What are the treatment approaches for adolescents receiving gender-affirming care?

From the Guidelines

Gender-affirming care for adolescents should involve a comprehensive, individualized approach that includes psychological support, social transition, puberty blockers, and hormone therapy, with the goal of improving mental health, reducing suicidality, and enhancing overall well-being. This approach is supported by recent studies, such as the 2024 study published in Anaesthesia, which highlights the importance of gonadotropin-releasing hormone analogues in suppressing testosterone and oestradiol, allowing adolescents to explore their gender identity without developing unwanted secondary sex characteristics 1.

Key Components of Gender-Affirming Care

• Psychological support from professionals experienced in gender issues
• Social transition, including adopting the name, pronouns, and gender expression that aligns with their identity
• Puberty blockers (GnRH agonists like leuprolide or histrelin) to pause puberty, typically around Tanner stage 2-3
• Gender-affirming hormones, such as estrogen (typically estradiol) for transgender girls or testosterone for transgender boys, introduced around age 16
• Ongoing monitoring of physical changes, bone density, and metabolic parameters

The 2023 study published in Clinical Psychology Review emphasizes the importance of empirically supported affirmative psychological interventions for transgender and non-binary youth and adults, highlighting the need for mental health professionals to play a critical role in providing care for this population 1. Additionally, the 2015 study published in Annals of Internal Medicine notes that research shows that when transgender persons receive individual, medically appropriate care, they have improved mental health, reduction in suicide rates, and lower health care costs overall 1.

Multidisciplinary Approach

A multidisciplinary team, including mental health professionals, endocrinologists, and primary care providers, should be involved in the care of adolescents receiving gender-affirming care, with each intervention requiring thorough assessment, informed consent, and ongoing support. The decision to institute a hormone therapy regimen or pursue sexual reassignment surgery for transgender individuals should be made on a case-by-case basis, taking into account the individual's unique needs and circumstances.

From the Research

Treatment Approaches for Adolescents Receiving Gender-Affirming Care

• Gender-affirming hormone treatment is a crucial part of care for trans adolescents, enabling them to develop secondary sexual characteristics congruent with their identified genders 2.
• The treatment approaches for adolescents receiving gender-affirming care include:
  • Pubertal blockade with gonadotropin-releasing hormone agonists to suppress endogenous sex hormone secretion 3.
  • Administration of gender-affirming hormones to maintain sex hormone levels within the normal range for the person's affirmed gender 3.
  • Social affirmation and support from mental health providers and primary care providers 4.
• The benefits of gender-affirming care for adolescents include improved mental health outcomes, such as decreased depression and suicidality 5.
• However, there are also potential risks and complications associated with gender-affirming care, such as the need for ongoing monitoring for adverse effects of sex steroids and reproductive organ cancer risk 3.

Barriers and Opportunities for Gender-Affirming Care in Primary Care

• Transgender and gender-diverse (TGD) adolescents experience barriers to receiving gender-affirming care, including microaggressions and poor psychosocial support 4.
• Delivering gender-affirming care in the pediatric primary care setting may help facilitate improved access and convenience for TGD adolescents and their caregivers 4.
• Opportunities for integrating primary care and specialty gender-affirming care include training and interdisciplinary collaboration, as well as improving primary care provider-to-specialist communication and collaboration 4.

Ethical Considerations for Gender-Affirming Care

• The provision of access to gender-affirming hormone treatment for consenting trans adolescents is ethically required, based on the principles of beneficence, nonmaleficence, autonomy, and justice 2.
• However, there are also ethical concerns and debates surrounding the use of gender-affirming therapy in children and adolescents, including the potential risks and lack of supportive scientific evidence for pharmacological and surgical interventions 6.