REVIEW URRENT C OPINION
Gynecologic care for transgender youth Ce´cile A. Unger
Purpose of review To provide an overview of the care of the adolescent transgender patient with regard to the guidelines and recommendations that currently exist, and to review the role of the clinician caring for transgender youth. Recent findings The World Professional Association for Transgender Health and the Endocrine Society continue to provide comprehensive guidelines for the care of adolescent transgender patients. The decision to perform surgery on a patient who is a minor remains a complex one, and a case-by-case approach should be taken with important ethical principles in mind. Cross-sex steroid use places transgender adolescents at risk for metabolic disorders, and careful surveillance is necessary. In addition, transgender teens are at high risk for depression, anxiety and suicidality and have been shown to engage in more high-risk behaviors compared with their nontransgender heterosexual counterparts. Summary Clinicians who care for adolescents can play an important role in the counseling, screening, health maintenance and support of their patients through the transition process. Keywords adolescence, gender dysphoria, gender identity disorder, transgender, transsexual
INTRODUCTION Gender-variant or nonconforming children experience and express gender in ways that do not conform to societal expectations and cultural norms [1]. Transgenderism refers to a state of being in which an individual’s self-identified gender does not match his or her biologic or ‘natal’ sex [2] and represents persistence of gender variance into adolescence and adulthood. Transgender teens will often describe a sense of being ‘trapped’ in the wrong body and feel a disconnect between their genitalia and who they feel they really are. Gender dysphoria refers to the distress that is caused by a sense of incongruity between an individual’s self-identified gender and natal sex, and is currently the official diagnosis transgender patients require to undergo transition to their self-affirmed gender [3 ]. In the medical community, there has been a growing body of literature on the care of the lesbian, gay and bisexual patient; however, there are sparse data on the medical and social needs and challenges faced by transgender and gender-nonconforming individuals, especially in the pediatric population. Some excellent publications exist, addressing some of the health indicators for transgender patients [4], but the overall evidence-based literature on the routine care and care during the transition process remains very limited and relies on data obtained &&
from observational studies. There are currently few gynecology-centered publications that focus on the care of these patients. The aim of this review is to provide an overview of the care of the adolescent transgender patient with regard to the guidelines and recommendations that currently exist, and to review the role of the gynecologist or other clinician providing gynecologic care (e.g. adolescent medicine specialist) for these patients.
PREVALENCE Currently, the most accurate way to describe sexual minority and gender variant youth is to refer to them as either lesbian, gay, bisexual, transgender or questioning (LGBTQ). The prevalence of LGBTQ youth, which includes children and adolescents, is
Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine & Reconstructive Surgery, Cleveland Clinic Foundation, Women’s Health Institute, Cleveland, Ohio, USA Correspondence to Ce´cile A. Unger, MD, MPH, Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine & Reconstructive Surgery, Cleveland Clinic Foundation, Women’s Health Institute, 9500 Euclid Avenue/A81, Cleveland, OH 44195, USA. Tel: +1 607 592 8258; e-mail: [email protected] Curr Opin Obstet Gynecol 2014, 26:347–354 DOI:10.1097/GCO.0000000000000103
1040-872X ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-obgyn.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent and pediatric gynecology
DIAGNOSIS
KEY POINTS The WPATH and the Endocrine Society continue to provide comprehensive guidelines for the care of adolescent transgender patients. The decision to perform surgery on a patient who is a minor remains a complex one, and a case-by-case approach should be taken with important ethical principles in mind. Cross-sex steroid use places transgender adolescents at risk for metabolic disorders, and careful surveillance is necessary. Transgender teens are at high risk for depression, anxiety and suicidality and have been shown to engage in more high-risk behaviors compared with their nontransgender heterosexual counterparts.
If a prepubertal child or teenager is showing signs of gender nonconformity and expresses dysphoria associated with these behaviors, it is the pediatrician’s responsibility to initiate a dialogue between herself and the patient as well as with the patient’s parent(s) or guardian(s), if the patient desires. There is a 27-item validated questionnaire that assesses gender identity and gender dysphoria in adolescents and adults, and can be used as a guide to assist clinicians in questions that they may want to ask during the gender evaluation [9]. When children demonstrate gender nonconforming behavior, it is imperative to monitor whether this behavior, and any associated dysphoria, remains consistent and persistent into the early-pubertal years so that support and intervention for parents and the child may be provided as early as possible (Fig. 1, [3 ]). The most current WPATH guidelines (version 7) for the care of adults, adolescents and children with gender dysphoria were published in 2011 [10]. Trained mental health professionals who are familiar with the WPATH guidelines with experience and training in child and adolescent developmental psychopathology should make the diagnosis of gender dysphoria and be involved in the initial treatment phase [10]. In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, ‘Gender Dysphoria’ has replaced the previous diagnosis of ‘Gender Identity Disorder’ and is used to describe the distress felt by individuals whose physical appearance does not match their gender identity. The change in terminology was meant to remove the ‘disorder’ aspect of gender dysphoria, to maintain consistency of the terminology used throughout the world, and to provide a formal diagnosis to &&
estimated to be approximately 3–6% in the USA [5]. Two household surveys performed in the USA reported that 0.3–0.5%, or close to 1 million, of adult respondents identified as transgender [6,7]. These types of reports are fraught with response and selection biases and are likely underestimates of the true prevalence. There are even less data on the pediatric population. In 2011, the Youth Risk Behavior Survey was administered to 2730 students in 22 public middle schools in a San Francisco school district. The authors of this study found that 3.8% of students identified as lesbian, gay or bisexual, and 1.3% of students identified as transgender [8 ]. Although this study also carries its own inherent biases, these are currently the best data we have on the prevalence of transgenderism in teenagers. &
Biologic (natal) sex refers to genetic sex and the biological and physiological characteristics that define maleness or femaleness Gender identity refers to an inherent sense of being male or female regardless of biologic (natal) sex Gender nonconformity or variance refers to the extent that an individual’s gender identity and/or expression differs from cultural or societal norms Transgenderism refers to individuals who identify with and/or desire to live and be accepted as the opposite sex rather than their biologic (natal) sex Transgender man/boy refers to self-identified gender; an individual is biologically female but identifies as male Transgender woman/girl refers to self-identified gender; an individual is biologically male but identifies as female Gender dysphoria refers to the discomfort or distress that is caused by a discrepancy between an individual’s gender identity and biologic (natal) sex*
FIGURE 1. Terminology. Current formal diagnosis found in the Diagnostic and Statistical Manual of Mental Disorders (5th edition) [3 ]. &&
348
www.co-obgyn.com
Volume 26 Number 5 October 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gynecologic care for transgender youth Unger
