Gender Affirming Care for Transgender Youth

Gender affirming healthcare for trans youth is under attack right now. Many governments, such as in the US are trying to ban its access for minors. This would seriously harm young trans and gender diverse people. Dr Helen Webberley outlines the basics on how to provide gender affirming treatment for transgender youth in order to best care for this beautifully diverse community.

Introduction

Caring for trans youth has become fraught with politics and debate, in the medical world and beyond. Some with very loud voices are seeking to prevent essential care and the voices of those who are desperate seem to be lost in the wind. Meanwhile, health is deteriorating and is at risk – something that must never be an acceptable outcome.

How do we define the care that is needed?

Traditionally, medical care is provided for ‘Treatment of disease, disorder or injury’ and is based on a simple premise – make the diagnosis, gain informed consent and agree on a management plan.

The condition that we are intervening in with treatment is Gender Incongruence, and it is problematic to consider something that is a simple variation in human identity as a disease, disorder or injury. However, we do recognise that medical intervention is necessary for some people to be able to live their best lives and to maximise their physical, psychological and mental health.

In the same way that a request for hormonal manipulation for contraception is not a disease, disorder or injury, neither is a request for hormonal manipulation for Gender Incongruence. But we are where we are.

How is the diagnosis made?

The 11th edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) has newly revised codes which include new changes to reflect modern understanding of sexual health and gender identity.

Z77.0 ‘Gender incongruence of adolescence and adulthood is characterized by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex, which often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual´s body align, as much as desired and to the extent possible, with the experienced gender. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.’

It really is that simple – a marked and persistent incongruence that leads to a desire to transition.

Who can make the diagnosis?

There are no hard and fast rules, if any at all! If someone is able to confirm that there is indeed a marked and persistent incongruence and a desire to transition, then you have made a diagnosis.

Am I Trans?

Gender is a social word that describes whether someone feels like a girl or a boy or both or neither. Gender is like a beautiful colour. It can be all one colour, a mix of colours, a blend of colours or lots of different colours.

Some people think that when you are born you can tell what gender they are by looking at their genitals or by seeing what chromosomes they have. This isn’t true, gender is not dependent on those things.

You can only know what someone’s gender is by asking them. They can tell you what their gender is by telling you what their gender is in their heart and their mind.

Some people have the heart and mind of a girl, some people have the heart and mind of a boy, some people have a blend of genders and some people don’t feel like they have a gender at all.

Questions:

1. When I was a baby, people thought I was a __________

2. I have the heart of __________

3. I have the mind of __________

4. If I had it my way, people would treat me like a:

Girl
Boy
Both
Neither

5. If I had it my way, when people talked about me they would say:

She
He
They
Name (no pronouns)

6. If I had it my way, my name would be __________

With thanks to Darlene Tando LCSW

What are the treatment options?

For adolescents seeking to undergo medical transition, they wish to rebalance their hormone profiles. There are two distinct medical interventions in common use in medical centres across the world.

Puberty blockers – these agents suppress natural puberty hormone production and prevent the person from developing secondary sex characteristics that do not match their gender identity. They prevent boys from menstruating and having gynaecomastia and they prevent girls’ voices from breaking and from growing beards and moustaches and size 12 feet. These preventable and irreversible changes are the ones that cause the most distress (gender dysphoria) in trans youth.
Hormones – the sex hormones are what give us the secondary sex characteristics that define our gender in today’s society. They are responsible for voice changes, breast development, chest size, body hair and fat distribution and they also have a huge impact on how we think and feel, our psychology. Transgender people seeking medical intervention ask to be prescribed hormones so that their bodies and minds will better match their identity.

What are the diagnostic criteria?

In medicine, we are used to meeting diagnostic criteria prior to intervention. The diagnostic criteria have been most recently published in the World Professional Association for Transgender Health, Standards of Care version 8.

Summary Criteria for Hormonal Treatments for Adolescents – WPATH

Puberty blocking agents

a. Gender diversity/incongruence is marked and sustained over time;

b. Meets the diagnostic criteria of gender incongruence in situations where a diagnosis is necessary to access health care;

c. Demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment;

d. Mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed; sufficiently so that gender-affirming medical treatment can be provided optimally.

e. Informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility;

f. Reached Tanner stage 2.

