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Pediatric Collections: LGBTQ+: Support and Care (Part 3: Caring for Transgender Children)

By American Academy of Pediatrics

Part 3 of this first-of-its-kind 3-part series helps show how pediatric primary care providers (PPCPs) are uniquely situated to screen, identify, and care for transgender and gender-diverse youths.

    1. Page 5
      Address correspondence to Jason Rafferty, MD, MPH, EdM, FAAP. Email: Jason_Rafferty@mail.harvard.edu

      As a traditionally underserved population that faces numerous health disparities, youth who identify as transgender and gender diverse (TGD) and their families are increasingly presenting to pediatric providers for education, care, and referrals. The need for more formal training, standardized treatment, and research on safety and medical outcomes often leaves providers feeling ill equipped to support and care for patients that identify as TGD and families. In this policy statement, we review relevant concepts and challenges and provide suggestions for pediatric providers that are focused on promoting the health and positive development of youth that identify as TGD while eliminating discrimination and stigma.

    2. Page 35
      Address correspondence to Robert W.S. Coulter, PhD, MPH, Graduate School of Public Health, University of Pittsburgh, 6129 Public Health Building, 130 De Soto St, Pittsburgh, PA 15261. E-mail: robert.ws.coulter@pitt.edu

      CONTEXT Compared with cisgender (nontransgender), heterosexual youth, sexual and gender minority youth (SGMY) experience great inequities in substance use, mental health problems, and violence victimization, thereby making them a priority population for interventions.

      OBJECTIVE To systematically review interventions and their effectiveness in preventing or reducing substance use, mental health problems, and violence victimization among SGMY.

      DATA SOURCES PubMed, PsycINFO, and Education Resources Information Center.

      STUDY SELECTION Selected studies were published from January 2000 to 2019, included randomized and nonrandomized designs with pretest and posttest data, and assessed substance use, mental health problems, or violence victimization outcomes among SGMY.

      DATA EXTRACTION Data extracted were intervention descriptions, sample details, measurements, results, and methodologic rigor.

      RESULTS With this review, we identified 9 interventions for mental health, 2 for substance use, and 1 for violence victimization. One SGMY-inclusive intervention examined coordinated mental health services. Five sexual minority–specific interventions included multiple state-level policy interventions, a therapist-administered family-based intervention, a computer-based intervention, and an online intervention. Three gender minority–specific interventions included transition-related gender-affirming care interventions. All interventions improved mental health outcomes, 2 reduced substance use, and 1 reduced bullying victimization. One study had strong methodologic quality, but the remaining studies’ results must be interpreted cautiously because of suboptimal methodologic quality.

      LIMITATIONS There exists a small collection of diverse interventions for reducing substance use, mental health problems, and violence victimization among SGMY.

      CONCLUSIONS The dearth of interventions identified in this review is likely insufficient to mitigate the substantial inequities in substance use, mental health problems, and violence among SGMY.

    3. Page 55
      Address correspondence to Caroline Salas-Humara, MD, Department of Pediatrics, New York University School of Medicine, 462 First Ave, Room A316, New York, NY 10016. E-mail: caroline.salas-humara@nyulangone.org

      Transgender and gender-nonconforming (TGNC) youth who suffer from gender dysphoria are at a substantially elevated risk of numerous adverse physical and psychosocial outcomes compared with their cisgender peers. Innovative treatment options used to support and affirm an individual’s preferred gender identity can help resolve gender dysphoria and avoid many negative sequelae of nontreatment. Yet, despite advances in these relatively novel treatment options, which appear to be highly effective in addressing gender dysphoria and mitigating associated adverse outcomes, ethical challenges abound in ensuring that young patients receive appropriate, safe, affordable treatment and that access to this treatment is fair and equitable. Ethical considerations in gender-affirming care for TGNC youth span concerns about meeting the obligations to maximize treatment benefit to patients (beneficence), minimizing harm (nonmaleficence), supporting autonomy for pediatric patients during a time of rapid development, and addressing justice, including equitable access to care for TGNC youth. Moreover, although available data describing the use of gender-affirming treatment options are encouraging, and the risks of not treating TGNC youth with gender dysphoria are evident, little is known about the long-term effects of both hormonal and surgical interventions in this population. To support ethical decision-making about treatment options, we encourage the development of a comprehensive registry in the United States to track long-term patient outcomes. In the meantime, providers who work with TGNC youth and their families should endeavor to offer ethically sound, patient-centered, gender-affirming care based on the best currently available evidence.

    4. Page 64
      Address correspondence to Martin den Heijer, MD, PhD, Department of Endocrinology, Amsterdam University Medical Center, Boelelaan 1117, 1081 HV Amsterdam, Netherlands. E-mail: m.denheijer@amsterdamumc.nl

      BACKGROUND AND OBJECTIVES The effects of endocrinological treatment on cardiovascular risk profile in transgender adolescents are unknown. In this retrospective cohort study, we aim to investigate these effects and assess obesity and dyslipidemia prevalence in transgender adolescents at 22 years compared with peers.