facilitate patient access to care and to help justify insurance coverage for treatment [3 ]. A diagnosis of persistent gender dysphoria is required for consideration of treatment, which includes the suppression of puberty and initiation of hormonal therapy in adolescents. Once children enter Tanner stage 2 of pubertal development, persistent gender dysphoria should be formally diagnosed and treated. At this stage of puberty, children are not likely to deviate from their self-identified gender; therefore, initial treatment begins with pubertal suppression [11]. Delay in pubertal development is a very important part of the initial treatment for adolescents because the intervention is reversible but provides patients and their families time to understand the process and to determine the right transition plan [12]. The recommendation to suppress puberty is based on the work done by Hembree et al. [13] in Amsterdam and is carefully outlined in the Clinical Practice Guideline for the Endocrine Treatment of Transsexual Persons, developed and published by the Endocrine Society and co-sponsored by many international pediatric societies and the WPATH. Prior to initiating endocrine therapy, a mental health professional must document the patient’s diagnosis of gender dysphoria as well as any other co-existing psychiatric conditions, outline the patient’s selfidentifying characteristics and confirm his or her eligibility for hormone therapy and/or sex confirmation surgery. The eligibility criteria for pubertal suppression, as outlined by the WPATH, are depicted in Fig. 2. &&
HORMONE THERAPY Many types of providers, including adolescent medicine specialists, pediatric and adolescent gynecologists, pediatric endocrinologists and reproductive endocrinologists, incorporate the endocrine care of the transgender adolescent in their practice. In 2011, Hembree [14] published a review of the guidelines for the treatment of adolescent transgender
patients, which is based on the most up-to-date comprehensive guidelines for adults and adolescents [13]. An article published in 2013 by Spack in JAMA [15 ] also offers excellent guidelines based on the Endocrine Society’s recommendations for the hormonal care of the adolescent. The first phase of endocrine therapy for adolescents is often referred to as the suppressive stage and involves pubertal suppression, which is considered reversible. Therapy may be initiated once a complete physical examination (documenting testicular volume and penis width in biologic boys and breast size in biologic girls, as well as terminal hair distribution in both) and baseline metabolic labs, sex steroid levels (confirming early puberty), as well as bone age and mineral density are completed. Once the examination is complete and patients and their parents are properly counseled about expectations, pubertal suppression is achieved with GnRH analogs. The most commonly used GnRH agonist is Lupron Depot (leuprolide acetate) 3.75 mg, which is an intramuscular injection administered monthly. The first dose may be administered at any time in boys and nonmenstruating girls. If female patients have reached menarche, Lupron should be administered in the luteal phase of the menstrual cycle to avoid a flare response during menses. If it is administered during the follicular phase of the menstrual cycle, concomitant progesterone or combined estrogen-progesterone therapy should be administered to avoid heavy menses during that cycle. Alternatively, a second injection of Lupron may be administered during the luteal phase. After initiating suppressive therapy, the Endocrine Society recommends close surveillance of the parameters depicted in Fig. 3. Most adolescent patients experience extreme relief and improvement in their dysphoria once suppressive therapy is initiated. The induction phase is the second phase of hormone therapy for adolescents and is recommended at age 16 [16]. Per the Endocrine Society guidelines, consent from a parent or guardian is preferable, but not required for &&
1) The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (suppressed or expressed). 2) Gender dysphoria emerged or worsened with the onset of puberty. 3) Any coexisting psychological, medical, or social problems that could interfere with treatment have been addressed; the adolescent is stable enough to start treatment. 4) The adolescent has given informed consent; when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.
FIGURE 2. Eligibility criteria for pubertal suppression. Adapted with permission from [10]. 1040-872X ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-obgyn.com
349
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent and pediatric gynecology
SURGERY
Every 3 months • Height (standing, sitting), weight, tanner stage • Serum LH, FSH, estradiol, testosterone Every 12 months • Renal function • Liver function • Lipid panel • Glucose and glycosylated hemoglobin • Bone density (DEXA) • Bone age (X-ray of the left hand)
FIGURE 3. Pubertal suppression surveillance. DEXA, dualenergy X-ray absorptiometry. Figure created from information found in [13].
this treatment. Although most 16-year-old patients are able to make informed decisions about their care, providers should abide by their institutional or departmental requirements with regard to obtaining parental consent for treatment. Cross-sex hormones are used to induce the desired feminizing or virilizing secondary sex characteristics. The effects of these hormones are considered to be partially reversible. If patients have not begun living full-time as their self-affirmed gender, commonly referred to as the ‘real life experience’, it is recommended that they do so at this stage, and that they also maintain their relationship with their mental health provider during this portion of the transition [10]. Per the Endocrine Society’s guidelines, male-to-female patients are prescribed daily oral estradiol and female-to-male patients are prescribed intramuscular testosterone, which is injected every 2 weeks. Three-month follow-up is necessary to monitor serum levels of sex steroids, and the doses are titrated every 6 months according to each patient’s response. Figures 4 and 5 depict the protocol for induction of puberty as well as the surveillance recommended for transgender boys and girls. GnRH suppression is continued with sex steroid therapy and is stopped if and when gonadectomy is performed as part of the surgical treatment for patients.
Confirmation surgery is often referred to as ‘genital reassignment surgery’ or ‘bottom surgery’. This refers to vaginoplasty procedures for male-to-female patients and phalloplasty procedures for female-tomale patients. Hysterectomy and oophorectomy for female-to-male patients can also be part of confirmation surgery, and are usually performed prior to and separate from phalloplasty. Similarly, orchiectomy for male-to-female patients is part of confirmation surgery, and can be performed prior to vaginoplasty procedures, but they are often performed concomitantly. ‘Top surgery’ usually refers to breast surgery: mastectomy with chest contouring for female-to-male patients, and breast augmentation for male-to-female patients. The media has played a large role in increasing the visibility of children and young teens who are undergoing transition to their self-affirmed genders; with the introduction of GnRH analogs for pubertal suppression and the early age of hormonal therapy initiation, the topic of when it may be ‘appropriate’ to perform confirmation surgery as the last and final step in the transition process has become a hot topic for discussion [17 ]. Timing for surgery can be very controversial and there are no studies that have evaluated the appropriate timing of surgery in adolescents. In the last 5 years, several cases of confirmation surgery have been reported in teens younger than the age of 18 in countries outside of the USA. For example, there are case reports of Thai transgender girls undergoing reassignment surgery between 15 and 16 years of age [18]. There have been other published successful surgical results in adolescents under the age of 18 following pubertal suppression and estrogen therapy [19]. In these patients, surgeons were able to achieve a cosmetically appealing result with low associated morbidity to the patient as well as reports of good patient satisfaction. The concern for vaginoplasty and phalloplasty procedures prior to age 18 is two-fold. First, (and probably most important), there is a concern &
Feminizing (female puberty): 17-β estradiol (oral) Initial – 5 µg/kg/day Increasing the dose every 6 months – 10 µg /kg/day 15 µg /kg/day 20 µg /kg/day Virilizing (male puberty): Testosterone enanthate or cypionate (intramuscular) Initial – 25 mg/m2 every 2 weeks Increasing the dose every 6 months – 50 mg/m2 every 2 weeks 75 mg/m2 every 2 weeks 100 mg/m2 every 2 weeks
FIGURE 4. Protocol for induction of puberty. Figure created from information found in [13]. 350
www.co-obgyn.com
Volume 26 Number 5 October 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gynecologic care for transgender youth Unger
Every 3 months • Height (standing, sitting), weight, tanner stage • Serum LH, FSH, estradiol, testosterone Every 12 months • Renal function • Liver function • Lipid panel • Glucose and glycosylated hemoglobin • Bone density* (DEXA) • Bone age (X-ray of the left hand)
FIGURE 5. Pubertal induction surveillance. Parameters measured until age 25–30 or until peak bone mass has been reached. DEXA, dual-energy X-ray absorptiometry. Figure created from information found in [13].
