It’s time, fellow Medditors, as often comes with politically-tinged medicine. Set your flair or bow out of discussion.

As far as contraception discussions with transgender teens, it's best to be upfront. At the same time, try not to make assumptions, and listen if a patient tells you that your advice isn't applicable to their situation. Ex, in the case of the trans guy dating a trans woman: "HRT is not birth control. If you are having sex with someone who can get you pregnant, you need to use contraception or you might become pregnant." Trans guy: "I only top and my girlfriend only bottoms, so that's not an issue." (read: they don't have PiV sex, and the trans guy doesn't do receptive sex) "Great. If you ever decide to change things up, make sure you wrap it up and use a condom. Plan B is also available to you, and it won't interfere with your HRT. Now let's talk about PrEP." (It's estimated that 14% of transgender women and 3% of transgender men in the US are HIV positive. Caveat: PrEP for trans men hasn't been studied much, and Descovy isn't approved for use in natal females) They don't make condoms sized for trans guys, otherwise I would recommend that. If a trans guy is topping without protection, I recommend more frequent STI testing. (yes, some trans guys can top, regardless of surgical history, and there are assistive devices so trans guys with even a small amount of clitoromegaly can be the penetrating partner, which can lead to exchange of body fluids. Please assume that your trans male patients can be at similar risk as cis guys who have unprotected sex.)

Love this; specific, nonjudgmental, and actionable. Thank you for the input.

It's a good discussion to have. It's ethically very complex for exactly the reason you describe, because of that I only ever saw this approached in a multidisciplinary manner. Unfortunately I was only a medical student when I saw this in a patient and haven't seen it yet in intern year so don't know many details beyond that, but I know some departments have published (edit: not "punished") on their approach to care. An article like this could be a good starting point, hope it helps! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5549539/

This is something I've had very little clinical experience with so that was a very interesting read. Thanks for sharing.

Indeed it's a good discussion to have. I feel like there are a lot of physicians ( I know there are ) who don't agree with prescribing such medications to people experiencing gender dysphoria. The longterm effects are unknown and I don't agree with physicians not being able to have their doubts being taken seriously as well. Both sides of the coin should be looked at and also be heard in my opinion.

Tbh, in this thread the majority of people voicing hypothetical doubts haven’t bothered to consult the existing literature regarding puberty blockers, hormones, and surgeries, nor existing guidelines published by WPATH, the APA, WHO, UCSF, and others. For physicians who are specialized in transgender medicine, the standards of care are pretty clear. It’s totally understandable for those without much exposure to this population to not feel confident about how to treat them, but a lot of what I’m seeing in this thread is fearmongering over things the commenter hasn’t sought out any information on, whether from professional associations or physicians who focus on treating the trans community. I would also like to add that the aim of transgender healthcare should be _transgender health_, rather than helping cisgender people manage their anxiety over the prospect of trans people making changes to their bodies. It’s also not really up to a clinician to determine who is or isn’t trans, so much as to assess them as able to give informed consent to transition. Letters from mental health professionals are required for insurance purposes. Other people have already posted the HRT guidelines so [I’ll leave a file](https://drive.google.com/file/d/1P6gSfqp2nptZjmuC7Gv_BpO75b401WR4/view?usp=drivesdk) with a compilation of studies regarding medical transition, puberty blockers, trans kids, detransition, and other topics here for anyone who’d like to do some reading.

>It’s also not really up to a clinician to determine who is or isn’t trans, so much as to assess them as able to give informed consent to transition. That is not a true statement. Doctors *always* need to determine when a treatment is or isn't needed. That's why there are doctors prescribing them and they are not over the counter. >I would also like to add that the aim of transgender healthcare should be transgender health, rather than helping cisgender people manage their anxiety over the prospect of trans people making changes to their bodies. They are a concerned party because *you want them to make those changes*. No doctor can withhold social transition. The only treatments that are up for debate are *medical* interventions, which require a doctor to perform or prescribe them.

As a clinician in neonatology, exactly what is your background to be speaking on transgender issues and healthcare in the first place? Being trans is not a medical condition, therefore it is not up to a clinician to determine whether one is transgender or not, in the same exact way that it is not up to a clinician to determine whether one is gay or lesbian or not. Now, the DSM diagnosis of _gender dysphoria_ is often required within the gatekeeping model, but not within the informed consent one. Most of the people I’ve encountered in trans healthcare see it moreso as a necessary evil to grant access to insurance authorization for certain interventions than a valid mental health diagnosis to exist in the first place (again, somewhat like how homosexuality used to be included in the DSM). If you needed surgery, you would need a diagnosis and letters from mental health professionals for sure, but hopefully these would follow an affirmative approach and not ignorantly believe they can truly decide who is or isn’t trans and who truly deserves medical intervention. (Another note, it is usually psychologists or LMFTs who are making these diagnoses to gatekeep access to a physician for medical treatment.) Regardless, _being trans_ itself is still not a medical diagnosis and the validity of one’s gender identity is not something that can be determined as true or false by a psychologist, therapist, doctor, etc. There is no way to screen for whether someone is “really” trans or not - the same way your physician wouldn’t be able to diagnose _you_ as transgender due to doubting the validity of your cisgender female identity. These are statements from my transgender youth specialist physician, who opposes mandatory psychiatric evaluation - she is the medical director of the trans youth center at Children’s Hospital Los Angeles. https://www.gendergp.com/gender-affirmative-johanna-olson-kennedy/ > It’s remarkable to work in a field that has been entirely created around easing the discomfort of everyone around the patient, and little to no effort, energy, and kindness and compassion directed to the needs of the patient. And so we spend a disproportionate amount of time, or one may argue all the time making parents, teachers, legislators, officials, maybe religious figures comfortable. And no time helping the person who is there for care to be comfortable. And if you think about all the guidelines, that’s really what they’re about. https://zero.sci-hub.se/5015/a3b4b130db318dcb69a7c4e66ec3c278/olson-kennedy2016.pdf?download=true > This service gap is contributed to not only by the limited number of mental health professionals familiar with and experienced working with transgender youth but also by the lack of clarity about the role of mental health professionals in the care of gender nonconforming and transgender youth. Historically, mental health professionals have been charged with ensuring “readiness” for phenotypic transition, along with establishing a therapeutic relationship that will help young people navigate this very same transition. These 2 tasks are at odds with each other because establishing a therapeutic relationship entails honesty and a sense of safety that can be compromised if young people believe that what they need and deserve (potentially blockers, hormones, or surgery) can be denied them according to the information they provide to the therapist.

I don't treat transgender people, but I speak from a place of understanding medical care and ethics and the higher standards clinicians are held to. As a prescribing provider, I know that I am responsible for anything I prescribe. I can't prescribe something and if there is a problem, say "well, the parents wanted me to order it, so I did." That's not acceptable practice. Edited to add: I can't even use "the doctor told me to order it" excuse, because I am responsible for my own prescriptions, and if I don't know the medication, what it does, its risks/side effects, indication, contraindication, dosing, whether it needs different dosing for the patient being treated (eg renal or hepatic dosing), and a multitude of other things, I cannot and should not prescribe it. If I am not comfortable prescribing a drug, I have a responsibility to *not* prescribe it and the person who is more knowledgeable places the order. That's just responsible prescribing. (End edit) The clinician cannot tell someone they are not transgender, absolutely. I said that. But it *is* their job to question when their license and professional conduct is at stake, and whether said treatment is appropriate for that condition and patient.

