The number of children and adolescents seeking transgender care has increased dramatically in recent years. Experts believe that this is likely due to greater awareness and acceptance of gender diversity in society, as well as an increased willingness of families to support and seek treatment for their transgender children. As with adult patients, endocrinology is a vital component of transgender care for children and adolescents. The term endocrinology refers to the medical specialty that cares for patients with hormonal conditions. Doctors that practice in this specialty are called endocrinologists.
Adult transgender patients have been treated with hormonal medications for more than 50 years, and most of the research in this field focuses on adult patients. In contrast, the body of research related to endocrinology care for transgender children is more limited. For this reason, it is paramount that parents choose a pediatric endocrinologist with specialized knowledge and experience in treating transgender youth.
The term “sex” is used to describe the physical characteristics that categorize a person as biologically male or female, such as genitalia. At birth, babies are typically assigned a sex according to these physical characteristics. A person’s gender identity, or their inner sense of self as male or female, may not be congruent with their assigned sex. Individuals who identify with a gender that is different than their assigned sex are known as transgender. Being transgender may be more common than previously thought. A recent survey conducted in Massachusetts found that 0.5% of adult participants identified as transgender.
It is important to point out that being transgender is not a disease or a mental health problem. Rather, being transgender is a normal and natural aspect of human diversity. Children who identify as transgender should be supported and encouraged to express their gender identity. Unfortunately, transgender youth are at an increased risk for a number of psychosocial challenges, including depression, anxiety, substance abuse, and suicide. However, research shows that transgender children and adolescents with very supportive families tend to have higher self-esteem and improved mental health outcomes, compared to their peers with unsupportive families.
While being transgender itself is not a mental illness, many transgender children and adolescents are diagnosed with a condition called gender dysphoria. Gender dysphoria refers to the discomfort and distress associated with being transgender. Symptoms can include depression, anxiety, and social isolation. Transgender individuals are often stigmatized and treated poorly in society, and experts believe that these symptoms can sometimes be related to that maltreatment. However, research shows that gender dysphoria symptoms typically increase when patients hit puberty, and improve when they receive hormonal treatments—suggesting a biological cause for this condition.
Doctors still aren’t sure exactly what causes someone to be transgender, but a variety of research studies highlight a biological basis for the condition. The results of several studies focused on transgender twins suggest that transgenderism is genetic. Additionally, a number of studies have examined the brains of transgender individuals. There are some important differences in the structure of male and female brains. Research shows that the brains of transgender individuals tend to be structured more like the brains of their experienced gender than their assigned gender. Additionally, the fact that many patients are diagnosed as young children suggests that the condition is likely biological in origin.
Two medical organizations have published guidelines that outline the appropriate treatment for youth who identify as transgender. These organizations are The Endocrine Society and the World Professional Association for Transgender Health, or WPATH. At the International Center for Transgender Care, our expert pediatric endocrinologists follow these guidelines when providing care for transgender children and adolescents. Notably, treatment typically varies depending on the child’s age, maturity level, and level of physical development. Ideally, all families who seek transgender care will first meet with a holistic therapist for mental health counseling and evaluation. From there, your therapist can provide a referral to an endocrinologist for possible hormonal treatment. The holistic therapy division at ICTC is headed by Caroline Gibbs, an internationally recognized expert in transgender mental health. Caroline has worked with many transgender children and their families.
Treatment for younger transgender children is usually limited to support and education for the patient and family. While it is certainly a good idea for children who identify as transgender to be evaluated by a doctor, patients who haven’t reached puberty do not require hormones or other medications. Instead, patients at this age and their families will typically benefit from assistance in understanding and coping with their condition. The treatment team at ICTC can also help parents to better advocate for their transgender children, and serve as a resource for families during the social transition process.
