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THE TREATMENT OF TRANS YOUTH

A comparison of international approaches.

Gender-Affirming Treatment for Trans Youth

The medical care of transgender youth has changed and developed over the past decade, with some countries adopting a more progressive approach than others. We compare the approaches of International Guidance with the NHS advice, which was updated in June 2020 to key comments and questions related to gender-affirming care for young people.
Who can provide care for Trangender Youth? WPATH Standards of Care: 2012:
Assessment and psychosocial interventions for children and adolescents are often provided within a multidisciplinary gender identity specialty service. If such a multidisciplinary service is not available, a mental health professional should provide consultation and liaison arrangements with a pediatric endocrinologist for the purpose of assessment, education, and involvement in any decisions about physical interventions.
UCSF Guidelines: 2016:
The care of transgender youth does not need to be limited to pediatric endocrinologists.
Endocrine Society: 2017:
In adolescents who request sex hormone treatment (given this is a partly irreversible treatment), we recommend initiating treatment using a gradually increasing dose schedule after a multidisciplinary team of medical and MHPs [Mental Health Professionals] has confirmed the persistence of GD/gender incongruence

And a pediatric endocrinologist or other clinician experienced in pubertal induction
Australian Standards of Care: 2018:
Medical assessment including fertility preservation counselling has been completed by a general practitioner, paediatrician, adolescent physician or endocrinologist.
American Academy of Pediatrics: 2018:
Many protocols suggest that clinical assessment of youth who identify as TGD [transgender and gender diverse] is ideally conducted on an ongoing basis in the setting of a collaborative, multidisciplinary approach, which, in addition to the patient and family, may include the pediatric provider, a mental health provider (preferably with expertise in caring for youth who identify as TGD ), social and legal supports, and a pediatric endocrinologist or adolescent-medicine gender specialist, if available.
NHS Choices: 2020:
Your child's GP can refer them to the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust.
Does GD in childhood persist into adulthood? WPATH Standards of Care: 2012:
Gender dysphoria during childhood does not inevitably continue into adulthood.
UCSF Guidelines: 2016:
While there still exists uncertainty as to which GNC children will continue into adolescence and adulthood with transgender identities and/or gender dysphoria and which will not, it is been noted in prior studies that increased intensity of gender dysphoria is a predictor of a future transgender identity.
Endocrine Society: 2017:
Prospective follow-up studies show that childhood GD/gender incongruence does not invariably persist into adolescence and adulthood.
American Academy of Pediatrics: 2018:
Accordingly, research substantiates that children who are prepubertal and assert an identity of TGD know their gender as clearly and as consistently as their developmentally equivalent peers who identify as cisgender and benefit from the same level of social acceptance.
NHS Choices: 2020:
In many cases, gender-variant behaviour or feelings disappear as children get older – often as they reach puberty. Many will go on to identify as gay or lesbian.
What is the view on social transition? WPATH Standards of Care: 2012:
Increasing numbers of adolescents have already started living in their desired gender role upon entering high school.
UCSF Guidelines: 2016:
For young children, decisions must be made to create safe environments that promote healthy growth and development. For some children this may include a social transition - changing of external appearance (clothing, hairstyle) and possibly name and pronouns to match one's internal gender.
Endocrine Society: 2017:
Transgender individuals should be encouraged to experience living in the new gender role and assess whether this improves their quality of life.
Australian Standards of Care: 2018:
Social transition should be led by the child and does not have to take an all or nothing approach. Social transition can reduce a child’s distress and improve their emotional functioning.
American Academy of Pediatrics: 2018:
Children who identify as transgender and socially affirm and are supported in their asserted gender show no increase in depression and only minimal (clinically insignificant) increases in anxiety compared with age-matched averages.
NHS Choices: 2020:
Many people with gender dysphoria have a strong, lasting desire to live a life that "matches" or expresses their gender identity. They do this by changing the way they look and behave.
When should blockers be introduced? WPATH Standards of Care: 2012:
Among adolescents who are referred to gender identity clinics, the number considered eligible for early medical treatment—starting with GnRH analogues to suppress puberty in the first Tanner stages—differs among countries and centers.
UCSF Guidelines: 2016:
In order to avoid the development of undesired secondary sexual characteristics, GnRH analogues ideally are initiated at the earliest stages of puberty (Tanner 2-3)
Endocrine Society: 2017:
We suggest that adolescents who meet diagnostic criteria for GD/gender incongruence, fulfill criteria for treatment, and are requesting treatment should initially undergo treatment to suppress pubertal development.