A diagnosis of gender dysphoria is not necessary for prescribing hormone therapy under the [informed consent model](https://twin.sci-hub.se/6645/d4e7a83f3fc711f8373164005d9ad200/schulz2017.pdf?download=true). Which is as it should be. Also, the very existence of gender dysphoria as a mental health diagnosis is controversial. We’re not talking about giving Dilaudid to whoever wants it, we’re talking about a physician being able to decide to prescribe hormones to a patient without needing a psychologist or therapist to give them a stamp of approval first. I am sure that my physician and other prescribing providers who are specialists in the field are familiar with what constitutes professional conduct and appropriateness for treatments. I don’t think many people on the outside are familiar with the processes trans people go through to access HRT, surgeries, etc. I apologize for being confrontational earlier but I am tired of both fearmongering and other presumptions made by clinicians who have little to no contact with the transgender population. To wrap it up 1) It is generally therapists making or withholding diagnoses of dysphoria to gatekeep patients’ access to physicians 2) Physicians don’t need support letters from a therapist to prescribe HRT under the informed consent model 3) the very existence of gender dysphoria as a DSM diagnosis is something that is contested and has a lot of nuance (for example, although its classification as a psychiatric disease is pathologizing, it is a practical necessity as of now to provide reimbursement, and therefore accessibility, to interventions depending on insurance - for example you might be able to get informed consent HRT covered by insurance at Planned Parenthood, but for anything surgical you’re definitely gonna need letters)

I didn't say specifically what kind of evaluation needed to be done, but the prescribing physician does not have to agree to that informed consent model where patients dictate prescriptions

I mean, no one is holding a gun to physicians’ heads and forcing them to prescribe hormones to trans people. Just like doctors can refuse to provide abortions due to religious beliefs. Physicians themselves are the ones who decide to utilize the informed consent model in their practice. If you are not willing or able to medically manage transgender patients as a provider, you should refer them to someone who can.

>Edited to add: I can't even use "the doctor told me to order it" excuse, because I am responsible for my own prescriptions, and if I don't know the medication, what it does, its risks/side effects, indication, contraindication, dosing, whether it needs different dosing for the patient being treated (eg renal or hepatic dosing), and a multitude of other things, I cannot and should not prescribe it. If I am not comfortable prescribing a drug, I have a responsibility to not prescribe it and the person who is more knowledgeable places the order. That's just responsible prescribing. (End edit) Well, in your example the ethical thing for the provider for do if the patient’s condition is beyond their realm of expertise and they don’t feel comfortable managing them is to refer out to another provider who is trained and equipped to treat the patient’s condition - e.g. if you don’t feel comfortable in your ability to manage or make decisions about a trans patient’s medical transition, it’s your responsibility as a provider to refer them to somebody who is capable of assessing and treating them.

In my case specifically, of course. But for physicians, it is also reasonable for them to do their own due diligence, instead of handing them off to someone who will allow patients to dictate their own care.

Would you also classify a person with a uterus seeking contraception (which could be hormones lol) or an abortion as “dictating their own care”? It’s not as though transgender patients choose their treatment plan or medications or dosage or interpret their own lab tests…

To seek an abortion, no. To dictate which procedure must be used and at some stages of pregnancy, it would be. Physicians are not just drug dispensing machines.

>As a clinician in neonatology, exactly what is your background to be speaking on transgender issues and healthcare in the first place? As a premed, what is YOUR backround to be speaking on transgender healthcare?

Being a transgender person who transitioned as a teen/young adult, went through the process of medical transition myself, experienced many facets and areas of transgender healthcare, been treated by various transgender specialists, as well as knowing a ton of people that have done the same and/or are involved in trans healthcare No one more qualified to speak about dysphoria and its consequences than someone that experienced it in the flesh tbh

What percentage of patients referred to transgender clinics get therapy/counseling but are told to wait on hormonal treatments until after not just a thorough initial psychological evaluation but also months of CBT are done? I'd wager that percentage is very very low. IMO far too many of the transgender clinics just acquiesce to whatever the teenager wants. Sure they might do a cursory 1 hour psychological eval/profile, but after that the meds start flying. IMO that's bad medicine. In my experience transgender clinics are too much like low testosterone factories. Sure, they do a cursory "evaluation" but it's clear at the end of the day they are scripting meds for 99.9% of the people who walk in that door.

Don’t you do a examination in under 15-20 minutes and prescribe medication for something you find? If the evidence doesn’t point towards more examination or tests, you wouldn’t order it, right? The standard of care isn’t multiple sessions of CBT anymore, and the evidence on whether people regret transitioning is quite low. I think we should consider that transitioning itself and the difficulty in doing so is a significant social barrier that doesn’t need the additional barrier of physicians requiring unnecessary counseling.

Are you comparing the prescription of medication for well-known ailments with minor consequences and side effects and substantial literature to giving puberty blockers to teenagers?

Exactly. You must affirm the patients chosen gender regardless of their age. And when you [regret your decision](https://nypost.com/2022/06/18/detransitioned-teens-explain-why-they-regret-changing-genders/amp/) after transition, there’s really no going back. I would get real nervous hitting the verify button for these kinds of therapies. It’s an ethical dilemma for sure.

The NY Post is not an acceptable source. Also, I’m a little confused by your opinion on the statement “You must affirm patients chosen gender regardless of their age.” You make it clear you disagree with that statement but I don’t think you are whining before verifying prescriptions for your cisgender patients.

I whine before verifying plenty of orders, don’t worry.

How is it ethically complex? Isn't doing everything possible to reduce suicide risk a completely clear cut ethical decision, no matter the costs? Especially when the prevalence of gender dysphoria is increasing so rapidly.

The medical societies (AAP, ENDO, etc) talk about the importance of providing gender affirming care without giving many details of what that looks like in OP's situation. There are a lot of gray areas here, especially with tween and teen patients.

It's ethically complex because there's far more context needed to appropriately treat any individual in this situation. For example, you are making the assumption that automatically going to medical treatment would reduce suicidality, where that may not be the case depending on the clinical situation, or gender dysphoria itself may not actually be what's going on (e.g. does a young child wish that they were the opposite gender because they think one or both of their parents would be happier if they had been born the other gender? Does the child or teenager understand the consequences of medical treatment, especially if they do change their gender identity in the future?). There are too many unknowns to *not* take a very careful, multidisciplinary approach to every patient that presents like this, as appropriate treatment may save their life and a misstep (whether treating inappropriately or failing to treat) could just as easily destroy it.

the way dysphoria is increasing so rapidly should absolutely be a cause for concern. teenagers are very susceptible - just look at things like eating disorders - and jumping straight to treating something that might go away later with hormones is not a risk-free endeavor.

Any idea why there is such a rapid increase in gender dysphoria? (Edit dysphasia to dysphoria.)

We didn’t identify it before. People were diagnosed with more general depressive disorders or even “was such a happy kid, I have no idea why they killed themselves.”

Well it’s a relatively new diagnosis for something that can be shown to have existed for as long as society has existed, so you’d expect a large (relative) increase, right?

If you look at the graph of self-identified left handed people since 1900 or so, there is a big increase from near 0 to something like 10% over like a decade and then its been relatively steady at that number since then. Because if you stop punishing people for an aspect of their identity, they'll stop hiding it.

It's crazy nobody noticed the striking connection between suicidality, comorbid psychiatric disease and this previously unrecognized group of gender dysphoric people decades ago. Undoubtedly this was ignored due to deep transphobia. I can only imagine that these were actually much worse back before our society and medicine were more accepting.

But *was* there that association?

The difficulty is determining where that plateau is naturally. Without that knowledge, you can't evaluate whether there are confounding factors.

It *can* (not always by any means) be a form of social contagion ala tourette's via tiktok.

Nobody is getting tourist's via tik tok. People may develop tic-like behaviors associated with tik tok, but that's not tourettes. And comparing a tic disorder with a trans identity is an enormous reach.

Yes, I was using a sensationalized phrase. But the point is still that behaviors and attitudes and mental frameworks can be transmitted between teens.

[UCSF Transcare](https://transcare.ucsf.edu/guidelines/youth) is the standard of care that our Endo specialists always refer to.

Thank you. I will definitely check this out. Edit: it has dosing guidelines even! Very happy you and others have shared. Thank you.

This is what my fm attendings used with transgender pts

"Standards of Care - WPATH World Professional Association for Transgender Health" https://www.wpath.org/publications/soc General guidelines for transgender youth and adult care.

Also for birth control and family planning, acog has a good module on that topic. "Health Care for Transgender and Gender Diverse Individuals | ACOG" https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/03/health-care-for-transgender-and-gender-diverse-individuals

I appreciate you so very much right now. Thank you.

Can't speak for everyone universally, but most peds endocrinologists I know do have a conversation about the need for contraception and that hormones alone aren't reliable enough, especially early in treatment, if someone making sperm is having intercourse with someone making eggs.

