Transgender Medicine: Clinical Care of Adolescents
Interview with Joshua D. Safer, MD, FACP
What difficulties are associated with adolescent care?
Actually, getting adolescents cared for is a challenge. In fact, it's a greater challenge because of our ability to diagnose individuals as transgender during adolescence has a few gaps. This is an area for current and future research.
At Boston Children’s Hospital there is a multidisciplinary transgender clinic. Their program is extremely selective. They report that out of 170 children who have gone through their program, so far only one individual has decided not to be transgender as an adult.
Tell us about the treatment transgender adolescents may receive.
The paradigm for adolescents is to use gonadotropin-releasing hormone (GnRH) analogs. Generally speaking, what it comes down to is the hypothalamus releases hormones to the pituitary. In turn, the pituitary releases its own hormones that direct various endocrine organ cells in the body. Sex steroid hormones (through the hypothalamus-pituitary-gonadal axis) are secreted depending on the individual’s age.
How is GnRH used in transgender medicine?
GnRH is administered as a bolus to shut down production of the patient’s sex steroids, which delays puberty. In adolescents who think they are transgender, we can put puberty on hold to allow them to age more, which may help clarify their view of self.
In a case where the adolescent is clearly transgender, we then can give the individual the hormones needed to fulfill a life as a male or female. This way, the adolescent goes through a puberty that matches desire.
For a transwoman (male to female), we can give estrogen earlier in the growth trajectory, which causes shorter height and avoids development of masculine facial features. Then analogously in reverse for a transman (female to male)—delay puberty to allow the individual more growth (eg, height) without breast development.
Do most transgender individuals follow through with surgical reassignment?
It's a very mixed bag, and it's confounded by insurance. Frankly, it is difficult to know what transgender individuals would really do given complete freedom. In The Netherlands, where surgical reassignment has been fairly organized for decades, the recommendation for transgender men has been hysterectomy. This recommendation is based on the thought that testosterone's effect on the uterus may put the individual at risk for cancers. These individuals tend to undergo the surgery, which is covered by insurance.
In the United States, this type of treatment tends not be covered. In fact, there are many individuals who have difficulty locating physicians for the medicines—some have resorted to the Internet to obtain medication. Surgery is definitely not on their radar.
Even those individuals who find physicians are still living a little "under the radar" as far as their insurance company is concerned. Because of the cost of reassignment surgery, many individuals do not pursue it. However, I can't tell you the degree of patient preference; it's mostly what's being dictated to them externally.
Transgender individuals who don’t live in a big city like Boston or San Francisco, how do they obtain treatment?
Some have access to good specialty care, perhaps through a primary care physician who is knowledgeable and supportive. Others are self-treating from products and medications they find on the Internet. A decade or so ago, these individuals would move to big cities and seek out underground networks. Although the Internet makes is easier, there is a great concern over self-treatment and products/medications of questionable providence.
What is needed to advance the care of transgender individuals?
The need for provider education and access to care is enormous, and of course, research. My mission is to expand awareness, remove barriers, and educate the world so transgender individuals easily obtain good care. Conceptually, it’s easy to envision where we need to go and how to get there.
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