine to endocrinology, gynaecology and urology are caring for transgender patients in increasing numbers. Current and evolving national and international best practice guidelines recommend offering a halt of endogenous puberty for patients with early gender dysphoria, in whom impending puberty is unacceptable for their psychosocial health and wellness. Pubertal blockade has implications for fertility preservation, transgender surgical care and psychosocial health, all of which must be considered and discussed with the patient and their family and/or legal guardian before initiation.

Behavioral Health Concerns and Eligibility Factors Among Adolescents and Young Adults Seeking Gender-Affirming Masculinizing Top Surgery.

Purpose: We evaluated behavioral health histories and eligibility factors for patients seeking chest reconstruction. Methods: One hundred and fifty-eight consecutive transgender patients were seen for initial masculinizing top surgery consults between May 2017 and July 2019. Chart review was used to assess behavioral health and demographic factors, and eligibility factors related to the World Professional Association for Transgender Health (WPATH) Standards of Care. Univariate and age-adjusted regression models were used to examine the relationship between demographic and behavioral health factors and WPATH criteria. Results: The average age of patients at the time of their first consult was 18 (standard deviation = 3.3, range = 14-33). Eighty-five percent had at least one behavioral health diagnosis; 27% had three or more. Sixty-four percent endorsed a history of self-harm or suicidal ideation, 13% within the last 6 months. Thirty-two percent reported a history of marijuana use and 19% a history of nicotine use. For those prescribed testosterone, additional months on testosterone were significantly associated with male (vs. nonbinary) gender (ß = 4.64, 95% confidence interval [CI] 0.37-8.90, p = 0.033), age (ß = 0.87, 95% CI 0.41-1.34, p < 0.001), living as one's affirmed gender for over 1 year (ß = 6.37, 95% CI 1.37-11.37, p = 0.013), history of marijuana use (ß = 4.54, 95% CI 1.10-7.98, p = 0.010), and history of nicotine use (ß = 6.23, 95% CI 2.22-10.26, p = 0.003). Conclusion: Patients seeking gender-affirming masculinizing top surgery are behaviorally complex, in ways not necessarily associated with surgical eligibility. Involving a behavioral health provider in perioperative assessment can help identify and address potential risks to recovery and outcomes.

Debate: Different strokes for different folks.

A gender social transition in prepubertal children is a form of psychosocial treatment that aims to reduce gender dysphoria, but with the likely consequence of subsequent (lifelong) biomedical treatments as well (gender-affirming hormonal treatment and surgery). Gender social transition of prepubertal children will increase dramatically the rate of gender dysphoria persistence when compared to follow-up studies of children with gender dysphoria who did not receive this type of psychosocial intervention and, oddly enough, might be characterized as iatrogenic. Parents who bring their children for clinical care hold different philosophical views on what is the best way to help reduce the gender dysphoria, which require both respect and understanding.

Cambios en los caracteres sexuales secundarios del paciente con disforia de género a consecuencia del tratamiento endocrino en Cuba / Changes in the secondary sexual characteristics of the patient with gender dysphoria as a result of endocrine therapy in Cuba

RESUMEN Introducción: La transexualidad es una incongruencia entre el sexo con el que se nace y el sexo al que se siente pertenecer, por tanto, estas personas desean cambios en su apariencia física que se logran mediante el tratamiento hormonal. Objetivo: Describir los cambios en los caracteres sexuales secundarios en pacientes con disforia de género en Cuba como consecuencia del tratamiento endocrino. Métodos: Se realizó un estudio de revisión de las historias clínicas en 76 pacientes atendidas por disforia de género en los últimos 15 años. Se extrajo la información relacionada con datos sociodemográficos y algunos cambios físicos, como resultado del traamiento hormonal. Para el análisis de los datos se obtuvieron distribuciones de frecuencia de las variables cualitativas, media y desviación estándar de las cuantitativas. Resultados: La mayoría de los pacientes corresponde a transexuales de hombre a mujer (THM). Al año, la mayoría de las personas ya tenían un estadio III o IV de desarrollo mamario (45,3 por ciento de estos tenían estadio III y el 32,3 por ciento estadio IV). Al año de iniciada la atención de los 58 pacientes, 41,4 por ciento tenían un patrón de vello triangular típico del sexo femenino con el que se identifican y a los 2 años ascendió al 80,5 por ciento. Al año se evaluaron 50 por ciento de todos los casos y en ese momento solo 5,1 por ciento mantenían un vello facial intenso y más de la mitad (56,8 por ciento), ya no tenían. Al inicio, la media del volumen testicular fue de 17,4 ml, a los 3 meses fue de 15,7 ml, a los 6 meses 14,3 ml y 9,7 ml al año. Conclusiones: Los pacientes con disforia de género en la mayoría de los casos logran cambios en los caracteres sexuales secundarios acordes al sexo con que se identifican(AU)