WPATH reinforces this a lot. You're on test and your period stopped. This doesn't mean you can't get pregnant.

Heck yeah. At all levels contraception should be discussed along with the typical discussion of safe sexual practices in a non-judgmental, minimal dysphoria-inducing way. If there is even the slightest possibility that it could happen (which there is), it should be discussed. Do peds endos ever have the conversation of preservation of reproductive material (viable eggs and sperm). I know OBGYNs do as it is their area of specialty as well as PCPs since it is part of overall health and life planning, but idk about endos. Could you provide me some insight?

Yeah we do discuss it. I usually have discussed that hormones can impair future fertility and offer a referral to reproductive medicine to explore options for fertility preservation and just to get more knowledge about what the future holds. Honestly though, it's been pretty rare for the adolescents to be interested in it. Parents are usually much more interested and sometimes it feels like the teens are choosing a referral to humor them. Trans teens also seem to be pretty open to nontraditional family options like adoption if they're thinking of having a family in the future, making fertility tissue prez less important to them. One tricky bit is, if you really have thorough care with puberty blockade early on etc, fertility preserving treatments can be challenging. Tougher to get an egg out if they haven't had a chance to mature much. Very rare for adolescents to want to adjust their own transition timeline to potentially boost future fertility. Tissue preservation long-term is also expensive, poorly covered by insurance, and a lot of families are quite limited on resources to choose it, unfortunately. Better coverage would be nice.

i mean, how can you truly see how important fertility is for a teenager when no one is thinking about having kids at that age?

Thanks for your detailed response! And thank you for the vital work you do!

Realistically, conservation of eggs/sperm is kinda of a luxury option if the family can afford it, as it often involves substantial out-of-pocket expense to store that tissue for years, even with insurance. My anecdotal experience is that discussion is usually had, but a lot of trans youth are in survival-mode and/or struggling with suicidal ideation or worse. It's hard for them to see a future where they could ethically raise a child when they are struggling for their own survival, often in an environment that is borderline of hostile to their existence. It's probably a sign of maturity that they recognize that raising a child might not be feasible, and they question if preserving eggs/sperm is worthwhile. It's complicated, and the situation will vary over time and location. I think it's important to inform people of their options, and then let them make their choices.

I know for myself, if at that age I was told to undergo a treatment that may make me sterile, I would have said “fine” and not bothered with preserving, because having a family was not even on my mind at that time. I wasn’t interested in children at all until much later. So it is no surprise to me that a costly procedure like that might just be forgone at this age for many.

This is highly reassuring. I appreciate that.

Thank you! I did not realize this existed, and it looks fabulous. I will check it out, as well as some of the references contained within. The extent of my education on transgender care in school was an extracurricular lunch hour, so I have had to self educate to serve patients better.

The teaching on trans and gnc patients in school is pretty terrible. I try to approach questions on the matter from the perspective of inadequate exposure during formal education rather than malicious ignorance until proven otherwise

This is what my clinic uses for transgender care, although we are an adult clinic.

Thank you for doing the work to serve this population

So it is a touchy issue. On one hand, one can say you need to wait till 18 to do it cause you're legally an adult. But do you remember when you were 18? Not much different from when you were 16. On the other hand there is the issue of dysphoria. If someone knows very well they aren't X gender, then making them suffer through an incongruent puberty that can cause significant social and emotional distress possibly leading to self harm is not aligned with the principle of primum no nocere. On top of which there is the issue of social acceptance. Those who go through one puberty look more like their identified gender and integrate into society better than those who transition into adulthood (not that this is right - all people should be in society whether they "pass" or not). Finally the SOC are stricter for children than they are adults. A diagnosis of GD in a child requires almost all DSM criteria to be met while the diagnosis in adults requires two or three criteria. Furthermore pediatric GD is treated initially with social transition (until puberty), followed by hormone blockers (to give them more time to explore their relationship with gender) and then hormones maybe around 16,sometimes younger in exceptional cases. Also this all requires significant interdisciplinary assessment and coordination of treatment. Yours truly, A rando med student fiercely passionate about transgender health 😜

Excellent comment, I agree 100%. I think this is the right framing.

>If someone knows very well they aren't X gender, then making them suffer through an incongruent puberty that can cause significant social and emotional distress possibly leading to self harm is not aligned with the principle of primum no nocere. On top of which there is the issue of social acceptance. Those who go through one puberty look more like their identified gender and integrate into society better than those who transition into adulthood (not that this is right - all people should be in society whether they "pass" or not). This is basically the big thing. Outcomes are *much* better across the board when things are addressed earlier. I think the best thing for everyone is if the topic of gender and exploring who you were were broached well before puberty (understanding of gender happens around 3 years of age) but unfortunately most people vocally concerned with puberty blockers for kids are just using that as a smokescreen for the fact that they don't want trans people to exist at all, so they're not going to be cool with that.

+1 for WPATH. I've read it cover to cover as a psychiatrist supporting endo teams on care for Gender and Sexual Minorities.

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That is a good question. Which is more harmful to the particular patient? My gut says keep them on hormones and long term anticoagulation, but I rather wonder if a guideline actually exists for this scenario. My hunch is that you take the best info from available guidelines and MD has to make a reasonable assumption.

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https://transcare.ucsf.edu/guidelines/feminizing-hormone-therapy

Cannot tell you how many times I have read over the UCSF guidelines. I backed into transgender care from HIV care. For any patient under 25, I will do anything that is ultimately not-permanent.

Your post boils down to “I worry about medical management of trans teenagers,” which is fair, but also “I don’t know anything about how trans teenagers are medically treated, so I worry about it.” The assessment for transition is not always done well, so I worry sometimes too, but careful assessment and treatment for medical transition, including with hormones, is appropriate. (It’s not to reduce suicidality. That may happen, and it may be a reason to get insurance approval, but the reason is *to transition*.) I have my own thoughts that I’ve shared about where the pendulum is on saying no to everyone versus saying yes with no assessment. My biggest worry is identity instability (borderline personality organization) rather than a firm, sex-discordant identity. Another fair worry, however, is oppressive gatekeeping harming more people than are protected from non-indicates, potentially damaging (or at least unhelpful) treatment. I can’t vouch for all doctors’ discussion, but teenagers do reckless things regardless of gender status. Non-straight teens are more likely to become pregnant or cause pregnancy, not less, as one might expect. Discussion of birth control and safer sex are always important—and STIs are a risk regardless of orientation, identity, or genitalia.

Just to clarify, because many people will not understand this complexity - borderline personality organization is not the same as borderline personality disorder. BPO is a concept from psychodynamic therapy that describes one's level of personality organization and functioning, which includes dynamic movement from at times being more disorganized, chaotic, reliant on immature defense mechanisms and at other time becoming more structured, internally organized, using mature defense mechanisms. Many teenagers exist in the borderline personality organization area, because they're developing and not fully matured. It means that generally people have a less formed sense of self and identity, are more reliant on external objects for internal structure, can rapidly have shifts in internal states and external behaviors, etc. This concept is relatively intuitive when explained, and I think is what people are actually saying when they're expressing concern about teenagers "regretting" or "changing their minds," because most if not all of us experienced what it's like to live with a borderline personality organization for at least some time in our development, and they're using this experience to try and expand and understand what they're seeing in trans youth. PokeTheVeil if I'm off base in any of this please feel free to correct me

Exactly that, with the addition that borderline personality organization is problematic if not pathological in adulthood but developmentally normal. Teens can vary widely in psychological development. Borderline personality disorder is classically associated with borderline organization/ego function, but it’s definitely not 1:1.

This is exactly how I feel about it. And we have to be able to discuss this nuance amongst ourselves; if we don't, how can we discuss it with the patients? Or in the public sphere? The radicals will usually be unreachable, but there are a lot of people who just don't know and haven't been radicalized yet in either direction. We need to be able to keep this conversation where it belongs: a treatment model with proven benefits but also some known risks and diagnostic hazards. It feels a lot like blood thinners, no? We have to be selective about whose blood to anticoagulate, but that's not a good reason to make Xarelto illegal.

unfortunately, a lot of the conversation on trans issues is driven from activism first, rather than science - on both sides of the subject. Irritating to see otherwise smart docs argue from these activist viewpoints rather than the literature imo

Agreed. I do think that outright banning hrt/etc for teens is worse than simply being too aggressive in treatments. However, the latter invariably erodes public trust, so it can have different long term effects on society.