      METHODS Changes in BMI, systolic blood pressure (SBP), diastolic blood pressure (DBP), glucose, homeostatic model assessment for insulin resistance (HOMA-IR), and lipid values during treatment, along with the prevalence of obesity and dyslipidemia at 22 years, were recorded in 71 transwomen and 121 transmen who started gonadotropin-releasing hormone agonists in their adolescence (15 years), with a subsequent addition of sex hormones (17 years).

      RESULTS In transwomen, changes in BMI (+3.0; 95% confidence interval [CI] 1.6 to 4.4), SBP (–2 mmHg; 95% CI –7 to 3), DBP (+10 mmHg; 95% CI 7 to 14), glucose (0.0 mmol/L; 95% CI –0.2 to 0.2), HOMA-IR (+0.6; 95% CI –0.6 to 1.9), and lipid values were similar or more favorable compared with peers. The same was true for transmen regarding changes in BMI (+2.3; 95% CI 1.7 to 2.9), SBP (+7 mmHg; 95% CI 3 to 10), DBP (+7 mmHg; 95% CI 5 to 10), glucose (+0.1 mmol/L; 95% CI –0.1 to 0.3), HOMA-IR (–0.2; 95% CI –0.8 to 0.3), and lipid values. At age 22, obesity prevalence was 9.9% in transwomen, 6.6% in transmen, 2.2% in ciswomen, and 3.0% in cismen.

      CONCLUSIONS Generally, endocrinological treatment in transgender adolescents is safe regarding cardiovascular risk. Because obesity is more prevalent in transgender adolescents compared with peers, body weight management should be important during the medical trajectory.

    5. Page 73
      Address correspondence to Julia C. Sorbara, MD, MSc, Division of Endocrinology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8. E-mail: julia.sorbara@sickkids.ca

      BACKGROUND Gender-incongruent (GI) youth have high rates of mental health problems. Although gender-affirming medical care (GAMC) provides psychological benefit, some GI youth present to care at older ages. Whether a relationship exists between age of presentation to GAMC and mental health difficulties warrants study.

      METHODS A cross-sectional chart review of patients presenting to GAMC. Subjects were classified a priori as younger presenting youth (YPY) (<15 years of age at presentation) or older presenting youth (OPY) (≥15 years of age). Self-reported rates of mental health problems and medication use were compared between groups. Binary logistic regression analysis was used to identify determinants of mental health problems. Covariates included pubertal stage at presentation, social transition status, and assigned sex.

      RESULTS Of 300 youth, there were 116 YPY and 184 OPY. After presentation, more OPY than YPY reported a diagnosis of depression (46% vs 30%), had self-harmed (40% vs 28%), had considered suicide (52% vs 40%), had attempted suicide (17% vs 9%), and required psychoactive medications (36% vs 23%), with all P < .05. After controlling for covariates, late puberty (Tanner stage 4 or 5) was associated with depressive disorders (odds ratio 5.49; 95% confidence interval [CI]: 1.14–26.32) and anxiety disorders (odds ratio 4.18 [95% CI: 1.22–14.49]), whereas older age remained associated only with psychoactive medication use (odd ratio 1.31 [95% CI: 1.05–1.63]).

      CONCLUSIONS Late pubertal stage and older age are associated with worse mental health among GI youth presenting to GAMC, suggesting that this group may be particularly vulnerable and in need of appropriate care.

    6. Page 83
      Address correspondence to Tim C. van de Grift, MD, MBA, PhD, Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Location VUmc, De Boelelaan 1117 (ZH-4D120), 1081 HV, Amsterdam, Netherlands. E-mail: t.vandegrift@amsterdamumc.nl

      OBJECTIVES Puberty suppression (PS) is a cornerstone of treatment in youth experiencing gender dysphoria. In this study, we aim to inform prescribing professionals on the long-term effects of PS treatment on the development of sex characteristics and surgical implications.

      METHODS Participants received PS according to the Endocrine Society guideline at Tanner 2 or higher. Data were collected from adolescents who received PS between 2006 and 2013 and from untreated transgender controls. Data collection pre- and post-PS and before surgery included physical examination and surgical information.

      RESULTS In total, 300 individuals (184 transgender men and 116 transgender women) were included. Of these, 43 individuals started PS treatment at Tanner 2/3, 157 at Tanner 4/5, and 100 used no PS (controls). Breast development was significantly less in transgender men who started PS at Tanner 2/3 compared with those who started at Tanner 4/5 and controls. Mastectomy was more frequently omitted or less invasive after PS. In transgender women, the mean penile length was significantly shorter in the PS groups compared with controls (by 4.8 cm [Tanner 2/3] and 2.1 cm [Tanner 4/5]). As a result, the likelihood of undergoing intestinal vaginoplasty was increased (odds ratio = 84 [Tanner 2/3]; odds ratio = 9.8 [Tanner 4/5]).

      CONCLUSIONS PS reduces the development of sex characteristics in transgender adolescents. As a result, transgender men may not need to undergo mastectomy, whereas transgender women may require an alternative to penile inversion vaginoplasty. These surgical implications should inform decision-making when initiating PS.