WPATH and Endocrine Society guidelines suggest that transgender children begin taking medication when they enter puberty. These medications are called GnRH agonists, or “puberty blockers”. Once a child develops the physical signs of puberty, such as breast development in biological girls or voice changes in biological boys, these changes can not be reversed without surgical treatment. Additionally, puberty can be especially challenging for transgender children. Oftentimes, gender dysphoria symptoms increase when a child begins to develop. Treatment with puberty blocking medications can prevent the physical signs of puberty from occurring, and decrease any gender dysphoria symptoms the patient may be experiencing. In essence, puberty blockers can buy the patient a little more time to sort through their feelings about being transgender and undergoing the physical transition process. Once they have matured emotionally and intellectually, the patient can then decide whether to begin the physical transition to their experienced gender. The effects of puberty blockers are completely reversible, so the patient can decide to discontinue these medications at any time and begin the puberty process for their birth gender (if they choose not to transition).
Doctors began treating transgender children with puberty blockers about twenty years ago, but these medications have also been used for decades to treat cisgender children who enter puberty too early. Puberty blocking medications are quite safe, but potential side effects can include decreased bone mineralization, decreased fertility, and unknown changes to brain development. Children who take these medications should get plenty of calcium and vitamin D in their diet. It is also important to follow your doctor’s instructions for monitoring the effects of the medication and return for regular check-up appointments.
It is appropriate to begin treatment with hormonal medications once the patient has reached a suitable level of emotional and intellectual maturity. Although each patient is unique, this generally occurs around the age of 16. Ideally, candidates for hormonal treatment have been taking puberty blocking medications for several years, but this is not a requirement. Many transgender adolescents first present for medical care in the later stages of puberty, and these patients can also be prescribed hormonal medications with good results.
Hormone therapy for transgender patients is also known as “hormone replacement therapy”, or HRT. HRT includes treatment with sex hormones that match the patient’s experienced gender, such as estrogen for trans girls and testosterone for trans boys. These sex hormones are responsible for the physical characteristics that we typically think of as feminine or masculine (breast development in women and facial hair in men, for example). Therefore, HRT can be prescribed to assist transgender adolescents in developing physical characteristics that are consistent with their experienced gender. HRT is an important first step in beginning the physical transition process to male or female—without HRT, physical transition is not possible.
Unlike puberty blocking medications, the effects of HRT are not completely reversible. Therefore, it essential that transgender adolescents fully understand the risks, benefits, and expected results prior to beginning an HRT regimen. It is also important to understand that taking HRT medications can have an impact on future fertility. At the International Center for Transgender Care, we believe that our patients are the experts in their own transition journey. Because we want you to achieve the very best results from your HRT, we encourage you to discuss any questions you may have with your endocrinologist.
The standard HRT regimen for trans boys includes treatment with testosterone, typically prescribed as an injection that goes into the muscle. Trans boys can expect to see results including increased muscle mass, facial hair, a deepening of the voice, and enlargement of the clitoris. Menstrual periods will also typically stop (or not begin in patients who have been taking puberty blockers). Side effects that are associated with testosterone use include facial acne, undesired weight gain, increased red blood cell count, and psychological changes. Your child’s endocrinologist can help manage any undesirable side effects that may occur with HRT.
For trans girls, the typical HRT regimen will include combined treatment with both estrogen and an anti-androgen medication. “Androgen” is another term for male hormones; anti-androgen medications can reduce the levels of testosterone in the body and allow the estrogen to have its fullest effect. Estrogen can be taken as an oral pill, a topical gel or patch, or an injection, and should be taken daily for best results. Trans girls who begin HRT can expect to see breast development; increased fat deposits on the hips, thighs and buttocks; decreased facial and body hair; and shrinking of the genitalia. Side effects of treatment with estrogen include can mood changes; an increased risk for blood clots, liver disorders, and high blood pressure; and increased sensitivity to insulin. A medication called finasteride may also be prescribed to reduce body and facial hair growth in trans girls.
Coping with being transgender is often challenging, but it is possible for transgender children and adolescents to thrive—particularly when they receive support from their family and appropriate treatment from a knowledgeable pediatric endocrinologist. At The International Center for Transgender Care, our team of clinicians are experts in caring for transgender youth. We’ve assisted thousands of children and their families in managing hormonal treatments and beginning the physical transition process. Contact us at 816-305-0943 to schedule a confidential consultation.