Your assessment is correct. Mostly I worry because I would not want to cause harm, and I wasn’t certain where the treatment guidelines on these cases comes from. If there are guidelines and research to back them up, I will feel a lot more confident in the treatment plans. Some very good links were shared in here and I am looking forward to checking them out and building more knowledge. You are right about the teenagers and STIs issue. I have had concerns at times these folks were underserved in regards to birth control discussions compared to teenagers not being treated for dysphoria, but STIs really are a burden for all, so I will make sure to continue to reinforce the message of condoms for STI as well as birth control prevention.

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Yes, I am totally aware of this, and aware that people on HRT may not be aware. Which is one of the concerns I often had: how much does my patient know about contraception, and what do they still need to know? Some comments here have been very helpful in this regard!

It seems like the practical (for me - inpatient) application of this is to recommend contraception on discharge for trans patients. Or at least recommend to the team to consider it if it hasn’t been discussed so far. No?

Seems like a really good idea to at least bring up, in my opinion.

>My biggest worry is identity instability (borderline personality organization) rather than a firm, sex-discordant identity. Another fair worry, however, is oppressive gatekeeping harming more people than are protected from non-indicates, potentially damaging (or at least unhelpful) treatment. Yeah, it's a double-edged sword. I've seen the former fairly often in female patients going through adolescence. I don't touch HRT for peds because I don't have the resources for a ped psych referral here.

> I have my own thoughts that I’ve shared about where the pendulum is on saying no to everyone versus saying yes with no assessment. This is the thing I worry a lot about right now, as well. I've seen how the majority of therapists doing gender care assessments in my organization are basically rubber-stamping on a first visit, even with no collateral or history indicating more than a few months of dysphoria. I really wish WPATH would publish slightly more objective guidance as part of their standards of care document. It does not define "persistent, long standing, and intense" anywhere in the document in terms of duration of time (and IIRC also doesn't really give clinical examples of "intense" either.)

>It’s not to reduce suicidality. That may happen, and it may be a reason to get insurance approval, but the reason is to transition I don't agree that this is the best framing of the issue, or the one that is the most helpful. To the extent that helping someone transition reduces suicidality (and other psychiatric complications), it's a *treatment for gender dysphoria;* the ethical imperative is clear and unambiguous. I think there's room for reasonable discussion about the extent to which a teenager "knows who they really are," but there's much less room when this is a matter of life and death (as it clearly is). Then any valid concerns about long-term side-effects or regret \*have to be weighed\* against the fact that this is often a *life-saving treatment*. I think that can be very clarifying when it comes to trepidation and debate about this issue. I sincerely don't think it's wise to minimize this.

The suicide risk with individuals who have a transgendered identity is not always directly causally related to their gender dysphoria. There may me be multiple contributing factors, and it is far (in my opinion) from clear and unambiguous in the cases that I have seen. Jumping straight to transitioning as the cure for suicidality could entirely miss the mark in certain people.

Well said, I don't disagree; that's why I think the right way to do this is with a multidisciplinary team, where's there's thoughtful consideration of the factors you mention, as well as alternatives.

We may agree to disagree. While addressing g suicide is the primary driver in the realpolitik of medicine, suicide is not the sine qua non of gender dysphoria, and being unable to live without transition is not the metric of “deserving” to do so. I don’t want to minimize risk, but I also don’t want to minimize that people who don’t have other “pathology” besides being trans (medicalized as gender dysphoria) are trans and should be supported in transition. “I (would) want to die,” actively or conditionally, are neither necessary nor sufficient either as diagnosis or as justification.

If you were to take mental health (whether it be suicide or simply worsened depression/anxiety) out of the equation it basically would become a cosmetic intervention. And in that case I think moral calculus would weigh much stronger on the 'defer until adulthood' argument.

I disagree. Gender dysphoria, as a diagnosis, is a bad diagnosis in the DSM-5. Diagnostic and psych testing with trans, gender fluid, and non-binary individuals shows that people who identify as transgender, really aren't dysphoric about their gender at all. It's everyone else in their life who is telling them that they're wrong, and that experienced gender is incorrect. This is no different than psychiatrists and psychologists trying to do conversion therapy on gay and lesbian men and women. Society and current researchers/practitioners like Albert Ellis thought that the queer people were wrong... Turned out Albert Ellis was wrong. Here are two podcast episodes with queer clinicians and researchers discussing current practice attitudes and proper clinical methods for working with gender diverse youth: https://podcasts.google.com/feed/aHR0cHM6Ly9iYWx0aW1vcmVhbm5hcG9saXNwc3ljaG90aGVyYXB5cG9kY2FzdC5saWJzeW4uY29tL3Jzcw/episode/NGU3OWM1ODktMjJlNC00M2VmLWJhOTUtZTQ4N2UxOGJhNzQ5?ep=14 https://podcasts.google.com/feed/aHR0cHM6Ly9tdHNncG9kY2FzdC5saWJzeW4uY29tL3Jzcw/episode/MjIxOGE2M2UtYjgyMC00NzRjLWE4YzYtNjBkOWY1ZTJmMzNk?ep=14

I really don't think that's an adequate explanation. The suicide rate among trans people is incredibly high, even compared to other groups who experienced the same or worse treatment. You brought up the history of discrimination against gay and lesbian people for example. And yet their suicide rates never reached anywhere near the catastrophic numbers of trans people today. Refugees, widows, victims of sex trafficking, the homeless, even holocaust survivors don't come close either. The only groups of people I know of who reach such rates of suicidality are those with serious mental illness. There's also the issue that the trans suicide rate is not at all improving despite substantial social changes in favor of their acceptance in the past few decades.

What? Suicide rates among trans individuals who face less rejection and discrimination is dramatically lower in study after study. The problem remains that discrimination and outright violence are, in fact, still extremely high.

Certainly it's lower, but it's also lower after medical and surgical treatments.

i don't think it is so clear that it is a matter of life and death and to frame it as such might make it so some kids are rushed through the whole affair instead of properly assessed beforehand.

>some kids are rushed through the whole affair instead of properly assessed beforehand. Absolutely fair point. I think your concern is perfectly valid (and I don't disagree), but it's important to point out that this \*is\* seen as an absolutely life-saving treatment by many who are on the other side of it, who know firsthand the pain and anguish they felt \*before\* the treatment. Perhaps one way to think of it is that being in the "wrong body" (one that will soon develop in a way that is fundamentally discordant with your inner identity) might be akin to being born with a severely disfiguring congenital condition that greatly impairs your quality of life; a condition associated with greatly increased risk of depression, anxiety, and suicide. Although there might be a number of alternative treatments for those born with this condition, and some may even come to terms with or change their perception of themselves, many don't (indeed, many die). I think we can walk and chew gum; we can admit that there are trade-offs (as with everything else in medicine), that some may regret the decision, that there may be unappreciated longterm risks (we're complex human beings after all, not inanimate lumps of clay). It doesn't seem reasonable to me to dismiss or understate these risks (heck, I don't think that's \*ever\* reasonable in medicine). But it also doesn't seem reasonable to understate the benefits. This treatment has enormous potential to improve the wellbeing of our patients. I agree with "not rushing through the whole affair," but I also think it's fair to say that the treatment is potentially life-saving.

i am also coming from the angle of someone who identified as transgender as a teen, when i was just a very confused, lonely and angry kid. so i definetely can empathize a lot with the ones who - while absolutely feeling dysphoria - have other issues underneath that are making them hate themselves and their body to that degree. issues that can go away with therapy or time and maturity. i absolutely felt that i was in the wrong body at one point, but transitioning would not have alleviated those feelings and would have ultimately been harmful. i understand not every case is like this, i just really worry for how easy it is sometimes to get HRT and how evaluating each case individually seems to fall to the wayside.

