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Transgender adolescents receive improved endocrine care at clinic
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SAN DIEGO — The management of transgender adolescents, although increasing across the U.S., is still sporadic and could be improved and standardized with research and systematic monitoring at dedicated centers, according to research presented at The Endocrine Society annual meeting.
“The number of transgender youth requesting medical attention is increasing nationwide,” Maja Marinkovic, MD, of the University of California San Diego, La Jolla, and Rady Children's Hospital, told Endocrine Today. “Although guidelines are available from The Endocrine Society, the World Professional Association for Transgender Health, and others, research data is lacking in many areas of transgender care.”
Maja Marinkovic
A formal gender management clinic established at the hospital to care for adolescents with gender dysphoria has experienced a surge since opening in 2012 and is striving to develop a team of therapists, psychiatrists and surgeons to meet the needs of the minority group.
“These patients require a comprehensive care from a multispecialty team,” Marinkovic said. “Additionally, education of medical care providers, including students and residents, nursing and support staff is also an essential part of providing better care for this vulnerable group.”
Marinkovic, with Ron S. Newfield, MD, conducted an observational, longitudinal analysis of 42 patients — 28 were female-to-male (FTM), 13 male-to-female (MTF) and one gender fluid (GF) (natal female) — referred to the clinic.
The patients (mean age at first visit, 15.5 years) had consented to entry in an endocrine database approved by institutional review board, and most were prospectively followed.
Following assessment by an experienced mental health professional for gender dysphoria, 38 patients started treatment — seven with gonadotropin-releasing hormone agonist, 32 with cross-gender hormones, and two on both.
Pubertal suppression was started when patients were aged 12.5 years, on average, and at Tanner stages 2 to 5; patients received depot-leuprolide injections or histrelin implant. Cross-gender hormones were started at age 16.5 years, on average.
No patients have expressed regret or discontinued therapy. The GF patient expressed desire to start testosterone treatment. FTM patients generally received depot-testosterone injections every 1 to 2 weeks. MTF patients received 17beta-estradiol orally/sublingually twice per day, and most also took spironolactone.
Two FTM patients (aged 16.3 and 18 years) underwent bilateral mastectomy; several other patients desire surgery but have not pursued it due to lack of local experienced surgeons or insurance coverage. Legal name changes to match affirmed gender have been completed by 12 patients (29%).
Among the group, 62% reported depression, cutting and/or anxiety, and 27% had additional psychiatric/behavioral conditions, including attention deficit hyperactivity disorder, Asperger's syndrome or bipolar disorder; depression and/or anxiety improved for many with recognition and treatment of gender dysphoria.
“A multidisciplinary approach is essential in providing adequate care, and ideally should include not only experienced therapists, endocrinologists, psychiatrists and surgeons, but also support groups, legal advisers and advocates,” Marinkovic said.
“Based on our clinical study, mental health problems in transgender youth improved significantly with acknowledgement and treatment of gender dysphoria.” – by Allegra Tiver
Reference: Marinkovic, M. Poster Board SAT-086. Presented at: The Endocrine Society Annual Meeting; March 5-8, 2015, San Diego.
Disclosure: Marinkovic reports no relevant financial disclosures.
Perspective
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Joshua D. Safer, MD, FACP
This report is interesting because it describes using hormone therapy in adolescents, pushing the envelope a little bit in terms of age. The generally agreed upon paradigm for taking care of transgender youth are gender management clinics, but they are still very insufficient in number.
A clinic was started at Children’s Hospital in Boston many years ago, and slowly other pediatric groups have been rolling these out. But we need more of them on a national level, so it is great to see this group in San Diego doing the same thing.
There are various schools of thought in terms of approach.
More conservative would be viewed as delaying giving cross-gender hormones until older ages, maybe age 18 years, with concerns for consequences from interventions; clinicians would hate to be doing that in children who are not going to be transgender after all.
The alternative reality is that the sooner transgender kids can get into a circumstance where they are living the lives they want to be leading, the better; certainly, teenage years are stressful years, and we would want children to be in situations that make them happy more of those years.
The San Diego group is not unique in their thinking. There are a number of groups, especially in California, including Los Angeles and San Francisco, with a similar logic pattern. Part of what they’re presenting is success.
These clinics are only moving the needle incrementally. They’re not giving cross-sex hormones to 11-year-olds, but they are taking it a little inside 18 years old. The guidelines from WPATH [World Professional Association for Transgender Health] and The Endocrine Society suggest that in the correct individual, cross-gender hormone therapy could begin as early as 16 years; these groups are right at the edge.
In this study, cross-gender hormones were started on average at age 16.5 years, which sounds fine, but the range is age 13.7 years to 18.2 years. The point the group makes is important: to date, none of these patients expressed regret or stopped therapy. The group contends if clinicians are quite conscientious, if there is good mental health support, if children are screened well so treatment is only given in very obvious cases where there is no grey area, results can be excellent.
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