regarding patient maturity and ability to provide informed consent for an irreversible surgery where the risk of regret far outweighs the benefit that might be obtained from having the surgery. Second, from a surgical point of view, the amount of genital skin that is available for reconstruction may be limited before age 18, especially in the setting of pubertal suppression, requiring more extensive grafting, which may alter the cosmetic result and feasibility of the surgery. The WPATH does not recommend genital reassignment surgeries until adolescents have reached the legal age of majority in their respective country [10]. In most countries, the legal age of majority is 18. The Endocrine Society also supports these recommendations. Although these standards of care serve as guidelines for most surgeons, there are published reports (mentioned above) as well as anecdotal, unpublished reports of adolescents under the age of 18 who have undergone confirmation surgery. As the transition process and need to delay pubertal development are occurring at younger ages, it is not implausible that adolescents are seeking surgical care at younger ages as well. With time, flexibility has been built into the age guidelines for chest surgery for female-to-male adolescents as the benefits of this type of surgery, despite its irreversibility, have been recognized. Currently, chest surgery in female-to-male patients is permissible at an earlier age in the context of ample time living in the desired gender role and after 1 year of testosterone treatment [10]. It is not hard to imagine that there may be special circumstances in which a severely gender dysphoric teenage girl may benefit from genital surgery at an earlier age. However, it is difficult to create guidelines for these younger ages, and it no doubt remains very controversial. Until 2014, the literature on the ethical principles guiding decision-making for surgical reassignment in adolescents was very sparse. A recent review on this
topic was published in the Journal of Sexual Medicine [17 ], and discusses the ethical principles that the surgeon should consider when counseling a minor about confirmation surgery. Each ethical principle requires careful evaluation and assessment and involves a contract and understanding between patient and surgeon. The decision to perform surgery on a patient who is a minor remains a complex one, and a case-by-case approach is recommended with the WPATH and Endocrine Society guidelines serving as an important framework for the decision-making process. Some gender nonconforming youth do not desire complete phenotypic transition, and experience significant improvement and even resolution of their gender dysphoria with their endogenous hormones alone, with exogenous hormone-only treatment, or with partial surgical gender confirmation surgeries. Most importantly, providers should recognize that transition goals and requests for treatment may change over time and they should remain supportive and adaptable throughout the process. Prior to surgery, providers should ensure that patients have lived continuously for at least 12 months in the gender role that is congruent with their gender identity, as surgery is considered the last and final step. The pediatric provider may act as an important social support for patients going through this real life experience, as this portion of the transition process can sometimes be very challenging in the context of school and/or an unsupportive family environment. &
CLINICIANS CARING FOR TRANSGENDER YOUTH Both the American Medical Association and American Academy of Pediatrics advocate for a multidisciplinary approach to caring for transgender adolescents. Both male-to-female and female-tomale patients may initially seek the care of a generalist or sub-specialist gynecologist. The sense of discomfort with their genitals sometimes prompts patients to discuss these concerns with providers who specialize in that anatomic region of the body. Parents of patients may initially feel that a gynecologic evaluation is necessary to help guide them in the right direction, especially if the gynecologist has experience with endocrinology and vaginal reconstructive surgery. Many transgender boys seek consultation for menstrual suppression. For these patients, menstrual suppression can be achieved with continuous oral contraceptives or depot medroxyprogesterone. The initial discussion of further pubertal suppression with GnRH analogs may take place at that visit as well, and under the right
1040-872X ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-obgyn.com
351
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent and pediatric gynecology
circumstances, treatment may be initiated according to the guidelines set by the Endocrine Society. In addition, providers should always ensure that their patients are not obtaining off-label hormone therapy from outside sources such as their friends or the Internet. Although there are little data on the actual percentage of patients who circumscribe the usual routes for obtaining prescription hormones, anecdotally, these patients exist in both the adult and adolescent population. Providers who are not comfortable with the initial or hormonal care of these patients should refer them to a provider who routinely cares for adolescents and who is specifically willing to care for patients with gender dysphoria. Adolescent patients may also present for consultation regarding their surgical options. The provider should be aware of the current guidelines for age and for referral requirements recommended by the WPATH, and should have a basic understanding of the reconstructive surgeries available to their patients. Sometimes a referral to a gynecologist who has previous experience with reconstructive genital surgery for the transgender patient is useful if the patient wishes to proceed with a vaginoplasty procedure. For the female-to-male patient, an important discussion is the one regarding desire for and timing of hysterectomy with or without oophorectomy. This is a service the gynecologist can provide, and should be comfortable performing. A minimally invasive approach (either vaginal or laparoscopic) to hysterectomy is recommended as a portion of the lower abdomen is often used as a graft site for some phalloplasty procedures and preservation of the vascular supply is important and is likely to be comprised with a transverse abdominal incision. If open abdominal hysterectomy is necessary, a vertical midline incision is preferred. Gynecologists may play an important role in counseling patients about the effect of hormonal therapy on future fertility. Despite their young age, adolescents should be counseled about these effects, as many hormonal therapies may have long-lasting effects on their fertility. Male-to-female patients should be made aware of the effects that GnRH analogs and estrogens may have on sperm production and should be made aware of the possibility of prehormonal sperm banking. Female-to-male patients should be counseled about the effects of testosterone on female fertility and should be made aware of the option for oocyte retrieval and cryopreservation in order to maintain future fertility. Additionally, the decision to undergo concomitant oophorectomy at the time of hysterectomy affects future fertility as well, and the gynecologist should be sure to address this with his or her patient when discussing timing of surgery. 352
www.co-obgyn.com
Transgender adolescent patients fall under the high-risk category for metabolic dysfunction and require more surveillance than their nontransgender counterparts. For example, androgen suppression and estrogen substitution in male-to-female patients can lead to increases in visceral fat, which is associated with increases in triglyceride levels, insulin resistance, hepatic dysfunction, and elevated blood pressure [13]; therefore, lipid and diabetes screening should be performed at each annual visit for these patients. If the patient has recently been started on cross-sex steroids, screening should be done more frequently according to the Endocrine Society’s guidelines. If the adolescent provider is not the prescribing provider, he or she should ensure that patients are followed closely by their prescribing provider, and should have access to the patient’s metabolic indices. One of the most important things a provider caring for transgender youth can do is not make assumptions about their patients’ sexual behaviors or preferences. In addition, screening for sexually transmitted infections (STIs) is an important part of the routine health of all adolescent patients, including those who are transgender. The data show that teenagers who self-identify as LGBTQ tend to take more risks with regard to sex behaviors than do their self-identified, nontransgender heterosexual peers [20,21]. A cross-sectional study by Robinson et al. looked at sexually risky attitudes and behaviors among a large population-based sample of LGBTQ and heterosexual-identified teenagers in middle and high school. The authors found that sexual risk disparities between LGBTQ and heterosexual youths began as early as the middle school years with peer victimization accounting for a significant portion of these disparities [22 ]. Importantly, we have data that show that transgender girls face the most sexual health disparities compared with other sexual minority youth, as this group has been shown to have a higher rate of STIs and HIV [23,24]. These studies have found that unsafe sex behaviors are the highest risk factor for acquiring HIV in this particular group [25]. Providers should establish good rapport with their teenage patients, openly acknowledge their patients’ gender identities, create a comfortable environment that facilitates disclosure about sex behaviors and attitudes and ask very specific and directed questions about these behaviors and preferences. Parental support may also play an important role in helping to mitigate some of these risk factors. There is evidence that shows that when parents reject their child’s identity and fail to offer support, these children are at risk for low selfesteem, low life satisfaction and depression, which can lead to high-risk sexual behaviors [26,27 ]. In &