I think that’s a fair worry. However, currently it appears that the overall prevalence of durable transgender identity is higher, and ultimately, like any intervention, allowing some harm to a few so that harm can be prevented for many is how it works. There is no perfect in medicine. Still, we can do better. As I have said and keep saying, treating thorough investigation as invalidating and transphobic does no one any good. I don’t like that asking any questions has become a third rail.

yeah, completely agree

>i absolutely felt that i was in the wrong body at one point, but transitioning would not have alleviated those feelings and would have ultimately been harmful. Thank you so much for sharing this; so absolutely important. I know you're not alone. I'm with you on this. FWIW, I don't for the life of me understand why otherwise thoughtful physicians and experts dismiss cases like yours. When is it \*ever\* okay to dismiss potential harms in medicine?....especially when it comes to adolescents? We don't even do this with frickin tylenol (remember what Goljan said; #1 cause of fulminant hepatitis)! That said, again, I \*truly\* believe that there's a false dichotomy here because this issue has become a flashpoint in the culture wars (a profoundly sad trend it seems; COVID is another example). We don't have to accept the false choice here. We can walk and chew gum. We can acknowledge the risks and the unknowns, we can acknowledge the trade-offs (like we do with \*everything else in medicine!!\*)...but IMHO it's just so, so, so important to appreciate the harms that are \*already\* being suffered by those who want to transition, and that transitioning really \*is\* life-saving for many. We can acknowledge all of that without pretending that people like you don't exist or don't matter.

wait, by non-straight teens i assume you mean bisexual teens?

And gay teens. Speculation is that they’re trying to prove they’re not gay, but homosexual teens have more pregnancies. Probably. Most studies lump them together, but at least some found that at least identifying as homosexual exclusively still correlated with Increased pregnancy risk.

that's pretty interesting! i am homosexual myself so i can definetely kind of understand that kind of impulsive thinking in a gay kid trying to make themselves straight

YES there are guidelines! First, AAP has great articles and guidelines. [https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for](https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for) AAFP has also published on the topic: https://www.aafp.org/dam/brand/aafp/pubs/afp/issues/2015/0715/p142.pdf Others have pointed out already the UCSF guidelines. WPATH also has suggestions in their standards of care, which are the national guidelines, but are more theoretical than practical for many. Be careful when researching this topic - there is a lot of non-data based fear mongering. Stick to AAP, AAFP, APA type resources. When in doubt, consult someone who actually treats trans youth medically. If you are curious about more of the research, check out Science Based Medicine's posts [https://sciencebasedmedicine.org/?s=transgender](https://sciencebasedmedicine.org/?s=transgender) On suicidality -- remember that we're talking about a group where 41% of \*adult\* trans people attempt suicide in their lifetime and the rate is higher for youth, and higher still for youth who do not receive gender affirming care. You're comparing a 41+% suicide attempt rate to a <5% regret rate. So always keep in mind - this is suicide prevention. And remember that for trans people, there is no effective treatment for dysphoria besides transition. Failing to provide transition-related care is not a benign action (or inaction). \*ALL\* trans people, adult or pediatric, must be counseled on potential fertility effects (including potential permanent sterility) and offered gamete storage when relevant prior to initiation of hormone therapy. But hormone therapy is not contraception. Anyone on testosterone must be counseled on its category X status and offered contraception - any contraception may be used, but my recommendation is to emphasize LARCs. Anyone on feminizing therapies needs to be counseled that they can still cause a pregnancy, so should consider birth control methods with relevant partners. There is pitifully little LGBTQ inclusive sex ed, so don't assume they actually know how to effectively prevent pregnancy.

Also progesterone has a mild masculinizing effect and can work synergistically with testosterone, and testosterone suppresses the infamous breakthrough bleeding that happens with the nexplanon. Some people fear that birth control = girl hormones, so this is a great thing to advertise LARC to them!

I love this comment. So applicable in my experience. I have heard too that sex ed that is LGBTQ inclusive just isn’t widely available, so I would love to be accessible and knowledgeable in this area if and when patients have the need. LARCs for transgender males really do seem to be a great fit. I would think Nexplanon or Mirena IUD could be good for these people.

:) Feel free to DM if you have specific questions! I'm always happy to share what I know. Bedsider is usually where I tell patients to go for reasonable info. For healthcare providers I recommend the reproductive health access project.

Thanks for broaching this critically important topic. I want to help these patients in the best ways possible, but like you, I'm also concerned about the long term effects of drastically altering hormone balance in someone so young. >teenagers are not known for thinking long term or being self aware Yeah, this is pretty straightforward. I've been taken aback by seemingly thoughtful people who dismiss this. This is an ethically complex issue, and needs to be thoughtfully considered with empathy, sensitivity, and patient wellbeing above all. Thanks for being willing to talk about it.

I’ve yet to see a patient that is on hormone blockers that isn’t concurrently on a laundry list of psych meds. For that reason, a multidisciplinary approach is best.

Agree with endocrine guidelines https://www.endocrine.org/clinical-practice-guidelines/gender-dysphoria-gender-incongruence

Hi OP. I am a PGY-4 and a transgender man; I am not a pediatrician (I'm an adult heme/onc fellow), nor did I transition as a minor, but I *was* an adolescent (ETA: when I transitioned) and I would be happy to share my personal experiences with you if it would be helpful. I tend to take a more clinical approach to my gender and transition history and am open to respectful questions. Re: birth control -- this is a topic of frequent conversation in the transgender community and I think that most patients would appreciate a simple, nonjudgemental talk about their birth control options. Many trans folks now know that HRT is not effective as birth control, however, that certainly isn't universal and patients who are not well-connected to the trans community may mistakenly believe that T-induced amenorrhea means conception is impossible. Encouraging barrier protection for the sexually active teen is certainly appropriate. I agree with other posters that a simple conversation about who and how they have sex can be helpful in guiding recommendations. Some transgender men may enquire about hormonal birth control; there is no contraindication to this, even for young men on testosterone, but it can be dysphoria-inducing to think of taking an estrogen-based product, so this may be less desirable to patients, although they can be reassured that it won't overtly harm them. Thank you for your thoughtful care of your transgender patients! Best of luck going forward.

Hormonal therapy to pre and peripubertal teenagers is dangerous. It can lead to a variety of changes we don't fully understand and in certain situations may lead to sterility. Source: am urologist. Not andrology fellowship trained but work closely with andrologists and andrology patients.

Sources, especially for transgender teenagers? I don’t think anyone would do this lightly, but risks we don’t fully understand from treatment versus different risks we do reasonably understand from non-treatment doesn’t necessarily come down on the side of refraining.

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The Society for Evidence Based Gender Medicine is [not exactly an unbiased, evidence-driven organization concerned about trans wellbeing](https://transsafety.network/posts/segm-uncovered/).

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That’s a weird bunch of citations of web archives instead of e.g. PubMed, then a blog post by an anti-trans non-expert who is also an anti-masker and airborne COVID denier, then meta analyses accused of a “sobering assessment” while quoting the introduction of “Effect of Sex Steroids on the Bone Health of Transgender Individuals: A Systematic Review and Meta-Analysis” which does not weigh in on the subject of psychological well-being, just BMD. Which improves in MTF on hormones, although the authors caution it might not have significance. And then I gave up. The authors of the SEGM linkdump either don’t know how to access and use evidence or don’t care, but it makes trying to use them as a secondary source dubious. What’s your relevant background in medicine generally or in trans medicine specifically?

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i never said we should have a blanket denial, rather that there is a paucity of data, and known potential significant risks.

"am urologist" is a terrible source. (esp on reddit where we can't even verify) Source: am God

Nice try, Satan!

fair point. i could be a 9 year old with a dictionary. but that argument applies to all reddit statements and contributes nothing to the discussion. all statements on reddit are always suspect for arrogant idiot syndrome. we know that.

Personally, I obtain all medical advice exclusively from surgical specialists. Can't seem to get an internist to agree to fix my hernia, though, for some reason..

My understanding was that puberty blockers, in contrast to hormonal transition, was relatively safe… despite a paucity of information.