Hormonal treatments

a. Gender diversity/incongruence is marked and sustained over time;

b. Meets the diagnostic criteria of gender incongruence in situations where a diagnosis is necessary to access health care;

c. Demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment;

e. Informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility;

f. Reached Tanner stage 2.

Have the diagnostic criteria been met?

Clearly we don’t have the luxury of blood tests or x-rays or biopsies or other traditional investigations that assist us in making a diagnosis. But we are used to this in medicine.

To diagnose someone with depression we have to ask and listen to how they describe their mood.
To diagnose someone with premenstrual syndrome, we ask them to describe their symptoms and how they are feeling and what impact this has on their life.
To diagnose someone seeking an abortion we have to listen to their reasons as to why continuing the pregnancy would be more harmful than terminating it.
To diagnose someone as needing a vasectomy, we listen to their reasoning as to why this irreversible procedure is right for them and how they won’t regret it.
To diagnose someone with gender incongruence we have to listen to how they perceive their gender identity and how it differs from the sex they were originally assigned at birth.

Have the treatment options been discussed with the patient?

Sometimes in medicine we feel we know all the answers and sometimes we understand that we are doing the best we can with the knowledge we have, understanding that to do nothing can result in more harm. Gender incongruence is an evolving area of healthcare and we may not know all the answers. But we know enough. We know that there is a substantially higher rate of mental illness and suicide in people who are requesting intervention but are unable to access it.

A recent systematic review found pubertal suppression in trans adolescents was associated with an improved social life, decreased suicidality in adulthood, improved psychological functioning and quality of life. Access to gender-affirming medical treatment is associated with a substantial reduction in the risk of suicide attempts.

As with all medical interventions, we have to weigh up the pros and cons with the patient. We have to discuss the benefits and risks of having a particular intervention with the benefits and risks of not having the treatment. We have to gather and share all of the available information and allow the patient to make an informed choice. We mustn’t prefer one treatment choice over another, that is not our decision to make. We should use published, peer-reviewed guidance to help us give our patients the options, and to inform the care we give.

Does the patient have the ability to give informed consent?

It is expected that people who have reached the age of 16 have the ability to make informed decisions about their care and to be able to make decisions based on the information available to them. People who are younger than that may be able to give informed consent and others may ask their parents or guardian to help them.

Gillick competence is well described in healthcare and lays out the principles by which young people can give their consent to treatment.

Which clinical guidelines should we follow?

Clinical guidelines should be based on published research from well-respected sources. They should be peer-reviewed so that there is no bias from the authors. Local guidelines are preferred which should be based on national guidance which again should be based on international research, evidence and best-practice. In the absence of robust peer-reviewed local and national guidance then international guidelines should be adopted.

In transgender healthcare there are some excellent resources and service providers would be advised to adopt these rather than create their own rules based on the opinions of a few.

Clinical Guidelines

Who should provide this care?

As healthcare has evolved over the years, we find many different healthcare professionals coming together to provide care. This can be hospital-based consultants, family doctors, physician’s assistants, nurses, pharmacists, therapists. The important thing is that they feel competent to provide the care they are providing and that a reasonable body of experts would agree with the care.

In transgender healthcare there is a lack of core competencies in the speciality curricula. There is a lack of formal training in this field and a lack of available training placements. However, the care is still needed and harm is occurring from a lack of availability. So it is down to us as individual healthcare providers to gain the necessary skills and knowledge through self-directed learning. We must learn how to provide care for our trans youngsters, we must follow available clinical guidelines and we must audit the care we have given to show the results. Did health outcomes improve as a result of the intervention as the guidelines say they will?

My colleagues in this field from other centres of excellence vehemently agreed that health outcomes improve and that is what we expect to happen for UK trans youth.

Conclusion

As ‘climate change is everyone’s responsibility’ so is the health and wellbeing of every healthcare practitioner’s trans patients. We seem to be on hold, waiting to be told what to do, waiting to be given permission, while people tell us that there is not enough evidence to tell us what to do. There is plenty of evidence, evidence that has informed standards of care across the world and that is helping so many trans youth in other countries.

If our colleagues across the water can care for their trans youth then so can we. Their health, safety and wellbeing is our responsibility and they are asking us to help them today. To deny them help and watch them suffer is inhumane.

Dr Helen Webberley, on behalf of GenderGP

Gender Affirming Healthcare for Transgender Youth: A Message to Healthcare Providers