&
Volume 26 Number 5 October 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gynecologic care for transgender youth Unger
one study, parental support was shown to increase regular condom use among transgender girls, whereas those without such support were more likely to report inconsistent condom use [28]. The research on the mental health of transgender adolescents is not as robust as the literature that currently exists on sexual minority children; however, the data that have been published show that there are higher rates of depression and high-risk behaviors in transgender teens compared with those who are nontransgender and heterosexual [29 ]. Anxiety and depressive disorders are thought to be common among transgender youth. In a Dutch study, up to one-third of children presenting with gender dysphoria were also diagnosed with anxiety disorders [30]. This anxiety may be related to real or perceived rejection, peer victimization and abuse as a result of the adolescent’s transgender status, or fear of being ‘outed’ or discovered if he or she is living as their self-identified gender [31]. Suicidality has also been shown to be higher among the LGBTQ community, and specifically in transgender individuals. In 2011, Grant et al. [32] published Injustice at Every Turn: A Report of the National Transgender Discrimination Survey, which was one of the first national, representative surveys of the transgender community. The survey found that suicide attempts were reported by 41% of the 6450 survey respondents. The authors also reported high rates of victimization: 78% reported harassment and 35% reported physical assault while in school (K–12) with 15% having left school because of harassment. In a recent survey on sexual harassment among adolescents, Mitchell et al. [33] found that transgender youth reported the highest rates of sexual harassment (81%), followed by gender nonconforming youth (69%). Providers caring for these adolescent patients should screen for low selfesteem, depression and other mood disorders, and they should help parents learn how to better support their children, as their support may help counterbalance the mental health impact of the stigmatization and societal marginalization their children may experience. &
CONCLUSION Transgender teenagers are high-risk patients with significant medical and social needs. There are few publications in the gynecology journals on the care of the transgender adolescent. This is surprising, as both the gynecologist and adolescent specialist play an important role in the care of these patients. Being equipped to take care of transgender teens first starts with understanding the stages of diagnosis and treatment that are recommended by the APA,
WPATH and Endocrine Society. Second, providers should understand their role in counseling, screening, maintaining health and supporting their patients through the transition process. With this knowledge, those who care for adolescents can successfully become part of the medical home for transgender youth. Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Stoddard J, Leibowitz SF, Ton H, Snowdon S. Improving medical education about gender-variant youth and transgender adolescents. Child Adolesc Psychiatric Clin N Am 2011; 20:779–791. 2. Grossman AH, D’Augelli AR. Transgender youth and life threatening behaviors. Suicide Life Threat Behav 2007; 37:527–537. 3. American Psychiatric Association. 2013. Gender dysphoria. http:// && www.dsm5.org/Documents/Gender%20Dysphoria%20Fact%20Sheet.pdf. [Accessed 25 April 2014] This document reviews the importance of the new ‘gender dysphoria’ diagnosis in the most up-to-date version of the DSM. 4. Gooren LJ. Clinical practice: care of transsexual persons. N Engl J Med 2011; 364:1251–1257. 5. Haas AP, Eliason M, Mays VM, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. J Homosex 2010; 58:10–51. 6. Gates GJ. How many people are lesbian, gay, bisexual, and transgender? Williams Institute, UCLASchool of Law. http://williamsinstitute.law.ucla.edu/ wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf. [Accessed 20 March 2014] 7. Conron KJ, Scott G, Stowell GS, Landers SJ. Transgender health in Massachusetts: results from a household probability sample of adults. Am J Public Health 2012; 102:118–122. 8. Shields JP, Cohen R, Glassman JR, et al. Estimating population size and & demographic characteristics of lesbian, gay, bisexual and transgender youth in middle school. J Adolscent Health 2013; 52:248–250. This cross-sectional study is the most recent and up-to-date data we have on the prevalence of transgender youth. 9. Deogracias JJ, Johnson LL, Meyer-Bahlburg HFL, et al. The gender identity/ gender dysphoria questionnaire for adolescents and adults. J Sex Res 2007; 44:370–379. 10. Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gendernonconformingpeople, Version 7. World Professional Association for Transgender Health. Int J Transgenderism 2011; 13:165–232. 11. Drummond KD, Bradley SJ, Peterson-Bidali M, et al. A follow-up study of girls with gender identity disorder. Dev Psychol 2008; 44:34–45. 12. Delemarre-Van de Waal HA, Cohen-Kettenis PT. Clinical Management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. Eur J Endocrinol 2006; 155 (Suppl 1): S131–137. 13. Hembree WC, Cohen-Kettenis PT, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2009; 94:3132–3154. 14. Hembree WC. Guidelines for pubertal suspension and gender reassignment for transgender adolescents. Child Adolesc Psychiatric Clin N Am 2011; 20:725–732. 15. Spack SP. Management of transgenderism. JAMA 2013; 309:478–484. &&
This is an important, recently published article describing the recommendations for the care of the transgender adolescent, based on the WPATH and Endocrine Society guidelines. 16. Olsen J, Forbes C, Belzer M. Management of the transgender adolescent. Arch Pediatr Adolesc Med 2011; 165:171–176.
1040-872X ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-obgyn.com
353
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent and pediatric gynecology 17. Milrod C. How young is too young: ethical concerns in genital surgery of the transgender mtf adolescent. J Sex Med 2014; 11:338–346. This is an interesting article addressing the ethical principles that should be considered when contemplating performing confirmation surgery on minor patients 18. Winter S. Thai transgenders in focus: demographics, transitions and identities. Int J Transgenderism 2006; 9:15–27. 19. Kreukels BPC, Cohen-Kettenis PT. Puberty suppression in gender identity disorder: the Amsterdam experience. Nat Rev Endocrinol 2011; 7:466–472. 20. Kann L, Olsen EO, McManus T, et al., Centers for Disease Control and, Prevention. Sexual identity, sex of sexual contacts, and health-risk behaviors among students in grades 9-12-Youth Risk Behavior Surveillance, selected sites, Unites States. MMWR Surveill Summ 2011; 60:1–133. 21. Friedman MS, Marshal MP, Guadamuz TE, et al. A meta-analysis of disparities in childhood sexual abuse,parental physical abuse, and peer victimization amongsexual minority and sexual nonminority individuals. Am JPublic Health 2011; 101:1481–1494. 22. Robinson JP, Espelage DL. Peer victimization and sexual risk differences & between lesbian, gay, bisexual, transgender, or questioning and nontransgender heterosexual youths in grades 7-12. Am J Public Health 2013; 103:1810–1819. This is an important study examining peer victimization in sex minority youth and transgender teenagers. 23. Garofolo R, Deleon J, Osmer E, et al. Overlooked, misunderstood and at-risk: Exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. J Adolesc Health 2006; 38:230–236. 24. Wilson EC, Garofalo R, Harris RD, et al. Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS Behav 2009; 13:902–913. 25. Berg MB, Mimiaga MJ, Safren SA. Mental health concerns of gay and bisexual men seeking mental health services. J Homosex 2008; 54:293–306. &
354
www.co-obgyn.com
26. Hong JS, Espelage DL, Kral MJ. Understanding suicide among sexual minority youth in America: an ecological systems analysis. J Adolesc 2011; 34:885– 894. 27. Simons L, Schrager SM, Clark LF, et al. Parental support and mental health & among transgender adolescents. J Adoles Health 2013; 53:791–793. This article shows the association between parental support and self-concept in transgender teenagers and concludes that parental support is paramount for social adjustment in this patient population. 28. Wilson EC, Iverson E, Garofolo R, Belzer M. Parental support and condom use among transgender female youth. Assoc Nurses AIDS Care 2012; 23:306–317. 29. Spack N, Edwards-Leeper L, Feldman HA, et al. Children and adolescents & with gender identity disorder referred to a pediatric medical center. Pediatrics 2012; 129:418–425. This is a comprehensive observational article describing the pediatric patient population that presents for transgender care at a tertiary medical center specializing in gender management services. 30. Wallien MSC, Swaab H, Cohen-Kettenis PT. Psychiatric comorbidity among children with gender identity disorder. J Am Acad Child Adolesc Psychiatry 2007; 46:1307–1314. 31. Herbert S. Female-to-male transgender adolescents. Child Adolsc Psychiatric Clin N Am 2011; 20:681–688. 32. Grant JM, Mottet LA, Tanis J, et al. Injustice at every turn: a report of the National Transgender Discrimination Survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011 ; http://www.thetaskforce.org/reports_and_research/ntds. [Accessed 20 April 2014] 33. Mitchell KJ, Ybarra ML, Korchmaros JD. Sexual harassment among adolescents of different sexual orientations and gender identities. Child Abuse & Neglect 2014; 38:280–295.