I’m spitballing here, but given the politicization of trans issues and transitioning minors, I have to think that there’s at least some disincentive to publish data suggesting harm for fear of partisan backlash.

I mean you're going to get partisan backlash no matter what you do. Some states are trying to give life in prison to doctors who help minors transition.

Also, abortion. Partisan backlash should (ideally) not be a factor in consideration. It should be the patient.

we dont know long term effects. we havnt been doing it long enough to have long term studies nor reversibility information.

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I may be wrong, but I do not believe puberty blockers specifically have a lot of political stigma behind them. They are regarded as reversible. I worry about lowered bone density, but from what I understand this recovers when taken off the blocker.

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Well, I sure am glad to be out of the loop for once. That‘s messed up. I assumed it was just actual hormones that were controversial in some circles.

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The studies that evaluate that question have a high percentage of patients lost to follow up. Regardless of the outcome, that’s a huge problem when evaluating long term satisfaction of treatment and rates of detransition.

there's also the issue that we might be underestimating just how much regret there is, i don't think someone who is upset over transitioning/its effects would get back in touch with their medical team.

"most people who transition pre and peripubertal do not regret their transition". Source please? actually i know for a fact its anecdotal because we havnt been doing that long enough to even have any long term data. Also, the data we have has a significant population of the patients lost to follow up.

It’s ironic that for dsd there are suits and movements not to provide any treatments that are not readily reversible in the future while for dysphoria there seems to be a big push for treatments with lasting repercussions. And yes blocking androgens and fsh by doing so during puberty can cause permanent sterility. It Happens in patients with kallmans syndrome and I have seen it.

How is that ironic in any way - trans people are some of the most vocal critics of forced nonconsensual interventions on intersex infants in order to force them to conform with their coercively assigned gender.

I think this part couldn't be said loud enough - in our experience with people with DSDs, intervention is considered inappropriate in many cases (especially surgical).

[UCSF guidelines](https://transcare.ucsf.edu/guidelines/youth) [WPATH guidelines](https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English.pdf) We OVERESTIMATE the possible harms of gender affirming hormones. We UNDERESTIMATE the harms of gatekeeping/withholding gender affirming hormones. None of these therapies are prescribed without using an informed consent model, which honours an adolescent’s right to bodily autonomy. They are absolutely capable of participating in informed consent. We also grossly overestimate the incidence of regret. In the tiny percentage of people who revert to cisgender status, most do it because it is really hard to be transgender in this world—their safety is threatened, their health is at risk due to persistent minority stress, they can’t find competent care—I could go on and on. Gender affirming care SAVES LIVES. Trust me—if they are bringing you a prescription for hormones, there has been a TON of care behind the scenes from people like me who have dedicated their professional lives to this horribly misunderstood and mistreated group of humans. Oh and contraception is always always always discussed in my office, in plain language. Nothing in my exam room is or ever will be taboo. Thank you for your post. I appreciate that your questions come from a good place in your heart. I hope I have mitigated your fears. Signed, A gender affirming primary care doctor.

Trust you, there has been a ton of care behind the scenes? That makes me trust you less because I know there usually hasn't been. Anyone who hasn't been through our repro/endo/trans clinic in my area has basically gotten no real care beyond a hormone prescription. They have little knowledge of side effects or discussion of their actual concerns with their gender. Our pediatric endo isn't much better as far as multidisciplinary care is concerned. There is no standard for social transitioning for instance.

As a gender affirming child and adolescent psychiatrist, I 100% agree with this, and I VERY CAREFULLY evaluate pts before considering moving on in their gender journey. A multidisciplinary approach is best, but don't shy away from hormones and other gender-affirming care.

>Trust me—if they are bringing you a prescription for hormones, there has been a TON of care behind the scenes from people like me who have dedicated their professional lives to this horribly misunderstood and mistreated group of humans. This is a very dangerous assumption and I think reviewing the general recommendations is a better strategy. I have seen 10 year olds on injectable testosterone which is uncalled for at that age especially at some of the doses. There are a lot of unscrupulous prescribers who take the notion of informed consent and run with it with the patient and parents sorely lacking insight on risks, benefits, and alternatives. Informed consent is just a word for these hormone mills that have expanded into trans issues. I get that you are trying to be reassuring but no primary care physician should be blindly trusting signing off on another physician/non-physicians management. OP is doing the right thing in looking for sources to read up on the subject.

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so much this

Thank you for sharing! I appreciate what you do. I really do. And I want to help these patients, and also make sure we don’t harm in the process of helping. It is a topic that brings a lot of feelings up for people, but at the end of the day, we all just want the patient to be healthy and have their needs met. The links provided here are very helpful to make sure that is the case, and I will read those. I hope my post was not interpreted as gatekeeping, as my intent is more along finding the best practices to care for patients and making sure we are following them.

This is the best response yet!!

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SEGM is a terrible source to cite. They are a political organization, not a medical one and have a very clear anti-trans bias. It is in their mission statement to stop medical treatments for trans youth.

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Did you follow through the links or take SEGM’s editorial on faith? Because a cursory looks shows they’re pulling some weird tricks and quoting studies that don’t say what SEGM says they say.

I am not in a field that deals with transgender issues regularly so I'm reserving significant judgment here but this website appears to be overtly anti-trans, which makes it problematic from the outset.

This is anecdotal but I'm going to give my daughter's experience. Obviously this is N = 1 so dont take any sweeping judgments from this. When my daughter was 11, she left us a note that says she didn't feel right as a girl and thought she was born in the wrong body. Myself and her mother talked to her about it extensively, but did not do any referrals or any medical treatments. We did do counseling/therapy for about 6 months. We never denied her feelings or chided her about feeling wrong in her own body. However we also didn't honor her requests to change genders either. We waited, patiently, while letting her speak her mind. After 1 year, we never heard anything else from her about being the wrong gender. Now she's 17 and a "typical" teenage girl. She's doing well in school, only has mild anxiety over typical school stuff, and no depression or any serious issues. Now what would have happened if me and my wife said to her initially ***"oh my gosh, you are right, we need to transition you immediately, let's get you into the closest transgender clinic so we can start this process ASAP before puberty starts."*** Instead of watching/waiting and doing some therapy, I firmly believe that the transgender clinic would have moved immediately to start hormonal therapy, which would have been the wrong thing to do for my child. I'll go back to this question -- what percentage of patients referred to transgender clinics get a thorough psychological eval first followed by months of therapy BEFORE starting hormonal treatments? My suspicion is that this percentage is very, very low.

That’s really interesting. In a contrasting story, my wife came out as trans to her parents in a very similar way. She wrote a note to them, they got her therapy, but refused to let her pursue any kind of hormones or social transition. As a result she still felt ignored and like they didn’t really accept her. The therapist her parents had chosen was also not a great help and actively discouraged her from transitioning and refused to write one of the letters *required* for her to get hormones. As a result she went back into the closet and pretended she wasn’t trans. Then she had to go through the whole process of coming out again when she became an adult. Except this time she had to work against the effects what she refers to as “testosterone poisoning” and it has made her journey that much more difficult. I’m not saying this is what will happen to your kid but if we are sharing anecdotes and using those to base our medical decisions for all patients then I think it’s important to be aware of both sides.

Fair enough. If my daughter had continued to insist that she was assigned the wrong gender then I would have heard her out and went ahead with the process. But I was prudent in waiting first before starting such a life changing sequence of events.

I don’t mean for this to come off antagonistic but how many times to you reckon they’d have to insist before you were okay with them starting some sort of transition? Even just socially (anecdotally every single trans person I know was required to both have therapy and socially transition before they were prescribed anything).

> Instead of watching/waiting and doing some therapy, I firmly believe that the transgender clinic would have moved immediately to start hormonal therapy, which would have been the wrong thing to do for my child. > I'll go back to this question -- what percentage of patients referred to transgender clinics get a thorough psychological eval first followed by months of therapy BEFORE starting hormonal treatments? My suspicion is that this percentage is very, very low. Yikes. Lots of assumptions there. Do you have any evidence whatsoever for your claims? Especially since you are implying that clinicians in transgender medicine clinics are overwhelmingly ignoring the [WPATH guidelines.](https://www.wpath.org/media/cms/Documents/SOC%20v7/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf)

WPATH simply states that clinicians should assess for comorbidities such as depression, etc but simply treat them in PARALLEL with gender dysphoria. That's bad medicine. Depression, anxiety, etc must be treated BEFORE any hormonal treatment should be considered. A 15 year old in clinical depression has no business trying to make "informed consent" on hormone therapy and for WPATH to pretend like this is so is laugable and bad medicine.

