Interviews with Ashleigh Lin, PhD, and Joshua D. Safer, MD, FACP
Initiating puberty suppression to manage gender incongruence in youth under age 18 years is typically a difficult decision for physicians and one that has triggered intense debate and discussion of ethics.
"Anecdotally, we know that these therapies are good for young people, in that they help them feel better with their gender,'' said study author Ashleigh Lin, PhD, a research fellow at the Telethon Kids Institute at the University of Western Australia, Perth. However, she added, "the evidence base is not there yet; much more research is needed."
With her colleagues, Dr. Lin reviewed the literature on puberty suppression, publishing her findings in The Lancet Diabetes & Endocrinology.1 Dr. Lin and her colleagues told EndocrineWeb that the very real advantages of treatment supports its safety, and discussed the best way forward in initiating puberty suppression.1
According to the World Professional Association of Transgender Health's (WPATH) standards of care,2 physicians may recommend suspending puberty in gender non-conforming youth who have undergone a psychiatric assessment and who have also reached at least Tanner Stage II of puberty, the researchers said.
The preferred treatment is gonadotropin-releasing hormone agonists. As for safety concerns, Dr. Lin commented that ''these medications have been used for many years in precocious puberty.''
Among the debates about puberty suppression, she said, is that youth who may identify as cross-gender at one age may change within a few years, and thus regret the decision to suppress puberty.
"But actually, those who reach puberty and continue to identify as transgender [at that time] are highly likely to retain this identity throughout adulthood," Dr. Lin told EndocrineWeb.
However, the concern that youth could change their minds remains, she said. However, "hormone therapy is completely reversible," she said of the treatment. "Once it is stopped, a child will go through puberty normally."
The lack of substantial research does leave unanswered questions such as, "we just don't know long-term outcomes,'' Dr. Lin said, citing potential effects on bone density and other health concerns.
Dr. Lin advised clinicians to take an integrated approach, recommending that any physician involved in the care of a transgender youth enlist a multidisciplinary team, including mental health professionals.
"Puberty suppression gives young people [with gender incongruence] time to breathe and to explore their gender identity and not have to face puberty—the development of sex characteristics—which can cause great distress," Dr. Lin told EndocrineWeb.
The benefits to mental well-being are substantial, Dr. Lin said, based on reports of the youth she has seen in her clinic, while acknowledging that published research is lagging behind. Very few studies have looked at the psychological benefits, she said. In the review, the authors cited research that had produced mixed results.1
For instance, one Dutch study followed 70 youth who were candidates for puberty suppression and cross-sex hormone therapy after about two years of GnRH agonist treatment, at the start of CSH therapy.3 At the end of follow up, the gender dysphoria and the dissatisfaction with sexual characteristics had not subsided.
However, the researchers speculated that the results might be based on a misalignment between body and gender identity that had not yet been corrected, a finding reported in several earlier studies.
The researchers found a reduction in depressive symptoms, as evaluated by the Beck Depression inventory, from a mean of 8.31 (SD 7-12) to 4.95 (6.72; p=0.004).3 While the patients had regular appointments with mental health providers, Dr. Lin noted, it was not clear if the benefits could be linked to the treatment itself or to ancillary factors.
However, when 55 of the same patients were evaluated a year after gender-assignment surgery, the dysphoria and dissatisfaction with sexual characteristics had remitted.3 No regret was reported, rather significant psychological morbidity was found to decline from 30% to 7%.
Other research had offered support for puberty suppression as a "necessary platform for a more favorable long-term outcome in terms of physical and psychological benefits,” Dr. Lin said. And suppression therapy establishes a setting that makes reassignment surgery easier later on, Dr. Lin said.
The review helps to ''shift the conversation toward more patient autonomy," Joshua D. Safer, MD, FACP, medical director of the Center for Transgender Medicine and Surgery at Boston Medical Center told Endocrine Web, citing it as a welcome change.
"There has been a developing recognition of the risks of using parents as surrogate decision makers for medical choices in circumstances where the children may later express opposition to the decisions made," said Safer. "This is especially true when the medical intervention may compromise future fertility."
The review reflects how understanding in the field has evolved rapidly in recent years. Dr. Safer reviewed the report but was not involved in the research.
The need for national and international research collaboration is crucial to advance understanding and amass evidence on treatment approaches, Dr. Lin said. She is hopeful that others will produce collaborative research, citing the Dutch research3 and collaboration as a model. "In Australia, we are working towards national collaboration in the care of transgender youth," she said.
As the numbers of youth identifying as transgender increases, gathering research will be easier, Dr. Lin said. "We are seeing upwards of 100 to 150 new referrals a year, at least, in our center," she says.
According to WPATH,2 prevalence estimates have been based primarily on studies looking at transsexual individuals seeking gender-transition care. Based on about 10 such studies, the prevalence is estimated to be at least 1 in 11,900 for male-to-female individuals and 1 in 30,400 for female-to-male individuals.2
The doctors had no relevant financial disclosures.