Volume 26 Number 5 October 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gynecologic care for transgender youth Ce´cile A. Unger
Purpose of review To provide an overview of the care of the adolescent transgender patient with regard to the guidelines and recommendations that currently exist, and to review the role of the clinician caring for transgender youth. Recent findings The World Professional Association for Transgender Health and the Endocrine Society continue to provide comprehensive guidelines for the care of adolescent transgender patients. The decision to perform surgery on a patient who is a minor remains a complex one, and a case-by-case approach should be taken with important ethical principles in mind. Cross-sex steroid use places transgender adolescents at risk for metabolic disorders, and careful surveillance is necessary. In addition, transgender teens are at high risk for depression, anxiety and suicidality and have been shown to engage in more high-risk behaviors compared with their nontransgender heterosexual counterparts. Summary Clinicians who care for adolescents can play an important role in the counseling, screening, health maintenance and support of their patients through the transition process. Keywords adolescence, gender dysphoria, gender identity disorder, transgender, transsexual
INTRODUCTION Gender-variant or nonconforming children experience and express gender in ways that do not conform to societal expectations and cultural norms [1]. Transgenderism refers to a state of being in which an individual’s self-identified gender does not match his or her biologic or ‘natal’ sex [2] and represents persistence of gender variance into adolescence and adulthood. Transgender teens will often describe a sense of being ‘trapped’ in the wrong body and feel a disconnect between their genitalia and who they feel they really are. Gender dysphoria refers to the distress that is caused by a sense of incongruity between an individual’s self-identified gender and natal sex, and is currently the official diagnosis transgender patients require to undergo transition to their self-affirmed gender [3 ]. In the medical community, there has been a growing body of literature on the care of the lesbian, gay and bisexual patient; however, there are sparse data on the medical and social needs and challenges faced by transgender and gender-nonconforming individuals, especially in the pediatric population. Some excellent publications exist, addressing some of the health indicators for transgender patients [4], but the overall evidence-based literature on the routine care and care during the transition process remains very limited and relies on data obtained &&
from observational studies. There are currently few gynecology-centered publications that focus on the care of these patients. The aim of this review is to provide an overview of the care of the adolescent transgender patient with regard to the guidelines and recommendations that currently exist, and to review the role of the gynecologist or other clinician providing gynecologic care (e.g. adolescent medicine specialist) for these patients.
PREVALENCE Currently, the most accurate way to describe sexual minority and gender variant youth is to refer to them as either lesbian, gay, bisexual, transgender or questioning (LGBTQ). The prevalence of LGBTQ youth, which includes children and adolescents, is
Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine & Reconstructive Surgery, Cleveland Clinic Foundation, Women’s Health Institute, Cleveland, Ohio, USA Correspondence to Ce´cile A. Unger, MD, MPH, Department of Obstetrics & Gynecology, Division of Female Pelvic Medicine & Reconstructive Surgery, Cleveland Clinic Foundation, Women’s Health Institute, 9500 Euclid Avenue/A81, Cleveland, OH 44195, USA. Tel: +1 607 592 8258; e-mail: [email protected] Curr Opin Obstet Gynecol 2014, 26:347–354 DOI:10.1097/GCO.0000000000000103
1040-872X ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-obgyn.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent and pediatric gynecology
DIAGNOSIS
KEY POINTS The WPATH and the Endocrine Society continue to provide comprehensive guidelines for the care of adolescent transgender patients. The decision to perform surgery on a patient who is a minor remains a complex one, and a case-by-case approach should be taken with important ethical principles in mind. Cross-sex steroid use places transgender adolescents at risk for metabolic disorders, and careful surveillance is necessary. Transgender teens are at high risk for depression, anxiety and suicidality and have been shown to engage in more high-risk behaviors compared with their nontransgender heterosexual counterparts.
If a prepubertal child or teenager is showing signs of gender nonconformity and expresses dysphoria associated with these behaviors, it is the pediatrician’s responsibility to initiate a dialogue between herself and the patient as well as with the patient’s parent(s) or guardian(s), if the patient desires. There is a 27-item validated questionnaire that assesses gender identity and gender dysphoria in adolescents and adults, and can be used as a guide to assist clinicians in questions that they may want to ask during the gender evaluation [9]. When children demonstrate gender nonconforming behavior, it is imperative to monitor whether this behavior, and any associated dysphoria, remains consistent and persistent into the early-pubertal years so that support and intervention for parents and the child may be provided as early as possible (Fig. 1, [3 ]). The most current WPATH guidelines (version 7) for the care of adults, adolescents and children with gender dysphoria were published in 2011 [10]. Trained mental health professionals who are familiar with the WPATH guidelines with experience and training in child and adolescent developmental psychopathology should make the diagnosis of gender dysphoria and be involved in the initial treatment phase [10]. In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, ‘Gender Dysphoria’ has replaced the previous diagnosis of ‘Gender Identity Disorder’ and is used to describe the distress felt by individuals whose physical appearance does not match their gender identity. The change in terminology was meant to remove the ‘disorder’ aspect of gender dysphoria, to maintain consistency of the terminology used throughout the world, and to provide a formal diagnosis to &&
estimated to be approximately 3–6% in the USA [5]. Two household surveys performed in the USA reported that 0.3–0.5%, or close to 1 million, of adult respondents identified as transgender [6,7]. These types of reports are fraught with response and selection biases and are likely underestimates of the true prevalence. There are even less data on the pediatric population. In 2011, the Youth Risk Behavior Survey was administered to 2730 students in 22 public middle schools in a San Francisco school district. The authors of this study found that 3.8% of students identified as lesbian, gay or bisexual, and 1.3% of students identified as transgender [8 ]. Although this study also carries its own inherent biases, these are currently the best data we have on the prevalence of transgenderism in teenagers. &
Biologic (natal) sex refers to genetic sex and the biological and physiological characteristics that define maleness or femaleness Gender identity refers to an inherent sense of being male or female regardless of biologic (natal) sex Gender nonconformity or variance refers to the extent that an individual’s gender identity and/or expression differs from cultural or societal norms Transgenderism refers to individuals who identify with and/or desire to live and be accepted as the opposite sex rather than their biologic (natal) sex Transgender man/boy refers to self-identified gender; an individual is biologically female but identifies as male Transgender woman/girl refers to self-identified gender; an individual is biologically male but identifies as female Gender dysphoria refers to the discomfort or distress that is caused by a discrepancy between an individual’s gender identity and biologic (natal) sex*
FIGURE 1. Terminology. Current formal diagnosis found in the Diagnostic and Statistical Manual of Mental Disorders (5th edition) [3 ]. &&
348
www.co-obgyn.com
Volume 26 Number 5 October 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gynecologic care for transgender youth Unger
facilitate patient access to care and to help justify insurance coverage for treatment [3 ]. A diagnosis of persistent gender dysphoria is required for consideration of treatment, which includes the suppression of puberty and initiation of hormonal therapy in adolescents. Once children enter Tanner stage 2 of pubertal development, persistent gender dysphoria should be formally diagnosed and treated. At this stage of puberty, children are not likely to deviate from their self-identified gender; therefore, initial treatment begins with pubertal suppression [11]. Delay in pubertal development is a very important part of the initial treatment for adolescents because the intervention is reversible but provides patients and their families time to understand the process and to determine the right transition plan [12]. The recommendation to suppress puberty is based on the work done by Hembree et al. [13] in Amsterdam and is carefully outlined in the Clinical Practice Guideline for the Endocrine Treatment of Transsexual Persons, developed and published by the Endocrine Society and co-sponsored by many international pediatric societies and the WPATH. Prior to initiating endocrine therapy, a mental health professional must document the patient’s diagnosis of gender dysphoria as well as any other co-existing psychiatric conditions, outline the patient’s selfidentifying characteristics and confirm his or her eligibility for hormone therapy and/or sex confirmation surgery. The eligibility criteria for pubertal suppression, as outlined by the WPATH, are depicted in Fig. 2. &&
HORMONE THERAPY Many types of providers, including adolescent medicine specialists, pediatric and adolescent gynecologists, pediatric endocrinologists and reproductive endocrinologists, incorporate the endocrine care of the transgender adolescent in their practice. In 2011, Hembree [14] published a review of the guidelines for the treatment of adolescent transgender
patients, which is based on the most up-to-date comprehensive guidelines for adults and adolescents [13]. An article published in 2013 by Spack in JAMA [15 ] also offers excellent guidelines based on the Endocrine Society’s recommendations for the hormonal care of the adolescent. The first phase of endocrine therapy for adolescents is often referred to as the suppressive stage and involves pubertal suppression, which is considered reversible. Therapy may be initiated once a complete physical examination (documenting testicular volume and penis width in biologic boys and breast size in biologic girls, as well as terminal hair distribution in both) and baseline metabolic labs, sex steroid levels (confirming early puberty), as well as bone age and mineral density are completed. Once the examination is complete and patients and their parents are properly counseled about expectations, pubertal suppression is achieved with GnRH analogs. The most commonly used GnRH agonist is Lupron Depot (leuprolide acetate) 3.75 mg, which is an intramuscular injection administered monthly. The first dose may be administered at any time in boys and nonmenstruating girls. If female patients have reached menarche, Lupron should be administered in the luteal phase of the menstrual cycle to avoid a flare response during menses. If it is administered during the follicular phase of the menstrual cycle, concomitant progesterone or combined estrogen-progesterone therapy should be administered to avoid heavy menses during that cycle. Alternatively, a second injection of Lupron may be administered during the luteal phase. After initiating suppressive therapy, the Endocrine Society recommends close surveillance of the parameters depicted in Fig. 3. Most adolescent patients experience extreme relief and improvement in their dysphoria once suppressive therapy is initiated. The induction phase is the second phase of hormone therapy for adolescents and is recommended at age 16 [16]. Per the Endocrine Society guidelines, consent from a parent or guardian is preferable, but not required for &&
1) The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (suppressed or expressed). 2) Gender dysphoria emerged or worsened with the onset of puberty. 3) Any coexisting psychological, medical, or social problems that could interfere with treatment have been addressed; the adolescent is stable enough to start treatment. 4) The adolescent has given informed consent; when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.