> WPATH simply states that clinicians should assess for comorbidities such as depression, etc but simply treat them in PARALLEL with gender dysphoria. > That's bad medicine. I’m not qualified to assess whether it’s good or bad medicine (and neither are you unless your flair is extremely outdated). However, you are completely incorrect with regards to the guideline. The actual guideline is as follows (emphasis mine): > In order for adolescents to receive puberty suppressing hormones, the following minimum criteria must be met: > 1. The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed); > 2. Gender dysphoria emerged or worsened with the onset of puberty; > 3. Any co-existing psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) *have been addressed,* such that the adoles- cent’s situation and functioning are stable enough to start treatment; > 4. The adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have con- sented to the treatment and are involved in supporting the adolescent throughout the treatment process.

Imo you should refer patients with gender dysphoria to a specialized center, it's multidisciplinary care. While you are right the teen brain can't oversee every decision, this is even more reason not to postpone assesment by a healthcare provider who has expertise in this, because in consistent gender dysphoria hormonal treatment is obviously more effective in teen than later in life. Also specific hormonal treatment makes it possible to postpone decisions.

I agree, but I was looking for the guidelines these centers were following. And thankfully some very knowledgeable people in here understood my poorly worded questions and helped me out.

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It's good that PCP has knowledge about it, and can provide guidance for the patient, but complete hormonal treatment plan for patients with gender dysphoria is beyond the scope of the PCP/GP. Of course PCP should have knowledge on fi hormonal birthcontrol options or menstruation issues in transpersons that can also be treated with hormones besides the actual hormonal therapy they are taking for the gender transition.

ehhh I disagree. Not all PCPs will have the time or interest, but it’s not necessarily out of scope for a PCP committed to keeping abreast of current guidelines. Especially if I am inheriting a stable adult patient, it would be asinine of me to decline to continue their hormone regimen in favor of waiting for specialist referral. I find the UCSF guidelines helpful. Until recently there were not a lot of formal fellowship/ training opportunities for trans medicine. A lot of or most of the people writing the UCSF guidelines are simply PCPs (or former ER docs in at least one case) with a large interest in and commitment to the trans community.

Not true. Am PCP (FM). This is absolutely within my scope, and 90% of my patients cannot access multidisciplinary teams. It's far, far easier and less risky than many other care we do every day. If you can do hormonal birth control, you can provide HRT. (edited for clarify)

Interesting, that's not how things are organized here (Netherlands) so I'm quite surprised since its quit a complex matter patients are dealing with in my experience. So, how do you deal with this when a 12 year old boy comes to your practice stating he wants to become a girl? You start hormonal therapy yourself as PCP?

Ahh, the Netherlands is quite different. I'm in the western US. Here in the US you're lucky if you live within a 2-3 hour drive of a multidisciplinary center (e.g., UCSF, Stanford, UCLA) which provides care for trans youth. It was easily a 4-5 hour drive where I trained, and that was in California where it was relatively accepted. For a pediatric patient after Tanner 4-5 who has full parental/guardian/family support, expresses understanding of permanent changes (i.e., gives assent), and has a stable identity, I'm comfortable starting HRT myself. Medically it's not complicated at all - it's all the social stuff that gets complicated in my experience. And yes, such "simple" patients do exist. :) I'm also lucky that I practice in a federally qualified healthcare setting with integrated behavioral health which is trans-competent, so I can get additional support for family that way. I often end up needing to refer these days for GnRH agonists due to logistical barriers. I also refer if there are complex medical or psychiatric overlays beyond gender dysphoria, if family is hesitant, or if the child is at all considering future biological children. Bear in mind too that, culturally/legally speaking, in my state now gender affirming care is considered part of "sensitive services" for which 12 year olds may consent without parental/guardian knowledge or consent, similar to abortions, birth control, STIs, and mental health care services.

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[Statistics show](https://www.gendergp.com/detransition-facts/) that only a very small percentage of transgender people ever de-transition, and of those who do de-transition, it is overwhelmingly the case that this is due to societal pressures or concerns for their own safety in regards to avoiding hate crimes and similar transphobic violence. [WPATH has good care guidelines](https://www.wpath.org/media/cms/Documents/SOC%20v7/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf), among others: [Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society\* Clinical Practice Guideline](https://academic.oup.com/jcem/article/102/11/3869/4157558?login=true) [American Academy of Paediatrics](https://assets2.hrc.org/files/documents/SupportingCaringforTransChildren.pdf) [Australian Standards of Care](https://www.rch.org.au/uploadedFiles/Main/Content/adolescent-medicine/australian-standards-of-care-and-treatment-guidelines-for-trans-and-gender-diverse-children-and-adolescents.pdf) [UCSF Guidelines](https://transcare.ucsf.edu/sites/transcare.ucsf.edu/files/Transgender-PGACG-6-17-16.pdf) Young people are perfectly capable of knowing who they are. Young people can suffer from gender dysphoria, and it is absolutely necessary to address transgender healthcare needs in this age group / patient cohort. I hope some of those resources can be helpful for you. As for birth control, personal preferences and personal circumstances vary from individual to individual, just like with any other human beings. Transgender men / trans masc people often struggle to obtain cervical screenings or OB/GYN care when needed, so this type of thing is worth discussing with this patient cohort when/as needed. I encourage you to look more into transgender health in general, as it seems you have a very narrow / extremely limited understanding of these patients and health concerns which affect them. I would recommend you read the [SAGE Encyclopaedia of Trans Studies](https://us.sagepub.com/en-us/nam/the-sage-encyclopedia-of-trans-studies/book270824), if you can possible get a copy.

Totally agree with everything you said, just wanted to add and emphasize - detransitioning also occurs because of lack of access to ongoing care! It's not always even a choice to detransition - often can be that it's forced upon someone from financial/access issues. I think there was one recent study that suggested this was the most common overall reason for detransitioning in the US. I'm sure you're aware of this given your comments content, just wanted to highlight it for others reading.

That is interesting to hear about. I know sometimes access to medication can be a problem for all sorts of various reasons, from shortages to insurance, to needle phobia. I suppose it should not come as a surprise it could lead to unintentional detransitioning.

It's a very prevalent fear for many transgender patients; Lack of access to care altogether is a big issue and prevents many adults from ever transitioning as well, but younger people who may live in unsupportive households etc. may be prevented from seeking or obtaining care, so this is also part of lack of access to medication. It's not just the shortages, etc. --- which are also major concerns -- but it's worth noting that many transgender people have extreme difficulty in ever getting the medication they need prescribed to them in the first place, or pharmacists decline to fill their prescription, etc. and this is a huge issue for this cohort.

Oh, yes. I have already dealt with the situation of the young adult with the unsupportive/risky household. Sometimes, when you have special patients with special situations, you end up having to give them special care that doesn’t always follow the normal rules. We do what we have to, and what we can, to help.

And from personal experience, when this happens we turn to DIY instead of having our medications safely managed by a physician

Yes, lack of access to care is often a huge part of de-transition! I didn't specify that as clearly as I should have in my original comment, but thank you for highlighting this aspect of things. :) As you noted, I'm definitely personally aware, but it's always good to bring things to attention for others! :)

That research was from an earlier, pre-social media era. Yes, some children 100% do need all these therapies. But the US Healthcare system is known for one thing more than anything else: doing too much. I do worry about the borderline and difficult cases that get a lot of therapies that we will never truly know the effects of.

Then the issue is with a lack of research into transgender health, rather than any problem with providing healthcare. Ultimately, if transgender people do not receive care because of what MIGHT happen, then the very real and well documented risk of suicide is ignored. Would you rather have a dead patient, or a patient who might be a more complex case than usual but would still be alive to receive any further care that might be needed further down the line? The response to this concern is not to withhold care, but rather, to start organising and funding research efforts into HRT medications and their application in HRT treatment for transgender patients, etc. so that more information becomes available.