We suggest that clinicians begin pubertal hormone suppression after girls and boys first exhibit physical changes of puberty.
Australian Standards of Care: 2018:
Puberty suppression is most effective in preventing the development of secondary sexual characteristics when commenced at Tanner stage 2.
American Academy of Pediatrics: 2018:
These reversible treatments can also be used in adolescents who experience gender dysphoria to prevent development of secondary sex characteristics and provide time up until 16 years of age for the individual and the family to explore gender identity, access psychosocial supports, develop coping skills, and further define appropriate treatment goals.
NHS Choices: 2020:
If you need more time to think through your gender identity and you are approaching puberty, you may be offered the choice of being prescribed hormone blockers in addition to talking therapy.
Are blockers reversible? WPATH Standards of Care: 2012:
Fully reversible interventions. These involve the use of GnRH analogues to suppress estrogen or testosterone production and consequently delay the physical changes of puberty.
UCSF Guidelines: 2016:
GnRH analogues offer a reversible intervention that allows youth temporary relief from an undesired, and potentially traumatic endogenous puberty.
Endocrine Society: 2017:
prolonged pubertal suppression using GnRH analogs is reversible
Australian Standards of Care: 2018:
Puberty suppression typically relieves distress for trans adolescents by halting progression of physical changes such as breast growth in trans males and voice deepening in trans females,9,20,21 and is reversible in its effects.1
American Academy of Pediatrics: 2018:
If pubertal suppression treatment is suspended, then endogenous puberty will resume.
NHS Choices: 2020:
Although the Gender Identity Development Service (GIDS) advises this is a physically reversible treatment if stopped, it is not known what the psychological effects may be. It's also not known whether hormone blockers affect the development of the teenage brain or children's bones.
What about mental health? WPATH Standards of Care: 2012:
The vast majority of children and adolescents with gender dysphoria are not suffering from underlying severe psychiatric illness such as psychotic disorders.
UCSF Guidelines: 2016:
Mental health support should not be sought in order to convince TGNC youth into accepting a gender identity that aligns with their assigned sex at birth, but rather, to provide a safe and welcoming space for young people to discuss and explore their gender, and any mental health challenges that may exist.
Endocrine Society: 2017:
If significant medical or mental health concerns are present, they must be well controlled.
Australian Standards of Care: 2018:
Sometimes, an adolescent’s medical, psychological and/or social circumstances are complicated by co-existing mental health difficulties, trauma, abuse, significantly impaired family functioning, learning or behavioural difficulties, or risk issues.
American Academy of Pediatrics: 2018:
There is no evidence that risk for mental illness is inherently attributable to one’s identity of TGD. Rather, it is believed to be multifactorial, stemming from an internal conflict between one’s appearance and identity, limited availability of mental health services, low access to health care providers with expertise in caring for youth who identify as TGD, discrimination, stigma, and social rejection.
NHS Choices: 2020:
Most treatments offered at this stage are psychological rather than medical. This is because in many cases gender variant behaviour or feelings disappear as children reach puberty.

Gender dysphoria is not a mental illness, but some people may develop mental health problems because of gender dysphoria.
When should gender-affirming hormones be allowed? WPATH Standards of Care: 2012:
Adolescents may be eligible for puberty-suppressing hormones as soon as pubertal changes have begun.
Endocrine Society: 2017:
We recognize that there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/gender incongruence
Australian Standards of Care: 2018:
The ideal time for commencement of stage 2 treatment in trans adolescents will depend on the individual seeking treatment and their unique circumstances. There is no empirical evidence to provide objective recommendations for the appropriate age for introduction of stage 2 treatment
American Academy of Pediatrics: 2018:
Medical Affirmation: This is the process of using cross-sex hormones to allow adolescents who have initiated puberty to develop secondary sex characteristics of the opposite biological sex.
NHS Choices: 2020:
From the age of 16, teenagers who've been on hormone blockers for at least 12 months may be given cross-sex hormones, also known as gender-affirming hormones.
What is the age of consent? WPATH Standards of Care: 2012:
Adolescents may be eligible to begin feminizing/masculinizing hormone therapy, preferably with parental consent. In many countries, )-year-olds are legal adults for medical decision-making and do not require parental consent.
UCSF Guidelines: 2016:
...some specialty clinics and experts now recommend the decision to initiate gender-affirming hormones be individually determined, based more on state of development rather than a specific chronological age.
Australian Standards of Care: 2018:
Adolescents vary in the age at which they become competent to make decisions that have complex risk-benefit ratios
NHS Choices: 2020:
From the age of around 16 and after additional assessment, you may be offered gender-affirming (cross-sex) hormone medication.
What are the dangers of withholding care? WPATH Standards of Care: 2012:
withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents.
UCSF Guidelines: 2016:
It stands to reason that transgender adults started as transgender youth, and if identified in childhood or adolescence may benefit from early access to hormone blockers and/or gender-affirming hormones.
Endocrine Society: 2017:
However, for many adolescents with GD/gender incongruence, the pubertal physical changes are unbearable.
Australian Standards of Care: 2018:
Withholding of gender affirming treatment is not considered a neutral option, and may exacerbate distress in a number of ways including increasing depression, anxiety and suicidality, social withdrawal, as well as possibly increasing chances of young people illegally accessing medications.31
American Academy of Pediatrics: 2018:
More robust and current research suggests that, rather than focusing on who a child will become, valuing them for who they are, even at a young age, fosters secure attachment and resilience, not only for the child but also for the whole family.
NHS Choices: 2020:
You may have to wait some time for a referral for an assessment at a gender dysphoria clinic because of more people needing gender dysphoria services.

If your child or teenager is distressed, ask the GP to refer them to the local Children and Young People's Mental Health Service (CYPMHS). CYPMHS may be able to offer psychological support while they wait for their first appointment at the Gender Identity Development Service.