FIGURE 2. Eligibility criteria for pubertal suppression. Adapted with permission from [10]. 1040-872X ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-obgyn.com
349
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent and pediatric gynecology
SURGERY
Every 3 months • Height (standing, sitting), weight, tanner stage • Serum LH, FSH, estradiol, testosterone Every 12 months • Renal function • Liver function • Lipid panel • Glucose and glycosylated hemoglobin • Bone density (DEXA) • Bone age (X-ray of the left hand)
FIGURE 3. Pubertal suppression surveillance. DEXA, dualenergy X-ray absorptiometry. Figure created from information found in [13].
this treatment. Although most 16-year-old patients are able to make informed decisions about their care, providers should abide by their institutional or departmental requirements with regard to obtaining parental consent for treatment. Cross-sex hormones are used to induce the desired feminizing or virilizing secondary sex characteristics. The effects of these hormones are considered to be partially reversible. If patients have not begun living full-time as their self-affirmed gender, commonly referred to as the ‘real life experience’, it is recommended that they do so at this stage, and that they also maintain their relationship with their mental health provider during this portion of the transition [10]. Per the Endocrine Society’s guidelines, male-to-female patients are prescribed daily oral estradiol and female-to-male patients are prescribed intramuscular testosterone, which is injected every 2 weeks. Three-month follow-up is necessary to monitor serum levels of sex steroids, and the doses are titrated every 6 months according to each patient’s response. Figures 4 and 5 depict the protocol for induction of puberty as well as the surveillance recommended for transgender boys and girls. GnRH suppression is continued with sex steroid therapy and is stopped if and when gonadectomy is performed as part of the surgical treatment for patients.
Confirmation surgery is often referred to as ‘genital reassignment surgery’ or ‘bottom surgery’. This refers to vaginoplasty procedures for male-to-female patients and phalloplasty procedures for female-tomale patients. Hysterectomy and oophorectomy for female-to-male patients can also be part of confirmation surgery, and are usually performed prior to and separate from phalloplasty. Similarly, orchiectomy for male-to-female patients is part of confirmation surgery, and can be performed prior to vaginoplasty procedures, but they are often performed concomitantly. ‘Top surgery’ usually refers to breast surgery: mastectomy with chest contouring for female-to-male patients, and breast augmentation for male-to-female patients. The media has played a large role in increasing the visibility of children and young teens who are undergoing transition to their self-affirmed genders; with the introduction of GnRH analogs for pubertal suppression and the early age of hormonal therapy initiation, the topic of when it may be ‘appropriate’ to perform confirmation surgery as the last and final step in the transition process has become a hot topic for discussion [17 ]. Timing for surgery can be very controversial and there are no studies that have evaluated the appropriate timing of surgery in adolescents. In the last 5 years, several cases of confirmation surgery have been reported in teens younger than the age of 18 in countries outside of the USA. For example, there are case reports of Thai transgender girls undergoing reassignment surgery between 15 and 16 years of age [18]. There have been other published successful surgical results in adolescents under the age of 18 following pubertal suppression and estrogen therapy [19]. In these patients, surgeons were able to achieve a cosmetically appealing result with low associated morbidity to the patient as well as reports of good patient satisfaction. The concern for vaginoplasty and phalloplasty procedures prior to age 18 is two-fold. First, (and probably most important), there is a concern &
Feminizing (female puberty): 17-β estradiol (oral) Initial – 5 µg/kg/day Increasing the dose every 6 months – 10 µg /kg/day 15 µg /kg/day 20 µg /kg/day Virilizing (male puberty): Testosterone enanthate or cypionate (intramuscular) Initial – 25 mg/m2 every 2 weeks Increasing the dose every 6 months – 50 mg/m2 every 2 weeks 75 mg/m2 every 2 weeks 100 mg/m2 every 2 weeks
FIGURE 4. Protocol for induction of puberty. Figure created from information found in [13]. 350
www.co-obgyn.com
Volume 26 Number 5 October 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gynecologic care for transgender youth Unger
Every 3 months • Height (standing, sitting), weight, tanner stage • Serum LH, FSH, estradiol, testosterone Every 12 months • Renal function • Liver function • Lipid panel • Glucose and glycosylated hemoglobin • Bone density* (DEXA) • Bone age (X-ray of the left hand)
FIGURE 5. Pubertal induction surveillance. Parameters measured until age 25–30 or until peak bone mass has been reached. DEXA, dual-energy X-ray absorptiometry. Figure created from information found in [13].