ABSTRACT Introduction: Transsexualism is an inconsistency between the sex with which someone was born and the sex he or she feels belong to; therefore, these subjects want to do changes in their physical appearance that are achieved through hormonal treatment. Objective: To describe changes in the secondary sexual characteristics in patients with gender dysphoria in Cuba as a result of endocrine therapy. Methods: A study was conducted to review the clinical records in 76 patients treated by gender dysphoria in the past 15 years. It was collected the information related to socio-demographic data and some physical changes as a result of the hormonal therapy. For data analysis were obtained frequency distributions of the qualitative variables, the mean and the standard deviation of the quantitative ones. Results: The majority of patients correspond to male to female transsexuals (THM, by its acronym in Spanish). A year after, the majority of the patients already studied had a stage III or stage IV of breast development (45.3 percent) of these had stage III and 32.3 percent had stage IV). A year after the start of the attention of the 58 patients, 41.4 percent had a pattern of triangular hair typical of the female sex which they feel identified with and after 2 years it increased to 80.5 percent. After a year, there were evaluated 50 percent of all cases and at that time only 5.1 percent maintained intense facial hair, and more than half (56.8 percent) had no facial hair. At the beginning, the mean of testicular volume was 17.4 mL, after 3 months it was 15.7 mL, after 6 months was 14.3 mL and 9.7 mL after a year. Conclusions: Patients with gender dysphoria in most cases achieve changes in the secondary sexual characteristics in accordance with the sex which they feel identified with(AU)

Historical and Current State of Dermatologic Care for Sexual and Gender Minority Populations.

The lesbian, gay, bisexual, transgender, and queer or questioning/sexual and gender minority (LGBTQ/SGM) community is a growing population with unique lifestyles, sexual practices, beliefs, health issues, and concerns. Although significant advances have been achieved in recent years to establish better care for LGBTQ/SGM patients, they still face insurmountable stigmatization and health care inequality. Dermatologists play an important role in LGBTQ/SGM patients' well-being because they not only treat their skin conditions, but also help them achieve desirable physical characteristics. This article discusses historical perspectives and current state of LGBTQ/SGM dermatology and attempts to define directions for future research and improvement.

Current approach to the clinical care of adolescents with gender dysphoria.

Over the last decade, we have witnessed a significant rise in the number of transgender young people seeking endocrine treatment, of which clinical service and gender dysphoria terminology have attempted to keep pace both in matching demand and better describing the condition. Although helpful guidelines for pubertal suppression and gender affirming hormones have been developed, uncertainties remain regarding treatment and monitoring during treatment, often because the clinical needs of the transgender population have outpaced medical expertise and training. Recently, multidisciplinary team work has evolved due to the increasing complexity of diagnostic and treatment decision-making and has been instrumental in creating a unique service with input from a range of specialists. In this article, the current approach in clinical management of adolescents with gender dysphoria is reviewed, with focus on the endocrine aspect of care in children and adolescents. Questions on what defines optimal clinical care of children and adolescents with gender dysphoria remain and should be the focus of future research.

Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study.

OBJECTIVE: Despite professional recommendations to consider gender-affirming hormone and surgical interventions for transgender individuals experiencing gender incongruence, the long-term effect of such interventions on mental health is largely unknown. The aim of this study was to ascertain the prevalence of mood and anxiety disorder health care visits and antidepressant and anxiolytic prescriptions in 2015 as a function of gender incongruence diagnosis and gender-affirming hormone and surgical treatment in the entire Swedish population. METHODS: This study used the Swedish Total Population Register (N=9,747,324), linked to the National Patient Register and the Prescribed Drug Register. Among individuals who received a diagnosis of gender incongruence (i.e., transsexualism or gender identity disorder) between 2005 and 2015 (N=2,679), mental health treatment in 2015 was examined as a function of length of time since gender-affirming hormone and surgical treatment. Outcome measures were mood and anxiety disorder health care visits, antidepressant and anxiolytic prescriptions, and hospitalization after a suicide attempt. RESULTS: Compared with the general population, individuals with a gender incongruence diagnosis were about six times as likely to have had a mood and anxiety disorder health care visit, more than three times as likely to have received prescriptions for antidepressants and anxiolytics, and more than six times as likely to have been hospitalized after a suicide attempt. Years since initiating hormone treatment was not significantly related to likelihood of mental health treatment (adjusted odds ratio=1.01, 95% CI=0.98, 1.03). However, increased time since last gender-affirming surgery was associated with reduced mental health treatment (adjusted odds ratio=0.92, 95% CI=0.87, 0.98). CONCLUSIONS: In this first total population study of transgender individuals with a gender incongruence diagnosis, the longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them.