    7. Page 91
      Address correspondence to Jack L. Turban, MD, MHS, Department of Psychiatry, Massachusetts General Hospital, 15 Parkman St, WAC 812, Boston, MA 02114. E-mail: jack.turban@mgh.harvard.edu

      BACKGROUND AND OBJECTIVES Gonadotropin-releasing hormone analogues are commonly prescribed to suppress endogenous puberty for transgender adolescents. There are limited data regarding the mental health benefits of this treatment. Our objective for this study was to examine associations between access to pubertal suppression during adolescence and adult mental health outcomes.

      METHODS Using a cross-sectional survey of 20 619 transgender adults aged 18 to 36 years, we examined self-reported history of pubertal suppression during adolescence. Using multivariable logistic regression, we examined associations between access to pubertal suppression and adult mental health outcomes, including multiple measures of suicidality.

      RESULTS Of the sample, 16.9% reported that they ever wanted pubertal suppression as part of their gender-related care. Their mean age was 23.4 years, and 45.2% were assigned male sex at birth. Of them, 2.5% received pubertal suppression. After adjustment for demographic variables and level of family support for gender identity, those who received treatment with pubertal suppression, when compared with those who wanted pubertal suppression but did not receive it, had lower odds of lifetime suicidal ideation (adjusted odds ratio = 0.3; 95% confidence interval = 0.2–0.6).

      CONCLUSIONS This is the first study in which associations between access to pubertal suppression and suicidality are examined. There is a significant inverse association between treatment with pubertal suppression during adolescence and lifetime suicidal ideation among transgender adults who ever wanted this treatment. These results align with past literature, suggesting that pubertal suppression for transgender adolescents who want this treatment is associated with favorable mental health outcomes.

    8. Page 101
      Address correspondence to Laura E. Kuper, PhD, Department of Endocrinology, Children’s Health Systems of Texas, 1935 Medical District Dr, Mail Code F4.05, Dallas, TX 75235. E-mail: laura.kuper@childrens.com

      OBJECTIVES Our first aim was to examine baseline differences in body dissatisfaction, depression, and anxiety symptoms by gender, age, and Tanner (ie, pubertal) stage. Our second aim was to test for changes in youth symptoms over the first year of receiving gender-affirming hormone therapy. Our third aim was to examine potential differences in change over time by demographic and treatment characteristics. Youth experiences of suicidal ideation, suicide attempt, and nonsuicidal self-injury (NSSI) are also reported.

      METHODS Participants (n = 148; ages 9–18 years; mean age 14.9 years) were receiving gender-affirming hormone therapy at a multidisciplinary program in Dallas, Texas (n = 25 puberty suppression only; n = 123 feminizing or masculinizing hormone therapy). Participants completed surveys assessing body dissatisfaction (Body Image Scale), depression (Quick Inventory of Depressive Symptoms), and anxiety (Screen for Child Anxiety Related Emotional Disorders) at initial presentation to the clinic and at follow-up. Clinicians completed the Quick Inventory of Depressive Symptoms and collected information on youth experiences of suicidal ideation, suicide attempt, and NSSI.

      RESULTS Affirmed males reported greater depression and anxiety at baseline, but these differences were small (P < .01). Youth reported large improvements in body dissatisfaction (P < .001), small to moderate improvements in self-report of depressive symptoms (P < .001), and small improvements in total anxiety symptoms (P < .01). No demographic or treatment-related characteristics were associated with change over time. Lifetime and follow-up rates were 81% and 39% for suicidal ideation, 16% and 4% for suicide attempt, and 52% and 18% for NSSI, respectively.

      CONCLUSIONS Results provide further evidence of the critical role of gender-affirming hormone therapy in reducing body dissatisfaction. Modest initial improvements in mental health were also evident.

    9. Page 110
      Address correspondence to Kristina Olson, PhD, Department of Psychology, Guthrie Hall 119A, Box 351525, Seattle, WA 98195. E-mail: krolson@uw.edu

      OBJECTIVE Transgender children who have socially transitioned, that is, who identify as the gender “opposite” their natal sex and are supported to live openly as that gender, are increasingly visible in society, yet we know nothing about their mental health. Previous work with children with gender identity disorder (GID; now termed gender dysphoria) has found remarkably high rates of anxiety and depression in these children. Here we examine, for the first time, mental health in a sample of socially transitioned transgender children.

      METHODS A community-based national sample of transgender, prepubescent children (n = 73, aged 3–12 years), along with control groups of nontransgender children in the same age range (n = 73 age- and gender-matched community controls; n = 49 sibling of transgender participants), were recruited as part of the TransYouth Project. Parents completed anxiety and depression measures.

      RESULTS Transgender children showed no elevations in depression and slightly elevated anxiety relative to population averages. They did not differ from the control groups on depression symptoms and had only marginally higher anxiety symptoms.

      CONCLUSIONS Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group. Especially striking is the comparison with reports of children with GID; socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex.

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