regarding patient maturity and ability to provide informed consent for an irreversible surgery where the risk of regret far outweighs the benefit that might be obtained from having the surgery. Second, from a surgical point of view, the amount of genital skin that is available for reconstruction may be limited before age 18, especially in the setting of pubertal suppression, requiring more extensive grafting, which may alter the cosmetic result and feasibility of the surgery. The WPATH does not recommend genital reassignment surgeries until adolescents have reached the legal age of majority in their respective country [10]. In most countries, the legal age of majority is 18. The Endocrine Society also supports these recommendations. Although these standards of care serve as guidelines for most surgeons, there are published reports (mentioned above) as well as anecdotal, unpublished reports of adolescents under the age of 18 who have undergone confirmation surgery. As the transition process and need to delay pubertal development are occurring at younger ages, it is not implausible that adolescents are seeking surgical care at younger ages as well. With time, flexibility has been built into the age guidelines for chest surgery for female-to-male adolescents as the benefits of this type of surgery, despite its irreversibility, have been recognized. Currently, chest surgery in female-to-male patients is permissible at an earlier age in the context of ample time living in the desired gender role and after 1 year of testosterone treatment [10]. It is not hard to imagine that there may be special circumstances in which a severely gender dysphoric teenage girl may benefit from genital surgery at an earlier age. However, it is difficult to create guidelines for these younger ages, and it no doubt remains very controversial. Until 2014, the literature on the ethical principles guiding decision-making for surgical reassignment in adolescents was very sparse. A recent review on this
topic was published in the Journal of Sexual Medicine [17 ], and discusses the ethical principles that the surgeon should consider when counseling a minor about confirmation surgery. Each ethical principle requires careful evaluation and assessment and involves a contract and understanding between patient and surgeon. The decision to perform surgery on a patient who is a minor remains a complex one, and a case-by-case approach is recommended with the WPATH and Endocrine Society guidelines serving as an important framework for the decision-making process. Some gender nonconforming youth do not desire complete phenotypic transition, and experience significant improvement and even resolution of their gender dysphoria with their endogenous hormones alone, with exogenous hormone-only treatment, or with partial surgical gender confirmation surgeries. Most importantly, providers should recognize that transition goals and requests for treatment may change over time and they should remain supportive and adaptable throughout the process. Prior to surgery, providers should ensure that patients have lived continuously for at least 12 months in the gender role that is congruent with their gender identity, as surgery is considered the last and final step. The pediatric provider may act as an important social support for patients going through this real life experience, as this portion of the transition process can sometimes be very challenging in the context of school and/or an unsupportive family environment. &
CLINICIANS CARING FOR TRANSGENDER YOUTH Both the American Medical Association and American Academy of Pediatrics advocate for a multidisciplinary approach to caring for transgender adolescents. Both male-to-female and female-tomale patients may initially seek the care of a generalist or sub-specialist gynecologist. The sense of discomfort with their genitals sometimes prompts patients to discuss these concerns with providers who specialize in that anatomic region of the body. Parents of patients may initially feel that a gynecologic evaluation is necessary to help guide them in the right direction, especially if the gynecologist has experience with endocrinology and vaginal reconstructive surgery. Many transgender boys seek consultation for menstrual suppression. For these patients, menstrual suppression can be achieved with continuous oral contraceptives or depot medroxyprogesterone. The initial discussion of further pubertal suppression with GnRH analogs may take place at that visit as well, and under the right
1040-872X ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-obgyn.com
351
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent and pediatric gynecology
circumstances, treatment may be initiated according to the guidelines set by the Endocrine Society. In addition, providers should always ensure that their patients are not obtaining off-label hormone therapy from outside sources such as their friends or the Internet. Although there are little data on the actual percentage of patients who circumscribe the usual routes for obtaining prescription hormones, anecdotally, these patients exist in both the adult and adolescent population. Providers who are not comfortable with the initial or hormonal care of these patients should refer them to a provider who routinely cares for adolescents and who is specifically willing to care for patients with gender dysphoria. Adolescent patients may also present for consultation regarding their surgical options. The provider should be aware of the current guidelines for age and for referral requirements recommended by the WPATH, and should have a basic understanding of the reconstructive surgeries available to their patients. Sometimes a referral to a gynecologist who has previous experience with reconstructive genital surgery for the transgender patient is useful if the patient wishes to proceed with a vaginoplasty procedure. For the female-to-male patient, an important discussion is the one regarding desire for and timing of hysterectomy with or without oophorectomy. This is a service the gynecologist can provide, and should be comfortable performing. A minimally invasive approach (either vaginal or laparoscopic) to hysterectomy is recommended as a portion of the lower abdomen is often used as a graft site for some phalloplasty procedures and preservation of the vascular supply is important and is likely to be comprised with a transverse abdominal incision. If open abdominal hysterectomy is necessary, a vertical midline incision is preferred. Gynecologists may play an important role in counseling patients about the effect of hormonal therapy on future fertility. Despite their young age, adolescents should be counseled about these effects, as many hormonal therapies may have long-lasting effects on their fertility. Male-to-female patients should be made aware of the effects that GnRH analogs and estrogens may have on sperm production and should be made aware of the possibility of prehormonal sperm banking. Female-to-male patients should be counseled about the effects of testosterone on female fertility and should be made aware of the option for oocyte retrieval and cryopreservation in order to maintain future fertility. Additionally, the decision to undergo concomitant oophorectomy at the time of hysterectomy affects future fertility as well, and the gynecologist should be sure to address this with his or her patient when discussing timing of surgery. 352
www.co-obgyn.com
Transgender adolescent patients fall under the high-risk category for metabolic dysfunction and require more surveillance than their nontransgender counterparts. For example, androgen suppression and estrogen substitution in male-to-female patients can lead to increases in visceral fat, which is associated with increases in triglyceride levels, insulin resistance, hepatic dysfunction, and elevated blood pressure [13]; therefore, lipid and diabetes screening should be performed at each annual visit for these patients. If the patient has recently been started on cross-sex steroids, screening should be done more frequently according to the Endocrine Society’s guidelines. If the adolescent provider is not the prescribing provider, he or she should ensure that patients are followed closely by their prescribing provider, and should have access to the patient’s metabolic indices. One of the most important things a provider caring for transgender youth can do is not make assumptions about their patients’ sexual behaviors or preferences. In addition, screening for sexually transmitted infections (STIs) is an important part of the routine health of all adolescent patients, including those who are transgender. The data show that teenagers who self-identify as LGBTQ tend to take more risks with regard to sex behaviors than do their self-identified, nontransgender heterosexual peers [20,21]. A cross-sectional study by Robinson et al. looked at sexually risky attitudes and behaviors among a large population-based sample of LGBTQ and heterosexual-identified teenagers in middle and high school. The authors found that sexual risk disparities between LGBTQ and heterosexual youths began as early as the middle school years with peer victimization accounting for a significant portion of these disparities [22 ]. Importantly, we have data that show that transgender girls face the most sexual health disparities compared with other sexual minority youth, as this group has been shown to have a higher rate of STIs and HIV [23,24]. These studies have found that unsafe sex behaviors are the highest risk factor for acquiring HIV in this particular group [25]. Providers should establish good rapport with their teenage patients, openly acknowledge their patients’ gender identities, create a comfortable environment that facilitates disclosure about sex behaviors and attitudes and ask very specific and directed questions about these behaviors and preferences. Parental support may also play an important role in helping to mitigate some of these risk factors. There is evidence that shows that when parents reject their child’s identity and fail to offer support, these children are at risk for low selfesteem, low life satisfaction and depression, which can lead to high-risk sexual behaviors [26,27 ]. In &