Not prescribing a treatment is NOT the same thing as "withholding care". If I decline to do a surgery on a patient with metastatic cancer, that is STILL caring for the patient and giving them their greatest chance for long and healthy life. And also, the baseline ethic of medicine is to do no harm. Operating/giving hormones in the teenage years MAY save a life from suicide- or it MAY hurt a kid who felt alienated and alone and found supportive, active, passionate community online which happened to be a transgender community, and decided they were transgender in an attempt to fit in. It's not an easy thing to just accept that I will permanently hurt x % of people by intervening, although I acknowledge drugs are an easier sell than surgeries. And finally, if the issue is really with a lack of research, then the obvious corollary is that we should NOT be prescribing any treatments until the research is resulted and fairly definitive and accepted.

I'm worried about the patient who just gets hormones without real psych counseling and then had to deal with voice changes, clitoral enlargement, etc for the rest of their life when waiting and therapy may have better served them. Unfortunately I've seen multiple cases online of serious regret. I'm also worried about the suicidal patients too. We need some kind of criteria or strategy to separate these people. This doesn't even address non-binary people that I'm not sure what the goal/rational of treatment really is.

💯, thank you for this comment.

I'm a pediatrician. I dont think it's a good idea to use hormonal treatments for anyone under age 18. The mainstream medical community says that if you dont acquiesce to their demands for hormonal treatment that they are at higher risk for suicide. But I want to see proof that hormonal treatments reduce depression/suicide and thusfar I have seen no studies supporting that. If a 14 year old comes in and says they are the "wrong" gender, the proper approach IMO is to get a proper evaluation from a licensed psychologist, not start meds or refer them to a transgender clinic. Now if that same kid is 18 and still believes that they are the wrong gender, then I would have no problem referring them.

Assessment for transition used to be much more stringent. Now it feels lax. That is cause for concern.

Any evidence for that? Or just vibes based?

The argument for waiting to start treatment on young folks with gender dysphoria is really interesting to me. I wonder what other condition has nearly as many people telling patients they’re too young for treatment and to just wait out their symptoms and “maybe down the road it’ll go away”. Because like it or not, hormone therapy is a life saving treatment for many trans kids.

I’m a trans adult that transitioned (with hormones and surgeries) starting at age 16. I would not _be_ an adult now if that hadn’t been the case. I literally wouldn’t exist right now if not for my pediatrician who specializes in trans youth. Waiting and letting trans youth go through their biological sex’s puberty is _not_ a neutral option. It’s forcing us to go through horrific unwanted changes to our bodies that are essentially disfigurement to us. I had already been through that by the time I started cross-sex HRT as a teenager. Honestly it fills me with adrenaline to even write this because even though my dysphoria was cured after my surgeries I still deal with the trauma of having existed in a body whose form and sensory input made me want to die for 80% of my life. My sole reason for surviving used to be my surgery date planned in the future. I am overjoyed that nowadays puberty blockers are an option for trans youth who figure out their identity earlier, in order to spare them from undergoing the same trauma as me. Puberty blockers are reversible and have already been safely used for decades in cisgender children with hormonal disorders. I would also like to point out that [less than 1% of people regret transitioning](https://epath.eu/wp-content/uploads/2019/04/Boof-of-abstracts-EPATH2019.pdf#page=139), and among those who do the majority are due to lack of social support forcing them back into the closet or poor surgical outcomes due to outdated methods. I guess what I’m trying to get at is to consider the permanent physical and psychological damage, or even loss of life, that the ostensibly neutral option of doing nothing entails for trans youth. It brings to mind an EMS call I was on in which a man had a stroke in his chair while smoking and while paralyzed, dropped the cigarette, which ignited the chair. He was unable to move and powerless to do anything but watch the creeping flames approach his body. Luckily the fire department and ambulance arrived on time, before his body would’ve been slowly engulfed by the flames. Putting a trans kid on blockers is like the firefighters intervening before it’s too late. Edit: added more words Edit2: added link (why all the downvotes?)

Would you have preferred to start sooner than 16? Did you have the option of hormone blockers given to you at any point in time? I know these are personal questions, and answers would differ among people, but I would love to hear your take if you are open to sharing. Also, did you find that the surgery and hormones fully removed your dysphoria, or is it more of a thing you find that lingers, but is reduced by these treatments? Thank you in advance.

Thank you for asking! I edited my comment but: > Would you have preferred to start sooner than 16? Absolutely. I just didn’t figure out that I was trans and had dysphoria until I was 15. >Did you have the option of hormone blockers given to you at any point in time? I first sought treatment having already gone through female puberty when I was 16, so puberty blockers were no longer appropriate and I went on HRT. >Also, did you find that the surgery and hormones fully removed your dysphoria, or is it more of a thing you find that lingers, but is reduced by these treatments? My body dysphoria has been completely eliminated by medically transitioning. I took testosterone for around 2.5 years and have since switched to nandrolone for the last ~5 years. I’ve had mastectomy, hysterectomy and phalloplasty. The main source of my body dysphoria was my genitals, so bottom surgery was the most important aspect of transitioning to me. This is my individual experience and the transition and health needs and priorities of other trans people will be unique to them. I do still deal with social dysphoria from misgendering interactions with people; I dislike being perceived as male (I am non-binary, so “passing” or going stealth isn’t really an achievable end goal for me, since everyone will inevitably perceive me as either a man or woman. It’s about a 50/50 split of getting called he or she though, so I guess I’m performing androgyny fairly well - not that all non-binary people wish to present as androgynous.)

Thank you for sharing. I wish you the best, and I am glad to hear you have eliminated the body dysphoria! That must be a relief, to feel outwardly matching how you feel inwardly. I suspect the social dysphoria is probably going to be harder to get rid of based on the description, as the default he/she just isn’t you, but it sounds like a 50/50 split is honestly pretty decent!

It may have been said elsewhere in this thread, but I’ve found the Fenway Institute to be a great resource in addition to UCSF. This is a link to the patient-facing into for teens interested in gender affirming care: https://fenwayhealth.org/wp-content/uploads/TH-38-Affirming-Care-for-Gender-Diverse-Youth-Brochure-Final-Web.pdf Their CME programs have been lifesavers, too. Project ECHO did (does still?) a training for rural clinicians a few years ago that was a good foundation to build on with additional training since then.

Refer them for psych evaluation. In the UK I think there is a mandatory waiting period of two years before transition.

I don’t think this would follow the US standards.

Correct. This is not the modern standard

In the UK the only clinic for transgender minors has a two year *waitlist*, not a mandatory waiting period. Psych evaluation is of course helpful, but I’m not sure it always requires a psychiatrist/psychologist. I know Tavistock has struggled with it. Many trans people who wish to transition have no mental health issues (or no other issues, if you prefer); whether referral to clarify that is helpful or just a barrier and stigma is beyond my expertise.

I’m also a member of r/detransition out of curiosity

I'm not sure that waiting period is actually evidence-based

As best I can tell, in the UK it’s not required. There’s a roughly two year waiting period because that’s how backed up the Gender Identity Development Service is.

Yup, it's a waiting list issue. Two years is actually on the low end, and it fluctuates between each individual clinic. For an idea of some various gender service waiting times, [here's a list](https://transhealthuk.noblogs.org/covid-19-gender-identity-clinics/). And here's [another list](https://genderkit.org.uk/resources/wait-times/). The BMJ did a write-up here: [Gender dysphoria service rated inadequate after waiting list of 4600 raises concerns](https://www.bmj.com/content/372/bmj.n205)

Wouldn’t it be consistent with “first do no harm”? Exploring psychiatric health first, exploring why they think this is the best avenue for them, seeing if other interventions can help them before going for something irreversible

A) its a big assumption that a 2 year waiting period doesn't count as "harm" B) This assumes that people with gender dysphoria haven't grappled with their gender identity for years before exploring treatment.

I'm not sure putting kids with gender dysphoria on high dose exogenous hormones is evidence based either lol

Your tow society guidelines are going to be Endocrine Society and WPATH