&
Volume 26 Number 5 October 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Gynecologic care for transgender youth Unger
one study, parental support was shown to increase regular condom use among transgender girls, whereas those without such support were more likely to report inconsistent condom use [28]. The research on the mental health of transgender adolescents is not as robust as the literature that currently exists on sexual minority children; however, the data that have been published show that there are higher rates of depression and high-risk behaviors in transgender teens compared with those who are nontransgender and heterosexual [29 ]. Anxiety and depressive disorders are thought to be common among transgender youth. In a Dutch study, up to one-third of children presenting with gender dysphoria were also diagnosed with anxiety disorders [30]. This anxiety may be related to real or perceived rejection, peer victimization and abuse as a result of the adolescent’s transgender status, or fear of being ‘outed’ or discovered if he or she is living as their self-identified gender [31]. Suicidality has also been shown to be higher among the LGBTQ community, and specifically in transgender individuals. In 2011, Grant et al. [32] published Injustice at Every Turn: A Report of the National Transgender Discrimination Survey, which was one of the first national, representative surveys of the transgender community. The survey found that suicide attempts were reported by 41% of the 6450 survey respondents. The authors also reported high rates of victimization: 78% reported harassment and 35% reported physical assault while in school (K–12) with 15% having left school because of harassment. In a recent survey on sexual harassment among adolescents, Mitchell et al. [33] found that transgender youth reported the highest rates of sexual harassment (81%), followed by gender nonconforming youth (69%). Providers caring for these adolescent patients should screen for low selfesteem, depression and other mood disorders, and they should help parents learn how to better support their children, as their support may help counterbalance the mental health impact of the stigmatization and societal marginalization their children may experience. &
CONCLUSION Transgender teenagers are high-risk patients with significant medical and social needs. There are few publications in the gynecology journals on the care of the transgender adolescent. This is surprising, as both the gynecologist and adolescent specialist play an important role in the care of these patients. Being equipped to take care of transgender teens first starts with understanding the stages of diagnosis and treatment that are recommended by the APA,
WPATH and Endocrine Society. Second, providers should understand their role in counseling, screening, maintaining health and supporting their patients through the transition process. With this knowledge, those who care for adolescents can successfully become part of the medical home for transgender youth. Acknowledgements None. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Stoddard J, Leibowitz SF, Ton H, Snowdon S. Improving medical education about gender-variant youth and transgender adolescents. Child Adolesc Psychiatric Clin N Am 2011; 20:779–791. 2. Grossman AH, D’Augelli AR. Transgender youth and life threatening behaviors. Suicide Life Threat Behav 2007; 37:527–537. 3. American Psychiatric Association. 2013. Gender dysphoria. http:// && www.dsm5.org/Documents/Gender%20Dysphoria%20Fact%20Sheet.pdf. [Accessed 25 April 2014] This document reviews the importance of the new ‘gender dysphoria’ diagnosis in the most up-to-date version of the DSM. 4. Gooren LJ. Clinical practice: care of transsexual persons. N Engl J Med 2011; 364:1251–1257. 5. Haas AP, Eliason M, Mays VM, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. J Homosex 2010; 58:10–51. 6. Gates GJ. How many people are lesbian, gay, bisexual, and transgender? Williams Institute, UCLASchool of Law. http://williamsinstitute.law.ucla.edu/ wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf. [Accessed 20 March 2014] 7. Conron KJ, Scott G, Stowell GS, Landers SJ. Transgender health in Massachusetts: results from a household probability sample of adults. Am J Public Health 2012; 102:118–122. 8. Shields JP, Cohen R, Glassman JR, et al. Estimating population size and & demographic characteristics of lesbian, gay, bisexual and transgender youth in middle school. J Adolscent Health 2013; 52:248–250. This cross-sectional study is the most recent and up-to-date data we have on the prevalence of transgender youth. 9. Deogracias JJ, Johnson LL, Meyer-Bahlburg HFL, et al. The gender identity/ gender dysphoria questionnaire for adolescents and adults. J Sex Res 2007; 44:370–379. 10. Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gendernonconformingpeople, Version 7. World Professional Association for Transgender Health. Int J Transgenderism 2011; 13:165–232. 11. Drummond KD, Bradley SJ, Peterson-Bidali M, et al. A follow-up study of girls with gender identity disorder. Dev Psychol 2008; 44:34–45. 12. Delemarre-Van de Waal HA, Cohen-Kettenis PT. Clinical Management of gender identity disorder in adolescents: a protocol on psychological and paediatric endocrinology aspects. Eur J Endocrinol 2006; 155 (Suppl 1): S131–137. 13. Hembree WC, Cohen-Kettenis PT, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2009; 94:3132–3154. 14. Hembree WC. Guidelines for pubertal suspension and gender reassignment for transgender adolescents. Child Adolesc Psychiatric Clin N Am 2011; 20:725–732. 15. Spack SP. Management of transgenderism. JAMA 2013; 309:478–484. &&
This is an important, recently published article describing the recommendations for the care of the transgender adolescent, based on the WPATH and Endocrine Society guidelines. 16. Olsen J, Forbes C, Belzer M. Management of the transgender adolescent. Arch Pediatr Adolesc Med 2011; 165:171–176.
1040-872X ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-obgyn.com
353
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Adolescent and pediatric gynecology 17. Milrod C. How young is too young: ethical concerns in genital surgery of the transgender mtf adolescent. J Sex Med 2014; 11:338–346. This is an interesting article addressing the ethical principles that should be considered when contemplating performing confirmation surgery on minor patients 18. Winter S. Thai transgenders in focus: demographics, transitions and identities. Int J Transgenderism 2006; 9:15–27. 19. Kreukels BPC, Cohen-Kettenis PT. Puberty suppression in gender identity disorder: the Amsterdam experience. Nat Rev Endocrinol 2011; 7:466–472. 20. Kann L, Olsen EO, McManus T, et al., Centers for Disease Control and, Prevention. Sexual identity, sex of sexual contacts, and health-risk behaviors among students in grades 9-12-Youth Risk Behavior Surveillance, selected sites, Unites States. MMWR Surveill Summ 2011; 60:1–133. 21. Friedman MS, Marshal MP, Guadamuz TE, et al. A meta-analysis of disparities in childhood sexual abuse,parental physical abuse, and peer victimization amongsexual minority and sexual nonminority individuals. Am JPublic Health 2011; 101:1481–1494. 22. Robinson JP, Espelage DL. Peer victimization and sexual risk differences & between lesbian, gay, bisexual, transgender, or questioning and nontransgender heterosexual youths in grades 7-12. Am J Public Health 2013; 103:1810–1819. This is an important study examining peer victimization in sex minority youth and transgender teenagers. 23. Garofolo R, Deleon J, Osmer E, et al. Overlooked, misunderstood and at-risk: Exploring the lives and HIV risk of ethnic minority male-to-female transgender youth. J Adolesc Health 2006; 38:230–236. 24. Wilson EC, Garofalo R, Harris RD, et al. Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work. AIDS Behav 2009; 13:902–913. 25. Berg MB, Mimiaga MJ, Safren SA. Mental health concerns of gay and bisexual men seeking mental health services. J Homosex 2008; 54:293–306. &
354
www.co-obgyn.com
26. Hong JS, Espelage DL, Kral MJ. Understanding suicide among sexual minority youth in America: an ecological systems analysis. J Adolesc 2011; 34:885– 894. 27. Simons L, Schrager SM, Clark LF, et al. Parental support and mental health & among transgender adolescents. J Adoles Health 2013; 53:791–793. This article shows the association between parental support and self-concept in transgender teenagers and concludes that parental support is paramount for social adjustment in this patient population. 28. Wilson EC, Iverson E, Garofolo R, Belzer M. Parental support and condom use among transgender female youth. Assoc Nurses AIDS Care 2012; 23:306–317. 29. Spack N, Edwards-Leeper L, Feldman HA, et al. Children and adolescents & with gender identity disorder referred to a pediatric medical center. Pediatrics 2012; 129:418–425. This is a comprehensive observational article describing the pediatric patient population that presents for transgender care at a tertiary medical center specializing in gender management services. 30. Wallien MSC, Swaab H, Cohen-Kettenis PT. Psychiatric comorbidity among children with gender identity disorder. J Am Acad Child Adolesc Psychiatry 2007; 46:1307–1314. 31. Herbert S. Female-to-male transgender adolescents. Child Adolsc Psychiatric Clin N Am 2011; 20:681–688. 32. Grant JM, Mottet LA, Tanis J, et al. Injustice at every turn: a report of the National Transgender Discrimination Survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011 ; http://www.thetaskforce.org/reports_and_research/ntds. [Accessed 20 April 2014] 33. Mitchell KJ, Ybarra ML, Korchmaros JD. Sexual harassment among adolescents of different sexual orientations and gender identities. Child Abuse & Neglect 2014; 38:280–295.
Volume 26 Number 5 October 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
